COLUMBIA LIBRARIES OFFSlIb HEALTH SCIENCES STANDARD HX00038725 (Columbia Hnibersiitj) ^"^^1. mtf)eCitpofi^eit)gorfe College of ^fjp^icians anb burgeons ^tttvtna ILihvavp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/diagnosistreatmeOOcros DIAGNOSIS AND TREATMENT OF DISEASES OF WOMEN DIAGNOSIS AND TREATMENT OF DISEASES OF A\ OMEN BY HARRY STURGEON CROSSEN, M. D. Professor of Clinical Gynecology, Washington University; Gynecologist to Washington University Hospital and Director of the Gynecological Clinic; Gynecologist to St. Louis Mullanphy Hospital, to Missouri Baptist Sanitarium, to Bethesda Hospital, and to the St. Louis City Hospitals; formerly Superintendent of the St. Louis Female Hospital; Fellow of the American Gynecological Society, of the American Association of Obstetricians and Gynecologists, and of the Western Surgical and Gynecological Association; Ex-President of the St. Louis Obstetrical and Gynecological Society, Member of the American Medical Association, Missouri State Medical Association, St. Louis Medical Society, Etc. SECOND EDITION, REVISED AND ENLARGED WITH SEVEN HUNDRED AND FORTY-FOUR ENGRAVINGS ST. LOUIS C. V. MOSBY COMPANY 1912 Copyright, 1910, by C. V. Mosby Company n\'^ Press of C, V. Mosby ComjMny St. Louis, TO THE MEMORY OF DR. HENRY HODGEN MUDD THIS WORK IS RESPECTFULLY DEDICATED AS A SLIGHT TOKEN OF APPRECIATION OF HIS SPLENDID PROFESSIONAL ATTAINMENTS, HIS UNSELFISH DEVOTION TO THE CAUSE OF MEDICAL EDUCATION AND HIS INSPIRING PERSONAL FRIENDSHIP PREFACE TO THE SECOND EDITION. The character of this work is indicated in the extract from the preface to the first edition. My endeavor has been to present clearly and in detail the foundation facts and principles of Gynecology — the anatomic, pathologic, diagnostic and therapeutic information underlying successful gynecologic work. Two hundred pages of text and fifty original illustrations have been added. The index, upon which the practical usefulness of a medical book so largely depends, has been greatly amplified, so as to include references and cross- references to every diagnostic and therapeutic item. In the new text special attention has been given to the presentation of pelvic inflammation and of tubal pregnancy — two hve and important subjects, upon each of which an enormous and chaotic mass of information has accumulated. To properly emphasize the established landmarks and point out important features of advance work — such was the task. Disturbances of function merit, and have received, careful and detailed consideration, both from the diagnostic and therapeutic standpoint. Medico-legal complications are claiming more and more attention each year, and those connected with gynecology are considered in a detailed and practical way. My thanks are due to Mr. Thos. Jones, the artist, for the careful work shown in the new drawings. I would appear remiss in gratitude did I not express my appreciation of the gratifying reception accorded the first edition by teachers and prac- titioners. H. S. Crossen. Metropolitan Building, St. Louis, September, 1910. VII EXTEACT ¥J{(m PREFACE TO THE FIRST EDITION. This work is devoted exclusively to the diagnosis and treatment of Dis- eases of Women as those diseases are met with in the office and at the bed- side by the general practitioner. No space is given to other considerations, except as necessary to bring the work to its highest usefulness as a prac- tical guide in the Hnes indicated. While no space is taken up with detailed technical descriptions of major operations, much care is taken to set forth clearly the differential diagnosis of the various conditions requiring such operative treatment, the kind of operation called for by the particular con- ditions present, what the operation is intended to accomplish, the prepara- tion of the patient for operation and the after-care necessary to complete the restoration to health. In my experience as a consultant and as a teacher I find that the two prin- cipal stumbling-blocks encountered in the way of accurate gynecologic work are, first, the difficulty of determining exactly the conditions present in the pelvis, and, second, the lack of a clear understanding of the indications gov- erning the selection of the particular treatment best adapted to each of the various classes of cases under each disease. Special consideration is given to these important phases of the subject. My endeavor throughout has been to present the important points clearly and SYSTEMATICALLY — SO clearly and so systematically that they will be readily understood and well retained in mind for use at the bedside. To this end much thought has been given to the ARRANGEMENT OF THE TEXT, so as to show not only the facts of a subject, but also the mutual relation of the facts and their bearing and relative importance in the diagnosis and treatment. The necessary facts are presented clearly and fully, and UNINCUMBERED by the vast and confusing mass of gynecological knowledge with which the specialist must deal. To this end, likewise, the illustrations have been most carefully selected, with the one idea of making clear the points under consideration. From the extensive field of gynecological literature I have endeavored to bring the BEST illustration available to elucidate each point. Those from reference works necessarily cover a wide range, and I wish here to express my hearty thanks to the authors and publishers of the works so used. I have added over two hundred and twenty illustrations of my own. In these I have endeavored particularly to show the actual care and handling of the patients, thus bringing to those who have not had the opportunity of gynecological hospital training many facts which can be satisfactorily pre- sented in no other way. For this purpose I have had taken over five hun- IX X PREFACE dred photographs. Only a part of them, however, could be used in this work on account of limited space. Most of these photographs were taken by my clinical assistant, Dr. R. E. Wobus, to whose skill and patience I bear appreciative tribute. My thanks are due to my colleague, Dr. Henry Schwarz, Professor of Obstetrics in Washington University, for helpful suggestions. I wish to thank Dr. F. J. Taussig and Dr. H. A. Hanser, my Senior Clin- ical Assistants, for valuable help in various ways. To Dr. R. W. Mills, the artist, I wish to express my appreciation. His painstaking care and fidelity in representation are apparent in all the draw- ings made by him. For engravings of instruments I am indebted to Mr. C. W. Alban, instru- ment dealer, of this city. The publishers have aided me throughout by their courtesy and cordial co-operation, for which I wish to express my sincere thanks. H. S. Crossen. St. Louis, May, 1907. ^t- CONTENTS. CHAPTER I. GYNECOLOciic Examination Methods. History, 1; Examination, 13; Abdominal examination, 14; Examination of external genitals, 31; Vaginal examination (digital), 39; Vagino-abdominal examination (bi- manual), 52; Recto-abdominal examination, 73; Recto-vagino-abdominal examination, 75; Instrumental examination, 77; Pelvic examination under anesthesia, 91; Preparations for gynecological examination, 98; Non-gynecologic examination methods in gynecological cases, 110. CHAPTER II. Gynecologic Diagnosis. Method of diagnosis, 118; Significance of findings in abdominal examination (promi- nence, discoloration, tension, tenderness, mass, area of dullness), 119; Significance of findings in examination of external genitals (leucorrhoea, bloody discharge, inflamma- tion, ulcer, malformations, lacerations, swelling), 170; Significance of findings in vaginal examination (roughening, tenderness, mass, changes in cervix uteri, mass in cervical canal), 224; Significance of findings in vagino-abdominal examination (changes in corpus uteri, mass or induration in pelvis or lower abdomen), 238; Table for differential diag- nosis of the various masses found in the bimanual examination, 287; Significance of findings in speculum examination (conditions of the vaginal wall, conditions of the cervix uteri), 289; Diagnostic significance of pain in the pelvis, back and lower abdomen, 297. CHAPTER III. Gynecologic Treatment. Classification of therapeutic measures, 394; Rest (complete rest, partial rest, sexual rest), 306; Applications to lower abdomen and exterior of pelvis (moist heat, dry heat, cold, counter-irritation), 307; Applications to external genitals, vagina and cervix (douches, concentrated solutions, powders, tablets, vaginal suppositories, tampons, tam- pon-capsules, pessaries, submucous injection of substances, local blood-lett?ng, curet, cautery, electricity, x-ray, Finsen light, radium), 311; Intrauterine treatmeat (medi- cated applications, hot water irrigation, curettage, cauterization, electricity, cervical dilatation, vacuum treatment), 346; Applications within rectum (hot water irrigation, low enemata, high enemata), 358; Applications to lower abdomen and interior of pelvis (pel- vic massage, pressure treatment, electricity), 359; Applications to body generally (gen- eral bathing, friction rubbing, general massage, dress corrections), 365; Postural methods and exercise (knee-chest posture, Trendelenburg posture, general exercise, special exer- cise), 367; Internal treatment (medicines, diet, psychotherapy), 370; Operations, 373. XI XII CONTENTS CHAPTER IV. Diseases of Exterxat, Genitals and Vagina. Points in anatomy, 375; Classification of diseases, 384; Gonorrhoea, 384; Other in- flammatory diseases of vulva (simple vulvitis, follicular vulvitis, erysipelas, cellulitis, gangrene, diphtheria, eczema, intertrigo, herpes, prurigo, parasitic diseases), 402; Other inflammatory diseases of the vagina (simple vaginitis, parasitic vaginitis, diphtheritic vaginitis, emphysematous vaginitis, adhesive vaginitis), 413; Ulcers of vulva (simple ulcer, chancroid, syphilis, tuberculosis, malignant disease, ulcus rodens vulvae), 419; Urethral affections (urethritis, peri-urethral abscess, prolapse of urethral mucosa, ure- thral caruncle), 438; Vulvo-vaginal gland affections (inflammation, abscess, sinus, cyst), 441; Non-malignant growths and swellings (condylomata, cysts, fibromata, lipomata, stasis hypertrophy, elephantiasis, pudendal hernia, pudendal hydrocele, hematoma, vari- cose veins), 444; Injuries of vulva and vagina, 457; Miscellaneous affections (kraurosis vulvae, pruritis vulvae, hyperesthesia of vaginal entrance, adhesions of prepuce and labia), 458. [The more pronounced malformations are considered in Chapter XIII.] CHAPTER V. Lacerations and Fistulae of Pelvic Floor. Perineum, Extern.\l Genitals and Vagina. Points in Anatomy, 467; Laceration of pelvic floor and perineum, 473; Cystocele and rectocele, 504; Recto-vaginal fistula, 506; Vesico-vaginal fistula, 510; Destruction of urethra, 519. CHAPTER VI. Inflammatory and NrTRiTi\-E; Diseases of Uterus. Points in anatomy and physiology, 520; Pathological changes resulting from inflam- matory and nutritive disturbances, 536; Classification of diseases, 537; Localization of diseases, 538; Affections of the cervix uteri (erosion, ulcer, endocervicitis, hypertrophy of cervix, polypi of cervix, laceration of cervix), 539; Affections of the corpus uteri (acute metritis and endometritis, chronic infected endometritis, chronic simple endome- tritis, subinvolution, hyperinvolution, sclerosis, tuberculosis, syphilis, echinococcus dis- ease), 562. CHAPTER VII. Displace:\ient of the Uterus. Points in anatomy, 595; Backward displacement of uterus (retroversion, retroflexion), 597; Prolapse of the uterus, 619; Forward displacement of uterus (anteflexion, ante- version), 624; Lateral displacement of uterus, f)24; Inversion of uterus, 624. CHAPTER VIII. FiBBOMYO.MA OF THE UtERUS. Points in pathology, 625; Symptoms, 631; Examination signs and differential diag- nosis, 634; Palliative treatment, 637; Curative treatment, 641; Choice of treatment, 642; Pregnancy and fibroid, 656; Lipoma of uterus, 658. CONTENTS XIII CHAPTER IX. M.\i.u;n.\nt Diseases of the Uteri's. Carcinoma of cervix, 659; Pathology, 659; Symptoms and diagnosis, 667; Choice of treatment, 673; Curative treatment, 675; Palliative treatment, 683; Carcinoma of corpus uteri, 686; Sarcoma of uterus, 689. CHAPTER X. Pki.vic Ixfla:mmatiox. ■ " Podnts in anatomy of Fallopian tubes, pelvic peritoneum and pelvic connective tissue, '691; Acute pelvic inflammation (salpingitis, oophoritis, pelvic peritonitis, pelvic cellu- ■ litisn 698; Chronic pelvic inflammation (salpingitis, oophoritis, pelvic peritonitis, pelvic cellulitis), 728. At CHAPTER XI. Other Affections of Faixopiax Tubes, Peritoneum and Connective Tissue. Pelvic tuberculosis, 760; Tubal pregnancy, 764; Pelvic hemorrhage, 793; Fulminating pelvic edema, 795; Tumors of Fallopian tubes, 796; Varicose veins of broad ligament, 797; Echinococcus disease of pelvis, 798; Pseudo-tuberculosis of pelvis, 798. CHAPTER XII. Tumors of the Ovary and the Parovarium. Points in anatomy and physiology, 799 ; Classification of tumors of ovary, 809 ; Cystic tumors of ovary, 810 ; Solid tumors of ovary, 831 ; Tumors of parovarium (broad ligament tumors), 832. CHAPTER XIII. Malformations. Points in development, 836; Anomalies of development, 840; Imperforate hymen, 841; Atresia of vagina, 842; Double vagina, 843; Malformations of uterus, 844; Pseudo-her- maphroditism, 845. CHAPTER XIV. Disturbances of Function. Disturbances of menstruation (normal menstruation, absence of menstruation, scanty menstruation, excessive menstruation, painful menstruation, irregular menstruation, pre- cocious menstruation, vicarious menstruation), 847; Disturbances of sexual intercourse (dyspareunia, sexual impotence), 892; Disturbance of childbearing (sterility), 895; Geni- tal discharge (leucorrhoea, bloody discharge), 900. CHAPTER XV. Invasion of the Peritoneal Cavity for the Treatment of Gynecological Diseases. Abdominal section (indications, contraindications, preparations, brief explanation of regular steps and special points), 909; Vaginal section (indications, contra-indications, preparations, steps), 942; Conservative surgery of ovaries, tubes and uterus, 945. XIV CONTENTS CHAPTER XVI. After-Tkeatmext of Operative Cases. Abdominal section (regular after-treatment, drainage cases, uterine replacement cases, severe shock, internal hemorrhage, persistent vomiting, acute dilatation of stomach, kid- ney insufficiency, constipation and intestinal paralysis, intestinal obstruction, peritonitis, suppuration in wound, phlebitis, pain during convalescence, subsequent disturbances), 948; Vaginal section, 965; Pelvic abscess, 968; Perineorrhaphy, 968; Trachelorrhaphy, 968; Curetment, 968; Extra-peritoneal shortening of round ligaments, 968. CHAPTER XVII. Medico-Legal Points ix Gyxecology. Rape, 968; Foreign bodies left in abdomen, 979; Transmission of venereal diseases, 985; Testimony in coroner's cases, malpractice suits and criminal trials, 985. APPENDIX. Formulae. Cathartics, 987; Emmenagogues, 987; Sedatives, 987; Stimulants, 988; Styptics, 988; Tonics, 989; Ointments, 989; Powders, 990; Solutions, 990; Suppositories, 991; Tablets, 991. ILLTTSTKATIONS. Relations of the Pelvic Oroaxs. FIG. PACE 1 Antero-posterior section of pelvis 1 2 Contour and measurements of two models 2 3 Antero-posterior section, with intestines out . 3 4 Posterior view of pelvic organs 4 5 Anterior view of pelvic organs 4 6 Relation of pelvic organs to external surface 5 _ Gynecologic Examixatiox Methods. The History. 7 Indicating general pelvic distress 6 8 Backache from pelvic disease 7 9 Sacral pain from pelvic disease 7 10 Pain in right tubo-ovarian region 8 11 Pain in appendix region 8 12 Pain in stomach region 9 13 Pain in liver region 9 14 Pain in right kidney region, laterally 9 1.5 Pain in right kidney region, posteriorly 9 16 Gynecologic history card, face 11 17 Gynecologic history card, reverse 11 Abdominal Examination. 18 Patient arranged for abdominal examination 13 19 Profile of normal abdomen 14 20 Surface of normal abdomen 15 21 Abdominal surface with landmarks 16 22 Abdominal surface with landmarks 17 23 Palpation of the abdomen, first step 18 24 Palpation of the abdomen, second step 18 25 Palpation with both hands 18 26 Deep palpation with both hands 18 27 Abdominal surface divided into quadrants 19 28 Usual anatomical division of abdominal surface 20 29 Division of abdominal surface with circle 21 30 Regions, by division with circle 22 31 Various areas of significant point-tenderness 23 32 Point for kidney tenderness, laterally 24 33 Point for kidney tenderness, posteriorly 24 XV XVI ILLUSTRATIONS FIG. PAGE 34 Relation of kidney to last rib , , , 24 35 Trying for a fluid wave across abdomen 24 36 Differentiating a fat wave from a fluid wave 26 37 Attempting to displace a mass upward 27 38 Ordinary percussion of abdomen 29 39 Deep percussion of abdomen 29 40 Lines for mensuration of abdomen 30 Examination of External Genitals. 41 Patient arranged for examination of external genitals and adjacent structures 32 42 Normal external genitals 33 43 Normal external genitals, multipara 34 44 Examining upper part of vestibule 35 45 Examining lower part of vestibule 35 46 Pressing pus from urethra 36 47 Appearance of pus about urethral opening 36 48 Drop of pus pressed from Skene's gland 36 49 Vulvo-vaginal gland 36 50 Appearance of pus about vulvo-vaginal gland 37 51 Palpating vulvo-vaginal gland 37 Vaginal Examination 'Digital Examination). 52 Position of fingers for vaginal examination 40 53 Hand gloved, ready for examination 40 54 Position of thumb and outside fingers 41 55 Bony arch above vaginal opening 43 56 Testing the pelvic floor with one finger 45 57 Testing the pelvic floor with two fingers 46 58 Showing separation of examining fingers 46 59 Another method of testing pelvic fioor 47 60 Palpating rectum through vaginal wall 48 61 Method of everting anal tissues 48 62 Showing possible eversion in some cases 49 Tagino-Ahdominal Examination (Bimanual Examination). 63 Bimanual examination, outside fingers folded in palm 53 64 Bimanual examination, outside fingers extended in gluteal crease 53 65 Palpating body of uterus 54 66 Depressing abdominal wall too close to pubes, sectional view 54 67 Depressing wall too close to pubes, outside view 55 68 Depressing wall at right height 55 69 Bimanual examination, body of uterus not found in front 56 70 Retroverted uterus found behind 56 71 Retroflexed uterus found behind 56 72 Palpating sides of uterus with one finger ■ 58 73 Palpating sides of uterus with two fingers 58 74 Drawing uterus down, to aid in examination 59 75 Invagination of perineum, elbow on knee 60 76 Same as Fig. 75 in bimanual examination 61 77 Invagination of perineum, elbow against iliac crest 62 78 Palpation of lateral regions, first step • • 62 \ ILLUSTRATIONS XVII FIG. PAGE 79 Palpation of lateral regions, second Btep 62 80 Showing marked depression of abdominal wall in pelvic palr)ation 63 81 Palpating the tubo ovarian region 65 82 Palpating the left tubo-ovarian region 65 83 Palpating the right tubo-ovarian region 66 84 Determining attachment of mass to uterus 67 85 Determining attachment to posterior part of uterus 68 86 Palpating region of right ureter 68 87 Location of pelvic nerve i-oots 69 88 Palpating pelvic nerve roots 69 89 Method of palpating coccyx 76 Instrumental Examination. 90 Instruments for regular speculum examination 78 91 Bivalve speculum in place 79 92 Introducing the bivalve speculum, first step 80 93 Speculum carried half way in 81 94 Speculum turned and carried all the way in 81 95 Bivalve speculum changed to Sims' speculum , , 84 96 Patient in Sims' posture 85 97 View from above, showing Sims' posture 85 98 Method of introducing Sims' speculum 86 99 Method of holding Sims' speculum 86 100 Cervix uteri brought into view 87 101 Instruments for exploration of interior of uterus 88 102 Recto-abdominal palpation 93 103 Method of palpating the pedicle of a tumor 94 104 Recto-vagino-abdominal palpation 95 105 Exploration of interior of uterus with finger . . . . • 97 Preparation for Gynecologic Examination. 106 Kitchen table arranged for gynecologic examination 98 107 Simple instrument boiler 101 108 Small instrument and dressing sterilizer 101 109 Articles needed for preparing for gynecologic examination 102 110 Use of gloves and drop-bottle for liquid soap 102 111 Wall fixture for liquid soap , 103 112 Patient arranged in bed for abdominal examination . . . „ , 104 113 Patient arranged in bed for vaginal examination 105 114 Patient arranged in bed for bimanual examination 106 115 Showing position of arms for accurate deep pelvic palpation 107 116 Regular cross-bed position 108 117 Partial cross-bed position 109 Gyxecologic Diag>'osis. Prominence of Alidomen. 118 Obesity, patient lying on back 119 119 Testing thickness of abdominal wall, first step 120 120 Testing thickness of abdominal wall, second step 120 XVIII ILLUSTRA.TIONS FIG. . PAGE 121 Obesity, patient standing 121 122 Obesity mistaken for ovarian tumor 121 123 Obesity mistaken for pregnancy 121 124 Tumor of abdominal wall' 122 125 Small umbilical hernia 122 126 Large umbilical tiernia 123 127 Contour of relaxed abdominal wall, patient recumbent 123 128 Same as Fig. 127, patient standing 123 129 Space between separated recti muscles 124 130 Projection of abdominal contents between separated recti muscles 124 131 Depression of wall between separated recti 125 132 Tympanites mistaken for pregnancy 126 133 Moderate ascites in relaxed abdomen 126 134 Marked ascites, showing contour 127 135 Extreme ascites, showing contour 127 136 Extreme ascites, with pyramidal contour 128 137 Extreme ascites, with different contour 128 138 Extreme ascites, view from in front 129 139 Contour of abdomen in pregnancy 130 140 Contour of abdomen in case of distended bladder 130 141 Case of ruptured bladder, section 130 142 Contour of abdomen in case of large pelvic cyst 131 143 Contour of abdomen in case of large solid tumor 131 144 Case of large cystic tumor 132 145 Case of exstrophy of bladder 132 146 Contour of abdomen in case of retroperitoneal tumor 133 Tenderness or Mass in Abdomen. 147 Right lower abdomen, important areas indicated 135 148 Point to seek for right tubo-ovarian tenderness 136 149 Palpating for right tubo-ovarian tenderness or mass 136 150 Point to seek for appendix tenderness 136 151 Palpating for tenderness or mass in appendix region 136 152 Palpating for the appendix 137 153 Another method of palpating for the appendix 137 154 Point to seek for tenderness of right ureter 13S 155 Palpating for tenderness or thickening about right ureter 13? 156 Left lower abdomen, important areas indicated 13& 157 Palpating for tenderness or mass in left tubo-ovarian region 140 158 Point to seek for tenderness or infiltration about left ureter 140 159 Central lower abdomen, showing the organs commonly affected 141 160 Point to seek for tenderness about uterus 142 161 Point to palpate for bladder tenderness 143 162 Region for right kidney tenderness in front 144 163 Region for right kidney tenderness at side 144 164 Region for right kidney tenderness behind 144 165 Region for left kidney tenderness 145 166 Palpating for mass in left kidney region 145 167 Right upper abdomen, important organs indicated 146 168 Site for gall-bladder tenderness or mass 147 169 Palpating for liver tenderness 147 170 Left upper abdomen 148 ILLUSTRATIONS XIX Fia PACE 171 Regions for splenic tenderness or mass I49 172 Central upper abdomen 150 173 Region for tenderness or mass from disease of stomach or pancreas .... 151 174 Site for tenderness about left lobe of liver 151 175 Indicating pain under left shoulder blade, common in stomach disease ... 151 176 Indicating pain under right shoulder blade, common in liver disease .... 151 177 Central abdomen (umbilical region) 152 178 Palpating for tenderness or mass in the umbilical region 153 179 Showing the direction of growth of various pelvic and abdominal tumors . . 153 Area of Dullness in Abdomen. 180 Indicating area of dullness from distended bladder 154 181 Indicating area of dullness from enlarged uterus 154 182 Indicating area of dullness from very large central pelvic mass 155 183 Indicating dullness from enlarged liver 156 184 Indicating dullness from enlarged spleen 156 185 Area of dullness in moderate ascites, patient on back 157 186 Relation of fluid to intestines in ascites 157 187 Relation of mass to intestines in tumor 157 188 Showing gravitation of ascitic fluid to lower side 157 189 Indicating dullness in moderate ascites, patient on side 158 190 Indicating dullness in moderate ascites, patient standing 158 191 Area of resonance in case of extreme ascites, patient on back 159 192 Same as Fig. 191, patient standing 160 193 Same as Fig. 191, the two resonant areas contrasted 161 194 Dullness in case of ascites and tumor, patient on back 162 195 Same as Fig. 194, patient standing 163 196 Same as Fig. 194, two areas of dullness contrasted 164 197 Indicating dullness in large tubo-ovarian mass 16-4 198 Indicating dullness in large appendiceal mass 164 199 Indicating irregularity of dullness from uterine fibromyoma . , 165 200 Indicating regularity of dullness from large ovarian cyst 165 201 Area of dullness in case of retroperitoneal growth 166 202 Indicating dullness in kidney tumor, without inflation of colon ...... 166 203 Same as Fig. 202, with inflation of colon 167 204 Kidney tumor removed in case of Fig. 202 167 205 Case of perirenal lipoma, section 168 206 Same as Fig. 205, from in front 169 Changes About External Genitals. 207 External genitals of virgin , 170 208 External genitals, diagrammatic 170 209 Various forms of hymen 171 210 External genitals of married woman 171 211 External genitals of multipara 172 212 Same as Fig. 211, prepared for operation 173 213 Same as Fig. 211, closer view 174 214 Same as Fig. 211, still closer view, with operating speculum in place .... 175 215 External genitals with some perineal laceration 176 216 Follicular vulvitis 180 217 Kraurosis vulvae 181 218 Chancroidal ulcers of vulva 181 XX ILLUSTRATIONS FIG. PAGE 219 Tubercular ulcer of vulva 182 220 Epithelioma of right labium 183 221 Beginning epithelioma of labium • . . 183 222 Epithelioma of clitoris 183 223 Case of adherent prepuce 184 224 Same as Fig. 223, after treatment 184 225 Adherent labia minora 184 226 Imperforate hymen 184 227 Hematocolpos 185 228 Distention of uterus and tubes from imperforate hymen 185 229 External genitals in case of absence of vagina 185 230 Double vagina , 186 231 Same as Fig. 230, each vagina spread open 186 232 Complete laceration of perineum 186 233 Complete laceration of perineum 187 234 Separation of sphincter ends in old complete laceration 187 235 Central perforation of perineum by child's head 188 236 Laceration of hymen from rape 188 237 Complete laceration of perineum from rape 188 238 Laceration of perineum, with resulting fistula, from violent coitus 189 239 Old laceration of pelvic floor from labor 189 240 Moderate cystocele and rectocele 190 241 Same as Fig. 240, showing section . 190 242 Large cystocele 191 243 Testing for cystocele with sound in bladder 192 244 Small rectocele 192 245 Large rectocele 193 246, 247 Differentiating between rectocele and colpocele 193 248 Hematoma of vulva 194 249 Stasis-hypertrophy of labia minora 194 250 Stasis-hypertrophy of vulva 195 251 Stasis-hypertrophy of vulva 195 252 Stasis-hypertrophy and edema 196 253 Marked stasis-hypertrophy 196 254 Stasis-hypertrophy with causative ulceration 196 255 Elephantiasis of vulva 196 256 Varicose veins of vulva 197 257 Scattered condylomata of vulva 197 258 Small masses of condylomata 198 259 Large masses of condylomata 198 260 Vulva covered with massed condylomata 198 261 Syphilitic condylomata about vulva 199 262 Syphilitic condylomata, flat variety 199 263 Syphilitic condylomata, pointed variety 200 264 Abscess of vulvo-vaginal gland 201 265 Abscess of vulvo-vaginal gland 202 266 Cyst of vulvo-vaginal gland 202 267 Hypertrophy of labia minora 203 268 Enormous hypertrophy of labia minora (Hottentot apron) 203 269 Hypertrophy of clitoris 204 270 Carcinoma of labium, beginning 204 271 Carcinoma of labium, later stage 205 272 Carcinoma of labium, still later stage - . . 205 ILLUSTKATIONS XXI FIG. PAGE 273 Carcinoma of vulvo-vaginal sland 206 274 Sarcoma of labium 207 275 Small fibroma of labium 207 276 Large fibroma of labium 207 277 Small cysts of labium 208 278 Large cyst of labium 209 279 Large cyst of labium 209 280 Cyst of clitoris 209 281 Inguinal liernia, becoming pu;lendal 210 282 Vaginal hernia, becoming puilendal 210 283 Prolapse of urethral mucosa 211 284 Urethral caruncle 211 285 Suburethral abscess 212 286 Exploring suburethral abscess-sinus 213 287 Prolapse of uterus, showing various stages 213 288 Prolapse of uterus, cervix at vestibule 214 289 Prolapse of uterus, uterus lialf out 215 290 Complete prolapse of uterus 216 291 Prolapse of uterus, bladder not prolapsed 216 292 Prolapse of uterus and bladder 217 293 Testing for prolapse of bladder with sound 217 294 Prolapse of uterus in nullipara 218 295 Prolapse of uterus in virgin 218 296 Bimanual examination in prolapsus uteri 219 297 Three portions of the cervix uteri 219 298 Hypertrophy of infravaginal portion of cervix, diagrammatic 219 299 Case of hypertrophy of infravaginal portion of cervix 220 300 Hypertrophy of supravaginal portion of cervix 220 301 Hypertrophy of intermediate portion of cervix 220 302 Peculiar hypertrophy of cervix 220 303 Pediculated fibroid tumor of ut 530 546 Blood supply of uterus 531 XXVI ILLUSTRATIONS FIG. PAGE 547 Blood supply of uterus 532 548 Lymphatics of uterus 533 549 Distribution of uterine lymphatics to various groups of glands 534 550 Ligaments of uterus 535 551 Section through an erosion of cervix 540 552 Lacerated cervix with erosion 551 553 Instruments for repair of cervix 552 554 Areas for denudation for repair of cervix 553 555 Areas for denudation 554 556 Incision through scar tissue at the angles 554 557 Denudation completed and sutures passed in right side 555 558 Sutures tied 555 559 Section through cystic cervix 558 560 Area for amputation in cystic cervix 558 561 Line of excision and method of suturing in partial amputation of cervix . . . 558 562 Partial amputation of cervix 559 563 Partial amputation completed 560 564-567 Regular amputation of cervix 561 568 Normal uterus and endometrium 568 569, 570 Polypoid endometritis 569 571 Instruments for curettage 572 572 Kitchen table arranged for curettage 573 573 Patient in position at end of operating table 574 574, 575 Cleansing vagina after patient is anesthetized 575 576 Self-retaining speculum introduced 576 577 Sterile sheet in place 576 578 Introducing large dilator 577 579 Large dilator in place 577 580 Introducing curet 578 581 Method of holding curet 578 582 Returning uterus to its normal position after curettage 579 583 Putting in vaginal packing 579 584-587 Dressing after curettage 580 588 T-bandage 581 589 Section of endometrium thirteen days after curettage 581 590 Section of endometrium thirty-one days after curettage 581 591 Section of endometrium three months after curettage 582 592 Section of endometrium fifty-three days after application of caustic .... 582 593 Section of pelvis showing normal position of uterus 595 594 View from above, showing position of uterus 596 595-597 Bimanual replacement of uterus 602 598 Bimanual replacement 603 599, 600 Bimanual replacement 604 601 Puncturing tenaculum-forceps 615 602 Transplantation of round ligaments 616 603 Transplantation of round ligaments 617 604 Transplantation of round ligaments 618 605, 606 Multiple fibromyomata of uterus 626 607 Single fibromyoma • 627 608 Diffuse adeno-myoma of uterus 628 609 Necrosis of part of intraligamentary fibromyoma 628 610 Necrosis of whole fibromyoma 629 611 Perforation of uterus by necrotic fibromyoma 630 ILLUSTRATIONS XXVII PAGE Large cystic fibromyoma tj31 Sarcoma developed in cervical stump after supravaginal hysterectomy for fibro- myoma 032 Section of original fibromyoma. showing sarcomatous areas 633 Displacement of bladder by large fibromyoma 034 Epithelioma of cervix associated with fibromyoma of corpus uteri (j60 Same as Fig. 616, section of uterus and fibroid 662 Epithelioma of cervix, more advanced 663 Epithelioma of cervix, in late stage 664 Advanced adeno-carcinoma of cervix 665 Damage to ureters and kidneys by advanced cancer of cervix 667 Necessary line of excision in radical operation for cancer of cervix uteri . . . 677 Beginning carcinoma of corpus uteri 687 Carcinoma of corpus uteri in advanced stage 687 Chorio-epithelioma of uterus 688 Beginning sarcoma of corpus uteri 690 Advanced sarcoma of corpus uteri 690 Section of genital tract, showing continuous opening into peritoneal cavity . . 692 Section of Fallopian tube near uterine end 694 Section of Fallopian tube near fimbriated extremity 694 Connective tissue of pelvis 697 Thrombo-phlebitis 700 Instruments for opening pelvic abscess 705 Opening pelvic abscess — Incision of vaginal wall 706 Opening pelvic abscess — Blunt dissection through connective tissue .... 707 Opening pelvic abscess — Puncturing abscess wall 708 Opening pelvic abscess — Drainage tube in place 709 Drainage tube with cross-piece 710 Drainage tube with cross-piece, another method 711 Same as Fig. 639 — Tube in place 711 Opening lateral abscess 713 Vaginal section for acute pelvic inflammation — Sectional view. . .... 715 Vaginal section for acute pelvic inflammation — View from above 716 Proctoclysis apparatus, in use in Murphy's clinic 723 Proctoclysis apparatus, one easily improvised 724 Chronic salpingitis, mild 730 Salpingitis, with exudate 731 Pyosalpinx, with and without surrounding exudate 732 Diffuse pelvic suppuration 733 Ovarian abscess and tubo-ovarian abscess 734 Hydrosalpinx 735 Nodular salpingitis 736 Pelvic adhesions 736 Pelvic cellulitis (parametritis) 737 Various situations in which a parametritic mass may be found 738 Cystic ovary 739 Direction of extension of gonococcal infection 749 Direction of extension of streptococcal infection 753 Pelvic tuberculosis, peritoneal form 761 Pelvic tuberculosis, tubal form 762 Situation of ovum in various forms of tubal pregnancy 766 Pelvic hematocele 767 Blood mass from repeated small hemorrhages 768 XXVIII ILLUSTRATIONS MG, PAGE 664 Free intraperitoneal rupture of tube 769 665 Free intraperitoneal hemorrhage 769 666 Tubal abortion — Tube distended 770 667 Tubal abortion — Extruded clots and embryo 77C 668 Pelvic hematoma 77C 669 Mother and child in case of extrauterine pregnancy carried to near term . . 771 670 Treatment for varicose veins of broad ligament 797 671 Showing attachment of ovary to broad ligament 799 672 Section of ovary, showing hilum and medullary portion and cortical portion . . 799 673 Graafian follicle and ovarian stroma 800 674 Development of the ovary 801 675 Corpus luteum 802 676 Corpus luteum, very large 802 677 Corpus luteum, showing interior arrangement . 802 678 Lutein cells 803 679 Corpus albicans 803 680 Scars in ovary . . . . " 804 681 Parovarium and paroophoron, embryonic 804 682 Parovarium, with surrounding structures 809 683 Follicular cysts of the ovary 810 684 Corpus luteum cysts 811 685 Lutein cells, the distinguishing feature in the wall of corpus luteum cysts . . 812 686 Tubo-ovarian cyst - 813 687 Patient with large ovarian cyst 813 688 Pseudo-mucinous cyst, with jelly-like contents 814 689 Pseudo-mucinous cyst, showing secondary growths 815 690 Lining cells of pseudo-mucinous cyst and of serous cyst contrasted 816 691 Small serous cyst, showing internal papillary projections 817 692 Larger serous cyst 817 693 Serous cyst, with secondary growths projecting through wall 818 694 Dermoid cyst of ovary 821 695 Dermoid cyst of ovary 822 696 Hair switch from ovarian dermoid 822 697 Balls of sebaceous material from dermoid cyst 822 698 Ovarian cyst, with torsion of pedicle 829 699 Small parovarian cyst 833 700 Larger parovarian cyst 834 701 Development of pelvic organs, indifferent stage 837 702 Development of pelvic organs, female 837 703 Development of pelvic organs, male 837 704 Development and malformations 838 705 Development of external genitals 839 706 Pseudo-hermaphrodite, external view 846 707 Pseudo-hermaphrodite, explanatory section 846 708 Stem pessaries 882 709 Division of cervix uteri for dysmenorrhoea 885 710 Dividing cervix 880 711 Suturing divided cervix . 886 712 Suturing in front of cervix 887 713 Safe position of arms during anesthesia 917 714 Dangerous position of arms during anesthesia 918 715 Dissection showing compression of brachial plexus 919 716 Diagram of brachial plexus, showing location of involved area 920 ILLUSTRATIONS? XXIX FIG. PA(;l.; 717 Arm hanging over table, a position of danger during anesthesia 921 718 Dressing abdominal incision 922 719 Dressing abdominal incision 922 720 Dressing abdominal incision 923 721 Dressing abdominal incision 924 722 Gauze-strip sponges for abdominal surgery 929 723 Gauze-strip sponges for abdominal surgery 930 724 Gauze-strip sponges for abdominal surgery 930 725 Gauze-strip sponges for abdominal surgery 930 726 Gauze-strip sponges for abdominal surgery 931 727 Gauze-strip sponges for abdominal surgery 931 728 Conservative surgery of ovary and tube 946 729 Strapping abdomen after removal of sutures 951 730 Cutting adhesive straps for inspection of healed incision 952 731 Scar exposed . , 953 732 Drainage tube, with sheet-rubber in place to protect general dressing .... 954 733 Gauze wick and applicator for emptying drainage tube 954 734 Gauze pieces about end of tube 954 735 Sheet-rubber folded over gauze 954 736 Tray of articles for care of drainage tube 955 737 Syringe and catheter for rapid removal of large quantity of fluid from tube . . 956 738 Elevation of head of bed for drainage immediately after operation 957 739 Regular Fowler posture 958 740 Elevation of foot of bed for treatment of shock 959 741 After-treatment in vaginal operations — Pitcher douche 965 742 After-treatment in vaginal operations — "Vulvar dressing 966 743 Catheterization — Keeping the labia apart 967 744 Catheterization — Grasping the catheter some distance from the point ..... 967 Fig. 1. Antero-posterior Section of Pelvis (semi-diagrammatic). (R. Walter Mills.) In order to .show the structures and relations exactly as they are in what may be considered a typical woman in the erect posture, the artist, Dr. Mills, made a detailed study of many drawings from frozen sec- tions for the internal relations, and of several well-formed women in the normal standing posture for the contour anrl external relations. This gave a result differing considerably from the usual representation of a patient standing, made by taking a drawing of a section of a flattened cadaver and turning it upright. The lumbar curve is more marked, the lower abdominal wall and the buttocks are more prominent and there is a change of the relations of the internal organs to the external landmarks. For the internal relations the admirable frozen sections of Sellheim were principally followed, and the exactness with which the pelvis and contents of the actual sections fitted into the contours of the living models was most pleasing and instructive. DISEASES OF WOMEX CHAPTER I. GYNECOLOGICAL EXAMINATION METHODS. The physician who wishes to do accurate work in diagnosis nmsl he in pos- session of certain facts, as follows : Knowledge of the anatomy and physiology of the organs involved. Reliable history and examination of the patient. Knowledge of the diseases to which the parts are liable. The essential organs in the group of structures involved in gynecological* diseases are shown in Figs. 1, 3, 4, 5 and 6. They are as follows : 1. The ovaries, in which the ova are formed. 2. The Fallopian tubes, which conduct the ova from the ovaries to the uterus. 3. The uterus, which receives and nourishes the fertilized ovum and expels the fetus at term. 4. The vagina, which is the connecting link between the uterus and the outside world. There are also several accessory structures — namely, the external genitals, the perineum, the pelvic floor, the pelvic peritoneum and the pelvic connective tissue. The gross anatomy of these organs and the prominent facts in their physi- ology are sufficiently known to you, from general anatomical and physiological study, to permit immediate consideration of the methods of obtaining the facts on which a diagnosis may be based. HISTORY. When called to see a patient with pelvic disease, the first thing to do is to obtain what information the patient can give concerning her trouble. This information, obtained from the patient or her friends, is called the history, and should include facts covering the points mentioned below. * As to the pronunciation of "gynecology," the weight of authority is decidedly in favor of soft g, short y and the accent on the third syllable-jin e kol' o je (Webster's Unabridged Dictionary. Century Dictionary, Standard Dictionary, Gould's Medical Dictionary. Keating's Medical Dictionary). A few authorities differ, some favoring soft g and long y, and others favoring hard g and long y. 1 / ) ' / \ / / \ \ / / / ^ // \ V / \ // \ / V ■" \ / \ \. \ \ \ / \ \ \\ / \ \\ \ \ 1 \ \ \ / \ ^\. \\ \\ 1 \\ \j \ -'--' \ Y ,'i_^ -^ \ \ \ ^ ^1 '-^ M \\ I ^ i: -^\ \ i. J '•■ r ( II' 4\ % \ ^- w La; t Ut t.5p """' f c ■^ if- 1 \i ^ p "( \ c r: \ 1 n I?, -1/ 1 / (f. r^ ■'.'^ T / I: , ^ t- 1 J, .b s ■.ne ,# -// V # \ <■ / / i ^ ^ ^ ^ \ /, 1: >^ ;^< \y f 1; / ^\ t/ k ■ — J / l'^^ r^ e i y / /•■ .,... ^^■ n_'^ -1 1^1 T C: /"^ / Y - .^ ^ ) /, 1/ \ % ^ ? \ 1 / ^ '4 /•• ■ / ^ ?'^ /^^ ^ / '/ \ V ^ ""T- L^ m r" «-i-^ ^N°" y ^ ly \ s ,'' f-^ ■S-" ■■'■■ \ ^^ -l^' ^ ^ y f \ ■^ \ \, c "'V ^^^3- Uf \ \ i f s \ v^ H \ % ; ■^ fi % ^ \ ^ ^ > Y \ \^ / \ ' Ki i s \ / / \ IeCoA \ / B > / \ / \ / ^cale ^'fo /' 1 / ' ■R 1 1 1 1 ) i / Fig. 2. A. Exact Contour and Measurements of the woman selected for Fig. 1. B. E.xact Contour and Measurements of another model, presenting a more pronounced lumbar and abdominal curve. The small squares represent one-inch squares at life size. (R. Walter Mills.) (A) Artist's model, aged 28, mother of two children (6 and 8 years old respectively), has worn corset prac- tically none, is in good health and fairly muscular. Height 5 ft. 7 in., weight 140 lbs., bust measure 36 in., waist 27 in. (2 in. above umbilicus), circumference at umbilicus 30 in., hips 30 in., thigh 22 ,'<> in. (2 in. below gluteal crea.se), antero-posterior diameter of body at waist 6 ji in., antero-posterior diameter of thigh (2 in. below gluteal crease) 6 j^^in. The other data are given on the outline. To conform to the so-called "perfect form" the hips should be a trifle larger and the weight somewhat more. (B) Young woman, aged 27, never pregnant, has worn corset very little, is in good health and muscular. Height 5 ft. 4 in.; weight 114 lbs., bust measure 32 in., waist 24 in. (2 in. above umbilicus), hips 38 in., thigh 22 in. (2 inches below gluteal crease), antero-posterior diameter of body at waist 6 V2 in-, antero-posterior diam- eter of thigh (2 inches below gluteal crease) 6 -^g in. The other data are given on the outline. The lumbar and abdominal curves are more pronounced than in (A). The numerous exact measurements given in Fig 2 constitute valuable data to guide in medical drawings ol this character. TAKINC THK HISTORY 3 Present Symptoms. Of what symptoms does tlio patient complain? A question directed to bring out this information Mill at once enlist the patient's interest and relieve any temporary embarrassment she may feel. The ])roininent symptoms are soon given and serve to indicate lines of special iiKpiiiy when taking the systematic history of the case. Fig. 3. Antero-posterior Section of Pelvis. Showing left half of body, with intestines removed. (Kelly — Operative Gynecology.) The systematic inquiry is begun at some convenient point in the patient's narrative. Beginning of Present Trouble. How long has the patient been sick? Ascertain accurately when the present trouble began. If it is of long duration, pass back of the several exacerbations and get the approximate date of the first acute attack or first appearance of decided symptoms. 4 TAKING THE HISTORY What were tliese first symptoms"? How severe were they? "What was done for them ? What caused the trouble at that time ? Had there been a severe sick spell or an injury of any kind? Had there been a labor or miscarriage, or menstrual Fig. 4. View of Pelvic Organs from Behind. (Dickinson — American Text-Book of Ohstetrics.) Fig. 5. Pelvic Organs from in Front. (Dickinson— ^m. Text-Book of Obstetrics.) disturbance or recent marriage, or extra work or anything that might have acted as a cause? Character and Duration of Principal Symptoms. Get an account of the present trouble from tlie day it began, down througli all the important changes, to the date of consultation. This does not mean to THE PRINCIPAL SYMPTOMS "waste time with a mass of iinuecessary detail, but to ascertain, by well-directed inquiries, the order of developmeut and the duration of the i)rincipal symp- toms, such as pain, fever, swelling, discharge, etc. Locate definitely the site of the pain or tenderness or other distress com- plained of. Is it in the tubal region or appendix region, or over the uterus or about the ureter or kidney? Have the patient point out the exact location of the pain. Figs. 7 to 15 indicate the location of the pain in various afifections. This definite localization helps to clarify the situation and makes the patient more careful and reliable in her statements. Of course no diagnosis shoidd be attempted from such necessarily uncer- Fig. 6. Relation of the Pehic Organs to the External Surface of thelbody. of Obstetrics.) (Dickinson — Am. Text-Book tain localization by the patient. This simply indicates what group of organs are probably aflfected and thus enables the physician to question the patient more definitely and accurately before beginning the physical examination. Ascertain also the effect of the disease on the general health. As to this effect, we have two guides— the weight and the activity of the patient. How much has she lost in weight, or has she gained? How much of the time has she been confined to bed? If able to be up and about part of the time, or all of the time, how much work or walking or shopping has she been able to do ? b TAKING THE HISTORY Ascertain also the frequency and duration of the exacerbations of the dis- ease. Has the trouble been getting worse gradually and continuously, or have there been exacerbations, followed by remissions, with partial or com- plete disappearance of the symptoms ? Inquire also concerning complications. Frequently there are complicating bladder or rectal disturbances or other associated local diseases, and the extent of these should be determined. Previous Health. Has the patient previously been well and strong? Any serious sickness, whether connected with the pelvic organs or not, should be inquired into. It Fig. 7. Indicating General Pel%ic Distress. This distress may be due to bladder or uterine or tubal or ovarian disease on one or both sides. may be an important factor in the origin of the present disturbance or it may point to some complication that must be taken into consideration in the treat- ment. Age, Married, Address, Occupation. This stage of the conversation is a convenient time to note the necessary facts not strictly medical. You may now ask the patient her age, occupation, etc., without the questions appearing irrelevant. If married, how long? If she has been married more than once or if she is a Avidow, she will probably mention the fact and also any correlated facts bearing on the present disturbance. The securing of the patient's address comes in very well here. Also other similar items of information that it may, for business reasons, be advisable CONFINEMENTS 7 to note in some eases — for example, the husband's occupation and business address. Is the patient engaged in any work aside from her liouschobl duties? If so, what is it and has it any bearing on the origin or continuation of the present trouble? Does she do any of her housework? If so, how much? Is it executed with facility, as when she was well, or is there pain and disability? Ascertain accurately the character of the distress associated with the work. What time of day does it come on, where is it located, is it a sharp pain or a dull aching, or a dragging weight and pressure? What posture aggravates or relieves it, does it necessitate lying down, does it recur soon after rising, is it present every day, does it vary from week to week or from month to month? Confinements. Has the patient had children? If so, how many and when? Was there serious trouble during any labor or during any pregnancy or afterward? Make particular inquiry as to whether the labor was so severe that instruments had Fig. 8. Backache from pehic disease. Indicating pain in the central lumbar region. Fig. 9. Backache from pelvic disease, ing pain extending down over the sacrum. Indicat- to be used, or whether the labor was followed by indications of sepsis or of laceration of the pelvic floor or cervix uteri. If after any labor the patient was sick in bed for two or three weeks, with pain in the lower abdomen and fever, she probably had sepsis in some form, the usual form being septic endometritis. Another very common history of mild sepsis is that the patient gets up as usual, but does not feel strong, and after a few days takes a "backset," and returns to bed or drags about the house with soreness in the lower abdomen, some fever and marked weakness. Of course, delays in convalescence after labor may be caused by complications outside the genital tract, but generally they are due to some trouble in the genital tract, such as infection of the uterus or subinvolution of the uterus or laceration of the pelvic floor. 8 TAKING THE HISTORY Miscarriages. Have there been any miscarriages ? If so, how many and when, and at what stage of pregnancy did each occur ? A\"hat was the cause of each miscarriage? Did it follow some accident or was it due to some acute disease, such as typhoid fever or pneumonia? If there have been repeated miscarriages, inquire carefully and circumspectly as to evidences of syphilis. Have the miscarriages been brought about intentionally (criminal abortion) — if so, in what way? Was each miscarriage complete and no trouble following? When incomplete, part of the fetal membranes are retained in the uterus and cause a persistent bloody discharge. Sepsis also may occur. Fig. 10. region. Indicating pain in right tubo-ovarian Fig. 11. Indicating pain in tlie appendiceal region. Sterility. When the patient has been married a long time and there has been no preg- nancy, it is well in some cases to inquire as to why there has been no preg- nancy. Menstrual History. How old was the patient when she began to menstruate? Has the men- struation been regular and of proper duration and amount, and free from severe pain? If there have been menstrual disturbances — for example, ab- sence of the menses or excessive menstruation, or irregular menstruation or inter-menstrual bleeding — ascertain the duration and severity of each. Last Menstruation. Invariably ascertain the date and duration of the last menstruation, that pregnancy may be excluded. ASSOCIATED DISEASES Disturbances of Other Organs. Inquiry should be made as to indications of diseases in remote organs, either complications of the pelvic trou])le or iutercurrent diseases. Fig. 12. Indicating pain in the region of the stomach. Fig. 13. Indicating pain in the liver. Fig. 14. Indicating pain in the region of the right kidney. Fig. 15. Another common way of indicating the dragging pain that accompanies di.sease and dis- placement of the kidney. If the patient gives any symptoms pointing to disease of remote organs — for example, of the heart or lungs or gastro-intestinal tract — those organs should be examined. In case of serious disease, and in all cases where an anesthetic is to be given, an examination of the heart and lungs and abdomi- nal viscera is imperative. 10 TAKING THE HISTORY The condition of the patient's blood, as indicated by her color, and the condition of the nervous system, as indicated by her appearance and actions, should be considered, and, if there is evidence of disease in either direction, further investigation should be carried out. The urine should be examined if the patient is seriously sick or if there are symptoms pointing to bladder or kidney disease, or if an anesthetic is to be given. Previous Treatment. Question the patient as to the character and duration of the previous treat- ment and its apparent effect. AVas it internal treatment only or local treat- ment at home (douches, vaginal suppositories or tablets or tampon-capsules), or local treatment at office (vaginal applications, tampons, intra-uterine treatment), or operation (curetment, repair of pelvic floor or cervix, vaginal section or abdominal section) ? Special Points. Each of the above mentioned points should be inquired into in practically every case of pelvic disease. In exceptional cases it is necessary to make inquiry along special lines — for example, in regard to the patient's family history (nervous diseases, tuberculosis, cancer), or, as in sterility, in regard to the husband's health. Summary of Chief Symptoms Demanding Relief. After completing the history and before beginning the examination, fix in mind the chief symptoms for which the patient seeks relief. Keep these in mind while making the examination and endeavor to find the lesion or con- dition that causes each of them. These symptoms serve to indicate the direc- tions for special investigation. The diagnosis should be made, to a consider- able extent, as the examination progresses. Before finishing the examination you should know whether or not you have found the cause or causes of the symptoms that brought the patient to you. Keep a Record. As to whether or not a record is kept, and, if so, in what way, depends of course on the inclination of the physician. However, if he does not keep a' record of cases, he deprives himself of something valuable. A short record, giving in a systematic way the principal facts of a case, may be made quickly and more than repays for the time consumed. And the principal advantage is not the permanent, record it gives for reference after some years (though this is important, especially to the teaclier), but the fact that it systematizes and steadies and improves the physician's work day by day. Such an ac- count of the case in black and white, referred to frequently, as the patient returns for treatment, is a constant stimulus to accurate diagnosis and a THE WRITTEN RECORD 11 constant help in the treatment, particularly if the case is a long continued one. Again, in court tlie physician is supposed to have some record of his work. You nmy at any time be called upon to testify as to the exact findings in the case of some patient whom you saw one or two or three years before. DATE NAME ADDRESS oc met. BY PREVIOUS M. CONFIX. MISC. «EG. A PAIN WITH ILL. RCa. KAIN L«»T MENSTR PRESENT ILLNESS EXAM. >ND DIAG Fig. 16. Gynecological History Card. The original card is 6 in. wide and 4 in. liigh. OUTLINE OF TR. CH. PD. □ ATE . NOTES Fig. 17. Rever.s'i side of History Card. 12 ' TAKING THE HISTORY The record should embody the important facts in the history, in the exami- nation findings, in the treatment given, and in the subsequent progress of the ease. The great drawback to records is the time required to make them. In order to make them at all, the physician must have some arrangement by which the record may be made in a very few minutes. Here comes in the utility of printed forms. On a printed form the physician may, in a few minutes, put down the notes necessary to make an accurate account of the case. Record cards, printed as desired, and arranged as a card-index, constitute the most convenient record system for the busy practitioner, and at a moder- ate cost. I use 4x6 cards, printed on one side for the principal record (Fig. 16), the back of the card being used for extra notes (Fig. 17). When more space is required, blank cards are attached as needed. When it is desired to have a sketch of the condition, a small outline of the pelvis or abdomen is stamped at some clear space on the card with the required rubber stamp (of which any desired kinds may be obtained at small expense), and the tumor or inflam- matory mass, or displaced organ is then drawn in. I use three kinds of form-cards, all the same size, but differing in color. For the gyneco- logical cases I use a white card and for the obstetrical cases a salmon card. For the obstetrical drawer there are two sets of monthly index cards, one blue and the other manila. When the obstetrical patient first comes, the clinical notes are made as to last menstruation, any disturbances, time for regular examination, etc., and the card is placed under the blue index card for the month of examination. So by a glance I can tell just what patients are awaiting examination each month. When the examination is made, the findings are noted and the card is then placed under the manila index for the month of delivery. After labor the card is finally noted up and placed in the general card-index of patients, that it may be readily referred to at any time. My operation cards are of the same size, but a different color, so that they also may be easily distinguished from the other cards of the general index. Jf one does not wish to invest in specially prepared cards and holders, a start may be made with some blank cards of the desired size, arranged upright in the ordinary desk drawer. Is a Pelvic Examination Required? After obtaining all the information the patient can give concerning her illness, the next step is to make the physical examination, provided there are symptoms making such an examination necessary. In the case of a virgin, pelvic examination is rarely indicated until after general therapeutic measures have been tried and have failed to give relief. Occasionally a young woman or a girl will present sucli serious syinptoins tliat an examination is indicated at the first visit, but such cases are extrenu'ly rare. On the other hand, in the case of a married woman, if decided pelvic symptoms are present, an examination should as a rule be made at once, particularly if there has been previous treatment without satisfactory, result, WIIKN TO MAKE AN KXAMIN ATlON 13 In such a case, wlien the patient's account of the trouble is finished, say to lier that an examination is necessary in order to determine the exact con- dition present. Usually the patient was aware that an examination would be necessary and came for that purpose. If not, she may make some slight protest, which may he waived aside. If she expresses a decided preference for another time, an appointment may be made for some other day. If the patient is menstruat- ing, the examination is of course postponed, unless the symptoms are very serious and urgent. A non-menstrual bloody discharge is not a contra- indication to examination, but rather an additional indication for it. If tlie patient is extremely anxious to avoid the examination, treatment without it may be tried for a while in a suitable case, even though immediate; examination seems decidedly preferable. When a girl is examined, her mother or some other relative should be present. PHYSICAL EXAMINATION. The order of examination which I find most convenient, when the patient can be placed on the table, is as follows : Abdominal examination. Inspection of external genitals, meatus, perineum, etc. Vaginal examination (digital). Vagino-abdominal examination (bimanual). Instrumental examination. Fig. 18. Patient on table and arranged for abdominal examination. 14 THE PHYSICAL EXAMINATION Exceptionally. Examination of rectum. Pelvic examination under anesthesia. Examination of bladder. When the patient is seen at home, the order of examination is more fre quently abdominal, vaginal, vagino-abdominal and, when indicated, a digital examination per rectum. Inspection of the external genitals and the specu- lum examination are usually not required in such a case (page 108). However, if there are symptoms pointing to disease of the external genitals, the parts should of course be inspected. Also, in any case, if it is thought that information of value may be obtained by the speculum examination, that procedure should be carried out. Fig, 19, Profile of Normal Abdomen, Patient arranged for abdominal examination. .^^ ABDOMINAL EXAMINATION. Have the patient lie near tiie edge of the bed or table, in a comfortable position, with the head slightly raised on a pillow and the knees drawn up sufficiently to relax the abdominal muscles (Figs. 18, 112). The abdomen is subject to : Inspection — Contour, Color, Eruption, Striae, Scars. Palpation — Tension, Tenderness, Mass, Fluctuation, Fluid Wave, Fat Wave; Fetal MoTement, Uterine Contraction, Friction Rub. Percussion — Area of Dullness. Auscultation — Fetal Heart Sounds, Vascular Murmur. ^—"Menstruation — For accurate comparison. THE ABDOMINAL EXAMINATION 15 iii Fig. 20. Normal Abdomen. The patient is tall ami rather slender. Notice how the anterior superior iliac spines stand out as landmarks. 16 THE PHYSICAL EXAMINATION INSPECTION OF ABDOMEN. Contour, Movement, Color, Eruption, Striae, Scars. The principal thing to determine by inspection is contour. Determine also the other items mentioned — movement of wall, color, eruption, striae, scars — but usually they are of secondary importance. As to contour, there may exist one of several conditions, as follows : FiK. 21 . The abdominal surface with the rib margins and the iliac crests outhned. The smootli, moderately full contour of tlie normal abdomen (Figs. 19, 20, 21, 22). The flat, sunken alxlomen of wasting disease, with empty intestines. A swollen, prominent abdomen. PALPATION OF THK ABDOMEN 17 The significance of prominence of the ahdoincn is taken up in detail in the chapter on Diagnosis (page 120). PALPATION OF ABDO:\IEX. Tension, Tenderness, Mass, Fluctuation, Fluid Wave, Fat Wave, Fetal Move- ment, Uterine Contraction, Friction Rub. vi / \ Fig. 22. Another abdominal surface, with the ribs and crests outlined. This patient is rather stout. Notice how much the landmarks ditler from those in Fig. 21. Texsiox and Tenderness. As to tension, we determine whether the wall is soft and easily depressed, or is firm and resisting from muscular tension. The latter condition may be 18 THE PHYSICAL EXAMINATION due to nervousness or fright, the patient fearing that the examination will cause pain, or it may be due to genuine tenderness from inflammation or irri- tation beneath the wall, as in peritonitis or intraperitoneal hemorrhage. The best way to begin palpation is to place the palmar surface of the Fig. 23. Palpation of the abdomen. First step. Hand flat on abdominal surface Fig. 24. Palpation. Depressing the wall with the fingers of one hand, in various situations. FIk. 2.'), Palpation witli both hands. Fig. 26. Dfej) Palpation witii i)otli lui'ndtj. METHOD OF PALPATION 19 whole hand flat on the abdominal wall (Fig. 23). Hold it there perfectly quiet for a moment, that the patient may see that you are not going to cause pain. Then, as the muscular tension relaxes, depress the wall carefully with the fingers (Fig. 24) in various directions and situations as the hand is moved about over the surface. Begin the movement of the hand gradiudly, almost impereeptil)ly at first, perhaps at the same time directing the patient 's atten- tion away by a question or two. When the patient's attention is fixed on llie palpating liands, th(n-e is likely to be troublesome tension of the wall. As the Fig, 27, The abdominal surface divided into Quadrants examination proceeds, deep palpation is made in various parts of the abdo- men in order to exclude disease in the various regions. Palpation with both hands (Fig. 25) assists much in determining the character and consistency of the tissues between them and under them, particularly when the abdomen is rather full. If a resisting area is found, work the fingers around it, de- pressing the wall and examining all portions of it (Fig. 26). The palpation should always be made gently, for, if the manipulations cause pain or frighten the patient, the. wall is immediately made tense and then no satisfactory ex- amination is possible. 20 THE PHYSICAL EXAMINATION Having determined the general tension and tenderness, search is made for local tenderness. The exact location of the tenderness should be carefully determined, and also whether it is circumscribed to that area or extends to other areas. When the area of tenderness has been accurately located, we know what organs are likely to be affected, and the further differentiation between affections of those organs may be proceeded with. Regions of the Abdomen. For convenience in designating the location of Fig. 28. The usual anatomical division of the abdomen into nine regions by two transverse lines and two vertical lines. The upper transverse line is at the level of the cartilages of the ninth ribs, and the lower with the highest points of the iliac crests. The two parallel vertical lines pass through the cartilages of the eighth ribs and the middle of Poupart's ligaments. tenderness or of a mass, the abdomen is divided into regions. There are many methods of division. A simple and useful one is the division of the surface into quadrants by an imaginary liorizontal line passing through the umbili- cus and a vertical line- through the same point (Fig. 27). This is very convenient for designating in a general way the location of large masses, but it is not sufficiently definite for the accurate localization of small masses or points of tenderness. For the more definite localization, the time honored division into squares, REGIONS OF THE ABDOMEN 21 by two vertical and tAvo horizontal lines (Fig. 28), is the one generally fol- lowed in anatomical and diagnostic works. However, as a practical working division for diagnostic and teaching purposes, this has been found decidedly inconvenient and unsatisfactory, as is attested by the many attempts of clinicians to devise a simple method of dividing the surface and of designat- ing the various regions. Failing to find a method of division that was satisfactory to me, I devised Fig. 29. Di\ision of the abdomen into regions by means of a circle witti a two-inch radius and two-inch horizontal lines. that shown in Fig. 29, which, so far as I know, is original. The only lines not marked by natural landmarks are a circle Avith a two-inch radius about the umbilicus and a short straight line extending horizontally for two inches from each side of the circle. The regions are designated as right lower, left lower, central lower, right upper, left upper, central upper, umbilical, and right and left lumbar (Fig. 'SO). This method of division is simple, and the names are easily remembered and are self-explanatory. In fact, these designations are the ones commonly used in cocversfition among physicians in describing the location of a mass 22 THE PHYSICAL EXAMINATION or area of tenderness. For example, we speak of tenderness in the right lower region of the alxlomen, or, more briefly, in the ''right lower abdomen," or in the "left lower abdomen," or in the "right upper abdomen," etc. V Lawer L-i- I U}^}^r Uft Li\^eir it'' ^ Fi};. 30. Another ahiloiiieii divided with the circle and stiort horizontal lines, and siiowini,' the names on the primary regions. The area within the circle carries the usual designation, "uuibihcal region." Within each of these principal regions there are one or more points which are of special interest. The special interest attaches to each one of these TENDERNESS IN THE ABDOMEN 23 points because well-defined tenderness limited to sneli point usually means an afiPection of a particular organ. It must he k(^pt in mind, however, that in some eases such point-t(^nderness is due lo ■•iii ;i(Tcc1i()ii of soiik^ adjacent K. St. xr ut 21 T~0. Fig. 31. Various areas of significant Point-tenderness. These are the areas to. be investigated during the course of an abdominal examination, 24 THE PHYSICAL EXAMINATION organ (as when inflammation within the caecum causes tenderness in the appendix region), or even of some distant organ which has become displaced (as when the right kidney has become displaced into the appendix region). Again, in some cases tenderness is due to an organic or functional dis- turbance of the nerves of the abdominal wall or to reflected pain, due to a Fig. 32. Point for Kidney Tenderness laterally. . Fig. 33. Points for Ividney Tenderness in the back. Fig. 34. Relation of the Ividney to the lower margin of the last rib. (Butler — Diagnostics of Internal Medicine.) TrN iiig lor ii ]''liiiil \\'a\ ^^ Mcross I ho iilidonu'ii. lesion in some other part of the abdominal cavity or to some organic or functional lesion in a distant part of the body. But even in these exceptional : " \ - -: - *! Fig. 67. Depres.sion of abdominal wall too close to the pubes. Outside view. Fig. G8. Depression of abdominal wall at tlie proper height. tion is being carried out. Get clearly in ndnd just exactly what movements are necessary to best palpate the uterus. In order to avoid this error just mentioned, place the abdominal fingers so that the depression of the wall wall be into the back part of the pelvis, and then carry the fingers by steady and continuous pressure toward the desired region. When you have advanced the fingers as far as possible, hold them there steadily and direct the patient to take a deep breath and then to let the breath all out. As expiration takes place, the fingers may be carried deeper into the pelvi.s — not by any sudden forcing movement, but by strong steady pressure that does not excite muscular contraction and resistance. If still the fingers are not deep enough in the pelvis, the same movements may be re- 56 THE PHYSICAL EXAMINATION peated several times. Because the uterus is not felt at once, do not cease the pressure there and begin to depress the ^vall at some other place. Start the Fig. 69. Explaiiiing one condition in Fig. 70. Search is then made in the pos- which the uterus is not found in the front tsrior part of the pehis, and the uterus is part of the pehis. (Ashton — Practice of found in retroversion. (Ashton — Practice Gynecology.) ' of Gynecology.) Fig. 71. Indicating the examination findings when the uterus is in retroflexion. Notice the marked angle which is palpable posteriorly at the junction of the cervix and corpus uteri. (.Vshton — Practice of Gynecology.) fingers in the right direction at first and then keep them going in that direc- tion steadily, firiidy, persistently, -without relaxing the pressure, until the depth of the pelvis is reached and the uterus felt. FACTS TO DETERMINE ABOUT CORPUS UTERI 57 In tlic subsequent steps ol' the palpation ul' llie uterus llic slight move- ment ol! the abdominal lingers that is necessary to bring them in position for good counter-pressure at the various parts of the uterus may usually be made Avithout relaxing the pressure, as the skin is loose enough to ])e slipped about over the underlying structures. If the body of the uterus is not found in front of the cervix (Fig. 69), then search behind the cervix (Figs. 70, 71) and then to each side of it. If the patient has no mass obstructing the pelvis and no extreme; tension of the abdominal wall, the body of the uterus should be distinctly made out. Facts to Determine. AVhen the l)0(ly of the uterus has been located, then tix in mind the following facts concerning it : 1. Position of the Corpus Uteri. Is it in anterior position, as it should Ix', or is it disi)laeetl l)acl\\vard or drawn to one side? 2. Size of Corpus Uteri. Is it apparently normal in size (about three inches long), or is it as large as the fist, or as large as a child's head? Figs. 72 and 7o indicate the method of palpating the margin of the uterus and also the method of determining its width by separation of the vaginal fingers. 3. Shape of the Corpus Uteri. Is it approximately pear-shaped and of regu- lar contour, or is it distorted by fibroids or other tumors? 4. Consistency of Corpus Uteri. Is it apparently a firm, solid body or does it contain fluid, or are there hard nodules in it, or is there marked softening? 5. Tenderness of Corpus Uteri. Does pressure on the uterus cause pain or does the attempt to move it cause pain? 6. Mobility of Corpus Uteri. Can the uterus be moved freely up and down, to right and left, forward and back-ward, or is it fixed more or less firmly by an inflammatory exudate or by a tumor? 7. Attachment of Corpus Uteri. Does the uterus seem to be attached or fixed to the pelvic wall at some point ? If so, where and by what ? When it is impossible to reach the various parts of the uterus sufficiently to obtain the necessary information, the cervix may be caught with a tenacu- lum forceps and the uterus pulled somewhat downward (Fig. 74). Care should be taken, however, not to pull the uterus down very far, for reasons explained later (page 71). PALPATION OF LATERAL REGIONS OF PELVIS. Tubes and Ovaries, Mass, Induration, Tenderness. In this region, on each side, lies the large area of connective tissue, beside the cervix and lower part of the corpus uteri. Here induration from inflam- mation or other cause is felt at once, low about the cervix, just under the 58 THE PHYSICAL EXAMINATION vaginal wall. Higher, beside the uterus, lie the Fallopian tube and the ovary. They are near the upper part of the broad ligament and so close together that ordinarily it is impossible to say, simply from the position of a mass there, whether it springs from the tube or from the ovary. Hence the region is spoken of as the "tubo-ovarian" region, as both organs lie there. The tubo- ovarian region lies high, and to palpate it satisfactorily requires special care. Steps in Palpation of the Lateral Regions. In palpating the tubo-ovarian region of the left side, proceed as follows : '''^•^.rr "^ Fig. 72. Palpating the margin of the uterus, to determine enlarge- ment or irregularity. (Edgar — Practice of Obstetrics.) Fig. 73. Estimating the width of the uterus by separating the vaginal fingers so that one goes to each side of the uterus. (Edgar — Practice of Obstetrics.) 1. Place the tips of the vaginal fingers to the left side of the cervix, and then push them backward and outward and upward as far as possible. In order to carry the finger-tips sufficiently far into the posterior lateral area of the pelvis, it is necessary to push the perineum for some distance into the pelvis. This is best accohiplished usually by utilizing the force of the body muscles, transmitted to the elbow either through the knee (Figs. 75, 76), with the foot on a small stool, or through the iliac crest (Fig. 77). Tliis leaves the arm muscles free for tlie deep delicate manipulation necessary to accurate palpation of the pelvic contents. PALPATION OF TUBO-OVARIAN REGIONS 59 2. With the al)domiual tiugers locate the anterior superior spiuc of tlio ilium ou the left side aud Iheu bring tlie lingers diredly inward (not down- ward toward the pubes, but directly inward or slightly upward) toward the median line for about two inches (Fig. 78). 3. Then, at that point, depress the abdominal wall into the posterior ])art of the side of the pelvis (Figs. 79, 80) until the tips of tlie abdominal lingers come close to the tips of the vaginal fingers. This brings the lingers near to each other back of, or at least in the region of, the tube and ovary (Fig. 81). - 4. If tiie adnexa are not felt in the back part of the pelvis, then bring the fingers of the two hands, held in the same relation to each other, slowly downward toward the pubes (Fig. 82), In this w^ay the tube and the ovary are made to pass between the examin- ing finger-tips and may be felt if decidedly enlarged. The fingers are then carried on downward and toward the median line in order to palpate the front part of the pelvis. By proceeding gently, so as not to excite contraction of the abdominal muscles, and at the same time steadily pressing tlie two sets of fin- gers toward each other, a little with each expiration, the finger-tips may be brought almost together in the various parts of the pelvis. In these manipulations the palpation proper is made principally with the vaginal fingers, the abdominal fingers serving simply to push the structures down within reach of tlie fingers below. A common error is to bring the tips of the examining fingers together too close to the pubes; hence the palpation is of the tissue in front of the tu])e and ovary, even if they are in normal position. It must be kept in mind also tliat the tube and ovary are likely to be displaced, especially if diseased, and the displacement is nearly always backward ; hence the importance of getting far back in the side of the pelvis when endeavoring to accurately palpate these structures. In order to avoid this error, be certain that the point of depression of the abdominal wall is well above the tubo-ovarian region, so that when depressed into the pelvis it wnll lie back of the tube and ovary. In palpating the right side of the pelvis follow the same directions, substi- tuting ''right" for "left" (Fig. 83). Fig. 74. Dra'.nngthe uterus down with a tenaculum-forceps to bring it within reach of the examining fingers. (Dudley — Practice of Gynecology.) 60 THE PHYSICAL EXAMINATION Facts to Determine. In the exploration in the tubo-ovarian region take particular care to search for: Tube and Ovary — usually not felt if normal ; Abnormal Mass — enlarged tube or ovary, exudate, tumor; Induration — Inflammatory infiltration or exudate, adhesions, scar- tissue ; Tender Area — normal sensitiveness of ovaries, inflammation, hyper- esthesia, tenderness from other cause. Fig. 75. Invagination of tlie perineum and pelvic floor, the force being transmitted through the knee. Tube and Ovary. In many eases the normal lube and ovary cannot ])e dis- tinctly felt, even by the experienced examiner, and the inexperienced will find it difficult even in comparatively easy cases. When the tube or ovary is de- cidedly enlarged, it can be felt to slip between the examining fingers as a distinct thickening or as a small rounded innss. After locating the adnexa, as above desci-il)ed, it is sometimes advantageous to try to trace the tube out from the uterus. The fundus uteri is located, the FACTS TO DETERMINE IN LATERAL PALPATION 61 examining fingers (vaginal and aluloiuiual mailing united euunler-pressure) pass to tlie upper outer angle, ajid tlu'ii feel for the tube as it leaves the uterus and runs along the top of the broad ligament. The best place to locate it usually, when not abnormally indurated, is just beyond the angle of the uterus. It is a much firmer cord here than farther out, where the cavity be comes large and the tube soft. The normal Fallopian lube may be felt in a suita])le ease (thin patient with Fig. 70. T'se of this maneuver forinvatrinating the ])elvic floor in tlie lieep biniainiul pulpatii relaxed abdominal wall and i-elaxed pelvic floor), in the po.sitiou indicated, as a small soft cord about the size of a slate-pencil. It presents very much tlie consistency of a piece of rubber tubing. It may, in a suitable case, be traced outward and is then lost in a region of the ampulla, where the tube becomes very soft and the ovary comes into prominence as a soft rounded movable body, a trifle larger than the end of the thumb and sensitive to pressure. When the tube is inflamed it becomes harder and larger, and is more easily felt. It then feels very much like a rather firm piece of rubber tubing of about the size of a lead-pencil or larger, extending outward from the angle of the uterus, with irregular curves and bendings and enlargements. From thi.s 62 THE PHYSICAL EXAMINATION Fig. 77. Transmitting the force to the elbow through the iliac crest in dsep bimanual palpation. I'if,'. 7.S. Palpation of the left lateral rcKion. Plat-- ing tlie lingers of the abdominal hand. They sliould be on a level with, or a httle above, the anterior .superior spino fin(nfated by tlie cross.) I'ig. 79. Palpation of tlie left lateral region. ing the abdominal wall deeply into the pelvis. Depress- OTHER REGIONS IN THE PELVIS 63 size it may enlarge to a mass tliat fills all that side of the pelvis. Usually, however, when the inflammation is at all severe, adhesions or plastic exudate surround the tube and ovary, binding them and the surrounding structures together in one mass and making their separate differentiation impossil)lc. If on examination the pelvic tissues are all soft and yielding, and no i)artieu- lar pain is caused by the palpation, you may be certain that tlie tul)es and ovaries are not seriously diseased, though you may not have felt them. Mass in Lateral Part of Pelvis. The pelvic tissues, with the exception of the uterus, are soft and yielding, and any firm body may be felt tlirough them, either a tumor or an inflammatory exudate or a firm blood-clot. Fluid blood or Fig. 80 palpation A view from anotiier direction, showing tlie marked depression of the abdominal wall in deep pelvic serous exudate cannot be felt unless it is incapsulated. If a mass is found to either side of the uterus, determine concerning this mass the same facts that you did concerning the uterus — namely, its position, size, shape, consistency, tenderness, mobility and attachments. Determine particularly whether or not it is attached to the uterus, and, if so, whether by a broad attachment or by a narrow one. Induration in the Lateral Part of Pelvis. In some cases where there is no ■ distinct mass felt, there is a very definite hardening of tissues at some point. Instead of the tissues being soft and pliable, and easily pushed before the ex- amining finger, as they are normally, there is a stiffness and fixation and 64 THE PHYSICAL EXAMINATION resistance, as though there were infiltration and thielvening, and the struc- tures beyond cannot be satisfactorily palpated. This resistance and fixation of tissue without a well-defined mass is designated by the term "induration." It may be due to infiltration (inflammatory, tubercular, malignant) of the tissues, to inflammatory exudate on surfaces, to adhesions, to scar-tissue or to a tumor not yet developed far enough to form a distinct mass. Tender Area in Lateral Part of Pelvis. The ovaries are usually rather sensi- tive on bimanual palpation, and allowance must be made for this normal sensitiveness when estimating the diagnostic significance of tenderness in this region. Tenderness on palpation may accompany almost any pathological condition in the pelvis, but it is especially marked in inflammatory trouble, in peri- toneal irritation from blood in the peritoneal cavity and in neuralgic affec- tions of the pelvis. PALPATION OF OTHER REGIONS. In the same way as already described, careful exploration is made of : Posterior Part of Pelvic Cavity — tenderness, induration, mass; Anterior Part of Pelvic Cavity — tenderness, induration, mass ; Ureteral Regions — tenderness, induration, mass ; Pelvic Nerve Trunks — tenderness; Lower Abdomen — tenderness, tension, induration, mass. If a mass is found, determine as accurately as possible its position, size, shape, consistency, tenderness, mobility and attachments. The method of determining whether a mass is attached to the uterus, and, if so, how intimately, is shown in Figs. 84 and 85, where the sulcus between the uterus and the mass is being palpated to determine its depth. In the case of a tumor with a long pedicle it is well to have an assistant hold the tumor up in the abdomen out of the way, while the examiner, by bimanual palpation, feels whether or not there is any connection with the uterus or appendages. Also, the uterus may be caught with a tenaculum forceps and pulled down- ward (Fig. 103), assisting still further in palpation. Another point is that in the case of a broad attachment to the uterus the mass and uterus move as one body, whereas with a long attachment the two may be moved separately. In palpating the interior part of the pelvis, if the body of the uterus is not felt in front and still the vaginal and abdominal fingers cannot be brought well together, have the patient pass the urine, and then examine again. If the patient cannot urinate, or does not seem to ein])ty the blad- der well, she may be catlieterized. A spontaneous urination in the up- right posture empties the bladder better, and is safer tlian eatlieterization, which may be followed by cystitis. A. partly filled bladder is not felt as a distinct mass, and yet there may be half a pint or more of urine — enough to make the palpation very unsatisfactory. Tlu> peculiar thing DIFFICULTY FROM A FULL BLADDER 65 about this condition is that here is nothing to indicate it, except the difficulty in locating the body of the uterus in deep palpation. No mass is felt and the tis- sues are all soft and yield- ing and there is no parti- cular pain. The fingers seem to sink into the pelvic tissues well, but for some unaccountable reason the uterus is difficult to feel. It seems too far back in the pelvis and yet when you try to bring the fingers together in front of it, they do not come together well. When such a condition is encount- ered in an apparently nor- mal abdomen (no marked obesity or muscular tension) it is probably due to a collec- tion of urine in the bladder or to intestinal coils in the pelvis. If it does not dis- appear after the bladder is Fig. 81. The ovary caught between (Ashton — Practice of Gynecology.) the examining fingers. Fig. 82. The abdominal fingers moving downward. evacuated, then elevate the patient's hips, to get the tympanitic intestinal coils out of the pelvis. The bladder and other tissues in front of the uterus should be palpated (Fig. 66) to determine if there is any mass or any marked tender- ness. The region of the ureter on either side is an interesting area which is usualh' over- looked in pelvic palpation. The ureter extends on each side from the base of the bladder backward, outward and upward, about half an inch from the cervix uteri. Ordinarily it is not felt. In a suitable case, however, it may be felt as a rather in- definite cord or line of ten- 66 THE PHYSICAL EXAMINATION sicn, extending from the base of the bladder in the direction indicated. Fig. 86 in dicates the method of palpating this region. If inflamed, the ureter is tender on pressure. If infiltrated and thickened, it is easily felt. If a stone is lodged in the lower portion of the ureter, it may be felt. In this way I was able to determine de- finitely that a stone was lodged in the left ureter, a short distance from the bladder, in the case of a pregnant woman with such sudden severe pain and threatening symptoms that it was at first feared that the trouble was rupture of an extrauterine pregnancy. The patient eventually recovered and carried the child to term. If much inflammation has taken place about a stone or an infected portion of the ureter, there may be considerable peri-ureteral infiltra- tion that in a measure obscures the ureter, and gives the signs simply of a cellulitis at that side of the uterus and extending toward the bladder. A cellulitis associated with per- sistent bladder symptoms should be carefully investigated, with the idea that it may come from the ureter. Determine if the induration runs into the region of the ureter and if there is tenderness farther up along the ureter or in the kidney, or if the urine gives evidence of disease in the urinary tract. In a considerable proportion of the cases presenting persistent bladder irritability and classed as chronic cystitis, the trouble is really located in the ureter. In- flammation or tuberculosis of the loAver part of the ureter, gives symp- toms very closely resembhng chronic cystitis. In cases where pelvic neuralgia or neuritis is suspected, palpate the pelvic nerve trunks (Figs. 87 and 88). Sometimes the pelvic tenderness, which at first seems widespread, may be localized in its greatest intensity along the nerve trunks of one or both sides. These may be reached by deep palpation per vaginam or per rectum. Fig. 83. Palpating right tubo-ovarian region. GENERAL OBSERVATIONS ON BIMANUAL EXAMINATION. It may seem hardly worth while to take the trouble to make out all these little points in regard to the uterus or a mass beside the uterus, but it is worth while, and the farther one advances in diagnosis the more he appreciates this fact. The abil- ity to make a correct diagnosis in deep seated pelvic disease depends largely on the ability to answer the above questions correctly, and until one can determine facts EDUCATE THE TOUCH 07 as above indicated, in regard to the uterus or other pelvic mass, his diagnosis is simply a guess and not a diagnosis at all. Importance of the Educated Touch. I want to emphasize the importance of training the hands— of acquiring the"tac- tus eruditis." The following quotation from an article of mine on the subject brings out this point. "The multiplication of instruments for diagnostic purposes has, to some extent, obscured the importance of the educated touch. The begin- ner in gynecological work is bewildered ])y the great variety of specula, tonacula and other instruments for diagnosis, and he is ac- cordingly impressed with the idea that the principal thing is to learn how to use instruments, and then to use them on every oc- casion. One of the first duties of a teacher in gynecology is to displace this erroneous idea by showing the importance of the use of the hands. Most of the serious dis- eases of women affect structures that lie beyond the reach of sight. To the teacher falls the duty of directing the student's efforts in such a way that he will acquire the abil- ity to distinguish these intrapelvic conditions in the only way that such conditions can be distinguished, namely, by touch. After the student has, by lectures, supplemented by charts and demonstrations, been helped to form a mental picture of the normal organs — their position, size, shape, structure and relations — then comes the task of helping him to recognize such conditions by the sense of touch. This is not a matter of a few days. It takes weeks and months of patient work and many careful examinations, to be able to recognize norma! conditions. The abdominal wall and the vaginal wall intervene between the examining fingers and the important organs. These intervening structures vary so much in thickness, in consistency, in tension and in sensitiveness, that there is infinite variety in the facility with which the organs may be outlined. Again, the organs themselves vary much within normal limits, in different individuals and in the same individual at different times. Fig. 84. Mechod of determining how intimately a mass is attached to the uterus. Palpating the sulcus between the two. (Kelly — Operative Gynecology.) 68 THE PHYSICAL EXAMINATION The beginner must learn to read the conditions first by learning the separate letters, so to speak, and then learning what certain groupings of letters mean. The separate items that must be recognized in this examination are the position, size, shape, consistency, tenderness, mobility and attachments of the organs. This takes much time and patience and well directed efforts through many examina- tions. It cannot be learned from lectures. It cannot be learned by seeing someone make examinations and appli- cations. It can be learned only through repeated bimanual examinations by the student himself, under competent in- struction. Hence the import- ance of the clinical portion of a gynecological course. ''Though it takes consider- able time to learn to recognize normal conditions, the time is well spent, for no real progress is possible without this knowl- edge. The normal must be known before the abnormal can be appreciated. This is self-evident and yet how many students at graduation, and physicians long after graduation, find it difficult to feel more than the vaginal walls and cervix. ''In the recognition of pathological conditions, the same points must be consid- ered (position, size, shape, consistency, tenderness, mob- ility and attachments), and this information, supple- mented by the history, de- termines tho diagnosis. This determination of the particular pathological con- ditions present is accom- plished almost altogether by the hands, either in the ord- inary bimanual examination or in the examination under anesthesia. / ^ T 1 i • 1 i ... I^'ig. 86. Palpating the I do not wish to mmimize Practice of Oynecologn.) Fig. 85. Determining what attachment there is between the uterus and a cyst back of it. The uterus is caught between the hands and brought forward and the examining fingers are crowded in between the uterus and the mass {Aahton — Practice of Gyn- ecology.) region of the right ureter. (Ashton^ TRAIN ONE HAND 69 Deep pptfcastric- - - Femoml rin(f.-^ U* lObtur.'forameil Middle hem- Vftg;-i# Fig. 87. Showing the exact situation of the large nerve roots in the pelvis. In the illustration the Itarge nerve roots appear a shade darker in color than the other strustures. (Kelly— Opei-aiive Gyne- cology.) the value of diagnostic instruments (specula, sounds, curets, etc). They are often helpful and in some cases indispensable to a positive diagnosis, and their use should not be neg- lected. But I want to em- phasize the fact that in gynecological examina- tions generally, instru- ments are of second- ary importance and only supplemental to the trained hand." Take every opportun- ity to educate the fingers to appreciate as accurate- ly as possible the various conditions found in the pelvis. When examining a suitable case, outline the uterus and all the pelvic structures as clear- ly as you can, even if not necessary to the diagnosis in that particular case. Each careful examination made serves to educate the fingers, or rather serves to educate the mind to appreciate what is between the fingers, and prepares you to make out the exact conditions in difficult cases. Train one Hand. In the bimanual examina- tion, it is well to train one hand for the vaginal manipulations. For this purpose, either the right or the left hand may be selected, as the examiner finds more convenient. I use the left, leaving the right free for the abdominal palpation and for the handling of instruments. The advantage of using the same hand in vaginal manipu- lations in practically all cases, is that the power of discrimina- tion by the fingers of that hand Fig. 88. (Dudley- Palpating the pelvic ■Practice of Gynecology.) nerve trunks per rectum. 70 THE PHYSICAL EXAMINATION increases as more and more examinations are made. At the same time, the ab- dominal hand becomes accustomed to the abdominal manipulations and as the examining hands are in practically the same relation in every case, deviations from. the normal are more readily recognized and more accurately defined than if the two hands were used indiscriminately and hence in different relations. This4s especially true when the examiner has the advantage of only a limited number of examinations. In exceptional cases, it is an advantage to use first one hand and then the other for vaginal palpation. In some cases, the right side of the pelvis can be explored better with the fingers of the right hand and the left side with the fingers of the left hand. Use Two Fingers. Use two fingers in the vagina when the vaginal opening is large enough to permit their use without pain. A deeper and more accurate examination can be made with two fingers (index and middle finger) than with the index finger alone. The upper part of the vagina is capacious. The only difficulty is at the vaginal en- trance. By lubricating the fingers well, and depressing the perineum and working carefully, the two fingers may be used without discomfort in practically all parous women, and in most non-parous women who havD been married. Examine Deeply in Pelvis. In many cases, in order to palpate the posterior part of the pelvis and particu- larly to satisfactorily palpate the tubo-ovarian regions, the vaginal fingers must reach farther than their length will permit. The extra reach is secured by carrying the perineum into the pelvis (invagination of the pelvic fioor) by strong steady pres- sure inward. The soft structures closing the pelvic outlet can be carried for a con- siderable distance inward without particular discomfort to the patient, provided all the muscles are relaxed. In parous women, from one to two inches may usually be thus added to the effective length of the examining fingers. The force required, while not great, is likely, if exerted by the arm muscles alone, to interfere with delicate palpation by the examining fingers. It adds much to the effectiveness of the examination to exert this pressure by the body muscles, leaving the arm muscles free for the internal palpation movements. This may be accom- plished either by placing the left foot (when examining with the left hand) on a stool or chair-round and resting the elbow on the knee (Figs. 75, 76), or by letting the elbow rest against the hip (Fig. 77). May Draw the Uterus Down. It is advantageous in the bimanual examination in some cases, to catch the cer- vix with the tenaculum forceps and draw the uterus downward, so that the exam- ining fingers may reach higher on its posterior surface (Fig. 74) . This is useful in those cases where the uterus lies so far back in the pelvis that it is difficult to reacli. After making the vagino-abdominal examination in the usual way, the tenaculum may then be introduced by touch and the cervix caught and Ijrought down, POSITION FOR EXAMINER 71 Only light traction should be made — not enough to unduly stretch the sacro-uter- ine ligaments, which might lead to subsequent trouble. I want to protest against the statement made l)y some authorities to the effect that the normal uterus may with impunity be pulled down until the cervix appears at the vaginal opening, or may without harm be turned into extreme retroversion, for the pui-pose of palpating the posterior surface or even hooking a finger in the rectum over the fundus and pal- pating the anterior surface. The uterus is usually mova])le in all directions, but the movements here mentioned are far beyond the normal range and can l)e accom- plished only i)y undue stretching of the structures intended to prevent such dis- placements. Of course, when the pelvic structures are already overstretched and lax, as in cases ot laceration of the pelvic floor with descent of the uterus or in cases of mov- able retrodisplacement, these extreme maneuvers may be carried out without further damage, and, in doubtful cases, with great advantage in regard to accuracy of diag- nosis. In a patient with practically normal uterine supports, however, the pulling down of the uterus or the backward displacement of the uterus for diagnostic pur- poses or for therapeutic purposes (as in curetment or repair of cervix), should be of ver}' limited extent. It is easy to overstretch the uterine supports but it is not so easy to restore tone to these structures so that they will again hold the uterus in just the right way. This is particularly important in regard to the postcervical supports (sacro-uterine ligaments and adjacent tissues) which are stretched every time the cervix is pulled downward. When these are once over-stretched and rendered lax, it is practically impossible to keep the uterus permanently in proper position except by operation. Preferable Position for Examiner. For the vaginal and bimanual examinations, it is decidedly advantageous for the examiner to stand directly in front of the vaginal opening, as shown in Fig. 75. This is especially important when very deep pelvic palpation is necessary. This is the usual position when the patient is examined on the table with foot-rests so that the hips may be brought entirely to the end of the table. When a patient is examined in bed, however, the usual directions are to pass the examining arm under one thigh. This puts the examining arm and hand at a de- cided disadvantage. The examiner should sit so that the examining arm passes between the thighs as shown in Fig. 114. This puts the arm directly in front of the genitals, the same as in the examination on the table. This brings the arm and hand in the most advantageous position for accurate palpation deep in the pelvis, as the reader can easily demonstrate to his own satisfaction by giving a trial of each method in some difficult case requiring deep palpation. Conditions in Different Patients. The facility with which the bimanual examination can be made varies much in different patients. In some, tlie fingers on entering the vagina are checked by the strong contraction of the muscles of the pelvic floor. When such is the case, turn the ofllmar surface of the examining fingers backward and make steady pressure 72 THE PHYSICAL EXAMINATION against the posterior vaginal wall and the contracting muscles. This gives you an idea of the strength of the muscles of the pelvic floor and soon, under the pressure, the muscles relax. Another troublesome obstacle to deep bimanual examination is tension of the abdominal wall. The methods of overcoming this have already been explained. In a thin patient, with a large vagina and a relaxed abdominal wall, the uterus can be outlined and the appendages felt, and any abnormal mass, even a small one, can be satisfactorily palpated. In a stout patient, with a thick layer of fat over the abdomen, the ordinary bi- manual examination is often unsatisfactory, particularly if there is inflammatory trouble with tension of the abdominal wall. In such a case, a mass of considerable size, if situated high in the pelvis, may be missed entirely. The only way to de- termine exactly the pelvic contents in such a case is to make an examination under anesthesia. Such an examination should be made in those cases where the symp- toms are urgent enough to make an immediate accurate diagnosis necessary. Get Intestines Out of the Way. In some cases, particularly when there is considerable tympanites, distended coils of intestine interfere with the bimanual palpation of the pelvic structures. To overcome this difficulty, elevate the patient's hips into the Trendelenburg pos- ture. Then work the intestines out of the pelvis and hold them out as the hips are slowly lowered into a more comfortable position. Leave the hips rather high, as high as the patient will stand without discomfort, and direct her to keep all the rnuscles loose and breathe quietly, so as not to force the intestinal coils back into the pelvis. The regular bimanual palpation may then be carried out, undisturbed by the troublesome intestinal coils. This is a very convenient maneuver also for getting a pediculated tumor out of the pelvis, that its pedicle and point of origin may be accurately determined by bimanual palpation. In case the table is not arranged for the convenient elevation of the hips, the hips may be elevated by means of pillows or the patient may be placed in the knee=chest posture for a few moments. With the clothing well loosened and the correct knee- chest posture assumed, the distended intestinal coils fall out of the pelvis better than in the Trendelenburg posture, but in the exertion of assuming the dorsal posture again they are likely to be partially forced back. Avoid this as much as possible by directing the patient to keep the upper part of the body on the table (not to raise it, as in partly sitting up) and to keep the abdominal muscles loose. Also place a thick pillow under the hips, as the dorsal posture is assumed. An additional expedient is to put a speculum in the vagina and in the rectum while the patient is in the knee- chest posture. The vagina and rectum then balloon with air, forcing the intes- tinal coils out of the pelvis. The specula are then removed and the openings close, retaining the air which helps to keep the intestinal coils out of the pelvis in the sub- sequent movements. PALPATION PER UKCTUM 73 Diminish Tenderness. In many patients satisfactory pelvic exploration is prevented by tenderness, par- ticularly in that large class of cases in which pelvic inflammation is a primary or complicating lesion. In some of these cases the symptoms are so urgent that an examination under anesthesia at once is advisable. In most of the cases, however, the symptoms are not so threatening as to necessitate immediate examination under anesthesia. The patient, has come for a diagnosis but an accurate diagnosis can not be made because of the tenderness which prevents deep palpation. What shall the examiner do under these circumstances? There are two measures which are useful in diminishing the tenderness and abdominal tension. ' 1. Administration of a sedative. The patient may be given J- gr. of codeine phos- phate hypodermatieally, or J- gr. or i gr. of morphia, and examined again after half an hour. If thought preferable, an appointment ma}" be made for the next day and an order given for the sedative to be taken Ijy mouth one hour before your visit. In the meantime the patient is kept quiet in bed and the bowels well opened. It is well to have an enema given half an hour before examination. 2. Treatment for the inflammation. The patient is kept in bed, the bowels well^ opened, hot vaginal douches given and the regular treatment for acute or subacute pelvic inflammation carried out This treatment continued for a few days or a week T\dll do much toward diminishing the tenderness, so that a thorough pelvic examination mav be made. RECTO=ABDOMINAL PALPATION. In many cases it is of decided advantage to follow the vagino-abdominal exam- ination by a recto-abdominal examination. In this form of bimanual examination, the index-finger, gloved and lubricated, is introduced into the rectum and passed upward betw^een the sacro-uterine ligaments as far as possible up the posterior sur- face of the uterus. With the fingers of the other hand pressing down the organs from above, all the structures within reach are palpated with the palmar surface of the rectal finger (Fig. 102). Disadvantages. Ordinarily, palpation of the pelvic structures may be carried out much more thoroughly by vagino-abdominal examination than by recto-abdominal examina- tion. Without anesthesia but one finger can be used in the rectum and this finger lies at a considerable distance from the uterus and adnexa, unless carried very high. It cannot usually be carried very high on account of the encircling sphincter and pelvic floor, except by the use of such force as to cause pain and resistance. In some cases where the pelvic floor is lax, the examining hand may easily carry the peri-anal structures some distance into the pelvis, thus allowing the examining finger to pass high up back of the uterus and permitting accurate bimanual palpation of the adnexa. The facility with which the organs may be felt is increased by catching 74 THE PHYSICAL EXAMINATION 1 the cervix -v^-ith a tenaculum forceps and bringing the uterus somewhat lower. In ■ all but exceptional cases, however, accurate examination of the pelvic contents by recto-abdominal palpation is practicable only under anesthesia. However, such palpation as can be carried out without anesthesia gives information of value -in some cases, as indicated in the following paragraphs. When Useful. It is well to employ digital examination per rectum, or conjoined (bimanual) recto-abdominal palpation, in the following cases: Mass in Cul=de=sac. Rectal palpation is useful when there is a mass of inflam- matory exudate or a tumor low in the peritoneal cul-de-sac back of the uterus. In the case of an inflammatoiy mass in that situation, fluctuation may be in some cases detected while it is not yet appreciable by vaginal examination. Malignant Infiltration. In malignant disease of the cervix extending out into the parametrium, rectal palpation will in some cases give additional information as to the extent of the infiltration and the mobility or fixation of the uterus. Rectal Disease. When a patient gives symptoms pointing to rectal disease, the rectum should of course be examined by palpation and also by inspection through rectal speculum if necessary to determine the exact condition. Obscure Cases. In cases where the other methods do not show lesions suffi- cient to account for the symptoms, a rectal examination should be made to de- termine if there is any rectal or perirectal disease that might account for the pelvic pain and distress. Occasionally in a Virgin. The information concerning the uterus and adnexa thus obtained is usually very indefinite, as explained below. In such examination the landmark is the ceindx uteri, which maj^ be easilj^ felt through the rectal wall. Notice if there is a distinct mass back of the cervix (inflammatory mass, tumor, fundus uteri in retrodi-splacement) or a point of special tenderness anywhere in the lower part of the j^elvis. BIMANUAL EXAMINATION OF A VIRGIN. As previously explained, local examination in the case of a virgin is to be avoided if possible. When it is necessar}^ to make an intrapelvic examination, what method should be used? The direction has been given, in various works, to examine virgins by the rectum when it is necessary to determine the condition of the uterus or adnexa, in order to avoid stretching the hymen. In a virgin those conditions which militate against a satisfactoiy palpation of the uterus and adnexa by recto-abdominal examination, are at their height. Usuallj^ after such an examination without anesthesia the examiner knows but little more concerning the uterus and adnexa than he did before the examination. Of course if there is a good sized mass low in the pelvis or a particularly tender area, its presence is determined. But the information is usually too indefinite for an exact diagnosis. Such an examination does very well EXAMINATION OF A VIRGIN 75 however, to "break the ice" so to speak, and it may be explained then that the conditions are such that a vaginal examination is advisable. In some cases the recto-abdominal examination is very satisfactory, the required information being obtained with fair accuracy. In the rectal palpation, the cervix uteri can be felt through the rectal wall. If there is no mass back of the cervix (inflammatory mass or tumor or fundus uteri deep in cul-de-sac) and no area of particular tenderness in the pelvis, it may be advisable to postpone further local examination and try general therapeutic measures for several weeks or months. Usually, however, when the symptoms are severe enough to warrant any local examination, they are severe enough to warrant a recto-abdominal examination under anesthesia, or a stretching of the hymen sufficiently to admit one finger, so that the regular vaginal and vaginal-al^dominal examination may he made. The condition of the uterus and the adnexa may be much more definitely determined in this way than by rectal palpation. In a large proportion of virgins, even the regular vagino-abdominal palpation does not permit accurate outlining of the uterus or of adnexal masses. Conse- quently, in the case of a virgin where there is serious pelvic trouljle necessitating an accurate palpation of the pelvic contents, an examination under anesthesia is usually required. In cases where the necessity of a thorough pelvic examination is apparent from the first, it is preferable, in a girl or a young unmarried woman, to at once examine the patient under an anesthetic. This eliminates the mental shock of the procedure and at the same time permits a thorough exploration. It is v/ell to employ recto-abdominal palpation first and then, if necessary, vagino-abdo- minal palpation. In addition, any operative measure required for diagnostic or therapeutic purposes, may be carried out, for example, dilatation and curetment ol uterus or removal of hemorrhoids. RECTO=VAQINO=ABDOMINAL PALPATION. In exceptional cases when making the recto-abdominal examination, it is advantageous to introduce the thumb into the vagina in order to grasp the lower part of a mass between the finger in the rectum and the thumb in the upper part of the vaginal canal, the structure being pushed down \\-ithin reach by the abdominal hand (recto-vagino-abdominal palpation). Where a mass is low enough to be grasped in this way, its outline and consistency can be very accurately determined. It is only in the cases of large vaginal opening and relaxed floor that this method is applicable, and to be of much service anesthesia is usually required. Occasion- ally, however, it is useful in the ordinary examination. I recall in particular one puzzling case, that was referred to me for differential diagnosis, in which this maneuver was of much assistance. The patient presented a mass of moderate size, pretty well filling the pelvis. The mass contained fluid, the cervix was somewhat softened and the uterine body could not be definitely locatel. The differentiation was between an enlarged uterus containing fluid (normal or abnormal pregnancy) and .some other fluid mass (cystic fibroid, extra- 76 THE PHYSICAL EXAMINATION uterine pregnancy, hydrosalpinx, ovarian or parovarian cyst). The history was uncertain and the findings in the ordinary examination were not positive. The crucial point was to identify the body of the uterus. Was this large mass the body of the uterus enlarged (pregnancy) or was the body of the uterus of practically normal size and located somewhere in the mass? Sounding of the uterine canal was not permissible until pregnancy could be excluded. The lower posterior part of the large mass presented a small firm portion, which might be the normal-sized body of the uterus displaced or simply a firm portion of an enlarged uterus. The firm area was so cov- ered over and surrounded by the mass that I could not make satisfactory bi- manual palation of it, neither could I definitely outline it through a sufficient extent by either vaginal or rectal palpation. Finally I tried to grasp this firm portion of the mass between the finger in the rectum and the thumb in the vagina. As the vaginal opening and pelvic floor were lax, I could carry the thumb to the top of the vagina without much discomfort to the patient, ao . by crowding the Fig. 89. Method of palpating the coccyx. The hand should be gloved. (Hirst — Diseases of Wornen.) mass down with the abdominal hand, I was able to grasp the firm portion between the finger and the thumb of the left hand and separate it from the fluid mass sufficiently to trace its outhne and get the consistency throughout. It was of about the size, shape and consistency of the normal uterus, and by working the finger and thumb toward each other above this firm part, I could demonstrate that the fluid portion of the mass had a separate wall. I now felt safe in introducing the sound, which confirmed the palpation findings. This firm area was the dis- placed body of the uterus, otherwise practically normal, and the surrounding fluid mass was a separate affair, an ovarian or parovarian c)'st. A modification of this method is to introduce the middle finger into the rectum and the index finger into the vagina and palpate the structures between the fingers, THE Sl'ECULUM ]0XAM1 NATION 77 as the uterus is pushed down from above. This particular method of recto-vagino- abdominal palpation has been found useful in determining the extent of involv- ment of the parametrium in cases of carcinoma of the cervix uteri. PALPATION OF COCCYX. In cases of persistent pelvic pain where no sufficient cause is found about the uterus or adnexa, the coccyx should be palpated. This small bone at the tip of the sacrum is not infrequently the site of neuralgia or rheumatism (affecting the joints or adjacent muscles) or a chronic inflammation resulting from an injury sustained months or years l:)efore. These injuries usually can be traced to child-birth though occasionally such a condition will result from a fall or blow. In rare cases, neuralgia or rheumatism or inflammation may become manifest here without previous injury. Tenderness of the coccyx or a mass about any portion of it or a deformity, may be easily determined by an examination with the index finger (gloved) in the rectum and the thumb over the coccyx (Fig. 89). The examina- tion is most conveniently made with the patient lying on her side. In this way the coccyx may be accurately outlined and any deviation from the normal de- termined. In some cases the coccyx appears to be normal until an attempt is made to move it, when there is severe pain, indicating trouble in the joint or about the fasciae or muscles. INSTRUMENTAL EXAMINATION. This term includes those manipulations in which it is necessary to use instru- ments. Coming under this classification are the following: Inspection of Vagina and Cervix through the Speculum (Speculum Examination) . Excision of Tissue from Cervix for Microscopic ExaminatioHo Exploration of Interior of Uterus with the Sound. Exploration of Interior of Uterus with the Curet. SPECULUM EXAMINATION. By means of certain instruments the vaginal walls may be spread apart so that those walls and the cervix uteri may be seen. Information of much value in some cases may be obtained in this way. Instruments for Regular Speculum Examination. The instruments needed for this examination are shown in Fig. 90. They are as follows: A Speculum for separating the vaginal walls; A long Dressing Forceps for sponging out the vagina, usually called "Uterine dressing forceps;" A Tenaculum Forceps, or "Volsellum," for catching the cervix and bringing it better into view. A Specimen Scissors. 78 THE PHYSICAL EXAMINATION Vaginal Speculum. The bivalve speculum (Fig. 90-a) is the kind most fre- quently used in ordinary office work. It consists of two blades, which are intro- duced closed and then opened by a mechanism at the handle. The vaginal walls are thus held apart (Fig. 91) and a very good view of the walls and cervix may be obtained. The bivalve speculum is convenient and gives good exposure of the cervix in most cases. There are many different modifications of the blades and also of the mechanism for separating the blades. The most satisfactory form that I have found is shown in the illustration. It is called the Graves speculum and has the advantage that it can be easily and quickly transformed into a fairly satisfactory Sims' speculum, Fig. 90. Instruments for the regular speculum examination, a. Bivalve Speculum, of which it is well to have three sizes— large, medium and small, b. Dressing Forceps for swabbing out vagina, c. Tena- culum-forceps for catching cervix to bring it well into view. b. Specimen Scissors, a small strong hawk bill scissors for clipping small specimens from the cervix in susyicious cases. which is a decided convenience in office work. Three sizes are useful — small (virgin), medium and large. The cervix is easier exposed in most cases if the an- terior blade of the speculum is somewhat shorter than the posterior. Some specula are made with three blades, instead of two, constituting a tri- valve speculum. They are made. on the same general principles as the bivalve but the mechanism is more complicated and, usually, without corresponding benefit. The bivalve speculum is used with the patient in the dorsal posture (Fig. 41). For sterilization of specula and other instruments, see Preparations for Exami- nation, at the end of this chaptero THE BIVALVE SPECULUM 79 The uterine dressing=forceps (Fig. 90-b) is a long strong forceps for sponging out the vagina and for making vaginal applications. It may be straight or curved as preferred. I find the forceps with a straight shank and a slight curve near the end more convenient than the much curved instrument. A vaginal depressor for pushing the vaginal wall out of the way is usually mentioned in an examining set Fig. 9L Bivalve Speculum in place. Sectional view, showing relations of speculum and exposure oi the cervix and vaginal vault by opening the blades. but it is generally not necessary, as the vaginal wall may be pushed aside sufficiently with the dressing-forceps. The uterine tenaculum=forceps is needed for catching the cervix and, bringing all parts of it into view. It should be light but strong, especially about the lock, K'here it is Hkely to work loose (Fig. 90-c) . 80 THE PHYSICAL EXAMIXATION The specimen scissors are for clipping out a small piece of tissue from the cervix, in cases presenting an appearance suspicious of mahgnant disease. The one shown in Fig. 90-cl I have found very convenient and satisfactorJ^ It presents at the end a small sharp ''hawk-bill" -^^liich cuts through the firmest tissue, clipping out a small piece "udth but little pain or bleeding. I appropriated it from the throat specialist's armamentarium, where it is catalogued as the Miles tonsil punch. Steps in the Regular Speculum Examination. Introducing the Speculum. The blades of the speculum are closed and the outer surfaces lubricated and the speculum held in the right hand, while with the other hand the labia are separated and the perineum depressed somewhat with one finger (Fig. 92). The speculum is then introduced and carried all the way to the upper end of the vagina T^ithout being opened. In most cases the speculum passes the vagin- al entrance most easily when held with its width almost vertical, the edge being held just far enough to one side to miss the urethra (Fig. 93). When well within the vagina, it is turned transversely and carried in as far as it "v\ill go (Fig. 94). Care is necessary that painful pres- sure be not made on the urethra or other structures beneath the pubic arch. Remember that when more room is required, the pressure must alwa3's be directed against the per= ineum, which mil gradually yield. Another common mistake with the inexperienced is to open the blades too soon^ before the speculum has been introduced all the way. The blades are not in far enough to satis- factorily expose the cervix and in closing them again for further introduction, pain is likely to be produced by pinching the vaginal wall. Exposing the Cervix. After the blades have been introduced well up to the top of the vagina, they are opened and the cervix and vaginal walls exposed (Fig. 91). By turning the speculum in various directions, all parts of the cer\dx and upper end of the vagina may be seen. If the cervix does not come well into view it may be caught vnth a tenaculum forceps and brought downward somewhat and turned from side' to side, exposing all portions of it and of the vaginal vault. Cleansing, the Vagina. If there is secretion obscuring any part of the vaginal wall or cer\-ix, wipe it away with cotton held in the dressing-forceps and dipped in an antiseptic solution. Fig. 92. Introducing the bivalve speculum. First step — depressing the perineum to give room for the speculum to be introduced. THE INFORMATION T(J BE OUTAINKI) S'x Exposing Lower Portion of Vaginal Walls. To inspect the middle and lower portions of the vaginal walls, turn the speculum so as to bring the various portions of the walls opposite the opening between the blades. Another way is to inspect ihe various portions of the walls just beyond the end of the speculum, as it is withdra^\^l. Specula with skeleton blades are made, but they are not necessary and ordinarily they are likely to prove unsatisfactory in a good many cases l^ecause of the prolapsing of the redundant vaginal walls through the large openings. Fig. 93. Introducing speculum. It has been car- ried part way in. Notice the oblique position, which prevents painful pressure on the urethra. Fig. 94. The speculum carried all the way in and turned into position for opening. Information Obtained in the Speculum Examination. The information sought in the speculum examination is obtained by inspection of the following structures: Vaginal Walls — Color, Discharge, Redundancy; Cervix Uteri^Position, Color, Size and Shape, Lacerations, Deviation of Axis, Eversion, Erosion, Hypertrophy, Cystic Change, Ulcer; External Os— Size and Shape, Color of Edges, Discharge, Polypi. Vaginal Walls. Are the walls of normal color or is there congestion? If con- gestion, is it active or passive? If the walls are bright red, that means active or arterial congestion and is due to inflammation or irritation. If the walls have a bluish tinge, that means passive or venous congestion and indicates either preg- S2 THE PHYSICAL EXAMINATION nancy or some interference with the circulation, as by a pelvic tumor or exudate or by failure in compensation in heart disease. If there is discharge, determine whether it originates in the vagina or in the uterus. If the vaginal walls are lax and redundant, they tend to collapse about the speculum. Cervix Uteri. Is the cervix in low position, so that it is easily exposed when the speculum is in but a short distance, or is it higher than normal, so that it cannot be well exposed vnth the speculum of ordinary length? Is the color normal or is there congestion, either active or passive? Here, as in the vaginal wall, active conges- tion means inflammation or irritation and passive congestion indicates either pregnancy or obstruction of the circulation. A bright red area extending a con- siderable distance out from the os, is usually due to the peculiar condition called "erosion. ' ' In regard to the size and shape, inspection may show the cervix to be: Normal. Long Conical. Lacerated, but largely united again. Lacerated and not united, but "without complications. Lacerated and everted, eroded, hypertrophied, or ^ith. cystic change or wdth a genuine ulcer. Is the axis of the cervix directed across the vagina, as it should be normally, or ALONG the vagina, as in retrodisplacement of uterus or anteflexion of cer\'ix? External Os. The size and shape show whether or not there has been lacera- tion and consequently are of considerable medico-legal importance in certain cases, because furnishing strong evidence for or against a previous childbirth. The color of the edges show whether they are normal or the seat of inflammation or erosion. The discharge may be of any of the varieties previously described. There is normally a clear sticky tenacious mucus in the cer\dx and about the external OS. The first effect of inflammation and irritation is to make this more abundant and later it becomes mixed v-ith pus. As long as the cervical inflammation is a prominent part of the process, the tenacious, string}^ quality ^^ill be a prominent feature of the discharge. If there is the least suspicion of gonorrhoea, make a spread of the discharge for microscopic examination. Occasionally a small polypus will be seen presenting at the external os or hanging by a pedicle. Difficulties in the Speculum Examination. Poor Light. If the light is so poor that the cervix and upper portion of the vagina cannot be seen, the ordinary head mirror, used in throat work, is of much assistance. At night, in emergency examinations and treatment, the light from a lamp may, with the head mirror, be thrown into the vagina and the landmarks easily seen. Painful abrasions. If there are painful abrasions or fissures about the vaginal orifice which interfere with the examination, the sensitiveness may be diminished THE SIMS SPECULUM §3 by the applifatioii of a small piece i)( ahsorbeiit cotton soaked in a 10% cocaine solution. Leave this in place for three to five minutes, then remove it and proceed with the examination. Redundant Vaginal Walls. When the va.iiinal walls are ver}- lax and redundant, as sometimes occurs because of subimolution following labor, they collapse about the speculum in such a way as to hitle the cervix. This difficulty may in some cases be overcome by using a longer speculum. When this does not expose the cervix satisfactorily, put the patient in Sims' posture and use the Sims speculum. Examination with Cylindrical Speculum. The cylindrical speculum consists simply of a tube with the outer end flaring and the inner end cut obhquely. It may be made of metal or hard rubber or glass. The cylindrical speculum is useful in certain foims of treatment, particularly when it is desired to apply to the cervix medicines from which the vaginal walls should be protected, but it is not much used in examination work. When in the examination of a girl it is necessary to inspect the cervix, this may be accomplished T\ithout disturbing the hymen by placing thepatientin the knee- chest posture and using one of Kelly's cystoscopic tubes. This is simply a small cylindrical speculum and, with the patient in the knee-chest posture, when the tube is introduced the vagina balloons out to some extent with air. Then by means of a light reflected from a head-mirror, the cervix and vaginal walls may be inspected and if necessary treated. Such an examination, however, is seldom required. In the virgin, a local examination should not be made except for urgent symptoms, and in cases with urgent symptoms the requirement is usually for a thorough bi- manual examination under anesthesia, rather than for a speculum examination. Examination with the Sims Speculum. The Sims speculum is a perineal retractor and for use requires the patient to be put in the Sims posture. Like any other retractor, it must be held in place either by an assistant or by a mechanism (.speculum holder), of which there are several varieties. The Sims speculum consists of a blade, somewhat resembling a duck's bill, and a handle. As usually made tw'o blades are placed on one handle, a large blade at one end and a small blade at the other. A further improvement is a flange near the larger blade. This flange holds the fleshy part of the right buttock up out of the w^ay. The Graves bivalve speculum, mentioned above, is easily and quickly changed into a satisfactory Sims speculum (Fig. 95), so it is not usually necessary to get a special Sims speculum. Sims' Posture. The principal points about the Sims posture, called also "left lateral posture" and the "semi-prone posture," are as follows: 1. All constriction must be removed from around the waist. 2. The patient lies on her left side, with left arm and hand behind her and the front of the chest turned toward the table as far as possible without discomfort. When in proper position, the upper part of the body rests on the left breast. 84 THE PHYSICAL EXAMINATION 3. The hips rest near the lower left corner of the table and the body extends diagonally across the table toward the right side. 4. The left thigh is drawn up so that it forms an acute angle with the body, and the right thigh is dra\\Ti up still more, and allowed to drop over the lower one. This puts the patient in the position shown in Figs. 96 and 97. It permits the abnominal wall and the intestines and uterus to fall forward. Use of Sims' Speculum. To introduce the speculum, the right labia are raised thus exposing the vaginal opening and then the speculum point, well lubricated, is carefully worked into the opening. At the same time, the perineum is pulled somewhat backward ^^ith the speculum point, in order to give more room for the point to slip in (Fig. 98). The blade is then carried all the way in. The spec- ulum is then grasped firmly and pulled backward, thus retracting the perine- um and exposing the interior of the vagina (Fig. 99). As the speculum is introduced the vagina becomes distended with air, and when the perineum is retracted the cervix and anterior vaginal wall may be seen. To bring the cervix into still better view, catch it with the tenac- ulum-forceps and bring it shghtly to- ward the opening (Fig. 100). When indicated. The Sims specu- lum vAih the Sims, posture is of de- cided advantage in the following con- ditions : 1. When the bivalve speculum fails to satisfactorily expose the cervix. This may be due to the vaginal walls being so lax that they fall about the blades and obscure the cervix or it may be due to the vaginal opening being so small that the blades cannot be sufficiently separated. Again, in some cases of inflammation of the uterus or about the uterus, the bivalve speculum cannot be opened sufficiently because the anterior blade causes pain by pressure on the inflamed structures. 2. When it is desired to expose a lacerated cervix without spreading the lips apart. The bivalve speculum, as it is opened, separates the lips of the lacerated cervix, causing considerable distortion and making it rather hard to judge of the amount of e version ordinarily present. Again, the weight of the uterus pushes the cervix into the vagina, in some cases making the cervix appear longer than it really is. In this way the bivalve speculum may lead to an erroneous diagnosis of elongation of the cervix. 3. When it is desired to expose the cervix ^vith the least possible stretching of the vaginal opening. The vaginal opening may be so tender that the bivalve speculum cannot be satisfactorily opened. Again, in removing cervical sutures Bivalve speculum changed to Sims' spe- THE SIMS POSTURE 85 after simultaneous repair of both cervix arul perineum, it is important to avoid stretching the newly healed perineum. In these cases, a narrow Sims speculum introduced in the Sims posture, causes the vagina to balloon and exposes the cervix and vaginal vault with much less stretching of the vaginal orifice than would be necessary with the bivalve speculum. 4. When it is desired to sound the uterus or to dilate the cervical canal or to make an intrauterine application. Fig. 96. Patient in Sims' posture. Notice how the upper knee drops |^// over the under one. ■' 5. When the vagina is to be packed, either for holding the uterus forward or for hemorrhage. 6. In clearing out the uterus with the curet for incomplete miscarriage. In many such cases where the miscarriage has just taken place, if the patient be placed in the Sims posture and all the manipula- tions made carefully, the uterus may be thoroughly cleared out with but httle pain and hence without an anesthetic. Fig. 97. View the arm behind son — American fiCS.) e, showing (Dickin- nf Obttet- 86 THE PHYSICAL EXAMINATION 7. When treating a sinus or abscess opening in the posterior vaginal fornix. When making the incision back of the cervix for pelvic abscess, the dorsal posture is the better one, as the cervix may be held out of the way by strong traction, but in the after-care of the case, the Sims posture is usually preferable. It causes the patient less pain and gives much better exposure of the opening back of the cervix. Fig. 98. Introducing the Sims speculum. Fig. 99. Speculum in place, and showing also the method of holding the same and of keeping the upper buttock out of the way. EXCISION OF TISSUE FROM CERVIX FOR MICROSCOPIC EXAMINATION. In many cases the naked-eye examination of the cervix is not sufficient to make a positive diagnosis between malignant disease and certain other affections of the cervix. In a suspicious case, particularly one that resists treatment, a small piece of the affected area should be excised for microscopic examination. A very con- venient instrument for this purpose is the specimen scissors shown in Fig. 90. With this a small piece of the su.spicious tissue may be chpt out of the cervix. If there is much bleeding, a suture may be placed under the bleeding surface and tied. Usually however a styptic application, with a firm vaginal packing, will stop the bleeding. The specimen excised from the cervix and also all curettings should at once be placed in a small bottle of alcohol (95%) or formol (10%) imd forwarded to the pathologist. THE UTERINE SOUND 87 EXPLORATION OF UTERUS WITH SOUND. Through the speculum the interior of the uterus may be explored with the uterine sound. The uterine sound (Fig. 101-a) is pliable so that it ma}^ be bent to accom- modate it to the uterine canal in different cases. It is graduated so that the exact depth of the canal may be told. It has a bulbous end so that there will ]m les.s danger of its puncturing the uterine wall. Fig. 100. Cervix caught with tenaculum-forceps and brought into view. Introduction of Uterine Sound. The sound should not be introduced by touch, as was formerly the custom and as is shown even in some recent text-lxx)ks, for when used in that way is is very liable to carry infection into the uterus. Before sounding, the speculum should be intro- duced, the cervix exposed and caught with a tenaculum-forceps and the cervix and vicinity cleansed with a reliable antiseptic solution. Then the sterile sound is introduced into the uterus without' Toaching the vaginal wall. Before intro- ducing the sound the approximate location of the fundus uteri should be deter- mined by bimanual examination and the sound should be shaped and guided 88 THE PHYSICAL EXAMINATION accordingly. The sound can usually be most conveniently introduced with the patient in the Sims posture and the cervix exposed with the Sims speculum. After the sound is sterilized do not touch the intrauterine portion with the lingers. If the end requires bending, dip a piece of absorbent cotton in a reliable antiseptic solution and grasp the uterine portion of the sound with this for bending. No force should be used in the introduction of the sound, other than is necessary to overcome a very slight stenosis. If the sound does not pass easily in the supposed direction of the canal, withdraw it slightly and try in other directions. If it does not then pass easily or if it causes much pain it should not be used further. Fig. 101. Instruments for exploring the interior of the uterus, a. Uterine sound, b. Three graduated metal dilators for enlarging the cervical canal, c. Small branched dilator, d. Small exploring curet. e. Intra-uterine applicator. Information Obtained by Uterine Sounding. As mentioned later, the introduction of tiie uterine sound is dangerous and rarely necessary. When it is necessary to use it, the information obtained should cover the following points: Size and Shape of Cervical Canal. Is thci-e stenosis? If so, is it located at llu' external os or the internal os or between the two? Is there anteflexion of cer.vix? This is indicated Ijy a sharp bend forward of thg canal at the internal os. In slich THE USE OF THE SOUND gg a case, even when there is no obstruction, the sound often stops at this point because it impinges on the posterior wall of the canal, and if force were used the wall would be injured. Curve the sound sharply so as to throw the point forward in a direction to pass the bend. Position of Body of L'terus. Does the point of the sound pass in the direction normally occupied by the uterine canal or is the canal, and consequently the body of the uterus, displaced? If so, is the displacement backward or forward or lateral? The direction of the canal helps also in determining which of two masses in the pelvis is the uterus, in cases in which this cannot be otherwise determined. Length of Uterine Cavity. Is there enlargement of the uterus? If so, to what extent? In chronic inflammation and in subinvolution there is slight enlarge- ment. In tumors, particularly in large intramural filjroids, there may be great elongation and distortion of the canal. Pain. There is usually some pain as the sound passes the internal os. In cer- tain cases of inflammation and of neuralgic trouble, the pain is much increased and the excessive tenderness may extend to the entire endometrium. Bleeding. A drop or two of blood may follow sounding when the uterus is nor- mal, but many drops or a slight stream following careful sounding, indicates a pathological condition of the endometrium. Centra-indications to Uterine Sound. There is considerable danger in the use of the sound, even when handled with care. It may carry infection into the uterus or it may, by the irritation, stir to activity a chronic inflammation or it may injure the wall of the canal or it may perforate the uterus and enter the peritoneal cavity. The danger of j^erforation is especially marked in a uterus recently pregnant or the seat of malignant disease. When proficiency in the bimanual examination is acquired, the introduction of the uterine sound will seldom be necessary. Remember the following rules as to sounding the uterus: Do not sound unless their is some special reason for it. Do not sound when there is active inflammation in the vagina or cervix with the body of the uterus free or when there is an acute or subacute salpingitis. Do not sound when there is a suspicion of pregnancy. If not extremely careful, you are liable in some doubtful case to inadvertently sound a pregnant uterus and cause serious trouble for the patient and for yourself. To avoid this, it is a good plan always, just before introducing the sound, to ask the patient, ''When did you menstruate last?" and to ask yourself, "Is there any sus- picion of pregnancy in this case?" If there is suspicion of pregnancy, put the patient on some treatment that cannot interfere with pregnancy and watch the- case until the next menstrual period. If you doubt the patient's statement that she is menstruating regularly, tell her that you must see her when menstruating the next time, that you may determine the nature of the flow. In that way you can determine whether or not she really menstruates. 90 THE PHYSICAL EXAMINATION EXPLORATION OF UTERUS WITH CURET. The exploration of the interior of the uterus with the curet, without anesthesia, is for the purpose of removing pieces of tissue for microscopic examination. Usually curetment imder anesthesia is preferable. In some cases, however, there are contra-inclications to anesthesia or for some other reason it is thought best to try to secure some tissue for microscopic examination so that a diagnosis may if possible be made before giving an anesthetic. The curet used for such exploration should be small and should have a sharp cutting edge (Fig. 101-d). Method of Procedure. The preparations are the same as for sounding the uterus — in fact, exploration with the sound should immediately precede exploration vnth. the curet. The slight dilatation required and the subsequent exploration with the curet, are usually best carried out ^^'ith the patient in Sims' posture. In some cases the cervix ^nll readily admit this small curet without dilatation. Usually, however, some dilatation is necessary and this is most easily effected with the graduated dilators (Fig. 101-b) of metal or hard rubber. Beginning "^ith the small size, the dilators are introduced one after another until the required dilatation is secured. The cervix is caught and steadied with a tenaculum-forceps, while dilatation is being made. As a substitute for uterine dilators, the ordinary steel bougies for the male uretha do very well in most cases. If preferred, the dilatation may be effected with a small bladed dilator (Fig. 101-c) or a curved uterine dressing-forceps. The bladed instrument is introduced closed and then gradually opened sufficiently to give the required dilatation. This is more painful usually and less convenient than the graduated dilators. All the manipulations should be made genth^, and nothing more than sHght dilatation should be attempted, as it would cause too much pain. This dilatation without anesthesia is not prac- ticable in the virgin, ordinarily, though in some cases it can be carried out very well. A method of securing a wider opening by slow dilatation is by packing the cervi- cal canal with antiseptic gauze. If carried out carefully this is safe, and is some- times effective. Under the same antiseptic preparation as for the other methods of dilatation, a thin strip of gauze is introduced into the uterus, past the internal OS if possible, and the cervical canal is packed firmly with it, the end being left out of the cervix. This is held in place by a vaginal packing of the same material. The patient should go to bed as soon as she reaches home and remain there until the time for the next treatment. In twentj^-four hours the packing is removed and the cervical canal is found considerably softened and dilated. Formerly tents were much used for dilating the cervix. Such a tent was simply a dry cone of some substance which, when moist, gradually expanded with suffi- cient force to dilate the cervix. The dilatation required several hours and sometimes several days, the patient in the meantime being given morphine on account of the pain. The substances used were sponge, laminai'ia and tupelo. EXAMINATION UNDER ANESTHESIA 91 Many deaths were caused by infection resultino; from the use of tents, and even in skihed hands and with all the modern antiseptic precautions, tents still cause serious tvouVile at times. Consequently their use has been almost abandoned. If used at all, the tent should be covered with a sterilized rubber tent cover. After the reciuired dilatation has been secured, the curet is introduced and por- tions of the diseased endometrium removed for microscopic examination. If there is persistent bleedinij; after the use of the curet, an intrauterine application of a 10 per cent copper sulphate solution may be used. If the bleeding still per- sists, a small piece of antiseptic gauze should be packed firmly into the uterine cavity and the vagina also packed with gauze. The gauze may be removed in t wo days and an antiseptic vaginal douche given once or twice daily for a few days. Contra=indications. The use of the curet for diagnosis is contra-indicated by tlie same conditions that contra-indicate the sound. The use of the curet with- out anesthesia, as just described, is not nearly as satisfactory as the regular curet/- ment under anesthesia. PELVIC EXAMINATION UNDER ANESTHESIA. The advantage of anesthesia is that it eliminates pain and Must:uLAR tension, the two factors that make the ordinary pelvic examination incomplete and un- satisfactory in certain cases. Preparations. In preparation for this examination the patient's bowels should be moved with a purgative on the previous day and the rectum should be cleared out with an enema an hour or two before the examination. The same preparatory examina- tion of the heart, lungs and urine should be made as though the anesthesia Ave re for an operation. Have ready a light strong tenaculum-forceps, so that the cervix may be caught and the uterus pulled down as desired. If the interior of the uterus is to be explored, the antiseptic preparation for curetment must be carried out. Examination Methods. The various manipulations employed in examination under anesthesia are as follows : Vagino-abdominal palpation, Recto-abdominal palpation, Recto-vagino-abdominal palpation, Recto-vesical palpation, Curetment, Exploration of interior of uterus with finger, Excision of i^iece of cervix for examination. VAGINO-ABDOMINAL PALPATION. In vagino-abdominal palpation under anesthesia, the same manipulations are employed and the same facts concerning normal and almormal pelvic structures 92 THE PHYSICAL EXAMINATION are sought, as in the ordinary vagino-abdominal (bimanual) examination. Under anesthesia, however, the examination is much more thorough. Deep palpation may be made in all portions of the pelvis, and the uterus, tubes, ovaries and ab- normal masses may be clearly outlined in nearly every case. The position, size, shape, consistency, mobility and attachments of a pelvic mass may be determined with far more accuracy than without anesthesia. In all doubtful cases, this method of examination should be employed before subjecting the patient to abdominal section. In the examination under anesthesia, the manipulations must always be made carefully and gently, otherwise a collection of pus may be broken open internally, causing peritonitis, or the sac of a tubal pregnancy may be ruptured, causing fatal hemorrhage. RECTO-ABDOMINAL PALPATION. The recto-abdominal palpation under anesthesia is made for the same purpose as the vagino-abdominal palpation and in the same way except that two fingers of the gloved hand are introduced into the rectum instead of into the vagina. Much additional information may be in this way obtained in some cases because, under anesthesia, the fingers can pass further up the posterior surface of the uterus. By catching the cervix with a tenaculum-forceps and pulling the uterus downward, the posterior surface of the uterus and the ovaries and the broad ligaments may be palpated with but little intervening tissue. To get the full benefit from this method, particular attention must be paid to details. After the patient is well under the anesthetic and as much information as possible has been secured by vagino-abdominal palpation, then make the recto- abdominal examination as follows: 1. Cleanse the rubber glove from all vaginal secretion or put on a fresh one (that no infection be carried into the rectum), and lubricate the glove with a drop or two of liquid soap. If the bare fingers have been used for vaginal examination, cleanse them and put on a rubber glove. If no rubber glove is at hand, fill the opace under the nails of the examining fingers by scraping across a bar of soap and then lubricate the fingers with a drop or two of liquid soap or with an abun- dance of vaseline or other bland ointment. If no rubber glove is worn, the exam- ining fingers should, immediately after the examination, be dipped at once (before putting them in soap "and water) into a strong antiseptic solution (e. g., bichloride 1-1000) and scrubbed in that with a piece of cotton. After that they are put through the regular scrubbing with soap and water and a brush. This immediate cleansing in a strong antiseptic solution before the regular scrubbing with soap and water, aids in removing the odor. 2. Introduce two fingers into the rectum. Under the anesthetic, the sphincter ani is readily dilated to admit the two fingers as they are carefully worked in. A much more thorough recto-abdominal palpation of the pelvic interior may be made with two fingers in the rectum than with only one. The fingers are worked past the rectal folds, up between the sacro-uterine liga- ments, which serve as landmarks, and then as far up beyond as possible. The anus and pelvic floor are pushed into the pelvis as far as they will go, by firm.pres- RECTO-ABDOMINAL PALPATION 93 sure against the elbow of the examining arm, the elbow resting on the knee or against the hip, as in deep vagino-abdominal palpation. In this way the tips of the examining fingers may be carried far up into the posterior part of the pelvis. There may be some difficulty in finding the rectal canal in the region of the sacro-uterine ligaments. Sometimes the interior of the rectum feels like a large pouch without any opening extending higher. If you are satisfied to make the pelvic palpation by attempting to carry up the wall of this pouch, you will be much hampered. By locating the cervix uteri and then the two sacro-uterine ligaments and working round to get past the rectal valves and folds, a small opening will be felt extending upward between the sacro-uterine ligaments. Follow this up (it dilates easily) and you will find further progress unobstructed. The fingers are carried as high as they will go and then the al^dominal wall is depressed from above by the other hand (Fig. 102). 3. The various structures in the posterior and central parts of the pelvis are then caught between the hands and outlined and otherwise examined ])v palpation, one at a time. The palpation proper is made principally with the rectal fingers, the abdominal fingers serving simply to push down the structures to within reach of the fingers below. In this palpation, the guide is the body of the uterus. The fingers pass up the posterior surface of the uterus to the fundus and then out to the lateral region of each side, palpating the tube and ovary and any abnormal mass. In a patient with only a moderately thick abdominal wall, the ovaries and tubes may be distinctly outlined, unless they are obscured by adhesions or by an inflam- matory mass or by a tumor. 4. Then catch the cervix with a tenaculum-forceps and draw it down gently, and have someone hold the forceps to keep the uterus in the do\\Tiward position. This drawing downward and forward of the cervix, throws the fundus backward so that it is caught between the rectal fingers and the abdominal fingers; and its size, shape, consistency, mobility and attachments may all be accurately made out. The fingers then pass to the adnexa, determining the same points concerning them. If there is a movable mass of doubtful origin, have some one catch it from the abdominal surface and pull it up towards the abdominal cavity so that the ex- amining fingers (rectal and abdominal) may meet between the mass and the pelvic structures. In this way, the pedicle of the mass (if it ari-ses from the pelvis) may be felt and traced to its origin, and also its length and thickness determined (Fig. 103). This is sometimes referred to as Hegar's method of examining the pedicle of a tumor. 5. Cautions. Particular care must be exercised that the structures be not in- Fig. 102. Recto-abdominal palpation. The hand should be gloved. (Montgomery — Proc^'ca/ gynecology.) 94 THE PHYSICAL EXAMINATION jiiriously pressed or pulled upon, for as the patient is anesthetized the usual warn- ing complaint of pain is absent. There are three points that it may be well to mention particularly: (a) Do not use much force in palpation. A pus sac may be broken, causing peritonitis, or a tubal pregnancy may be disturbed sufficiently to cause a fatal hem- orrhage. In fact, a patient with suspected tubal pregnancy should not be examined under anesthesia until she is gotten to the hospital or until things are ready in the home, so abdominal section could be carried out immediately should threatening symptoms arise during the examination. Again, if much force is used the examining fingers may be pushed through the I'ectal wall into the peritoneal cavity. Kelly mentions cases in which this accident occurred and in which immediate abdominal section, or vaginal section, was carried out to repair the rent in the bowel- wall and prevent fatal peritonitis. (b) Do not draw do"^Ti the uterus very far nor very forcibly, for reasons alread}' given. I make it a rule to luring the uterus dovrn no further than is absolutely necessary to satisfactorily palpate it. In most of these cases all that is necessary is a slight downward displacement, that permits the fundus to go somewhat back-ward so that it can be grasped well l^etween the rectal fingers behind and the al:>dominal fin- gers in front. The extreme downward displacement of the cervix, to the vag- inal entrance or even outside, is not necessary nor advisable, except in cases where there is already prolapse of the uterus. The occasion for it does arise if the fingers are carried up the rectum by invagination of the pelvic floor, as above described. (c) The suggestion to use the whole hand in the rectum for exploration in difficult cases, was long ago made and carried out with disastrous results. This method should not be used. It has led to rupture of the rectum, with fatal peritonitis. Furthermore, no need for it is experienced if the palpation with two fingers is carried out vnth close attention to the details above given. Fig. 103. Palpatins the pedicle of a tumor, with the tumor pushed up into the abdominal cavity and the uterus caught with a tenaculima- f creeps and pulled downward. (Montgomery — Practical Gynecology.) RECTO-VAGINO-ABDOMINAL PALPATION. In some cases, additional information may be obtained by this method. With the two fingers in the rectum, the thumi) of the same hand is passed into the vagina and the lower part of the pelvic mass or of the uterus is grasped between the fingers and the thumb, the structures being pressed down within reach by the abdominal hand (Fig. 104). In some cases, this is of decided assistance in outlining a small mass low in the DlAGNOSriC CURETMENT 95 pelvis and in determining the exact consistency of different parts of it. In certain cases, where there is a wide vaginal opening and relaxed pelvic floor, the examiner ma}' palpate the uterus or other mass low in the pelvis, with almost as much accu- racy as though it were removed and lying free in the hand. A modification of this method is to introduce the middle finger into the rectum and the index finger into the vagina and palpate the structures between the fingers as the uterus is pushed down from above. This method of recto-vagino-abdominal palpation has been found useful in determining the extent of involvment of the parametrium in cases of carcinoma of the cervix uteri. RECTO-VESICAL PALPATION. In the recto-vesical palpation under anesthesia, a medium sized urethral bougie (about 21 F) is introduced into the bladder, and one or two fingers into the rectum. The tissues between the rectum and the end of the bougie are carefully palpated by the rectal fingers. This method is used in only two conditions — (a) in determining the presence or absence of the uterus in cases of atresia of va- gina and (b) in distinguishing between inversion of the uterus and a large pedunculated fibroid hanging from the cervix. In a very stout patient, this method may be the only means of mak- ing a positive diagnosis in the classes of cases mentioned. If the bladder is not irritable, this method may be em- ployed gently ^\'ithout anesthesia, but the examination under anesthesia is far more satisfactory. Caution. Palpation with the finger introduced through the dilated urethra, I mention only to condemn. It is dang- erous in that it is liable to cause per- manent incontinence of urine, a condi- tion which resulted in several reported cases. Fig. 104. Recto-vagino-abdominal palpation. One or two fingers of tbe gloved hand are intro- duced into the rectum and the thumb into the vagina, and the uterus, or other mass low in the pelvis, is grasped between them, as it is pushed down by the abdominal hand. (Montgomery — Practical Gynecology.) CURETMENT UNDER ANESTHESIA. Curetment for diagnostic purposes is carried out the same as regular curetment for therapeutic purposes. By it tissue is obtained from all portions of the endo- metrium for microscopic examination. As previously stated, this is much more satisfactory than the partial curetment without anesthesia, for by the curetment under anesthesia tissue is removed from practically all parts of the cavity. Conse- quently, if in the subsequent microscopic examination no malignant tissue is found, we may be fairly certain that there is no malignant disease. Furthermore, regular 96 THE PHYSICAL EXAMINATION curetment under anesthesia combines with its diagnostic vakie a decided therapeutic effect, for it removes the diseased endometrium and diminishes bleeding and dis- charge. As will appear later, curetment is often indicated in a particular case by both therapeutic and diagnostic considerations. For example, when a patient has uterine bleeding or discharge that resists ordinary treatment, curetment is indicated to stop the bleeding or discharge and also to furnish tissue for microscopic examination. Of the various conditions that give rise to persistent bleeding and discharge the follomng produce characteristic changes in the endometrium: Chronic endometritis, Malignant disease (carcinoma, sarcoma), Tuberculosis of the endometrium, Recent abortion. There are other conditions, for example, extrauterine pregnancy, in which the microscopic appearance of the curettings is not pathognomonic but in wliich the information obtained in this way, added to the symptoms, may make the diagnosis positive in an otherwise doubtful case. Collecting Curettings. In a diagnostic curetment, observe the following points: 1. Remove the endometrium from all parts of the uterine cavity. 2. Put all the curettings into a small vessel immediately and shake with water to remove blood-clots. If the water is so bloody that it is desired to change it for further wasliing, it is poured through gauze. The gauze catches the curettings, which are then emptied into fresh water. The water into which curettings are placed should be clear and clean. Normal saline solution is preferable to plain water as it causes less sweUing of the cells, hence it should be used for the washing when the curettings are to be subjected to any particular or special examination. 3. Then transfer all the tissue fragments, without compression, to the small bottle containing 95% alcohol or 10% formol solution and send to the laboratory. 4. If the pathologist is in a distant city, the little bottle should be corked securely and put in a mailing tube or wrapped with cotton and other'^dse packed securely for safe transmission. 5. With the specimen, send a note stating the nature of the specimen (curettings from within uterus), when obtained, name and age of patient and some of the important facts in the history of the case. EXPLORATION OF UTERINE CAVITY WITH FINGER. Exploration of the interior of the uterus with the finger may be employed when satisfactory information cannot be obtained otherwdse. The cervix may be di- lated in the same manner as for curetment, i. e., with a strong bladed dilator, but the dilatation must be carried much further, as it takes a larger opening to admit the finger than to admit the caret. The dilatation required for satisfactory explo- ration with the finger must be so wide that it is only in exceptional cases that it can be secured in the non-puerperal uterus with the ordinary dilator. DIGITAL KXPLOUATIO.V OV UTERINK CAVITY 97 To secure satisfactory dilatation, Schatz's metranoikter may be used. This consists of two blades separated by a strong spring. They are introduced into the cervix closed. The removal of the introducing handle releases the spring which gradually effects wide dilatation of the cervix, within twelve to twent3^-four hours. The pain is controlled by morphine. This instrument causes wide dilatation and may be used in preparation for examination under anesthesia where for some particular reason it is desired to palpate the interior of the uterus. It may be used also to dilate the cervix for curetment without anesthesia or even for explora- tion of uterus with the finger without anesthesia. Hirst has modified the Schatz metranoikter, making it with foui- blades instead of two. A more certain and satisfactory method, when the patient is given an anesthetic, is to dilate the cervical canal to the usual extent with the regular bladed dilator and then divide the wall of the cervix with a knife or scissors, in the median line anteriorly up to or above the internal OS. The bladder must of course first be separated from the cervix and pushed up out of the way. This allows a thorough exploration of the interior of the uterus with the finger. It is a rather formidable procedure for ex- ploration alone and usually is employed only after preparations have been made to do a hysterectomy or other opera- tion immediately after the exploration, if such is found necessary. After sufficient dilatation has been obtained by one of the methods men- tioned, the finger is introduced into the uterine cavity and the walls pal- pated, the uterus at the same time being pushed downward and steadied by the other hand the same as in bimanual examination. Some additional information may be obtained by this method, for example, we may determine the presence of irregularities of the uterine wall, of projecting growths, of softened or broken down places or of areas of induration. Exploration of the uterine cavity with the finger is seldom necessary in the non- puerperal uterus. In all but exceptional cases, the diagnosis may be made without it. In the puerperal uterus, it is exceedingly useful for determining the presence of placental remnants (Fig. 105) and for safely clearing out the same. InlTie recently pregnant uterus no special dilatation measures are necessary be- cause the cervix is so soft that abundant dilatation is secured with the ordinary bladed dilator or in some eases even with the finger alone. Fig. 105. Exploration of the interior of the uterus with the finger. This represents a puerperal uterus with retained placental remnants. (Edgar — Practice of Obstetrics.) EXCISION OF TISSUE FROM CERVIX. Excision of a piece of tissue from the cervix for microscopic examination may be quickly carried out following curetment or other exploratory examination, 98 THE PHYSICAL EXAMINATION \5^hen thought advisable. In this way a positive diagnosis of maUgnant disease of the cervix may be made in the early stage. This aid to diagnosis should be car- ried out during the examination under anesthesia whenever a suspicious ulcer or induration is present. A small wedge-shaped portion of the suspicious area, in- cluding some healthy tissue, is excised and the wound thus made is closed by one or two sutures. The sutures should be left in about ten days, the patient in the meantime receiving one or two antiseptic douches daily. She need not remain in bed. Fig. 106, Kitchen table, with portable foot-rests attached ready for a gynecological examinatioa. PREPARATIONS FOR GYNECOLOGICAL EXAMINATION. The various points considered under this head may be grouped as follows.- Office Arrangements. Directions to Patient; Antiseptic Preparations. Soap, Brushes, Lubricant. Use of Rubber Gloves. Avoid Unnecessary Exposure. Preservation of Specimens. Examination on Bed.' PREPARATIONS FOR GYNECOLOGIC.VL EXAMINATION 99 OFFICE ARRANCJEMENTS. There are three thin.sis of particuhir importance in the liandliiiii; of f?ynecological patients: 1. Screened Area in the consulting room. The portion of the room that is used for the examination should be siiital)ly screened from the other part, so that the patient may remove the corset and make such other arrangement of the clothing as she wishes, in privacy. It is very convenient to have a separate room for the examining- room, with an attached toilet-room. Where no separate room is avail- able, a neat substantial screen, affording the patient privacy for the required prepa- ration, does ver}' well and is inexpensive. 2. Table. A satisfactory table for gynecological examinations is the regular surgical chair with foot-rests. The advantage of the foot-rests is that the pa- tient's hips may be brought to the end of the table without her feet being forced so near the buttocks as to be uncomfortable. In the absence of the surgical chair, portable foot-rests may be attached to a plain kitchen table (Fig. 106;. With these portable foot-rests are furnished also tall uprights for use as leg-holders, by which the feet and legs may be held out of the way during examination under anesthesia or during an operation. They are convenient for use during minor operations at the patient's home (Fig. 572) . 3. Nurse. When a physician is doing much gynecological work it will be found a wise investment to have a nurse, to prepare the patients for examination and to prepare the necessary articles needed in office examination and treatment. Aside from the great convenience to the physician, it makes the patients more at ease and in addition tends to protect the physician from blackmail by designing persons. Where a nurse is not required for other work, she may be hired just for the office hours and thus the expense reduced. DIRECTIONS TO PATIENT. Direct the patient to remove the corset and loosen all bands about the waist, so that the clothing may be pushed up and down sufficiently to bare the abdomen. This is necessary at first, for the first examination should be thorough, including examination of the entire abdomen as well as the pelvic exploration. Examina- tion of the breasts may be necessary in cases of suspected pregnancy. If there are indications of disease of the heart or lungs, those organs also should be ex- amined, and the same is true of the nervous system. In the subsequent visits, it may not be necessary to remove the corset or loosen the clothing, depending of course on what treatment or further examination is required. It is not necessary in ordinary cervical or vaginal treatments. Any treatment however necessitating deep bimanual palpation, such for example as replacement of a retro-displaced uterus, requires the removal of the corset and loosening of bands. After completing the abdominal examination, direct that the hips be brought to the foot of the table. The patient is covered mth a clean sheet and under the 100 THE PHYSICAL EXAMINATION sheet the skirts are pushed up above the knees and out of the V7SLy. The sheet is then parted so as to expose the genitals onty, being draped so as to cover other parts. It is well, as a rule, to inspect the genitals, for often information of value is obtained in cases where the history gives no intimation of disturbance externally. If it is thought unnecessary to inspect the genitals, the hand is carried under the sheet for making the vaginal and vagino-abdominal examination. ANTISEPTIC PREPARATIONS. If you wish to protect your patient and likewise your hands from the danger of infection, certain antiseptic precautions must be taken. The necessar}^ measures are simple and easily earned out, and if employed regularly become more or less of a habit. The needed disinfection T^ill be incUcated by naming the dangers to be avoided, which are as follows: 1. Infection of the patient from your hands. If your hands are well cleansed before each examination, there can be no infection from them. 2. Infection of j^our hands from the patient. If there is a scratch or abrasion anywhere about the fingers, the hand should be co\'ered "uith a rubber glove (Fig. 53). If no rubber glove is at hand, a rubber finger-cot should be sHpped over the abraded finger or the abrasion covered with collocUon spread over a few fibers of cotton. If the collodion rubs off during the examination of a patient "oith syphilis or chancroid or other infectious disease, the abrasion must be immed- iately touched with pure carbolic acid or nitric acid and again covered with col- lodion. We hear a gi'eat deal about the danger of the patient becoming infected, but very little about the danger to the physician; and yet I suppose there are few physicians of experience who do not number among their professional friends, one or more who have become infected T^ith syphilis through abrasions of the hands. Dudley states that he is acquainted vdth not less than twenty physicians who have been infected \^ith s^-^Dhilis through abrasions of the fingers in digital examinations. Each physician must look out for himself and Ms family. Remember that "pre- vention is better than cure," and, it may be added, a great deal easier. 3. Infection of the patient from instruments. If the instruments are sterilized each time before use, there can be no danger from them. 4. Infection of the patient from the table. To prevent this, place under the patient's hips a rubber pad or piece of rubber cloth and over that a clean folded towel, which is changed ^xith each patient. Precautions. The precautions to be taken in order to avoid infection may be summed up in three rules, as follows: 1. Disinfect and Protect the Hands. Trim the finger-nails short and clean under them. Cleanse the hands Avell with soap and water and dry them with a clean towel. Protect any abrasion on the hand with a clean ruJjber gloN'e. If there is any break in the protecting epithelial layer of the vulva or vagina or cervix, or if the interior of the uterus is to 1)o explored, the hands should be further cleansed in 1-2000 bichloride or other reliable antiseptic solution (i. e., they should be put through the regular process of surgical disinfection) or boiled rubber gloves may be slipped on. PRECAUTIONS AC.AINST IN I'ECI'K ).N 101 Fig. 107. A simple instrument boiler. 2. Sterilize the Instruments. This may be accomplished ]yy .soakiii^r tliciv in pure carbohc acid (95%) for ten minutes or in a 10% carboUc solutioirfor tliirty minutes. A safer plan is to boil them for five or ten minutes. For boiling the instruments, a 1% solution of sodium carbonate (wa.shing soda) is preferable to plain water. It dissolves the resisting capsule of l^actcria and destro3's them more quickly (in five minutes l)oiling) and also tends to diminish rusting of instruments. Any kind of a pan, set on a stove or over an alcohol lamp or gas flame, will do for an in- strument boiler. The ordinary fish- boiler of granite-iron makes a very good instrument sterilizer. A satis- factory simple boiler for instruments is shown in Fig. 107. Nicer and more convenient instrument boilers may be purchased as desired. There are a number of satisfactory patterns. The one shown in Fig. 108 has the advantage that the ch-essings for a small operation may be sterilized at the same time with the instruments. In office or clinic work when through examining a patient, wash the instruments and drop them into the boiler and in a few minutes they are sterilized, ready to use for another patient or to be put away. Edged instruments, such as knives and scissors are more or less dulled by the boiUng. Consequently when there is plenty of time, it is better to sterilize them by soaking them in carbolic acid or other suitable antiseptic. When a knife is put in with other instruments for ster- ilization the cutting portion should be wrapped with cotton. The instrument tray also must of course be sterile. It is contaminated every time a soiled instrument is laid back in it and unless disinfected may carry disease from one patient to an- other. To obviate this, each instrument after use may be laid on a clean towel (if it is to be used again during that examination) or dropped in a basin for later cleansing. Again, a light shallow pan may be used as an instrument boiler and instrument tray combined, the instruments being boiled in it each time before use. This gives, in a few minutes, sterile instruments in a sterile container. 3. Do not touch the intrauterine part of any instrument. This rule should be very carefully observed, for in it lies one of the secrets of avoiding infection of the uterine cavity in office examination and treatment. The hands may have been well disinfected or they may have been covered with Fig. 108. A small instrument and dressing sterilizer. The dressings for a small operation may be sterilized in the trays above the boiling instruments. 102 THE PHYSICAL EXAMINATION Fig. 109. The articles needed for preparing for the gynecological examination, arranged conveniently on a stand, a. Finger-nail instruments, b. Rubber gloves, c. Powder for dustir-g in rubber gloves, to make them slip on easily, d. Liquid soap in a drop-bottle, e. Hand brushes, f . Bichloride solution, g. Cotton balls, h. Lubricant in compressible tube. Fig- 110. Methpd of using the drop-bottle coijtainiiig licjuid soap. ARTICLES FOR PREPARATION OF HANDS 103 boiled rubber gloves, giving a perfectly sterile covering, but in office work the field of examination has not been disinfected. The hands necessarily touch un- disinfected surfaces and hence do not remain sterile. Consequently, when hand- ling an instrument for intrauterine work, it is important, even when wearing rubber gloves, to observe the rule not to touch that part of the instrument that is to enter the cervical canal. When bending the end of the uterine sound, dip a large piece of absorbent cotton in a reliable antiseptic solution and grasp the part to be moulded with that. If the uterine canal is to be cleansed M-ith a cotton-wrapped appli- cator, use one of those previously prepared, as described under intra-uterine treat- ment in chapter iii. If one must be prepared for immediate use, be sure to cleanse carefully the fingers that touch the cotton and also, before introducing the cotton, dip it in an antiseptic solution. The other antiseptic precautions necessary in intrauterine exploration and treat- ment have already been given. F SOAP, BRUSHES, LUBRICANT. Soap. Use some liquid preparation of green soap. The free use of such a soap is the most important step in hand disinfection. A number of excellent and con- venient preparations of liquid soap have been put on the market by various firms, in drop bottles (Fig. 109-d) from which the soap may be dropped as needed without waste. Such a bottle may be filled with ordinary tincture of green soap (tincture sapo viridis) or any other required prep- aration, purchased in quantity or made up as desired. Fig. 110 shows the use of the drop bottle. A still more convenient arrangement is the stationary holder for liquid soap, fastened just above the wash- stand. Fig. Ill shows a good pattern. Slight up- ward pressure against the projecting stem at the bottom causes the liquid soap to flow into the hand. Some liquid preparation should be used entirely for soap. The ordinary cake soap is not effective for surgical cleansing. Brushes. For cleansing the irregularities about the ^^s- m. a convenient waii- ° fixture for liquid soap. Slight fingers, a brush is necessary. The ordinary small upward pressure on tiie metal hand-brush of vegetable fiber with a plain back (Fig. ^^^-^ ^^ ^^e bottom causes the soap to flow into the open hand. 109-e), does very well. Such brushes are cheap and will stand boiUng and are effective as long as the fiber portion is uniforml}' stiff. When a brush becomes too soft from repeated boiling, it should be thrown away or laid aside to be used on surfaces where a softer brush is required, such as the abdominal surface or genitals of patient being prepared for operation. A brush used in scrubbing the hands after examining an infected or doubtful case, must be boiled before being used again. It is convenient to have several brushes boiled and kept in a jar ready for use. They may be kept dry or in an anti- septic solution, 104 THE PHYSICAL EXAMINATION Lubricant. A drop or two of liquid soap on the wet fingers or glove makes a most satisfactory lubricant. The smallest quantity lubricates thoroughly and is in a measure antiseptic and is easily removed. Glycerine I do not find satisfactory. Unless used in such large quantity as to be inconvenient, it does not lubricate well. In the absence of liquid soap, any clean unirritating ointment will do. When an ointment is used, it is well to have it put up in a compressible tube (Fig. 109-h), for then the unused part is kept sterile. USE OF RUBBER GLOVES. I wish to call attention to the routine use of rubber gloves in examination and office treatment, particularly in cases where any infection is present or suspected. Fig. 112. Patient arranged for abdominal exataination in bed. For ordinary office work, it is convenient to put them on dry. When a small amount of boric acid powder or talcum powder is dusted into each glove, it slips on easily. The glove-covered hands are then put through the regular washing with liquid soap and water. After the examination, the gloves are slipped off and thro^^^l into a basin for subsequent boiling. Thus the infective material is kept away from the washstand as well as from the hands. After the office work is finished, water is poured into the basin of soiled gloves antl they are boiled for ten minutes. It is well to have a towel in the basin to protect the gloves from injury by direct contact with the hot metal ])ottom and sides. After the steriliza- tion, the gloves are taken out, cleansed in water to remove all foreign particles adhering to them, dried on a clean towel (being tui-ned inside out often enough to secure good drying), dusted inside and out with a drying ]-)Owder, wrapped in THE USE OF RUHBEU CLOVES 105 a clean towel, and laid away for subsequent use. When there is an examination or treatment requiring sterile hands, a pair of the rubber gloves is wrapped in a small towel and dropped into the water on top of the instruments, to be boiled with them. When putting on the boiled gloves fill them with sterile water to make them slip on easier. When no cool sterile water is at hand for distending the glove, a drop of liquid soap rubbed over the hand will enable the glove to slip on easily. In putting on a sterile glove, do not touch the fingers of the Fig. 113. Patient arranged for vaginal examination in bed. In this and the two succeeding photo- graphs, the sheet has been pushed aside to show the necessary relations. As a rule the examination can be conducted under the sheet without any exposure of the gentials. glove with the other hand. When it is necessary to push the glove on a finger, use a portion of the tow^el in which the gloves were boiled. Two or three pairs of rubber gloves, kept ready for use, constitute one of the best investments the practitioner can make, for the following reasons: 1. They protect the hands from syphilitic or other infection through some un- noticed crack or abrasion. 106 THE PHYSICAL EXAMINATION 2. They prevent disagreeable odors clinging to the hands, as otherwise happens in vaginal examination in cases of advanced uterine cancer and in all rectal exam - inations. 3. They do away with the severe scrubbing of the fingers and hands, which is otherwise necessary after each examination or treatment of a patient with any form of infection. This frequent severe scrubbing keeps the skin rough and in bad condition. 4. Boiling the gloves after use, eliminates all danger of carrying contamination from one patient to another and keeps the infective material away from the wash- stand and other office fixtures. Fig. 114. Deep bimanual examination with the patient in bed. Showing the relations of the examining hand and arm. The examiner sits on the side of the bed and the arm lies between the widely-separated thighs, so that the examination is made from directly in front of the pelvis. 5. When an absolutely sterile covering for the hands is desired, it is easily se- cured by boiling the gloves immediately before use. AVOID UNNECESvSARY EXPOSURE. In all the steps of the examination and in all examinations and treatments, avoid exposing the patient any more than is necessary. Do not let your study of the clinical and scientific features of the case so preoccupy your mind that you neglect this. OTHER POINTS IN THE EXAMINATION 107 The carelessness manifested in this respect by some physicians Is? extremely reprehensible. This careless disregard of the natural modesty of the patient is seen both in private work and in clinic work but especially in the latter, where it is just as reprehensible as in the former. To the physician studying the difficult features of a case in an endeavor to save the patient's life or restore her to health, this may seem a small matter — but nevertheless it is an important one and should be thought of. Furthermore, the poor patient, who in the clinic puts herself under the care of the teacher and his assistants, is just as much entitled to thought- ful consideration in this matter as the woman m Ijettcr financial circumstances who comes as a private patient. PRESERVATION OF SPECIMENS. The preservation of speci- mens for microscopic examina- tion is a very simple proceed- ure and yet in many doubtful cases, curettings or cervical polypi removed or pieces of tissue passed spontaneously, are thrown away or kept in such a manner that they are not fit for microscopic exam- ination. Thus is lost a valu- able aid to early diagnosis, in conditions where early diag- nosis is important. A good all-around preserva- tive for these specimens is alcohol (95%). It is nearly always at hand and it preserves the specimen indefinitely in good condition for microscopic examination. As soon as pos- sible after removal and with- out unnecessary handling, the specimen is dropped into a small bottle containing the preservative and then for- warded to the pathologist. A 10% solution of formol is another good preservative. Formol, which is a 40% solution of formaldehyde gas, is known also as formalin and as formalde- hyde solution. For particular points in the saving and transmission of curettings for diagnostic purposes, see previous pages (curetment under anesthesia). Fig. 115. Deep bimanual palpation with tlie patient in bed, show ing the abdominal arm bettveen the thighs. The otiier arm is partially hidden by the sheet. 108 THE PHYSICAL EXAMINATION EXAMINATION ON BED. When a patient is seen at her home, sick in bed, the methods of exploration employed are usually abdominal, vaginal, vagino-abdominal and, in some cases, recto-abdominal. A patient who is too sick to come to the office for a pelvic examination, is usually suffering, not with a superficial disturbance that can be seen by inspection of the external genitals or through a speculum, but with some (ieep-seated trouble, the nature of which can be determined only by deep internal palpation. In such a case , the inspection of the genitals and the speculum exam- c5:*'!^ Fig. 116. Regular "cross-bed" position. The patient is turned directly across the bed, with the hips rest- ing on the edge of the bed and each foot on a chair. ination add nothing of importance to the information otherwise obtained, and as they are particularly disagreeable to the patient they may be dispensed with. In such a case, the abdominal examination is first made. The patient is di- rected to move to the edge of the bed and the clothing is loosened and pushed up and down, to expose the alxlomen, and the knees are drawn up to relax the ab- dominal muscles (Fig. 112). The abdomen is then examined by the various me- thods previously explained. The vaginal and vagino-abdominal examinations, with deep bimanual palpation. may be conveniently and satisfactorily conducted with but little disturbance to the patient by observing the following directions, some of which were partially carried out in arranging for the abdominal examination: METHOD OF EXAMINATION ON BED 109 1. Direct the patient to move close to the left edge of the bed. There is but little disturbance — she lies just as she is in the bed, except nearer the left edge (or the right edge, if the examiner uses the right hand for the internal palpa- tion). A patient seriously sick, even with peritonitis, may usually be moved over sufficiently without much pain. 2. Remove the heavy bed-clothing, all except the sheet with perhaps a light blanket, and have the patient draw up both knees so that the feet are near the buttocks (Fig. 113). Fig. 117. Another method of arranging a bed-patient for examination of external genitals. This is useful when the patient is very sick or when movement is painful. The hips are simply slipped to the edge of the bed and one foot placed on a chair. 3. Sit on the bed, or on a chair placed at the side of the bed, against the patient's left foot and direct the patient to separate the knees widely. The sheet is then raised sufficiently to permit the examining hand (with the index and middle fingers well lubricated) to be passed between the patient's thighs (Fig. 114) — not under one thigh, as ordinarily directed. The hand is carried to the perineum and the examining fingers are introduced deeply into the vagina, taking care to depress the perineum sufficiently to allow their introduction without pain. 4. After the simple vaginal examination is completed, then the right hand, passed under the sheet, is made to depress the abdominal wall into the pelvis as in the regular bimanual examination (Fig. 115). In Figs. 113 and 114 and 115, 110 THE PHYSICAL EXAMINATION the sheet has been pushed aside in order to show the necessary relations. Ordi- narily the entire examination may be conducted under the sheet and without ex- posing the patient in the least. I call special attention to the details given above because I find that their accu- rate carrying out aids materially in securing needed information in deep-seated pelvic troubles. By following the directions closely, the examining hands and arms are made to occupy practically the same advantageous relation to the pelvis as in the regular office examination with the patient at the end of the table — that is, the examination is made from directly in front of the pelvis. The usual procedure of sitting on a chair beside the bed, with the examining arm passed under the thigh (instead of between the thighs) is much less effective when deep pelvic palpation is required. While the examination steps above mentioned are generally the only ones re- quired when the patient is sick in bed, there are some cases in which further ex- amination is advisable. Whenever the patient complains of sores about the genitals or of itching or burning or profuse discharge, the genitals should be inspected in a good light. Likewise in any case in which it is thought that additional infor- mation of value may be obtained by the speculum examination, that procedure should be carried out. For the inspection of the external genitals and for the speculum examination, the patient may be turned across the bed with the hips near the edge and each foot resting on a chair (Fig. 116). This is often referred to as the "cross-bed" position. If movement of the patient to this extent is likely to cause pain, she may be simply turned shghtly and one foot placed on a chair while the other foot rests on .the bed, as shown in Fig. 117. NON-QYNECOLOQIC EXAMINATION METHODS IN GYNECOLOGICAL CASES. The physician must consider the whole patient. His work Is to ascertain what is troubling the patient — in whatever part of the body the disease may be located or whatever organ or organs may be affected. It is not enough to find one well- marked disease. All the important troubles present, both organic and functional, should be found, for then only is the physician in a position to judge accurately as to how far each disease is responsible for the patient's disaliility and what the line of treatment -should include and what the result will probably be. To do this the physician must employ, in gynecological cases, various methods of examination which belong to other departments of medicine, and the detailed consideration of which would be out of place here. 1 will simply call attention here to the classes of patients with pelvic symptoms in which such extra-gyne- EXAMINATION OF THE URINE UJ cologic examinations are especially required in the course of diaf^nosis or treat- ment. The examination methods to which 1 wish to call attention are, aside from the usual {ihysical examination of the chest, as follows: Examination of Urine. Blood Examination. Sputum Examination. Examination of the Nervous Svstem. EXAMINATION OF URINE IN GYNECOLOGICAL CASES. The examination of the urine gives important information as to the metabolism of the body and as to the condition of the most important excretory organs. In the following cases it is especially important that the urine be examined. 1. When the patient is seriously sick from any cause. In such a patient it is important to know the state of the body metabolism and excretion. 2. When there are bladder or kidney or ureteral symptoms. Do not treat the patient for weeks or months for frequent painful urination or pains in the kidney region, without examining the urine to see whether or not there is a local lesion. And when there is trouble in the urinary tract, make frequent examinations that you may keep posted as to the improvement. 3. When the patient is to undergo anesthesia, either for operation or examina- tion. The discovery of diabetes mellitus or chronic interstitial nephritis is made with much more satisfaction to yourself and much better prognosis to the patient before anesthesia than afterward, when the patient may be in diabetic coma or urameic convulsions. Again, in the milder cases, it is not pleasant to be obliged to date the patient's persistent nephritis from your operation or anesthesia, when in all probability it was there before, but you have no proof of it. Again, a know- ledge of the patient's kidney function may cause you to postpone the operation or anesthesia for a time, until the temporary disability is overcome. 4. In doubtful cases — cases in which the cause of the patient's local symptoms or general debility is not clear. You wonder why the patient does not pick up and improve more rapidly under your excellent treatment. You are annoyed by the patient's reiterated complaint of the bladder irritability or the loin-pain or the headaches tliat come without reason or the digestive disturbances that persist without good and sufficient cause. There is a hidden cause. It may be in the urinary tract. It may, on the other hand, be in the digestive tract or in the blood or in the nervous system or in the lungs. Find it. BLOOD EXAMINATION IN GYNECOLOGICAL CASES. The points in blood exannnation which are helpful in certain patients with gynecological symptoms are the hemoglobin percentage, the red-cell count, leu- cocytosis, poikilocytosis and certain special conditions (Widal reaction, malaria Plasmodium, pyogenic bacteria or other bacteria in the blood). 112 THE PHYSICAL EXAMINATION The cla'sse* )f cases or conditions in which definite information on one or more of these points may be of material assistance are as follows: Marked Anemia. Acute Conditions of Doubtful Character. Inflammation of Uncertain Progress. Inflammation with Uncertain Resistance. Blood Examination in Marked Anemia. In gynecological patients with marked anemia, there are three conditions in which a blood examination is especially useful: 1. When the cause of the anemia is not dear. You may be mistaken in your idea that the persistent anemia and increasing weakness is due to the chronic pelvic disease. Possibly the patient has one of the various forms of pernicious anemia. An examination of a stained specimen of the blood will tell at once. I remember a patient whose anemia was supposed to be due to an associated chronic malaria and she was treated for that many months, until her condition be- came desperate. When I saw her, there were some pelvic symptoms but not suffi- cient to account for the deterioration of general health. Being at a loss to account for the anemia and weakness, and finding nothing of special importance in the urine, I took specimens of the blood. Examination of these made the case clear at once. There was an advanced leukaemia, of which the patient died within a few months. The pelvic disturbance had nothing to do with the serious symptoms. In a doubtful case, if not prepared to make the blood examinations yourself, make some cover-glass spread preparations of the blood, pack them securely in a pill-box or other suitable container and mail them to a pathologist, vnth. a brief statement of the history of the case. 2. When anesthesia or an operation is required. In a patient markedly anemic, anesthesia is a serious matter even though it is only for . a small operation or simply for examination. All the organs are below par and some condition that would be a trivial matter at other times might lead to a fatal termination. A red-cell count or a hemo- globin estimate will give definite. information as to the oxygen carrying power of the blood. If the hemoglobin is below 30%, the operation or anesthesia should be postponed if possible until the patient has been put in a better condition, by the administration of iron and such other tonics as are indicated. 3. When trying to overcome serious anemia. In such a case a hemoglobin fcsumate or blood count at regular intervals will show definitely the effect of the treatment. Blood Examination in Acute Conditions of Doubtful Character. There are .several' conditions arising in patients with pelvic symptoms in which the ascertaining of one or another fact concerning the blood is a decided help in determining the cause of the patient's serious illness. 1. Fever. The patient has persistent fever and pelvic disturl)ance, but the cause EXAMINATION OF TllK HLOOU 113 is not altogether clear. Is the fever due to uterine or pelvic inflammation from puerperal or non-puerperal infection, or is it due to typhoid fever or malaria? Malaria may usually be easily excluded by the administration of quinine, but not always. Examination of the blood, taken at the proper time, will show almost certainly whether the trouble is typhoid fever (Widal reaction, no leucocytosis) or malaria (plasmodium, no leucocytosis) or something else. I recall two cases in particular in which I felt that decided help was given by the blood examination. I was called to see a patient who had had a miscarriage several days before and during the past two days there had been considerable fever. The temperature (forenoon) was 101'. Pelvic examination showed no decided pathological condition. The local conditions seemed about as they should be at that time after a miscarriage. When I saw her that night the temperature had gone to 103*^, but was subsiding. There was evidently serious trouble and I made arrangements to clear out the uterus the next morning. That night when thinking over the case, for I was somewhat puzzled by it, it occurred to me that it might be typhoid fever, though no particular evidence of this had l^een noticed in the examination, except a persistent headache out of proportion to the fever. The next morning the temperature was again lower and I felt safe in waiting for the report of the blood examination before disturbing the uterus. A good Widal re- action was found and the subsequent course of the disease showed it to be typhoid fever, from which the patient recovered without any uterine disturbance. Par- ticular inquiry revealed the fact that the patient had been feeling "under the weather" for some days before the miscarriage. Possibly the miscarriage was due to the beginning typhoid fever, though of that I am not certain. In the other case referred to, I was called in consultation to see a young woman who for two or three days had had fever, running up to 103° and 104° in the after- noon but lower in the morning. The patient had had a miscarriage a week before and examination showed a subacute gonorrhoea. There was considerable discharge and gonococci in abundance but no decided evidence of a septic metritis or of a periuterine inflammatory focus. Because of the regularity of the fever and the absence of the evidences of a local lesion sufficient to account for it, I suspected typhoid fever. Blood examination showed no Widal reaction, neither was there a marked leucocytosis. A second blood examination gave the same result except tnat there was more leucocytosis. Typhoid fever was thus excluded. I then sent the patient to the hospital on account of the pelvic trouble and in a short time there developed unmistakable signs of a focus of pelvic suppuration, which I drained per vaginam with satisfactory result. The pus from the abscess showed a mixed infection, but principally gonococci. 2. Pain. There is severe persistent pain in the pelvis and marked tenderness, without much fever. Is the pain due to severe pelvic neuralgia, or other functional nervous disturbance, or to bleeding from tubal pregnancy. Ordinarily the differ- ential diagnosis is easily made by the symptoms and physical signs. But when the blood in the peritoneal cavity is fluid (no induration) and not of sufficient quantity to seriously affect the pulse, the pain and tenderness (preventing satisfactory pelvic examination) are about the only signs present. If decided hemorrhage is present, a leucocytosis may be found. 114 THE PHYSICAL EXAMINATION When the pain is associated with fever, a marked leucocytosis (principally poly- nuclear) points to some acute inflammatory trouble, such as salpingitis or appen- dicitis. In uncomplicated pelvic tuberculosis or tubercular peritonitis there is no leu- cocytosis. In certain post-operative conditions leucocytosis may be of assistance in con- nection with the other symptoms. The patient has abdominal pains and there is marked distention of the abdomen and vomiting and persistent failure to secure a bowel movement. Is it gaseous distension of a sluggish bowel or intestinal obstruc- tion? It is said that the latter condition nearly always gives a leucocytosis of 20,000 within the first 24 hours, while in simple distension the leucocyte count is but little above normal. If this observation proves generally true, it will be a most valuable help in the early differential diagnosis in these very trying cases. Blood Examination in Inflammation to Determine if it is Spreading. Here the point is to determine the presence or absence of marked pathological leucocytosis, and the important thing is not so much the absolute increase of leu- cocytes as the relative increase of poly nuclear leucocytes. In physiological leuco- cytosis, which takes place under many ordinary normal conditions (after a meal, after a cold bath, after exercise, during pregnancy, in the puerperium, during menstruation), the relative proportion of 60% to 75% polynuclears is preserved. In the ordinary pathological leucocytosis the proportion of polynuclear leucocytes runs higher, particularly in the presence of pus. As a general proposition it may be said that polynuclear leucocytosis is present wherever there is acute resistance to the spread of inflammation or irritation. It is present then in practically all ordinary inflammatory lesions, except when the acute symptoms have subsided and the absorption has ceased (focus is well walled off) or where the inflammation is so very virulent that the body resistance is over- whelmed and there is little reaction. It is absent in uncomplicated typhoid fever, malaria, tuberculosis, influenza and measles. In the following cases the blood examination may help some in determining whether the inflammation is seriously spreading. 1. Acute salpingitis (non-puerperal). The patient is in the midst of a primary attack of salpingitis with accompanying pelvic peritonitis, or there is an acute exacerbation of an old salpingitis. The fever is running moderately high and there is much pain. Is it safe to wait for the interval operation to remove the diseased structure or should the operation be carried out now in the presence of this fresh virulent infection? If the inflammation is subsiding, the former plan is the better. If the inflammation is. spreading and threatening a general peritonitis, the latter plan is the better. In all but exceptional cases, the ordinary symptoms and examination findings, if carefully worked out and considered, will place the patient decidedly in one class of the other and with far more certainty than will a blood test. In some doubtful cases, however, repeated examination of the blood at short intervals, to determine EXAMINATION OF THE SPUTUM XX5 whether the leucocytosis is rising or falUng, will aid materially in deciding the question. 2. Puerperal sepsis. Here also the ordinary examination methods furnish the most reliable information concerning the local and general condition, and they must not be neglected or slighted in the false hope that laboratory tests will supply the desired knowledge. But in cases that are still dou])tful, in spite of careful analysis of the symptoms and examination findings, considerable help may in some instances be obtained by repeated examinations of the blood at short intervals to determine whether the leucocytosis is rising or falling, and to determine also the number and character of the bacteria in the blood at different times. The exact determination of these two facts may give substantial aid, in exceptional cases, in directing treatment and in prognosis. Blood Examination in Inflammation to Determine the Vital Resistance. Pathological leucocytosis means resistance. A slight inflammation awakens a slight resistance (slight leucocytosis) . A severe inflammation awakens a strong resistance (marked leucocytosis), if the patient has the required vital force. There are exceptional cases in which the infection is so very virulent that the vitav forces are overwhelmed and offer but little resistance, but these cases are compar- atively infrequent. In ordinary acute inflammation of severe grade, a good leu- cocytosis means good body resistance and reserve force, and a poor leucocytosis means poor body resistance. This is the case particularly with inflammation of the serous membranes, including the peritoneum. This fact may be turned to account in cases of advanced general peritonitis that are not seen until late and where it is a question whether an operation could possibly do any good. A marked leucocytosis means that there is still decided vital resistance and there is a chance of recovery if nature is judiciously aided in the fight. The ab ence of well marked leucocytosis, in the presence of this severe and active inflammation, means that the patient's reserve force is exhausted, and operation would probably have no effect except to hasten death. In attaching importance to leucocytosis in a patient in this desperate condition, be careful that you be not misled by the leucocytosis that comes "in articulo mortis.' SPUTUM EXAMINATION IN GYNECOLOGICAL CASES. The two points of importance are the presence or absence of tubercle bacilli and the presence of elastic fibers, indicating destruction of lung tissue. The gynecological cases in which sputum examination is required are those presenting the following conditions: 1. Suspected Pelvic Tuberculosis. Pelvic tuberculosis is nearly always secondaiy to a tubercular focus elsewhere in the body, and the most frequent sites of the primary focus are the lungs and the intestinal tract. The patient may not ac- knowledge that she has a cough, it is so slight. But the direction to save, in the ig THE PHYSICAL EXAMIXATION Dottle that is given her, all the mucus that can be gotten up in the morning, will usually bring sufficient for examination, if there is any trouble there. 2. Unwarranted Emaciation and Debility. The patient has some pehdc distur- bance but not enough to cause the poor general health. What does cause it? Possibly it is from beginning pulmonary tuberculosis. Determine whether or not such is the case. EXAMIXATIOX OF THE XERVOUS SYSTEM IX GYXECOLOGICAL CASES. That portion of the nervous system distributed to the pelvis furnishes its quota of local painful disturbances (neuralgia, neuritis, transferred pains) and local par- alyses, which must be taken into consideration in the diagnosis and treatment of pelvic diseases. There are, in addition, certain general cUseases of the nervous system which cause complaint of pelvic symptoms and occasion much confusion in diagnosis. They are principally four, as follows: Hysteria, Neurasthenia, H}'pochondria, Melancholia. The recognition of these chseases depends of course on a knowledge of the cHnical manifestations of each disease and a careful consideration of the symptoms pre- sented by the patient. This differential diagnosis cannot be taken up here. My purpose is simply to call attention to certain classes. of patients -^ith pehic symp- toms in which this special investigation of the nervous system should be carried out. They are as follows: 1. Very ner\'ous patients. I use the term ''nervous" in the ordinary commonl}-- accepted meaning of the word. The patient is perturbed more than one would expect under the circumstances. She may be simply frightened or embarrassed or, on the other hand, she ma}'' have some decided organic disease of the brain or nervous system, or some functional nervous disturbance. The patient may have a well marked pelvic lesion, but that does not cause the evidences of an unstable nervous system. What does? This particular consideration of the nervous system need not necessarily be made at the first ^^sit. The patient may be observed for a time, and possibly it will be seen that the nervous manifestations largely disappear as acquaintance is astablished. As long as the nervous symptoms persist, however, they constitute an undetei-mined factor in the case, with a possible bearing on the patient's loss of health. 2. Pelvic Distress without Corresponding Lesion. The complaint of a gyne- cological affection for which no evidence can be found, not even tenderness, may be due to pronounced hypochondria. The persistent manifestation by the patient of a fixed idea that she has some EXAMINATION' OF THE NERVOUS SYSTEM ]]J pelvic disease, which in fact is not present, may be due to beginning melan- cholia. On the other hand such complaints may be due to a deliberate attempt on the part of the patient to deceive the physician — hoping thereby to secure an opinion that would be useful in a suit for damages or for divorce, or hoping that the physi- cian may use some examination method or treatment that would lead to an abor- tion. \'erily the diagnostician must be well balanced, and must have his eyes open m all directions. iis CHAPTER II. GYNECOLOGIC DIAGNOSIS. The diagnosis in any case is based upon the symptoms given by the patient and the signs found on examination. It should, as far as possible, be both an ana- tomical and a pathological diagnosis — that is, it should state the location of the lesion and the character of the pathological process. Method of Diagnosis. Accurate diagnosis is much facilitated by a grouping of diseases under certain prominent symptoms. This is the natural method, the one that is followed un- consciously. The prominent sign or symptom in the case brings to mind a group of diseases, and then by the consideration of other ascertained facts, the diagnosis is narrowed down to one or two diseases. This differentiation should be made as one proceeds with the examination. For example, suppose, during an examination, a sore (ulcer) is found on the external genitals. Immediately arises the question, " Is this a chancroidal ulcer or a syphihtic ulcer or a tubercular ulcer or a malignant ulcer or a simple ulcer?" Endeavor to settle the question then and there. Recall the facts in the history bearing on the differential diagnosis. Notice the characteristics of the lesion. Are there, in other parts of the body, evidences of syphilis or tuberculosis or malig- nant disease? Is there an irritating discharge, that could cause a simple ulcer? . Each important sign must be thus critically considered, and the habit of doing so should be assiduously cultivated. In a few cases the diagnosis is apparent from a few prominent facts, but in most cases, particularly in deep-seated and serious diseases, the diagnosis must be established by a critical analysis of the mass of in- formation obtained in the history and examination. It is this critical analysis, this testing and elimination of diseases that do not stand the test, that makes the difference between the careful diagnosis and the snap diagnosis, between a real diagnosis and a guess, between a reliable diagnostician and an unreliable one. This effective application of the signs to the diagnosis should, as far as practi- cable, be made promptly and rapidly as they are encountered in the examination. Though in a systematic histoiy and examination, all the important facts are sup- posed to be obtained, yet if the a})pli(;ation of the symptoms to the diagnosis is made as oik; proceeds, .certain points of pai'ticuhir impori-aitce in the diagnosis in that case will bo given tlie special attention which they require. Hence the im- portance of haviug mentally stored, and ready for immediate use, the diagnostic signifi(;ance of the various facts brought out in the history and in the examination. The following resume of the diagnostic signiftcan(;e of certain signs and symp- toms is given, not as a complete collection of the diagnostic points in the various POINTS IN THE ABDOMINAL EXAMINATION H'J diseases, but simply as a working plan for the lapul difTcrentiation of (ho more common gynecological affections and other conditions likely to l)e confcnmded with them. The rarer diseases and the less common diagnostic points and tiio con- ditions present in anomalous cases, may be found in the appropriate chapters. POINTS IN THE ABDOMINAL EXAMINATION. In this examination the abdomen is, as already explained, subjected to inspec- tion, palpation, percussion, and, in exceptional cases, to auscultation and mensu- ration. The principal points of diagnostic importance in connection with the al)doiiiiii;il examination are, in the order in which they are encountered in the examination, as follows: Prominence of Abdomen, Movement of Abdominal Wall, Discoloration of Abdomen, Tension of Abdomen, Tenderness of Abdomen, Mass in Abdomen, Area of Dullness in Abdomen. Fig. 118. Obesity. The most prominent feature in thib case is the marked Obesity— see Fig. 121. There is also a fibroid tumor of the uterus and a small amount of ascitic fluid. 120 GYNECOLOGIC DIAGNOSIS PROMINENCE OF THE ABDOMEN. Decided prominence of the abdomen is due to many different affections, which may be conveniently arranged in five groups, as follows: A. Some Affection of Abdominal Wall; B. Something in Intestines; '' C. Something in Peritoneal Cavity; D. Some Enlarged Organ; E. Tumor from Pelvis or Abdomen. A. Abdominal Prominence from Some Affection of Wall. Obesity (Fig. 118). There is evidence of fat deposit in other parts of the body. The abdominal wall may be picked up as a thick roll, and the fingers made to almost meet beneath (Figs. 119, 120), showing that m.ost of the prominence is due to the thickness of the wall. There is no distinct localized mass, hke a tumor in the wall. Percussion gives resonance all over the abdomen. Sometimes a distinct "fat wave" may be obtained, but it may be distinguished from a " fluid wave" by the expedient shown in Fig. 36, and also by percussion. In some cases, when the patient stands, a distinct roll of fat drops belov/ the general abdominal contour, as shown in Fig. 121. Fig. 122 shows a case of obesity mistaken for ovarian tumor and sent to a hospital for operation. Fig. 123 shows a case of obesity which was mistaken for pregnancy. Fig. 119. Testing the thickness of the Abdominal Fig. 120. Testing the thickness of the Abdominal Wall. First step. Wall. Second step. The fingers carried beneath the ■vvall. PROMINENCE OF THE ABDOMEN 121 ,» \ ^B^r^SZ^^a 1 '■ . -'I K?^^' H^'^" ^1 M ^»i Bi^yL 1 J Fig. 122. Obesity, mistaken for ovarian tumoi. This patient was sent to a hospital for operation for a suDposed ovarian cyst. (Hirst — Diseases of Women.) Fig. 121. Obesity. Patient standing. Same patient as shown in Fig. 118. Notice the thick roll of subcu- taneous fat that drops down below the general contour of the abdomen. Tumor of Wall. There is a distinct mass, which is superficial and moves with the wall and is apparenty inseparably connected with it. The mass may be picked up and the fingers approximated beneath it. There is no apparent connection with any intra-abdominal "organ. There is dullness on light percussion, but resonance on deep percussion. Fig. 124 shows a tumor of the abdominal wall. Inflammatory Mass in Wall. Same as tumor with evidences of inflammation added — pain, tenderness, fever and, in some cases, rodness and fluctuation. Some years ago I witnessed, as a visitor, an Fig. 123. Obesity, mistaken for pregnancy by pa- tient. (Williams — Obstetrics.) 122 GYNECOLOGIC DIAGNOSIS Fig. 124. (Montgomer A Tumor of the Abdominal Wall. y — Practical Gynecology.) operation upon a supposed strangu- lated ventral hernia. The patient gave a history of a long-standing sweHing some distance to the left of the umbilicus. This suddenly- enlarged and became painful, the enlargement being accompanied by abdominal pain, vomiting, con- stipation and evidences of inflam- mation in the mass. The patient was brought before a medical class for operation. As the hernial site was evidently infected, it was de- cided to open the abdomen else- where and deal with the intestine through the clean opening. Ac- cordingly the peritoneal cavity was opened by a median incision. Ex- ploration showed that the peri- toneal surface of the abdominal wall on the affected side was per- fectly normal. There was no her- nia. The trouble was an abscess of the abdominal wall, probably resulting from the suppuration of a tumor. A large operative open- Fig. 125. A small Umbilical Hernia, with a relaxed abdominal w:ill. (Ilirbt — Dis- eases of Women.) PROMINENCE FROM RELAXED WALL 123 ing into the peritoneal cavity in siicn ctose proximity to an al^scess, made a very uncomfortable state of affairs for the surgeon, particiilarly as the al)sccss was so Fig. 126. A large Ventral 'Hernia at the site of an operation scar. (Hi.-sl — Diseases of Women.) Fig. 127. The Contour of a Relaxed Abdominal Fig. 128. Same patient (Fig. 127), Standing. Notice Wall, with the patient Recumbent the marked Projection of the Relaxed Abdominal Wall. 124 GYNECOLOGIC DIAGNOSIS Fig. 129. Median grooving of the abdominal wall where there is Separation of the Recti Muscles. The wonian is represented as Ijang on her back. (Webster — Diseases of Women.) large and so near the surface that it was thought necessary to open it at once. It was opened as far as possible from the median incision. The patient recovered. Ventral Hernia. There is a dis- tinct localized protrusion, which is most pronounced when standing or sitting, and diminishes when the patient hes do"WTi. Coughing makes the mass prominent and gives a dis- tinct impulse to it. The mass is re- sonant on percussion, when contain- ing intestine, and is partially or wholly reducible. "When the mass is reduced, the margin of the open- ing may be felt. Fig. 125 shows an umbilical hernia. Fig. 126 shows a ventral hernia in an operative scar. When strangulated and so inflamed as to prevent satisfactory palpation, a ventral hernia may give much trouble in diagnosis, particularly if it contains only omentum. Relaxation of Wall. There is general protru- sion of wall when sitting or standing, which large- ly disappears when pa- tient lies do'UTi, unless tympanites is pronounc- ed (Figs. 127, 128), On palpation the walls are lax and no ab- normal mass is felt. The abdomen is every- where resonant on per- cussion. Separation of Recti Muscles. The recti muscles are ordinarily held firmly together by the junction of the sheath of one side with that of the other side, Fig. 130. Patient with marked Separation of the Recti Mu.srlcs. The illustration shows the marked bulginR between the separated recti as the head and chest are raised from the table, the abdominal muscles being thus made to contract. (Webster — Z>««ea«es o/ Women.) PROMINENCE FROM TYMPANITES 125 forming a strong fibrous septum in the median line. In some cases of alidominal distension from pregnancy or a tumor, the tissue between the recti muscles is great ly Fig. 131. Patient with mariied Separation of the Recti. Tlie photograpli froiu which this illustration was made, was taken as the upper part of the body was being raised from the table. The physician's fist is buried in the gap between the muscles, which are contracting. In this case there was pionounced pendulous abdomen. As the patient lay relaxed on her back, the distance between the muscles at the level of the umbilicus measured five and one half inches. (Webster — Diseases of Women.) \ J Fig. 132. Tympanites, mistaken for pregnancy by the patient. The small figure in the upper corner shows the internal condition as determined by the bimanual examination, the uterus being of normal size. (Edgar— Practice of Obstetrics.) 126 GYNECOLOGIC DIAGNOSia stretched laterally and remains so. This gives a wide weak place between the recti muscles, in which the tissues are lax and thin (Fig. 129). When the patient raises her head and shoulders from the pillow, or otherwise makes strong intra-ab- nominal pressure, there is bulging of this weak portion of the wall between the recti (Fig. 130). In such a case, the hand may be sunk deeply into the abdomen between the separated recti muscles (Fig. 131). B. Abdominal Prominence from Something in Intestines. Gas (tympanites). This may cause marked prominence when associated with relaxation of abdominal wall. There is no distinct mass felt on palpation. Per- cussion shows hyper-resonance over all the abdomen. There are usually symptoms indicating gastric or intestinal indigestion. Tympanites is fre- quently associated with enteroptosis. Fig. 132 shows tym- panites which the pa- tient mistook for preg- nancy. Fecal Impaction. Fecal impaction may cause localized promi- nence in any part of the abdomen but it is usually situated along the course of the colon. The diagnosis depends largely on the exclu- sion of other causes of enlargement, the history of constipation and the effect of treat- ment directed toward clearing out the intestinal tract. Have the patient take a purgative until free bowel movements are secured, then a large enema and then return for another examination. Fig. 133. Ascites. A moderate amount of fluid in a relaxed abdomen. Notice how the abdomen spreads out at the sides. (KeWy— Operative Gynecology.) C. Abdominal Prominence from Something in the Peritoneal Cavity. General Ascites. This may l)o sliglit (Fig. 133) or marked (Figs. 134,135, 136, 137). In ascites,!, c. free fluid in the peritoneal cavity, the abdomen is incUned to spread out at the sides and flatten at the top. There is usually a dis- tinct fluid wave, obtained as previously explained (Fig. 35), which may be dis- tinguised fi'om a fat wave as shown in Fig. 36. When the patient is turned on the side or when she sits or stands, the area of dullness changes, because the fluid seeks the lowest part of the peritoneal cavity. (Figs. 185, 189, 190). PROMINENCE FROM ASCITES 127 Another diagnostic point is that in some cases where there is free fluid in the peri- toneal cavity, when the patient stands there is decided protrusion of the uiiibiH- Fig. 134. Marked Ascites. Notice the gentle slope at the lower and upper portions of the abdomen. In the case of a tumor the rise is usually much more abrupt. (Kelly — Operative Gcnecology.) Fig. 135. Extreme Ascites. In the patient from which this photograph was taken, the abdomen was so distended with fluid that the wall was raised higher than the mesentry would permit the intestine to float, giving dullness about the umbilicus as well as elsewhere (see Figs. 191, 192). The rise of the wall from below is rather abrupt. There is also edema of the wall, as shown by the persisting groove where the skirts were tied about the waist. 128 GYNECOLOGIC DIAGNOSIS cus (Fig. 138), which protrusion disappears when the patient is in the recum- bent posture. Encysted fluid (pus or serum or blood). A distinctly Hmited collection of fluid, walled off or encysted, may be present in peritoneal tuberculosis and also in abscess from salpingitis or appendicitis. There may be considerable sohd exu- date associated with the swelling, and also other evidences of inflammation, either Fig. 136. Another case of extreme Ascites, giving dullness about the umbihcus aa well as in the flanks. Notice the markedly pyramidal form of this abdomen. {KiTst— Diseases of Women.) Fig. 137. Another case of extreme Ascites, giving dullness about the umblilicus and and showing a very abrupt rise of abdominal wall below. (Rivai— Diseases of ]Vomen.) septic or tubercular. The diagnosis between the two forms of inflammation may usually be readily' made from the history and the accompanying symptoms. Extra-uterine pregnancy, like the inflammatory processes just mentioned, may present the evidences of encysted fluid. P'or the points in differential diag- nosis, between extra-uterine pregnancy and ordinary pelvic inflammation, see chapter xi. PROMINENCE FROM AN ENLARGED ORGAN 12Q Pseudo=cyst of the Lesser Omentum. Following injuries of tlie pancreas or disease of the same, there may be a collection of flui.l in the lesser peritoneal cav- ity, causing prominence of the abdomen and evidence of encysted fluid. The diagnosis is usually made during the progress of the operation, Jn all these cases of encysted fluid or solid exudate, there is dullness over that portion of the mass lying against the abtlominal wall and resonance elsewhere. D. Abdominal Prom- inence from Some Enlarged Organ. Uterus pregnant (Fig. 139). There is dullness over the mass and resonance at the sides (Fig. 181). There is no change of outUne of dullness on change of position of patient. There are also the vari- ous signs of pregnancy, including the fetal heart sounds if the pregnancy is far enough advanced. Bladder distended with urine. The re- tention of ,urine to such an extent that the dis- tended bladder pro- duces a distinct prom- inenceof the abdomen, happens occasionally in pregnancy with re- tro-displacement of uterus (Fig. 141), in labor (Fig. 140), in pelvic tumors compressing the urethra and in certain nervous affections. There is dullness over the mass and resonance at the sides. There is usually a fre- quent desire to urinate, with the passage of only a small amount of urine. But there may be a constant dribbling of urine due to over distention. If the bladder be emptied with a catheter the diagnosis becomes clear. Use a long soft-rubber catheter, as the ordinary female catheter may be too short to reach the entrance of the bladder, and if the catheter be not flexible it can not follow the devious Fig. 138. Extreme Ascites. Patient standing. Notice the protrusion of the umbilicus, which is pushed out by tlie- fluid behind it as the patient stands. This is the same patient shown in Fig. 135. 130 GYNECOLOGIC DIAGNOSIS Fig. 139. Contour of the abdomen in Pregnancy, with patient recumbent. (Edgar — Practice of Obstetrics.) I Top o/si/mpht/sis / i ( ■■ I I, Fig. 140. Contour of the abdomen in a case of Dis- tended Bladder. The patient is in labor. Notice how well the bladder prominence stands out from the general abdominal prominence due to the pregnant uterus. (Norris— ^m. Text- Bool: of Obstetrics.) course of the distorted urethra. Patients have died from rupture of the bladder due to unrecognized over-distention (Fig. 141). Spleen enlarged from chronic malaria, leu- kemia or other cause. Liver enlarged from malignant disease, hypertrophic cirrhosis or other cause. Gall=bladder enlarged on account of oc- clusion of duct and distension with mucous secretion and inflammatory exudate. It sometimes becomes so much distended a; ) to form a large cystic mass in the right aide of the abdomen. Fig. 141. Frozen section of the body of a woman who died fiom Rupture of a Distended Bladder. The cau.se of (lie re'eiition of urine, was a retroverted uterus four months preg- nant. (Norri.s— .-Iw. Text-book of Obstetrics, from Arch, of Oyn.) PROMINENCE FROM PELVIC TUMOR 131 E. Abdominal Prominence from a Tumor. A tumor projecting up from the pelvis (Fig. 142). Such a tumor has its point of attachment in the pelvis, the free margin of the growth extending upward into the abdominal cavity. The growth may be either cystic or solid. There is Fig. 142. Contour of the abdomen in a case of large Cystic Tumor (parovarian). Notice the abrupt rise of the abdominal wall at both the lower and upper portions. (Kelly — Operative Gynecology.) Fig. 14.3. Contour of the abdomen in a case of large Solid Tumor (uterine fibroid). The irregularity, so common in solid tumors, is well marked. (Kelly — Operative Gynecology.) dullness over the mass and resonance at the sides (Fig. 1S2). There is no decided change of outline of dullness with change of position of patient, except where there is complicating ascites. There are found also the usual symptoms caused by the particular variety of pelvic tumor present. 132 GYNECOLOGIC DIAGNOSIS The ordinary new growths that project up from the pelvis are: Fibroid tumor of uterus (Fig. 143). MaUgnant tumor of uterus (carcinoma, sarcoma). Cj^stic tumor of ovary (ovarian cyst, Fig. 144). Cystic tumor of broad hgament (parovarian cyst). SoHd tumor of ovary (fibroma, carcinoma, sarcoma, papilloma). Solid tumor of bladder (Fig. 145). Solid tumor of rectum. Fig. 144. Another case of large Cystic Tumor. Here thie tumor (an ovarian cyst) is extremely large and the rise of the abdominal wall at both lower and upper portions is very abrupt. (Bovee — Practice of Gynecology.) Fig. 145. Appearance of the abdomen in a case of Extrophy of the Bladder. A carcinoma has developed in the <^leformed and turned-out bladder. {Ke\\y— Operative Gynecology.) A tumor connected with some abdominal structure (Fig. 146). Such a tumor has its point of attachment in the abdomen with the free margin of the growth extend- ing toward, and some- times into, the pelvic cavity. There is dull- ness over that portion of the mass lying against the abdominal wall and resonance elsewhere, unless there be associated ascites. There are symptoms also pointing to the organ affected and the nature of the growth. The principal tumors that originate in the ab- domen are: PROMINENCE FROM ABDOMINAL TUMOR 133 Solid tumors of the caecum, sigmoid, or other parts of the intestinal tract (usually malignant). Solid tumor of the stomach (usually malignant). Solid tumor of the liver (usually malignant). Solid tumor of the spleen. Solid tumor of kidney. Solid tumor of pancreas. Solid tumor of retro-peritoneal structures (Fig. 146). Fig. 146. Contour of the abdomen in a case of Retroperitoneal Tumor (sarcoma). The projecting mass in the region of the umbiUcus is well shown. The outline of the palpable mass and also the area of dullness are shown in Fig. 201. (Patient of Dr. Elsworth Smith, Jr., to whose kindness I am indebted for this photo graph.) Cystic tumor of kidney. Cystic tumor of pancreas. Cystic tumor of omentum. Cyst of mesentery. Pseudo-cyst of lesser omental cavity. 134 GYNECOLOGIC DIAGNOSIS MOVEMENT OF ABDOMINAL WALL. In certain cases some information may be obtained by watching the movements of the abdominal wall. In painful affections within the abdomen, such as peritonitis or intra-peritoneal hemorrhage or intestinal obstruction, the wall is held rigid to a considerable extent and the respiratory movements of the wall are very slight. In the case of a tumor splinting the wall, the portion of the wall raised by the tumor remains stationary, while the remainder shows the respiratory movements. It is important to know whether or not a tumor moves with respiration. As a rule a tumor of an abdominal organ moves up and dow^n with the dia- phragm in respiration, and this up and down movement may often be dis- tinctly seen and felt through the wall at the lower margin of the growth or at the prominent part of the mass. If the tumor is firmly adherent to the wall, this movement under the wall can not then take place. In some cases this fact may be turned to account in determining the presence or absenje of adhesions. A growth from me pelvis does not move with respiration. Movement of the child may sometimes be plainly indicated in late pregnancy by a prominence moving beneath the wail, due to an extremity moving from 3ne part of the uterus to another and pushing out the wall as it moves. Occasionally the intermittent contraction of a pregnant uterus may be noticed by its raising the wall as it becomes firmer and more prominent. Pulsation of the abdominal wall may be due to an aneurysm. Not infrequently, especially in thin patients, the pulsations of the normal aorta are transmitted to the overlying wall, either directly or through an intervening tumor. In some cases of intestinal obstruction or marked tympanites, a distinct peri= staltic wave may occasionally be seen to pass across the abdomen in the course of the distended bowel. It is usually accompanied by a cramp-like pain. DISCOLORATION OF ABDOMINAL SURFACE. Occasionally there is a well-marked central line of pigmentation, extending from the pubes to the umbiUcus (Fig. 20). This is usually the result of a previous pregnancy. Dilated veins at the lower part of the abdominal surface, as a rule mean that there is some mass compressing the intra-pelvic veins. Edema of the wall may be due to inflammation in the wall, or to heart or liver or kidney disease. Striae (Fig. 18) from a former stretching of the wall, usually mean a former pregnancy continuing to near term, but they may come from any large tumor or from a former obesity of the abdominal wall. Such striae are occasionally seen on the thighs of patients who have been stout. When the wall is relaxed, i. e., has been overstretched and has not regained its tone, it is very uneven and the skin appears wrinkled and corrugated. This folded redundant condition is nearly always present in decided enteroptosis. TENSION OF THE ABDOMEN 185 The eruption of secoiidaiy syphilis (syphiHtic roseohi) is occasionally of decided help in deterniiuiiig the character of an atypical vulvar lesion. An eczema or other eruption near the site of a proposed operative incision, may necessitate postponement of the operation until the eruption is removed. A scar indicates tliat there was at one time a burn or a blister or an ai'ca of ulcera- tion of the Avali or an injury of the wall or an operative incision (Fig. IGO). TENSION OF ABDOMEN. Tension of the abdominal wall interferes very much with a thorough pelvic ex- amination. It is due to one of the following conditions: Fear or timidity or em= barrassment, causing the mus- cular wall to be held tense. This tension usually disap- pears as the examination pro- gresses and the patient sees that you are not going to cause pain. Even in very trouble- some cases, relaxation of the wall may usually be secured by directing the patient to take a full breath and then let the breath all out. During ex- piration, when not forced, the wall relaxes and deep palpation may be made. In sinking the fingers into a region or about a mass for palpation, proceed gently and firmly and steadily toward the desired point,going a little deeper with each expiration. Do not gouge or jab or endeavor to reach the depths of a region by sudden forced movements. These all invite failure by causing reflex contraction of the abdominal muscles. Inflammation, local or general, beneath the wall causes tension of the over- lying muscles. This tension is usually both voluntary and involuntaiy. The patient can relax the wall to some extent but not entirely, providing the inflam- mation is acute and severe. There is also marked tenderness over the affected area and other evidences of an inflammatory affection. Mass, solid or containing fluid. If lying immediately beneath the wall this Fig. 147. The Right Lower Abdomen. The organs com- monly affected and the areas accordingly of particular inter- est, are indicated by tlie stippling 136 GYNECOLOGIC DIAGNOSIS gives a sensation of tension or resistance to the palpating fingers. In exceptional cases, as in an extra large tumor or very marked ascites, the abdomen may be so filled that the outer abdominal wall is stretched and tense. Hysterical contraction of the muscular wall is sometimes seen. When taking place in an irregular way (part contracted and part relaxed) and associated Fig. 148. Indicating the point to seek for Tender- Fig. 149. Palpating for Tenderness or a Mass ness due to Tubal or Ovarian disease of tlie right side. in tlie Right Tubo-ovarian region. Fig. 150. Indicating the point to seek for Appendix Fig. 151. Palpating for Tenderness or a Mass in Tendemeea. the Appendix Region. TENDERNESS IN ABDOMEN 137 with tympanitic distension and with marked hyperesthesia, it may cause the condition known as "phantom tumor," which has led to so many serious mis- takes in abdominal diagnosis. The administration of a purgative to clear out the intestines and diminish the tympanites and of some nerve sedative to diminish the hyperesthesia and nerve irritability, may remove the tension sufficiently to admit of a satisfactory examination. If not, the patient should be examined under anesthesia, provided the symptoms are serious enough to make a positive diagnosis necessary at once. Under anesthesia the tension of the abdominal wall disappears, and deep palpation may be made in the affected region and the presence or absence of an abnormal mass determined. Fig. 152. Palpating for the Appendix itself, to determine whether or not there is any appreciable infiltration and thickening of it. When thickened, the appendix is felt as a small tender roll, deeply placed. Fig. 153. Another method of palpating the Appendix. Beginning near the umbilicus, the fingers are carried in deeply and then brought slowly outward toward the anterior superior iliac spine. .\s the appendix passes under the examining fingers, it is felt as a small roll between the fingers and the posterior abdominal wall. TENDERNESS IN ABDOMEN. For the purpose of studying the significance of tenderness in the abdomen, it is convenient to divide thecavity as previously explained, into nine regions: the right, left, and central portions of the lower abdomen; the right, left and central por- tions of the upper abdomen; the central portion of the abdomen (umbilical region); and the right and left lumbar legions (Fig. 30). In any of these, a local tenderness takes on particular significance. Again, there are certain diseases that cause a diffuse tenderness, extending throughout the whole abdomen, 138 GYNECOLOGIC DIAGNOSIS Fig. 154. Indicating the site to search for Tenderness of the Right Ureter. This may be found anywhere from the point indicated to some distance inside the circle, towards the umbilicus. Appendicitis. Tenderness is most marked at about the middle of a line drawn from the right iliac spine to the umljilicus (McBm-ney's point, Figs. 150, 151) . By sinking the fingers deep- ly into the abdomen near the um- bilicus and then carrying them outward toward the iliac spine, the appendix may often be felt to roll under the fingers as a tender cord (Figs. 152, 153). There is usually a history of stomach or bowel disturbance and of attacks of pain radiating about the um- bilicus and finally settling down in the appendix region. Some Disease of the Caecum or Ascending Colon. Inflamma- Tenderness in Right Lower Abdomen (Fig. 147). Tubal or Ovarian or Broad Ligament Disease (inflammation, tumor, extrauterine pregnan- cy) . The tenderness is most marked low in the side near Poupart's ligament (tubo-ovarian region. Figs. 148, 149) . It does not ordinarily extend to the appen- dix region though it m a y , in exceptional cases, involve both re- gions. A mass may be felt on vagino -abdom- inal palpation between the uterus and the pel- vic wall. There-; is a history of uterine and pehic inflammation or other pelvic disturb- ance. Fig. 155. PaliJiUing for Teucteruesa or Thickening about the Right Ureter. TENDERNESS IN RIGHT LOWER ABDOMEN 1:5!) tion, tumor ami intussusccptiou mv the more cDiuiiion alYcctifHis of the caccuiii. Tliey present iiiucli the same local signs as mild a[)pen(liritis. The tenderness and the mass are not localized to the appendix region, however, hut extend up along the ascending colon. Ureteritis. There is a painful point over the ureter (Figs. 154, 155) and tender- ness extending up and down the course of the same (Fig. 147). There is usually pain extending from the kidney along the ureter, to the hlad- der. There is nearly always decided tenderness over the kidney (Figs. 162, 163 and 164). Movable Kidney. A rounded mass is felt on deep palpation in or near the appendix region. It is somewhat tender. It is movable and may be displaced upward into the kidney region. Special methods for palpating same are shown later (Figs. 413, 414). There is a history of irritable bladder, particu- larly when standing or w^alk- ing. There may be pain radiat- ing from the kidney region along the ureter to the bladder. The urinary findings will indi- cate whether or not there is inflammation or irritation along the urinary tract. Kidney disease, for example, a tumor or tuberculosis or in- flammation, may cause tender- „. ,„ _,, t f^ t auj tu i,. ' -^ Fig. 156. The Left Lower Abdomen. The organs commonly neSS extending from the kid- affected and the areas accordingly of particular interest, are ney down into the right lower '''^''■'^^ ^^ *^« ^*'pp"'^^- abdomen. Kidney disease is indicated by tenderness and enlargement found in palpation, and by the urin- ary findings. Intestinal Disease. Painful diseases of the small intestine, either acute or chronic, may give rise to tenderness in the right lower abdomen. Tubercular Peritonitis and other forms of peritoneal disease occasion tender- ness here, when extending to this region. Nervous affection. Various organic and functional nervous diseases cause marked hj^ersensitiveness of the abdominal surface and of the intra-abdominal struc- 140 GYNECOLOGIC DIAGNOSIS Fig. 157. Palpatating for Tenderness or a Mass in the Left T'jbo-ovarian region. tenderness in the left lower abdomen are the same as those just given for the right lower ab- domen, substituting the sigmoid flexure and the descending colon for the appendix, caecum and ascending colon. Fig. 157 shows palpation for left tubo-ovarian tenderness and Fig. 158 indicates the point for left ureteral tenderness. Tenderness in Central Lower Abdomen (Fig. 159). Intestinal Disease. There are many affec- tions of the intestines that give pain on pres- sure in the central lower abdomen, for example, ordinary enteritis, mu- tures. The pain complained is out of proportion to any obvious sign of disease. By palpating over the abdomen it is found that there is ten- derness ever}' where, even up on the chest walls. Pinch- ing" up the skin may cause almost as much pain as the pressure on deeper struc- tures. General observation of the patient will show that she is nervous. Special ex- amination will show evi- dence of neurasthenia, hysteria or other disease of the nervous system. Tenderness in Left Lower Abdomen (Fig. 156). The affections that cause Fig. 158. IndicatinK the place to search for Tenderness or Infiltra- tion about tlie Left Ureter, TENDERNESS IN CENTRAL LOWER ABDOMEN 141 ecus enteritis, tubercular enteritis and typhoid fever. The tenderness is wide- spread, usually extending into the upper part of the abdomen. There are also the gastro-intestinal symptoms that accompany these diseases and, in addition, the symptoms and signs peculiar to each disease. Inflammation of Uterus. The tenderness is confined to the central part of the lower abdomen (Fig. 160) and is elicited usually only by deep pressure. There are also the various special evidences of uterine infiamniation. Fig. 159. The Central Lower Abdomen, showing the organs com- monly affected by local disease. Pelvic Inflammation. Pelvic inflammation in any form is likely to give rise to tenderness extending throughout the lower abdomen. Even if the inflammation is confined strictly to the tube on one side, there is usually some tenderness on pressure in the median line. There is a history of pelvic inflammation, with characteristic tenderness of the affected adnexa in the bimanual examination, and perhaps also a distinct mass. 142 GYNECOLOGIC DIAGNOSIS Bladder Disease. The tenderness is very low, just above the pubes (Fig. 161). There is a history of frequent, painful urination. Pressure on the affected region may cause a desire to urinate. Examination of the urine will show evidences of bladder or kidney disease. Tubercular Peritonitis. This tenderness is widespread over the abdomen. There is encysted fluid or a mass of exudate or general ascites. The trouble is usually chronic. There may be evidence of tuberculosis elsewhere (lungs, intestines) . There is no apparent focus of ordinary infection, such as salpingitis or appendicitis. ^^t£f^f^f3r '^^)r Fig. 160. Indicating the place to seek for Tenderness of tbeUterus. Tenderness in Right or Left Lumbar Region. Renal and Suprarenal affections are the pathological conditions peculiar to the lumbar regions, and the usual cau.ses of tenderness there. Fig. 162 shows the point to seek for kidney tenderness in front. Fig. 163 indicates the. point in the lateral lumbar region to make pressure for kidney tenderness, and Fig. TENDERNESS IN UPPER ABDOMEN 143 164 shows the point posteriorly. Fig. 165 shows the area for kidney tender- ness in the left lumbar region, and Fig. 166 shows the method of palpating for a mass in the same region, one hand being placed behind and the other in front bo as to catch the structure l>etween the palpating fingers. Tenderness in Right Upper Abdomen (Fig. 167). Diseases of the QaU=bladder or of the Liver are the common causes of tender- ness in the right upper alxlomen, the usual condition Ijeing cholelithiasis or hepa- Fig. 161. Indicating the region to palpate for Bladder Tenderness. titis or tumor of the liver. Fig. 168 indicates the point to seek for gall-bladder ten- derness. It may be found anywhere from thepoint indicated by the finger out- ward to the costal margin. The characteristic gesture of liver tenderness (firm pressure over the liver) is shown in Fig. 13, while Fig. 169 shows the method of palpating for general liver tenderness. Occasionally an affection of the pyloric end 144 GYNECOLOGIC DIAGNOSIS Fig. 162. Indicating the region for Kidney Tenderness in Front, on the right side. of the stomach or of the duodenum or of the hepatic flexure of the colon or of the right kidney, causes tenderness extending well into the right upper ab- domen. But in practically all these conditions the tenderness may be traced out of this region and for a considerable distance along the organ affected. Tenderness In Left Upper Abdomen (Fig. 170). Diseases of the spleen or of the splenic flexure of the colon or of the cardiac end of the stomach or of the left Fig 163. The point for Kidney Teuderneaa Fig. 164. The point for Kidney Tenderness Posteriorly. Laterally. PALPATINd THE LUMHAll REGIONS 14 5 Fig. 165. The area for Left Kidney Tenderness in Front. Fig. 166. Method of Palpating for a Mass in the Kidney Region. The structures are caught between the hand behind and the one in front. 146 GYNECOLOGIC DIAGNOSIS kidney or suprarenal capsule, are the usual causes of tenderness in the left upper abdomen. Fig. 171 indicates the area to search for splenic tenderness. The dragging pain from an enlarged spleen is usually referred by the patient to about this area. Tenderness in Central Upper Abdomen (Fig. 172). Tenderness in this region is usually due to an affection of the stomach or of the liver. Fig. 173 indicates the point to seek for stomach tenderness, and Fig. 174 i; i Fig. 167. The Right Upper Abdomen. The site of the gall- bladder, the area of particular interest in this region, is indicated by the letters G. B. the point to seek for tenderness of the left lobe of the liver. In doubtful cases, when there is so much widespread tenderness that there is uncertainty as to whether it is from the stomach or the liver, remember that stomach disease is often ac- TENDERNESS IN CENTRAL ABDOMEN 147 companied by attacks of pain under the left shoulder-blade (usually indicated by the patient as in Fig. 175) while liver disease is frequently accompanied l)y pain under the right shoulder-blade (Fig. 176). Less freque.:tly, tenderness ■n the region is due to disease of the pancreas or to some affection of the peri- toneum. Tenderness in Umbilical Region (Fig. 177). Diseases of the small intestine and diseases of the peritoneum and omentum, ire the usual causes of tenderness localized in this resion. In the lower outer Fig. 168. Indicating the site for Tenderness or a Mass due to disease of the Gall-bladder. It may be found anywhere from the point indicated downward and outward to the margin of the ribs on the right side. Fig. 169. Palpating for general Tenderness of the Liver. portions of the region the ureters encroach, and may cause point tenderness on one or both sides (Figs. 154, 158). Fig. 178 shows palpation for tenderness in the umbilical region. Diffuse Tenderness Throughout Abdomen. The usual causes of this are general peritonitis, tubercular peritonitis, gastro- enteritis, neurasthenia and hysteria. Appendicitis, gastritis and many other con- ditions give rise to tenderness or pain which is diffuse at first, but it soon becomes distinctly localized. 148 GYNECOLOGIC DIAGNOSIS MASS FELT OX ABDOMINAL PALPATION. The masses of particular interest in gynecologic diagnosis are those situated in in the lower abdomen. For exact differential diagnosis these are preferably taken up later. Consequently here I shall simply indicate by name the various masses Fig, 170. The Left Upper Abdomen. The site of the spleen and of the splenic flexure of the colon, tiie organs in this region most commonlj^ affected, are shown by the stipling. TMaen normal, the spleen lies considerably higher in the abdominal cavity than is generally supposed. Its anterior projection is shown here in dotted outline, with ^_he lower end in contact with the splenic flexure of the colon. found. It must be kept in mind, however, that in addition to the various masses that may originate in an}^ region, masses from elsewhere may be found in that region, becau.se of growth or displacement or both. In Fig. 179, the ar- rows indicate the usual direction of growth, or displacement, of a tumor of the various organs outlined. MASS FELT IN LOWER ABDOMEN 14!) Mass Felt in Right Lower Abdomen (Fig. J 47). Tiil)al Inflanmiation (salpingitis, pyosalpiiix, ]iy^e^¥TZW7. Fig. 179. Showing the Direction of Growth of Tumors of various Abdominal and Pelvic organs. In prac- t:cally all cases, the direction of enlargement is toward the umbilical region. (KeWy— Operative Gynecology.) 154 GYNECOLOGIC DIAGNOSIS Fig. 180. Indicating the Area of Dullness due to moderate Distention of the Bladder. Mass Felt in Left Upper Abdomen (Fig. 170). Enlarged Spleen. Tumor of Spleen. Abscess of Spleen. Fig. 181. Indicating the .A.rea of Dullness from a large Mass of regular outline springing from the Center of the Pelvis, for example tne pregnant uterus. The dotted line shows the upper limit of the mass as determined by palpation. MASS FELT IN UPPER ABDOMEN Tumor of Cardiac End of Stomach. Tumor of Splenic Flexure of Colon. Tumor of Kidney. Abscess of Kidne3\ Tuberculosis of Kidney. 155 Fig. 182. Indicating the Area of Dullness from a Cen- tral Pelvic Mass which has enlarged to such an extent that it nearly fills the abdomen. Notice that the corona of resonance, surmounting the area of dullness, is sjin- metrical on the two sides. If the mass were lateral, for example, an ovarian or parovarian tumor, the area of resonance would be decidedly less on the side of the tumor than on the opposite side. Mass Felt in Central Upper Abdomen (Fig, 172), Tumor of Stomach. Tumor of Left Lobe of Liver. Fecal Impaction in Transverse Coion. Tumor of Transverse Colon. Tumor of Duodenum. Tumor of Pancreas. 156 GYNECOLOGIC DIAGNOSIS AREA OF DULLNESS IN ABDOMEN. An area of dullness in the abdomen indicates that something solid or fluid is lying against the abdominal wall, pushing the intestines away or flattening out the intes- tine between the mass and the wall. When an area of dullness is found in percuss- ing over the abdomen, the first thing to do is to ascertain its exact outline. The getting of the shape of the area clearly in mind is much facilitated by outlining it, wholly or partially, with a lead pencil or other marker. This outlining of the area shows what region or regions it is situated in, and also shows whether or not it is of such position and size and shape as would be likely to be caused by the en- Fig. 183. Indicating the region for Dullness from ^ig 134 indicating the region for Dullness from Enlarged Liver. Enlarged Spleen. largement of any adjacent organ. In some cases the employment of both super- ficial and deep percussion may aid some in differential diagnosis. Then determine if the area of dullness can be shifted by pressure — by attempt- ing to push about any mass that may be in the abdomen. Then determine if the outUne of the dullness changes with the position of the patient. For example, mark out the area with the patient lying on the back, then have her turn on one side and mark it in that position. Then have the patient stand, if she is able, and mark the outline of the dullness in that position. This is of much importance in the diagnosis of free fluid in the peritoneal cavity. An area of dullness where there should be resonance may be due to any of the following conditions: — An enlarged organ — for example, the bladder distended with urine (Fig. 180), a pregnant uterus or other median mass (Figs. ISl, 182), the liver enlarged from various causes ''Fig. 183) or the spleen enlarged from various causes (Fig. 184). AREA OF DULLNESS IN ABDOMEN 157 The dullness extends to the region normally occupied by the organ. It has about tiic shape to be expected in symmetrical or asymmetrical enlargement of the organ in question. There are other evidences of disease of that organ. There is nothing else found to account for the dullness. Each of these points should be Fig. 185. Showing the Area of Dullness in moderate Ascites, with the patient lying on her back. considered when endeavoring to ascertain whether or not a mass is due to enlarge- ment of some particular organ. Free Fluid in Peritoneal Cavity (Acites). In this condition the fiuid of course seeks the lowest part of the peritoneal cavity, being drawn there by gravity, and the upper margin of the fluid, represented by the upper margin of the area of dullness, is approximately horizontal. As the patient changes position, the fluid changes its relative position, to conform to the law just given — hence the change in the outline of the area of dullness, which is so characteristic in these cases. To illus- trate the application of this law, take a case of moderate.ascites. With the patient on her back the dullness would be as re- Fig. 186. Showing the reason for the disposition of the Dull and Resonant Areas ''n a case of moderate Ascites. (Butler — Diagnostics of Internal Medirine.) Fig. 187. Indicating the relation of the Dull and Resonant Areas in the case of a Tumor occupying the central lower abdomen. (Butler — Diagnostics of In- ternal Medicine. ) Fig. 188. Ascites. Representing the patient turned on one side. The fluid gravitates to the underside, leaving the upper flank resonant. (But- ler— /^frt (/hos/ics of Internal Medicine.) 158 GYNECOLOGIC DIAGNOSIS Fig. 189. Indicating the Area of Dullness in a case of moderate Ascites, w'th the patient turned on the left side. Fig. 190. Indicating the Area of Dullness in moderate Ascites, witli the patient standing. presented by the dark area in Fig. 185, with a corona of resonance about the umbihcus, which is the highest point. Fig. 186, which represents a cross section of the body in such a case, explains the cause of the dull and re- sonant areas. Fig. 187 shows the con- trasting condition produced by a tumor, and the area of surface dullness pro- duced by the same is indicated in Fig. 181. When the patient \\dth ascites turns on her side, the fluid shifts as indicated in Fig. 188 and the area of dullness changes as shown in Fig. 189, the upper flank becoming resonant. When the patient stands, the fluid again shifts, seeking the lowest part, and the outline of dullness changes to that shown in Fig. 190. Notice that in all positions of the patient, the fluid occupies the lowest part of the DULLNESS FROM ASCITES 159 peritoneal cavity, and the upper margin of the fluid is approximately horizontal. Of course the height of the area of dullness varies in different cases, depending on the amount of fluid in the cavity. The illustrations already referred to indicate the dullness in the cases of ascites of moderate severity. If there is only a small amount of fluid in the cavity, there may be only a small area of dullness appre- ciable in each flank, as the patient is lying on her back. When the patient turns on the side, the area of dullness increases appreciably in the lower side and disap- pears entirely in-the upper flank. When the patient stands, there may be a small area of dullness in lower abdomen just above the pubes, or there may be no dull- Fig. 191. A case of Extreme Ascites. Same patient as shown in Fig. 135. Showing the Area of Dullness when the patient is on her Back. The light area is all that is resonant. ness appreciable anywhere in the abdomen, because the amount of fluid is so small that it is all concealed in the depth of the pelvic portion of the peritoneal cavity. On the other hand, in exceptional cases the amount of fluid is so great that it fills the peritoneal cavity and raises the abdominal wall above the intestines (higher than the mesentery will permit the intestines to float), giving dullness about the umbilicus as well as elsewhere. This does away with the corona of resonance about the umbilicus, which is so characteristic a feature of ordinary ascites. Fig. 135 shows a patient sent to me with a supposed ovarian cyst. The general 160 GYNECOLOGIC DIAGNOSIS appearance was very much like that of a cyst distending the abdomen. The area about the umbilicus was dull, excluding ordinary ascites. " In percussing care- fully over the whole abdomen, however, I found an area of resonance in the left upper abdomen. Fig. 191 shows the outline of this area when the patient was lying on her back. Fig. 192 shows the outline of the area of resonance when the patient was standing. A comparison of these two areas (Fig. 193) showed that there was decided variation in the area of dullness with the change of position, Fig. 192. Extreme Ascites. Area of Dullness with patient Standing. Same patient as shown in Fig. 191. Notice the marked change in the resonant area. The upper limit of the dullness is now almost horizontal. The former marks have not been completely removed. without any important change in the general shape of the abdomen, a condition that could be caused only by free fluid in the peritoneal cavity. As the patient stood, there was distinct bulging of the umbilicus (Fig. 138) and distinct fluctua- tion through the thin umbilicus. There was present also edema of the abdominal wall. On vaginal examination, no tumor was felt in the pelvis. These signs were considered sufficient to exclude ovarian cyst, and I sent the patient back to her physician with a diagnosis of ascites. As there was no decided kidney disease or heart lesion, the marked ascites was supposed to l)e of hepatic origin, which CHANGEABLE OUTLINE OF DULLNESS 161 diagnosis was confirmed by the women's death from sudden gastric hemorrhage and by the partial post-mortem examination, the details of which were kindly given me by her physician. Figs. 136 and 137 show other cases in which the amount of ascitic nuid was so great that the abdominal wall was raised above the intestines, and the corona of resonance about the umbilicus was consequently absent. t / / Fig. 193. Extreme Ascites. Same patient as shown in Fig. 191. The Two Resonant Areas contrasted. The area enclosed by the sohd hne is resonant when the patient is on her back, while all elsewhere is dull on percussion. The area enclosed by the dotted line is resonant when the patient stands, while all elsewhere is dull. The change of outline of the dullness on change of posture, is clearly marked. Again, ascites may be associated with an abdominal tumor, either as a complica- tion or from some intercurrent disease. In either case, the association of the two is indicated by the outline of the area of dullness with the patient in different positions. Fig. 118 shows a patient presenting obesity and a fibroid tumor and moderate ascites. The obesity was very apparent on inspection. On palpating, to j^2 GYNECOLOGIC DIAGNOSIS determine if there were any further causes for the prominent abdomen, I found that there was a distinct mass extending upward from the pelvis into the central abdomen. Nothing more was found on palpation, except considerable tenderness over the tumor. Passing to percussion of the abdomen, with the patient lying on her back there was dullness over the mass extending, in the median line, to a short distance above the umbilicus and extending symmetrically to each side. In trying to determine accurately the area of dullness in the left side, I found that it extended horizontally along the flank as shown in Fig. 194. Percussion in the right flank showed about the same area of dullness there. The patient was then directed to stand and percussion was again employed. When standing, the area of dullness was as shown in Fig. 195. A comparison of these two outlines (Fig. 196) makes it plain ■^ ,^Sm Iff SP- " ■^.. m 1 d ;: Hits :r %, t '^K d : f • .\.l '-\ ^ m - f • . - . r fi m : ::: ::: 11 :::: f "^ :: ;: ij. - l^i ^ ■ - - %'^W il^Hl :: 1? ■ I l^^ft Wise«ses of Women.) Fig. 251. Stasis Hypertrophy of the Vulva. {HiTst— Diseases of Wo^.fa->. 196 GYNECOLOGIC DIAGNOSIS Fig. 252. Stasis Hypertrophy about external genitals and edema from pregnancy. (Dickinson —American Text-book Obstetrics.) Fig. 254 shows the scar tissue about the bony arch, distorting the tissues and inter- fering with the return flow of blood and iymph. Another cause of stasis hypertrophy, is the infiltration and hypertrophy due to the lymph vessels being choked with a parasite, the filaria sanguinis hominis. This is seen almost exclusively in tropical countries. Elephantiasis of Vulva. The term "ele- Fig. 253. So-called Elephantiasis — probably stasis hypertrophy. (By- ford, after Winkel — Manual of Gyne- cology.) Fig. 254. Stasis Hypertrophy of Vulva, with en- larged parts raised so as to show the ulceration and scar tissue about the pubic arch. (K\\ia.r\\— Surgical Diagnosis.) Fig. 255. Elepnaiitiasisof the Labia. (V>-jiidy—Am,erirn,i Te.rt- book of (rynecology.) SIMPLE CONDYLOMATA OF VULVA 197 phantiasis'' is very appropriately applied to the cases of enormous labial hyper- trophy, such as shown in Fig. 255. The stasis hypertrophy previously described, is often spoken of as "elephantiasis," but I think it not advisable to use the term so loosely (see chapter iv). Fig 256. Varicose Veins of the Vulva. (Hirst— Diseases of Women.) Fig. 257 Scattered Condylomata of the Vulva. ( Hirst- Z>iseases of ffomen.) 198 GYNECOLOGIC DIAGNOSIS Varicose Veins of Vulva. These not infrequently cause marked swelling, as shown in Fig. 256. Seri- ous enlargement of the veins is found most fre- quently in pregnancy or in the case of some pelvic tumor or inflammatory mass obstructing the pelvic cir- culation. Alarming hem- orrhage has followed the rupture of ah enlarged vein in such cases. Condylomata of Vulva. From Chronic Irritation. As a result of persistent irri- tation and discharge about the vulva, small papillary masses grow from the skin at various points (Fig. 257). They may come from any persistent irritation, though chronic gonorrhoea is the most frequent cause. Sometimes they appear in great profusion (Fig. 258) and occasionally they coalesce and form large papillary masses (Figs. 259, 260) . These papillary growths are called pointed condylomata, in contra- distinction to the fiat condylomata which are usually due to syphilis. From Syphilis In secondary syphilis, white areas with infiltration sufficient, Fig. 258. Small Masses of Condylomata. Gynecology .) (Gilliam — Practical Fig. 259. Condylomata forming large Masses. (Pozzi — Treatise on Gynecology.) Fig. 260. The whole vulgar region occupied by Massed Condylomata. (Kustner— A'M?-ces Lehrhuch dcr (lyna- Icologie.) SYPHILITIC CONDYLOMATA OF VULVA 199 to raise them above the surface, often appear about the external genitals. They may be few or many (Figs. 261, 262), and they may be raised much or little. Fig. 261. Syphilitic Infiltration and Condylomata about the vulva. (Hirst — Diseases of Women.) Fig. 262. Syphilitic Condylomata. Flat variety. (Bovfee — Practice of Gynecology.) 200 GYNECOLOGIC DIAGNOSIS They are usually flat condylomata, only rarely being pointed or papillary (Fig. 263). Vulvo-vaginal Gland Cyst or Abscess. The swelling has much the same appear- ance whether it be a cyst or an abscess. Figs. 264 and 265 show abscesses of the gland. Fig. 266 shows a cyst of the gland. Hypertrophy of Labia. The hypertrophies affect principally the labia minora, either the free portion on one or both sides (Fig, 267) or that portion extending up over the clitoris as the prepuce. The hypertrophied portions contain much re- b'ig. 263. Syphilitic Condylomata. Pointed variety. (Hirst — Diseases of Women). dundant tissue and are corrugated and usually somewhat pigmented. In some cases the hypertrophy becomes very marked, as in the Hottentot apron, shown in Fig. 268. Hypertrophy of CUtoris. This is much rarer than hypertrophy of labia. Occa- sionally the clitoris is considerably enlarged. Fig. 269 shows such case. Malignant Disease of Labia or Clitoris. Malignant disease (carcinoma or sar- coma) appears upon the lal)ia as a small reddened nodule, which later ulcerates. ABSCESS OF VULVO-VAGINAL GLAND 201 Fig. 221 shows a beginning carcinoma of left labium majus. Fig. 270 shows a small carcinoma of labium minus. Figs. 271 and 272 show carcinoma of the labium at a later stage. Fig. 273 shows an advanced carcinoma of the vulvo-vaginal gland. Fig. 274 shows a sarcoma of the labium. Fig. 222 shows a carcinoma of clitoris. Non-malignant Tumor of Labia or Clitoris. Fibromata and lipomata and cysts occur here, though not very frequently. Fig. 275 shows a small fibroma of the left labium majus. Fig. 276 shows a larger solid tumor of the labium. Fig. 277 Fig. 264. Abscess of Vulvo-vaginal Gland, left side. (Kelly— Opera- tive Gynecology.) shows a number of small cysts on the labium. Figs. 278 and 279 show large labial cysts. Fig. 280 shows a cyst of the clitoris. Pudendal Hernia. A hernia of intestine or omentum or other mtraperitoneai structure, may take place through the inguinal canal and appear in the labmm majusof that side (Fig. 281). • /x^- Another form of pudendal hernia is that which comes by way of the vagina (tig. 202 GYNECOLOGIC DIAGNOSIS Fig. 265. Another case of Abscess of Vulvo-vaginal Gland, right side. (Hirst — Diseases of IFomen.) -pm^^:-^=^^^^^^'-^^-^y--- ^^ Fig. 266. Cyst of the Vulvo-vaginal Gland. (Montgomery — Practical GynS' cology.) HYPERTROPHY OF LABIA MINORA 203 Fig. 267. Hypertrophy of the Labia Minora. {Hiist— Diseases of Women.) Fig. 268. Enormous Hypertrophy of the Labia Minora— the so-called "Hottentot Apron." The first cut shows the patient standing, with the hypertrophied labia hanging between the thighs. The second cut shows the patient on her back, with the labia separated. (Garrigues, after Z'weiiel— Diseases of Women.) 204 GYNECOLOGIC DIAGNOSIS Fig. 269. Hypertrophy of the Clitoris. (Hirst— X>iseases of Wmnen.') Fig. 270. Carcinoma of Labium Minus, beginning. (Hirst— Z>iseases o/ Women.) CARCINOMA OF LABIUM 205 Fig. 271„ Carcinoma of Labium at a larger stage. (Hirst — Diseases of Women.) I <* .,^ Fig. 272. Carcinoma of Labium in a still later stage. (Hirst— Z>i8eo«es of Women.") 206 GYNECOLOGIC DIAGNOSIS Fig. 273. A large Carcinoma of the left Vulvo-vaginal Gland. (Kelly- Operative Gynecology.) FIBROMA OF LABIUM 207 Fig- 274. Sarcoma of Labium. (Hirst— /diseases of Women.) Fig. 276. A large Fibroma of the Labium. (Montgomery— Pwc^'cni ai/ne- cology.) Fig. 275. A small Fibroma of lert Labium «ajus. {^aXAy— American Text-hook of Gyne- eoloaii.) 2D8 GYNECOLOGIC DIAGNOSIS Fig. 277. Small Cysts of the Left Labium Minus. (Kelly — Operative Gynecology.) Fig. 278. A large Labial Cyst. (Uirst— Diseases of Wome7i.) CYSTS OF VULVA 209 Fig. 279. Another large Labia! Cyst. (Hirst— /diseases of Women.) Fig. 280. A Cyst of the Clitoris. (Kelly— Operative Gynecology.) 21C GYNECOLOGIC DIAGNOSIS Fig. 281. An Inguinal Hernia becoming Pudendal. (Dudley — Practice of Gynecology.) 282), the protrusion taking place in front of the uterus in some cases (Fig. 327) and be- hind the uterus in others. Pudendal Hydrocele. A collection of fluid occasionally occurs in the canal of Nuck, forming a hydrocele, which corresponds to hydrocele of the cord in the male. Tumor of Round Ligament. Fibromyoma of the round ligament is a rare condition and one that causes much distortion of the structures about the inguinal canal, conse- quently it is likely to lead to an erroneous diagnosis. It should be considered when- ever there is a peculiar swelling in the neighborhood of the inguinal canal. Prolapse of the Urethral Mucosa (Fig. 283). This occurs to a slight extent in many women who have borne children or have had inflammation of the urethra. Not infrequently the protrustion is marked and no doubt leads in many cases to an erroneous diagnosis of caruncle. The prolapsed mucosa encircles a considerable part of the circumference of the meatus, and a close inspection will show that the small mass presents the smooth, though irregular, surface of hypertrophied mucosa, instead of the papillary projections usually present in urethral caruncle. Again, the meatus is much widened from the previous injury or inflammation, and the pro- lapsing of the mu- cosa may bring into view the orifice of the duct, or Skene's gland, on one or both sides (Fig. 48). Urethral Caruncle (Fig. 284). This is a distinct new growth, usually papillary in form, springing from the region of the mea- tus. It may have a narrow pedicle or a broad attachment, but does not tend to en- circle the meatus as does prolapsed nui- cosa. Fig. 282. A Pudendal Hernia which came by way of the Vagina. Macnaughton-Jones, after Winokel— /diseases of Women.) (H. PROLAPSED URETHRAL MUCOSA AND CARUNCLIO 211 Malignant Disease of Urethra. This starts usually in some small spot of irrita- tion about the meatus, and in the early stage presents a small ulcer or induration. Later the infiltration involves the vestibule, urethra and adjacent tissues. Suburethral Abscess. This consists of a pouch formed by a diverticulum from the urethra, usually from the inferior wall. Inflammation and suppuration take place in this pouch, which may or may not drain irregularly into the urethra. When distended, it may project at the vaginal orifice (Fig. 285) like a small cyst of the anterior vaginal wall. Fig. 286 gives a clear idea of the condition. it&/ Fig. 283. Prolapse of the Urethral Mucosa. (Montgomery — Practical Gynecology.) Fig. 284. Urethral Caruncle. (Montgomery- Practical Gynecology.) Prolapse of Uterus (Fig. 287). When the uterus prolapses sufficiently, the firm cervix, with the external os near the center, appears at the vestibule (Fig. 288). or it may come farther out, as shown in Fig. 289, or it may come still farther, so that the entire uterus is outside the body (Fig. 290) . The bladder may or may not prolapse along with the uterus. Fig. 291 represents a case in which the bladder does not prolapse. Fig. 292 represents a case in which the bladder does come down with the displaced uterus. The method of locating the bladder by the introduction of a sound, is shown in Fig. 293. Ulcers of various 212 GYNECOLOGIC DIAGNOSIS Fig. 285. Suburethral Abscess. View from in front. (Kelly — Operative Gynecology.) SUBURETHRAL ABSCESS 213 Fig. 286. Testing for Suburethral Abscess. (Ashton— Practice of Gynecology.) Fig. 287. Prolapse of the Uterus, showing the various steps in the process. (KeWy— Operative Gynecology.) 214 GYNECOLOGIC DIAGNOSIS Fig. 288. A case of Prolapse of the Uterus. The cervix is at the ve^-dbule. (Hirst — Diseases of Women.) PROLAPSE OF THE UTERUS 215 Fig. 289. Another case of Prolapse of the Uterus. The uterus comes still farther out. 216 GYNECOLOGIC DIAGNOSIS Fig. 290. Another case of Prolapse of the Uterus. The uterus and vagina lie outside the body. The ulceration, so frequent in these cases, is very e\'ident, (Hirst — Diseases of Women.) Fit;. 291. Prolapse of the Uterus. Sectional view The bladder remains in place. (Kelly — Operative Gynecology.) PROLAPSE OF BLADDER, WITH UTERUS 217 Fig. 292. Prolapse of the Uterus and Bladder. (Doderlein and Kronig— Operative Gynakologie.) Fig. 293. Testing for Prolapse of the Bladder with the uterus, by means of a sound in the bladder. (Ashton— Practice of Gynecology.) 218 GYNECOLOGIC DIAGNOSIS sizes and shapes, may appear on the exposed irritated surfaces. Such ulceration is shown in Fig. 290. Prolapse may occur in a woman who has never had a child (Fig. 294) or even in the virgin (Fig. 295). The position of the fundus is made out by recto-abdominal palpation, as indicated in Fig. 296. Fig. 294. Prolapse of the Uterus in a Nullipara. (Hirst — Diseases of IVomen.) Fig. 295. Prolapse of the Uterus in a Virgin. (Kustner — Kurzes Lehrhuch der Gynalcologie.) HYPERTROPHY OF THE CERVIX UTERI 219 Elongation of the Cervix produces a condition which is not infrequently mistaken for prolapse. If the hypertrophy affects only the infra-vaginal portion of the cer- vix(Fig. 297-a)the vaginal walls are not carried downbut remain in normal position, producing the condition shown in Figs. 298 and 299. When the elongation affects the supra-vaginal portion(Fig. 297-c), both vaginal walls are carried down with the pro- Fig. 296. Locating the body of the Uterus by recto -abdominal palpation, in a case of suspected Prolapse. (Ashton — Practice of Gynecology.) trading cervix, producing a condition (Fig. 300) very likely to be mistaken for uterine prolapse, unless the depth of the uterine cavity be measured or the body of the uterus be carefully outlined by bimanual palpation. In these cases the drag- ging of the relaxed and redundant vaginal walls, seems to be an important factor in producing the elongation of the cervix. When the hypertrophy or stretching, as the case may be, affects the intermediate por- tion of the cervix (Figs. 297-b), the an- terior vaginal wall is usually carried down while the p o s te r i o r wall remains in place (Fig. 301). The time- honored division of the cervix into three por- tions, as indicated in Fig. 297, is convenient for fixing in mind the conditions ordinarily present in these cases, Fig. 297. The Three Divisions of the Cervix : (a) Infra-vaginal Portion. (6) Intermediate Portion, (c) Supra- vaginal Portion. (Byford — Manual of Gyne- cology.) Fig. 298. HjTDertrophy of the Infra- vaginal Portion of the Cerv'ix. (Byford — ■ Manual of Gynecology .) 220 GYNECOLOGIC DIAGNOSIS Fig. 299. Hypertrophy of the Infra-vaginal Portion of the Cervix. (Kelly — Operative Gynecology.) but it must be remembered that in many cases the vaginal wall does not run very much further up on the 1 1 •JnP I ^i^^^M 4- f^ 1 1 i Fig. 300. Hypertrophy of the Supra- vaginal Portion of the Cervix, carrying down the vagina and cervix to the vulva. The uterine cavity in this case measures five and a half inches. An area of erosion is present on the posterior lip of the cervix. {GUliam— Practical Gynecology.) Fig. 301. Hypertrophy of the Inter- mediate Portion of the Cervix, carrying down the anterior vaginal wall and bladder but not the posterior vaginal wall. (By- ford —Manual of Gynecology.) Fig.[302. A specimen presentinc a pcciiliar HjTjer- trophy of the Cervix. The posterior vaginal, wall is carried down but not the anterior. (Herman— Diseases of Women.) DIAGNOSIS OF CERVICAL HYPERTROl'HV 221 posterior part of the cervix than it does on the anterior and, consequently, elon- gation of the middle or intermediate portion of the cervix does not always carry down the anterior vaginal wall and leave the posterior in place — in fact, in the case shown in Fig. 302, it has carried down the posterior wall and left the anterior. The differentiation from prolapse of the uterus is made l:)y locating the fundus uteri at about the normal position in the pelvis, by vagino-abdominal or recto- Fig. 303. Pediculated Fibroid Tumor of the Uterus, protruding at the vulva. (Kelly— Operative Gynecology.) abdominal palpation, and, if necessary, by sounding the uterus to determine the length of the uterine cavity. In elongation, the cavity is increased in length suf- ficiently to account for the appearance of the cervix at the vulva. In prolapse of the uterus, there is usually some elongation of the supravaginal portion of the cervix by the dragging of the prolapsing vaginal walls, but it is of secondary importance. 222 GYNECOLOGIC DIAGNOSIS Fig. 304. Complete Jiivei&ionof the Uterus, forming a large mass at the vulva. This is a post partum inversina and the placenta is still attached to the turned-out fundus uteri. (Williams— Obstetrics.) Fig. 305. A small Cyst of the Vaginal Wall. (Uirat— Diseases of Women.) CYSTS OF THE VAGINAL WALL 22:i In the cases in which the elongation of the cervix is the principal lesion, there is usually some prolapse of the uterus, due to the dragging of the heavy cervix. Tumor of Uterus. A mass appearing at the vulva, may be a pediculated fibroid (Fig. 303) or a malignant tumor from the uterus. Inversion of Uterus (Fig. 304). This rare condition may produce an appearance Fig. 306. A medium-sized Vaginal Cyst, caught with a forceps and brought into view. (WiTst— Diseases of Women.) very closely resembling a necrotic, bleeding tumor protruding from the vulva. The internal conditions are shown in Fig. 312. Vaginal Cyst. This may be confounded with cystocele or vaginal hernia or sub- urethral abscess. The differential diagnosistic points are the absence of inflamma- tion, the distinct fluctuation, the tenseness of the sac containing the fluid and its attachment to some part of the vagina. Figs. 305 and 306 show such vaginal cysts. 224 GYNECOLOGIC DIAGNOSIS POINTS IN THE VAGINAL EXAMINATION. ROUGHENING OF VAGINAL WALLS. Astringent Douche. Any astringent douche, for example, one coniaining alum or bichlorid, will cause temporary roughening of the vaginal wall. But there is no particular tenderness. Inflammation. It is found in acute vaginitis, simple or gonorrhoeal, and in some cases of chronic vaginitis. In addition to the rough granular feel, there is tender- ness of the wall, and the speculum examination shows reddening TENDERNESS ON VAGINAL PALPATION. Inflammation of Vaginal Entrance. The tenderness is noticed as soon as the ex- amining finger begins to enter the vagina. There may be diffuse redness of the sur- face around the vaginal orifice or there may be simply reddened areas that are ten- der on pressure or there may be abrasions or slight fissures or there may be one or more distinct ulcers. Inflammation of Vulvo-vaginal Gland or Duct. There is swelling and tenderness at the site of the gland and redness about the duct, and in some cases pus may be squeezed from the duct. Hyperesthesia of Vaginal Entrance. There is great exaggeration of the reflex sen- sibility of the tissues immediately about the vaginal orifice, and yet no evidence of inflammation or fissure or ulcer or other adequate cause for pain. In some cases the reflex excitability is so great, that contact causes spasm of the levator ani and asso- ciated muscles to such an extent as to prevent the examination. This uncontrol- lable spasmodic closure of the vaginal orifice is known as " vaginisimus. " Inflammation of Vagina. There is purulent discharge and the vaginal walls are rough and hot. Speculum examination shows marked reddening of the walls (arterial congestion) and also discharge upon them. Inflammation of Urethra. The tenderness is along the lower part of the anterior vaginal wall and is complained of when pressure is made along the course of the urethra. There may be distinct thickening about the urethra, which may be felt as a firm cord beneath the public arch. In most cases there is redness about the meatus, and some discharge may be pressed out by compressing the urethra from above downward (Figs. 46, 47). Inflammation or Other Painful Affection of the Bladder. Pain is caused b}^ pres- sure upward along the middle of the anterior vaginal wall, which lies against the base of the bladder. There are also the symptoms of bladder irritation (frequent urination, painful urination), and also the findings on urinary analysis. Inflammation or Other Painful Affection of the Rectum. Pain is caused by pres- sure backward along the posterior vaginal wall (Fig. 60). There is also evidence of rectal irritability (pain on defecation, rectal tenesmus), and possibly the passage of blood or mucus. Inflammation Around Uterus ''cellulitis, salpingitis, pelvic peritonitis). Pain is POINTS IN THE VAGINAL EXA.MINAITON 225 caused by pressure on the vaginal wall around the uterus, either in front of the cer- vix or behind it or at one side. Pain is caused also by any attempt to move the uterus, as by pushing on the cervix. MASS FELT IN VAGINAL PALPATION. Prolapsed Vaginal Wall (colpocele). The vaginal wall is more redundant than it ought to be and part of it descends toward the opening. It may be the anterior vaginal wall (anterior colpocele) or the posterior vaginal wall (posterior colpocele) (Fig. 239) or both. The mass presents the characteristics of relaxed vaginal wall. There is no distinct firm body in it. Prolapse of Bladder (cystocele). In some cases of prolapse of the anterior vaginal wall, the bladder follows the vaginal wall (Fig. 241). This is known as cystocele, as previously explained. The bladder wall is soft and therefore can not be felt dis- tinctly in the mass, as the uterus can. It is noticed, however, that there is much more soft tissue in the mass than would be furnished by the prolapsed vaginal wall and, as the bladder lies next to the vagina, it is to be assumed that this extra tissue is bladder wall. Sometimes there is enough urine in the prolapsed pouch of bladder to give fluctuation. Usually there is some bladder irritability (frequent, painful urination), and in some cases the patient has found that she must push back the mass each time before she can urinate satisfactorily. If there is still doubt as to whether or not the bladder descends with the vaginal wall, and it is important to know certainly, introduce a steel urethral bougie (about No. 20F) and see if the tip passes easily into the mass (Fig. 243). Prolapse of Anterior Wall of Rectum (rectocele) . The anterior wall of the rectum may follow the posterior vaginal wall in its descent through the vaginal orifice (Figs. 244, 245). A digital examination per rectum will quickly show whether or not the cavity of the rectum extends into the mass (Figs. 246, 247). Prolapse of Uterus (Fig. 287). The cervix is felt much lower (closer to the va- ginal entrance) than normal, or it may present at the vaginal orifice or even project far outside (Fig. 289). Bimanual examination shows that the body of the uterus also is lower than usual (Fig. 296), and consequently that the condition is prolapse of the uterus and not simply elongation of the cervix. Elongation of Cervix. The cervix is felt much lower than it ought to be. Bi- manual examination shows that the body of the uterus is in normal position. If the bimanual examination does not make plain the length and position of the body of the uterus, the uterus may be sounded. This will show that the length of the uterus is sufficient to account for the low position of the cervix. In some cases the two conditions, prolapse of the uterus and elongation of the cervix, are both present. Tumor of Uterus. There is a solid or semi-solid mass lying in the vagina (Figs. 307, 308, 309, 310, 311). The finger may be passed all around, between the mass and the vaginal wall. When the finger is passed around the mass, its connection with the cervix is felt. It may spring from a portion of the cervix within reach, or it may be connected with a pedicle extending up into the canal. Inversion of Uterus (Fig. 312). There is a mass the size of the uterus lying in the 226 GYNECOLOGIC DIAGNOSIS Fig. 307. A small Pediculated Fibroid of Uterus, projecting into the vagina. (Montgomery — Practical Gynecology.) Fig. 308. A large Pediculated Uterine Fibroid lying in the vagina. (Thomas and .\Iunde — Diseases of Women.) Fig. 309. \ Pediculated Fibroid, with the sound in place to differentiate it from inversion of the uterus. (Dudley — Practice of Gynecology.) A MASS FEI/r IN THE VAOINA 227 Fig. 310. A Sarcoma of the Uterus projecting into the vagina and causing partial inversion of the uterus. (Kelly — Operative Gynecology.) 311. Grape-like Sarcoma springing from the Cervix uteri and forming a mass in the vagina. (Kustner— A'Mr~e« Lehrbnch der Gynakologie.) "m GYNECOLOGIC DIAGNOSIS vagina, having a raw looking mucous surface exposed. Palpation of the upper part of the mass shows that it is connected with the cervix by a broad pedicle, and the dilated cervical ring may be felt around it. Figs. 313 to 321 give a clear idea of inversion and conditions that may be confounded with it. Fig. 312. Inversion of the Uterus, forming a mass in the vagina. (Kelly— Operotire Gynecology.) Fig. 313. Begining Inver- sion of the Uterus. Fig. 314. Submucous Fib- roid with short pedicle. Fig. 315. Submucous Fib- roid and beginning Inver- sion. DIAGNOSIS OF INVERSION OK UTKHUS 229 Fig. 316. Partial Inver sion of Uterus. Fig. 317. Submucous Fib- roid with long pedicle. Fig. 3 18. Pediculated Fib- roid and partial Inversion. Fig. 319. Complete In- version of Uterus. Fig. 320. Pediculated Fib- roid filling upper part of vagina. Fig. 321. Complete Inver- sion of Uterus, with a pedi- culated subperitoneal Fib- roid occupying the normal site of the uterus. Figs. 3 13 to 321. Inversion of the Uterus and Conditions that Simui>ate it. (Dudley— Practice of Gynecology.) Fig. 322. F'S- 323. Diagnosis of Inversion of the Utercs. Fig. 322 shows the method of determining the absence of tlie body of the uterus froia the pelvic cavity. Fig. 323 shows the determination of the presence of a cup-shaped depression above the cervix. (Ashton— Practice of Gynecology.) 230 GYNECOLOGIC DIAGNOSIS Bimanual examination (under anesthesia, if necessary) shows the body of the uterus absent from where it should be (Fig. 322), and instead there is a cup like depres- sion above the cervical ring (Fig. 323). Also, a sound will not pass up into the uterine cavity but is stopped on all sides a short distance within the cervical open ing (Fig. 324) . There may be inversion associated with a tumor (Fig. 325) . Fig. 324. Differential Diagnosis of Inversion by means of the sound. On all sides the sound is stopped a short distance within the cervix. (Ashton — Practice of Gynecology.) Fig. 326. A group of small Cysts of the Vaginal Wall. (Montgomery — Practical Gynecology.) Fig. 325. A Pediculated Fibroid Causing Inversion of the Uterus. This shows also a danger to be avoided in treatment. Ampu- tation of the fibroid by cutting across the pedicle at the level of the line A, B, would open the peritoneal cavity. (Thomas and Munde — Diseases of IFomen,) Fig. 327. Anterior Vaginal Hernia. (Ashton -Practice of Gynecology.) CHANGES FELT IN THE CERVIX 231 Tumor of Vaginal Wall. This is usually a cyst. A rounded mass containing, fluid is felt and, tracing it up, it is found to be attached to the vaginal wall (Fig. 326). It can not be reduced into the peritoneal cavity lilve a hernia, neither is there any evidence of any obstructive bowel disturbance. Solid tumoi-s of the vaginal wall sometimes occur. Vaginal Hernia (Fig. 327). This is felt as a soft elastic mass, causing projection of the vaginal wall. It can be reduced into the peritoneal cavity but returns when the patient coughs or bears down. It disappears when the patient is in the knee- chest posture, unless strangulated or incarcerated. There may or may not be sym- toms of intestinal obstruction, partial or complete. Abscess Pushing Vaginal Wall Inward. Such an abscess may arise in the con- nective tissue beside the cervix or in the posterior cul-de-sac or in front of the cer- vix or as an ischio-rectal abscess. It may arise also in the recto-vaginal septum. Rectum Distended with Fecal Masses. If the fecal masses are in the lower part of the rectum their character is apparent, but if in the upper part of the rectum, back of the uterus, they may be confused with other masses. The characteristics of such a fecal mass are that it is situated in the course of the rectum, that it is not particularly tender, that it has a putty-like consistency and may be indented by the examining finger and the dent remains, that it may be moved along to a dif- ferent part of the rectum and that an enema removes it. Tumor of Rectum. There is a mass felt through the posterior vaginal wall. There are the evidences of rectal irritation and also the facts that may be made out on rectal examination. Tumor of Bladder. A mass is felt through the anterior vaginal wall. There are the evidences of bladder irritation (frequent, painful urination) and also the urinary findings. Mass in CuI=de=Sac of Douglas. This is felt back of the cervix and may be a re- troflexed uterus (Fig. 393), a tumor (Fig. 392), a prolapsed ovary or tube (Fig. 391), an inflammatory exudate (Fig. 401), an abscess or a hematocele. CHANGES IN CERVIX UTERI FELT ON VAGINAL EXAMINATION. Displacement of Cervix. Forward Displacement (pointing forward) may be due to backward displacement of the uterus (Figs. 328, 329), to anteflexion of the cer- vix (Fig. 330) or to an inflammatory mass or a tumor back or the cervix pushing it forward. Backward Displacement may be due to a distended bladder (Fig. 344), or a tumor of the bladder, to an inflammatory mass or a tumor in the front part of the cervix pushing it backward or to old adhesions back of the cervix pulling ii backward. Lateral Displacement of the cervix may be due to an inflammatoiy mass, a blood mass or a tumor at the side of the cervix pushing it toward the oppo- site side, or to old adhesions or to scar tissue in the vaginal wall on one side pulling the cervix to the same side. Enlargement and Distortion of the Cervix may be caused by inflammation with e version of mucosa (Fig. 331), or by laceration with eversion of mucosa (Figs. 332 to 337), or by chronic inflammatory infiltration and obstruction of gland ducts from 232 GYNECOLOGIC DIAGNOSIS I i Fig. 328. Fig. 329. The Relation of the Cervix to the Examixisg Fixger. Fig. 328. Retroversion of the Uterus, showing the Relation of the Cer\'ix to the examining finger. Com- pare this with Fig. 329, which shows the relation of the cervix to the examining finger when the uterus is in uormal position. (Keating and Coe — Clinical Gynecology.) Fig. 330. Anteflexion of the Cen'ix Uteri. In this condition the axis of the cervix points toward the examiner, as in retroversion, though the corpus uteri is well forward. SWELLING AND EVEKSlUN FROM INi'LA.NLMATlUN 233 Fig. 331. Eversion of the Cervical Mucosa due to inflammation within the cervix. (Cullen — Cancer of the uterus.) There has been no laceration of the cervix in this case, the patient being a Nullipara. This eversion of the cervical mucosa by inflammation only, without previous laceration, is a rare con- dition. It is likely to lead to a mistaken diagnosis of laceration of the cervix. It is also of medico-legal importance, as the appearance of laceration may lead to the erroneous conclusion that the patient has at sometime given birth to a child. 23* GYNECOLOGIC DIAGNOSIS scar-tissue, causing cystic degeneration (Fig. 337), or by a fibroid tumor of the cer- vix or by a malignant tumor of the cervix. Idiopathic elongation of tlie cervix, also, may cause it, but that is a very rare condition. Softening of the Cervix may be due to normal pregnancy or to extra-uterine pregnancy or to a recent pregnancy (terminated by labor or miscarriage). In Fig. Fig. 332. Fig. 333. Figs. 332 and 333, Side and Front Views of a Simple Bilateral Laceration, requiring no treatment. Fig. 334. Front view of a Unilateral Laceration requiring no treatment. Fig. 335. Side View of a Unilateral Lacera- tion. Such a laceration may cause abor- tion in the early months of pregnancy. Fig. 336. Side View of a Bilateral Fig. 337. Front View of a Bi- Laceration, requiring treatment. The lateral Laceration, showing eroded lip.s are everted, and the Nabothian area and Nabothian follicles, follicles stand out as small hard lumps. Figs. 332 to 337. Lacerations of the Ceuvix Uteri. (Baldy— .//"erjcinj Teiit-hook of (ii/necologi/.) 338, the softened portion is represented by the dotted area. This feels soft, like the vaginal wall or like velvet, as explained in chapter i. It has been aptly said that " the cervix normally has about the consistency of the tip of the nose. When it is as soft as the lip, look out for pregnancy. " This softening begins at the lower part of the cervix in the first few weeks of pregnancy and gradually progresses upward until, in CHANGES IN THP: CONSISTENCY OF THE CERVIX 235 the last month, the whole cervix is so softened that it is sometimes hardly felt in the examination. That this is a softening, and not a shortening as was formerly sup- posed, is shown in Fig. 339, where it is seen that the cervix at term is still of normal length. Occasionally marked chronic congestion, from the presence of a tuinoy or inflammatory mass, will be accompanied by sonic softening or the cervix. Fig. 338. Palpating the Cervix to Determine Softening. The light stippled area represents the softened portion. The uterus is represented as enlarged from early pregnancy. Fig. 339. Section of the Cer- vix, in pregnancy at term, show- ing that the cervix is still of Full Length. The sensation of short- ening imparted to the examining finger is due to the softening, causing the lower part to be not easily appreciated by the finger- (Dickinson, after Waldoyer — American Textbook of Obxtet- rics.) Fig. 340. Beginning Carcinoma within the Cervix, causing a Hard Nodule, which can be felt on digital ex- amination. (Kelly— Operative Gynecology.) 236 GYNECOLOGIC DIAGNOSIS Hard Nodule in the Cervix may be due to scar tissue from laceration, to a fibroma, to beginning malignant disease (Fig. 340) or to a glandular cyst (Fig. 341). In scar tissue, the induration corresponds with the scar and follows the course of the scar, and it does not increase in size under observation. In cystic disease (Figs. 560, 341), if the nodule be punctured and pressed upon, the characteristic clear glairy substance will be extruded and the induration will largely disappear. In fibromyoma. fibroids elsewhere in the uterus may be found, making it probable that the cervi- Fig. 341. Cysts of the Cervix. These feel like Hard No- dules and hence may lead to a mistaken diagnosis of malig- nant disease in the cer^'ix, as happened in the case from which this specimen was taken. At operation the car- cinoma (which was diagnosed from curettings) was found to be confined to the corpus uteri, as shown in the speci- men, instead of extending to the cerv^ix as was previously supposed. (Kelly — Operative Gynecology.) cal nodule is similar in nature. A nodule in the cervix that does not correspond with any of the conditions just mentioned, may be beginning malignant disease. A piece of it should be excised and submitted to microscopic examination, to establish certainly the diagnosis at a time when a diagnosis will do some good. Tenderness of the Cervix usually means inflammation around the uterus. The tissue of the cervix is ordinarily not painful to pressure even when diseased. The tenderness so often complained of when pressure is made on the cervix, is usually POLYPI IN THE CERVIX 237 due to a slight involvment around the uterus and consequent pulUng on in- flamed peri-uterine tissues due to the moving of the uterus. Fixation of the Cervix may be due to inflammatory exudate, to a tumor about the uterus or to scar tissue in the upper part of the vagina. Abnormal Mobility of the Cervix is due to stretching of the supporting tissues around it and of the pelvic floor below it. MASS FELT IN CERVICAL CANAL. On palpating the cervix some one of the following small masses may in some cases be felt just within the external os or projecting slightly from it. Blood Clot. This is soft and easily broken, if it projects far enough to permit of its being caught between the fingers. When it is up in the canal so that only the Fig. 342. Mucous Polj-pi of the Cervix. (Jliist— Diseases of Women.) 238 GYNECOLOGIC DIAGNOSIS lower edge or end can be felt, it may feel very much like a piece of tissue. Intro- duce the uterine dressing forceps beside the finger and catch the small mass and bring it outside for inspection. Placental Remnants. In incomplete miscarriage a small piece of tissue may often be felt in the cervical canal, showing that there are retained remnants that must be removed. It is in this same class of cases that a firm blood clot in the cer- vix may lead to an erroneous diagnosis, hence the importance of removing the small mass with a forceps so that it may be examined to determine certainly whether it is a piece of tissue or only a blood clot. To determine if it has the bushy projections of placental tissue, spread it out in water. If it is of doubtful char- acter, submit it to microscopic examination. It may be a broken off papillary mass from a malignant growth in the uterus. Mucous Polypus. Mucous polypi are frequently found projecting from the cer- vix or up in the canal (Fig. 342) . They may be so soft as to be hardly noticed in the digital examination but, when projecting from the canal, are very apparent in the speculum examination. Fibrinous Polypus. This is a polypus which has gradually enlarged from accre- tions of fibrin about a placental remnant or other small mass in the uterine cavity. Its character is determined bj" microscopic examination. Fibroid Polypus (Fig. 307). This is a small pediculated submucous fibroid, the pedicle of which has become stretched sufficiently to permit the mass to appear at the external os or to project from the same. It may be attached in the body of the uterus or in the cervix, usually the former. Malignant Polypus. A malignant growth in the cervix or in the body of the uterus may send out a papillarj^ projection that appears at the external os as a poly- pus. Again malignant change may be present in, or may develop in, apparently simple poh^i. For this reason all polypi of whatever kind removed from the cer- vis. should be preserved that their exact character may be determined by micro- scopic examination. POINTS IN THE VAGINO=ABDOMINAL EXAMINATION. CHANGES IX CORPUS UTERI. Backward Displacement of the Uterus (Fig. 343) , The body of the uterus is not made out in front (Fig. 69). In the back part of the pelvis there is felt a body, ap- parently continuous with the cervix, and of the size, shape and consistency of the corpus uteri (Figs. 70, 71). It may bo movable or fixed, tender or not tender. No other mass is felt in the pelvis. Such a mass is in all probability the bod}' of the uterus in backward displacement. If some of the necessary points can not be made out distinctly and there are circumstances which make it important to know at once the exact location of the corpus uteri, this may be determined certainly by introducing the sound into the uterus. But do not use the sound except when there is some special reason for doing so, and remember the contra-indications to sounding given in chapter i. POINTS IN THE BIMANUAT. i:\AMlNATION 239 This retro-displacement of the body of the uterus may be due to a full bladder (Fig. 344) or to an infianmiatory mass in the front part of the pelvis or to a tumor. On the other hand, the displacement itself, with or without an accompanying in- flammatory trouble, may be the principal lesion. Fig. 343. Retrodisplacement of the Uterus, showing the first, second and third Degrees. (Skene — Diseases of Women.) Forward Displacement of the Uterus. Forward displacement of the body of the uterus may be due to the body of the uterus being heavy and softened, as in early pregnancy (Fig. 348) and also in certain inflammatory conditions, or to an inflam- matory mass or a tumor pushing the fundus forward and downward. Lateral Displacement of the Uterus may be caused by an inflammatory mass (Fig. 345) or by blood a mass (Fig. 387) or by a tumor (Fig. 346), pushing the uterus toward the opposite side. It may be due also to Fig. 344. Uterus displaced backward by i ?ull Bladder. (Montgomery — Practical Gynec- ology.) VAGINA RECTUM Fig. 345. Uterus displaced laterally by an In- flammatory Mass. (Edgar— Prrtcitce of Obstetrics.) 240 GYNECOLOGIC DIAGNOSIS old adhesions drawing the uterus to the side (Fig. 347), or it may be due simply to a heavy uterus leaning to the side. Slight Enlargement of the Uterus may be caused by early pregnancy. There is usually decided anteflexion of the softened uterus in this early stage (Fig. 348), Fig. 346. Uterus pushed to the left side by a Tumor or Inflam- matory Mass in the opposite side. (Findley — Diagnosis of Diseases of Women.) Fig. 347. Uterus Drawn to the left side by Adhesions or Infiltra- tion in the same side. (F'mdXey— Diagnosis of Diseases of Wometi.) Occasionally there is backward displacement of the pregnant uterus (Figs. 349, 350). From about the sixth to the twelfth week there is a peculiar softening and compressibility of the lower portion of the body of the uterus which contrasts markedly with the less compressible portion above. This is known as Hegar's SLIGHT ENLARGMKNT OF Till-: UTERUS \'A\ Pdr'es- recti Vesica urin. • V. dorsalis clitor. " Clitoris Flacmfa Grif. inf. uteri Orif. ext. nteri Excav. vesica Fornix vagin. post. ^f. sphincter ani ext. Tunica muscul. recti M. sphincter ani ext. Urethra Tunica muscul. urethr. Vagina P'ig. 348. Frozen Section of a body showing the Uterus Enlarged from early Pregnancy. Notice the sluvrp anteflexion of the softened uterus. (Waldeyer — Das Becken.) 242 GYNECOLOGIC DIAGNOSIS Fig. 349. Early Pregnancy with Retrodisplaeement of uterus. (Edgar— Practice of Obstetrics.) Fig. 3.50. Early Pregnancy with a more marked Reir-...)is|.lapcment of the uterus. (Edgar— Pmcrice of Obstetrics.) HEGAR'S SIGN IN EARLY PREGNANCY 24? Fig. 351. A Sectioned Uterus in early Pregnancy, showing the two halves and the interior arrangement whicli gives ilepar's Sign. (Edfrar, after Pinard — Practice of Ohstetrica.) Fig. .3.52. Showing the Sen.sat ions im- parted to the examining fingeis by dif- ferent portions of the uterus in Early Pregnancy, particularly the marked Com- pressibility of the portion just above the internal OS (Hegar's Sign). (Dickinson — American Text -book of Obstetrics.) Fig. 353. Palpating for Hegar's Sign, with the uterus forward in the usual position. (Edgar— Practice of Obstetrics.) :=£?•■' A' Fig. 354. Palpating for Hegar's Sign, with the fundus uteri pushed backward, the abdominal fingers being in front and the vaginal fingers back of the rer\-ix. (Williams— Obstetrics.) 244 GYNECOLOGIC DIAGNOSIS sign, and when well marked is a strong indication of early pregnancy. Fig. 351 shows the section of a uterus in early pregnancy. Fig. 352 explains the sensation imparted to the examining finger. The examination may be made in the usual way, with the abdominal fingers back of the uterus (Fig. 353), or the abdominal fingers may be pressed in front of the fundus uteri, which is displaced! somewhat backward, while the vaginal fingers are placed behind the uterus (Fig. 354). Fig. 355. Hard Nodules in tlie Corpus Uteri, due to small Fibromyomata. (Montgomery— Practical Gynecology.) Fig. 356. Larger Fibromyomata, in var- ious situations in the uterine wall. (Schaef- fer — Hand-Atlas of Gynecology.) SHght enlargement of the uterus may be due also to tubal pregnancy or to chronic inflammation or to one or more fibroid tumors (Figs. 355, 356, 357, 358) or to car- cinoma of the corpus uteri (Fig. 359) or to sarcoma (Fig. 360) or to lipoma (Fig. 361) or to pyometra (Fig. 382) or to tuberculosis of the uterus (Fig. 362). Marked Enlargement of the Uterus may be due to normal pregnancy (Figs. 363, 364, 365.) Figs. 366 and 367 show the height of the fundus at the various weeks of a normal pregnancy. Bear in mind that the pregnant uterus is not always regular in shape, but is occasionally quite irreg- ular (Figs. 368, 369, 370). Enlargement may be due also to a pregnancy somewhat abnormal, for example, presenting back- ward displacement or hy dramnios or hyda- tidiform mole or hematom-mole. Again, marked enlargement of the uterus may Fig. 357. Other varieties of Fibromyomata, be CaUSed by interstitial prCgUaUCy (Fig. giving rise to a diffuse and more uniform enlarge- 371) Or by pregUaUCy in a SCptate UtcrUS ment of the uterus. (Montgomery— frac^isoZ /"P'tr ^79^ Gynecology.) \'^'^&- ■^1 ^) • SLIGHT ENLARGEMENT OF UTERUS 245 Fig. 358. A Single Fibroid, in the posterior wall of the uterus. (Byford- Manual of Gynecology.) Fig. 359. Slight Enlargement of the Corpus Uteri caiised by Carcinoma. (Cullen— Cancer o/ I Fig 361 A Lipoma of the Posterior Uterine Wall. Notice the cavity of the uterus running along the anterior wall, and the marked thickening of the endometrium near the fundus. This is an exceedingly rare form of uterine tumor. (Knox— Johns Hopldns Hoapital Bulletin.) 248 GYNECOLOGIC DIAGNOSIS Fig. 362. Tuberculosis of the Uten^s. This specimen was removed by supravaginal hysterectomy, the lower portion of the cervix being left. (J. Bland-Sutton— ^ssaj/s on Hysterectomy.) n ' Fig. 363. Pregnancy, about four months. fEdgar— PrffctJce of Obstetrics.) ENLARGEMENT FROM ADVANCED PREGNANCY 249 Fig 364. Pregnancy, about five months. (Edgar- Practice of Obstetrics.') Fig. 365. Pregnancy at Full Term. (Edgar- Practice of Obstetrics.) Fig. 366. The Pregnant Uterus contrasted with the non-preg- nant uterus, showing the enormous increase in size. The height of the fundus at various weeks of pregnancy is indicated by the numbers. (Dickinson — American Textbook of Obstetrics.) 250 GYNECOLOGIC DIAGNOSIS Fig. 367. The Height of the Fundus Uteri at various weeks of Pregnancy. (SVi\]ia.ms— Obstetrics.) Fig. 369. Fig. 370. Fig. 368. Figs. 368 and 369 and 370. Irregular Shapes that Pregnant Uteri may present, and which may lead to mis- takes in diagnosis. (Edgar— Practice of Obstetrics.) ENLARGEMENT FROM ABNORMAL PREGNANCY 251 AmRion Ulerine cavity.- .ervix. - Partially separated placenta. Fig. 37L Interstitial Pregnancy. (Williams, after Bximm— Obstetrics.) Fig. 372. Pregnancy in the RightHalf of a Septate ffenxs. (Kelly -Operative Gynecology.) 252 GYNECOLOGIC DIAGNOSIS Aside from pregnancy, the usual causes of marked enlargement of the corpus uieri are fibromyomata (Figs. 373; 374, 375, 376, 377) and malignant disease (Fig 378). Fig. 373. Uterus Enlarged by a large soft single Fibroid. (Bishop— Uterine Fibromyoviata.) In some cases there is an association of fibroid and pregnancy (Figs. 379, 380) or o: malignant disease and pregnancy (Fig. 421). In rare instances the uterus has become enlarged from menstrual blood retained ENLARGEMENT OF UTERtJS FROM FIBROIDS 25.' Fig 374. Uterus Svmmetically Enlarged from Fibroids. This might be mistaken for a pregnant uterus, on account of the close resemblance in shape. (Kelly— Operative Oynecologij.) Fig. 375. Subperitoneal Fibroids, showing the irregularity and distor- tion often present. {KeWy— Operative Gynecology.) 254 GYNECOLOGIC DIAGNOSIS Fig. 376. Single Large Fibroid in anterior uterine wall, choking Fig. 377. Large Fibroids, filling the pelvi.s and tliepeivi.s. (Kelly— Operative Gynecology.) lower abdomen. {\.Ma.rtin— Atlas of Gynecology.) Fig. 378. LUerus Enlarged from Carcinoma. The in- terior of the uteru.s is occupied by the growth and it has extended through, forming some nodules on the outer surface. (Kelly — Operative Oi/nerotagy.) Fig. .'^79. I'iljiiiid Tumor and Pregnancy, the tumor forming tlie most of the mass. (Dudley — Practice of Gynecology.) 1 ITERUS EM.ARCKD llioM OTHER CAUSES 255 because of atresia of the cervix (hematometra, Fig. 381) or from a collection of pus (pyometra) or of pus and gas (pyophysometra, Fig. 382). Softening of the Corpus Uteri is caused by the various forms of intra-uterine preg- nancy. In most cases of early pregnancy the characteristic compressibility of a portion of the uterus (Hegar's sign) may be made out, and when well marked is of Fig. 380. Fibroid Tumor and Pregnancy, the pregnancy forming the larger part of the mass. (Norris, after Simpson — American "^^^t-hool: of Obstetrics.) Fig, .381. Uterus distended with Menstrual Blood (Hematometra), due to atresia of the cervix. (Mont- gomery — Prartiral Gynecology.) (ten assistance in differential diagnosis. Softening of the corpus uteri may be caused also by extra-uterine pregnancy and likewise by a recent pregnancy (i. e., for a few weeks following labor or miscarriage). It is caused also by edema of the uterine wall, from adjacent in- flammation or from a tumor interfering wAth. the circulation or from marked dis- placement. Hard Nodules felt in the Corpus Uteri may be due to parts of the child in preg- nancy or to fibromyomata or to a malig- nant tumor. In rare cases an athero- matous or sclerotic process may cause hardening of areas appreciable to the finger. Also, a mass of exudate or some adherent structure may cause a hard mass that appears, on bimanual examination, to be a part of the uterus. Fig. 382. Uterus, enlarged by^ collection of Pus and Gas (Pyophysometra) above an occluded canper- ous cervix. (Kelly — Operative Gynecology.) 256 GYNECOLOGIC DIAGNOSIS Marked Tenderness of the Uterus may be caused by inflammation of the uterus, by inflammation around the uterus, by hemorrhage around the uterus, by pelvic neuralgia or by functional hyperesthesia (hysteria, neurasthenia). Fixation of the Uterus may be due to an inflammatory mass, to a hemorrhagic mass, to old adhesions, to a new growth or to scar tissue from vaginal laceration. Abnormal Mobility of the Uterus is due to overstretching of the supports around it and of the pelvic floor below it. MASS OR INDURATION In Pelvis or Lower Abdomen, Felt ox Bimaxual Examination. MASS LOW in Pelvis, and to RIGHT of Cervix. A. Mass or Induration FIRM (No Fluid Felt). 1. Body of the Uterus Displaced to the Right. The mass is directly continuous with the cervix and is about the size and shape of the body of the uterus. The uterus can not be felt elsewhere. If not adherent or very tender, it may be pushed back to the normal position of the corpus uteri. The uterus may he somewhat to one side, though freely movable, or it may be dra-oii to one side by adhesions, or it may be pushed over by a tumor or an inflammatory mass or a blood mass. The displaced uterus may be of a normal size or it may be enlarged. If enlarged, it may be of regular shape or distorted. It may be of normal consistency or soft- ened or presenting hard nodules. If there is inflammation in the uterus or around it, it may present decided tenderness. Whether it is movable or fixed depends on the cause of the displacement. If there is attachment by adhesions to the pelvic wall or to an inflammatory mass or to a tumor, determine whether it is at the lower or upper part of the uterus. 2. Salpingitis -Cvith Exudate, extending to the side of the cul-de-sac. The in- flamed tube itself is situated higher, but some fibrinous peritoneal exudate has extended doT\m so that it is felt to the right side of the cervix posteriorly. 3. Salpingitis with Prolapse of Thickened Tube. The enlarged and indurated tube may be movable, or it may he bound in its abnormal situation by adhesions. 4. Salpingitis with Secondary Infiltration of the connective tissue about the cer- viz. This presents practically the same signs low in the pelvis as a primary cellu- litis, but in addition there is felt higher, the mass formed by thickened tube and peritoneal exudate. 5. Oophoritis with Prolapse of Ovary. The ovary is usually enlarged and cystic, but none of the cysts are yet large enough to give distinct fluctuation. Ordinarily, the ovary feels much softer on palpation than either an infiltrated tube or a mass of exudate. This softness may be so marked as to lead to the erroneous idea that fluctuation (a well marked cyst) is present, while in fact the ovarian tissue may be practically normal. The chronically inflamed ovary is occasionally as firm as other tissue which is the seat of inflammatory infiltration. This is the case partic- ularly in the cirrhotic ovary, which is also usually smaller than the normal ovary. SOLID MASS TO RIGHT OF CERVIX UTERI 257 The fact that the mass, felt to the right of the cervix posteriorly, is the ovary, is determined by noticing its position, size, shape, consistency, tenderness, mobility and point of attachment. The ovary is usually decidedly tender, even when nor- mal, and pressure upon it produces a peculiar sickening pain. One of the characteristics of the prolapsed ovary, when not adherent, is that it is freely movable. It slips away from the examining finger and may he pushed up out of the lower part of the pelvis. Following the mass up and making deep bi- manual palpation, its point of attachment is found to be in the tubo-ovarian region. If there has been any peritoneal exudate, the ovary is likely to be fixed in its abnor- mal position by adhesions. 6. Small Abscess from any of the above conditions, near the posterior lateral part of the cervix and with such a thickened wall that no fluctuation is obtained. There is a point of marked tenderness, with fixation of the tissues in the vicinity. If of recent origin there will be some fever, but in an old abscess the temperature may be practically normal. The history of the trouble and the findings elsewhere in the pelvis, will indicate the character of the primary lesion. Fig 383. The Three Spaces or Areas in the Pelvis. A. Peritoneal Cavity. B. Sub- peritoneal connective tissue area or Parame- tria! Space. C. Ischio-rectal Space. The white line between B and C represents the levator ani muscle. (Dudley — Practice of Gynecology.) Fig. 384. On the right is a large inflam- matory mass in the Parametrial Space. This is what is meant ordinarily by the term Pelvic Cellulitis. On the left is a small inflammatory mass in the Ischio-rectal Space. From inflammatory trouble in this region comes the well-known Ischio-rectal Abscess. (Dudley — Practice of Gynecology.) 7. Adhesions at the side of the cervix from any of the above affections. In the absence of pus or active inflammation, there is usually not much tenderness. The principal signs are induration, without a definitely-outlined mass, and fixation. 8. Cellulitis. This may be acute or subacute. The induration is situated very low and blends with the cervix. It may be a small mass or may fill all that side of the pelvis, extending out to the pelvic wall. As a rule its shape corresponds ap- proximately with the connective areas (Fig. 383). If the inflammation is in the parametrium (above the levator ani), it is immediately about the cervix (Fig. 384). If it is below the levator ani, in the ischiorectal space, the induration will be lower, along the vaginal wall and rectum, and there will be induration near the anus. In 258 GYNECOLOGIC DIAGNOSIS pelvic cellulitis, except in the acute cases, the induration feels exceptionally hard, possibly because there is but little intervening soft tissue between the examining finger and the infiltration. The hardness is so marked in some cases as to give the impression of a cartilaginous growth from the pelvic wall. The uterine attachment of the mass is low, principally about the cervix. The outer extremity extends to the pelvic wall, where it is intimately attached over a broad surface (Fig. 384). 9. Small Abscess from Cellulitis, with wall so thick that no fluctuation is obtained. There is a point of marked tenderness, with some fever, and a mass or induration presenting the characteristics of cellulitis. 10. Scar Tissue from former Cellulitis. As explained elsewhere, uncompHcated cellulitis, like other forms of lymphangitis, runs its course and ends in resolution or abscess formation with discharge of the pus. In either case the accompanying in- flammatory infiltration eventuates in the formation of new connective tissue which contracts like other scar tissue, causing persistent induration and fixation of tissues in the affected area. There is not much tenderness from the scar tissue itself, but the resulting compression or constriction of nerves and interference with the circu- lation by distortion, may exceptionally cause persistent tenderness and pain. 1 1 . Scar Tissue from Laceration in Labor. Not infrequently tears of the cervix are so extensive that they involve the vaginal wall and the parametrium, giving scars that may be felt beside the cervix. The induration may be linear or wide- spread. The fixation of the cervix may be slight or marked, depending on the amount and situation of the scar tissue. Usually there is not much tenderness. 12. Malignant Infiltration of the parametrium, extending from the cervix uteri or the bladder or the rectum. The induration is firm and is situated immediately beneath the vaginal wall and usually follows approximately the outline of the con- nective area. Ordinarily there is not much tenderness, unless there is complicating inflammation. The amount of fixation of the cervix depends on the extent of the infiltration. 13. Fibroid of Uterus, growing into right broad ligament. The mass projects out from the side of the uterus, has a rounded well-defined outer border and is firm and not tender. The mass is fixed by a broad attachment to the side of the uterus but the uterus and mass together are movable in the pelvis, unless the mass is so large that it extends to the pelvic wall or there is complicating inflammatory fixation. 14. Affection of Right Ureter. A mass about the ureter may be caused by in- flammation in and around the ureter. The inflammation may be due to a stone lodged in the ureter or to tubercular ureteritis or to an ascending pus infection. The mass is situated in the course of the ureter, is small at first and may give the impression of a small nodule like an enlarged gland in the tissues. It is firm, very tender, fixed, but not intimately attached to any of the adjacent organs until extensive infiltration has formed. Fig. 385 shows a mass from the right ureter. A mass from the ureter is accompanied by bladder irritability and urinary abnor- malities. 15. Solid Tumor of Ovary or Tube, bound down by adhesions and forced to grow towards the cervix. The mass would necessarily become of considerable size be- fore reaching that region. It is approximately spherical, though of somewhat irreg- ular outline. It is firm and usually somewhat tender because of the accompanying FLUID MAS« TO RIGHT OF CERVIX UTERI 259 inflammfition, but not as tender as an inflammatory mass of the same size would be. It is fixed in the pelvis and attached to all surrounding structures. The uterus is usually pushed far to the opposite side, but the history does not show the .severe disturbance that would necessarily accompany a purely inflammatory mass of like size. Fig. 385. Mass in 'Right Ureter. It is a Calculus of enormous size, situated in the ureter and extending into the bladder-wall; a, calculus; b, upper part of right ureter (thickened); c, left ureter; d, sigmoid; e, left Fallopian tube; f, bladder pushed to one side. (Bovfee — Practice of Gynecology.) B. Mass Contains Fluid (Fluctuation May be Obtained). 1 . Pelvic Abscess (Fig. 386) from salpingitis, with secondary involvement of con- nective tissue, or from primary cellulitis, or from suppuration in a fibroid tumor or in a cyst or in a hematoma in this situation. The mass usually fills in all the lower part of that side of the pelvis, and is surrounded by infiltration which shades off gradually into the surrounding tissues. The area of fluctuation is surrounded by induration. There is marked tenderness at the point of fluctuation, which diminishes usually as the periphery of the mass is reached. There is fixation of all the involved tissues and of the adjacent organs, including the uterus. The his- tory and the findings elsewhere in the pelvis, indicate the seat of the primary in- riammation. 2. Pelvic Hematoma (Fig. 387). This usually comes from a tubal pregnancy, 260 GYNECOLOGIC DIAGNOSIS which has ruptured between the layers of the broad Hgament. The induration runs down close around the cervix, and may be small or may fill all that side of the pelvis extending up to the top of the broad hga- ment. It has a general rounded outline; much more so generally than an inflam- matory infiltration in the connective tis- sue; though it is limited anteriorly and posteriorly by the separated peritoneal layers of the broad ligament. It is largely fluid and there is distinct fluctuation over a considerable area, as in a cyst. Also, there is not so much sur- rounding induration as in an abscess, though usually considerably more than in a cyst. The tenderness is not nearly so marked as in a collection of blood in the peritoneal cavity. Of course the tender- fig. 386. Mass beside Uterus, formed by Ab- cess in broad ligament. (Montgomerj' — Practi- cal Gjinecology.) Fig. .387. Hematoma of Right Broad Ligament. Practical Oynecologt/.) (Montgomery- ness varies somewhat, being more marked when the hemorr- hage is recent and extensive, in which case it may be very marked. Ordinarily the ten- derness from a hematoma is not nearly so marked as tender- ness from an abscess. There is fixation of themassinthe situa- tion in which it is found, and, if extensive, it fixes the uterus to the pelvic wall. The history and the findings elsewhere will show the cause of the trouble. 3. Hydrosalpinx coming low in the pelvis. The cystic mass runs up into the tubal region. It is somewhat elongated and sausage-shaped and extends from the upper angle of the uterus to the pelvic wall. It fluctuates freely and gives the impression of a thin-walled cyst. Fre- quently some induration from exudate or adhesions, may be felt. It is iiot tender ordinarily. It is somewhat movable, though not as much so as a small pedicu- lated ovarian tumor. It is attached to the uterus and to the pelvic wall and along the upper part of the broad ligament. 4. Parovarian Cyst (Fig. 388). It is Fife. 388. A Parovarian Cyst, forming a large Ma-^ and displacing the uterus. (Ashton— Practtce vf Oijnecology.) OTHER FLUID MASSES BESIDE CERVIX 261 situated near the center of the broad Ugament and, if as large as an orange, it begins to come down about the cervix just beneath the vaginal wall. It is approximately spherical, though somewhat irregular in shape. It fluctuates freely throughout and the fluid seems very close to the examining fingers. There is no tender- ness, unless complicated l)y inflammation or neuritis or other painful affection. It is fixed, as a rule, but not firmly. The peritoneal layers of the broad liga- ment stretch sufficiently to permit con- siderable movement in some cases, especi- ally later, when the cyst has gotten so large that it rises out of the pelvis. The uterus is displaced to the opposite side, and the cyst is attached to it and to the pelvic wall, but not intimately as a rule. If in- flammation takes place about the cyst then there is marked fixation and attach- Fig. 389. An Ovarian Cyst growing in beside the uterus. (Montgomery — Practical Gynecology.) ment to all adjacent organs, and the cyst as it grov\^s may elongate the body of the uterus. 5. Ovarian Cyst growing toward the cervix (Fig. 389). An ovarian cyst which has been fixed in the pelvis by inflammation may grow in this direction. It presents the same characteristics as a parovarian cyst complicated by inflammation, except that fluctuation is not so uniform throughout the mass. There may be firm portions repre- senting thick septa or small areolar cysts. 6. Cystic Fibroid. This presents the ordinary characteristics of a fib- roid, except that there is a point of fluctuation and there may be some tenderness. 7. Uterus containing fluid and displaced to one side. This fluid in the uterus may be due to pregnancy, normal or abnormal, or to a cystic fibroid or topus in the uterus or to blood in the uterus. 8. Rudimentary Horn of Uterus, containing blood (Fig. 390) or other fluid. There may be pregnancy in such a horn (Fig. 408). 9. Vaginal Cyst. Vaginal cysts may come from remnants of the WolfTan duct or from aberrant gland structures in the vaginal wall. They protrude into the va- Fig. 390. the Uterus. VULVA. Hematometra in a Rudimentary Horn of (Montgomery — Practical Gynecology .) 262 GYNECOLOGIC DIAGNOSIS gina more or less, are small and rounded, have fluctuation throughout with a thin wall and are not tender unless complicated. They are fixed in the lower part of the pelvis and lie just beneath the vaginal wall, to which they are closely attached. 10. Ureter Greatly Dilated. The fluid in the dilated ureter may be urine (hydro- ureter) or pus (pyo-ureter) . The upper part of the ureter and the kidney is usually dilated also (hydronephrosis, pyonephrosis). A fluctuating swelling is found in Fig. 391. Thickened Tube and Ovary prolapsed into tne cul-de-sac behind the uterus. (Montgomery — Practical Gynecology.) Fig. 392. A Fibroid Tumor, forming a Mass behind the uterus. (Montgomery— Prac;. 410. Diagram showing various positions in wiiich the Appendix vermiformis may lie, with the caecum in tne usual place. (Kelly— Diseases of the Appendix.) In cases where the caecum varies from the usual position, the appendix may be still farther from its normal position, as indicated in Fig. 411. In a case of appendicitis there may be a point of pain and tenderness elsewhere in the abdomen, in addition to that in the appen- dix region. Then immediately arises the ques- tion, "Do any of these additional areas of ten- derness represent an additional lesion or is the pain and tendeigfiess simply reflex from the in- flamed appendix?" My friend. Dr. Leonidas Kirby,of Harrison, Arkansas, recently called my attention to the following method of identifying the reflex areas of tenderness. With the patient's knees drawn up to relax the ab- dominal muscles as in regular abdominal pal- pation, note the areas of tenderness. Then make steady pressure exactly over thfe appen- dix sufficient to cause decided pain and, while Fig. 411. Diagram showing various positions which the Caecum and Appendix may occupy, in cases where the caecum is displaced. (Kelly — Diseases of the Ap- pendix.) MASSES FROM INTESTINAL TRACT 273 maintaining this pressure over the appendix, i);il[):i((Mvith the other hand the areas \vh ch are tender. When the tenderness in the otlier areas is rcHex, it disappears as long as the pressure over the appendix is maintained, to reap])ear as soon as the pressure over the appencUx ceases. Dr. Kirby has found this simple expedient very helpful in a considerable number of tloubtful cases. 13. Fecal Mass, in caecum and extending along the ascending colon. 14. Tumor of Caecum. This is usually malignant. It presents chronic irrita- tion in the caecal region, generally leading to a diagnosis of chronic appendicitis. There are exacerbations of trouble at times, due apparently to irritation in the caecum from retained fecal material. In some cases there is a swelling in this Fig. 412. Movable Kidney, showing the outline of the displaced kid- ney as determined by palpation. Notice that the kidney comes well be- low a line drawn from the umbilicus to the right anterior superior iliac spine (marked by a cross) . region, that comes and goes. It is most marked usually during the days of pain and disappears largely when the bowels are well opened. Later a permanent mass appears, though it may vary consideral:)ly in size at different times, due to the vary- ing amount of fecal material in the caecum. This same history may be present at times in chronic caecitis without a tumor, l^ut in such a case of course there is no permanent tumor, unless there is some complicating inflammatory trouble around the caecum. 15. Intussusception. The mass extends along the caecum and ascending colon. 274 GYNECOLOGIC DIAGNOSIS There is the history of intestinal obstruction, the passage of bloody mucus from the bowel and the rectal tenesmus. It is most frequent in children. 16. Displaced Kidney (Fig. 412). The mass has approximately the size and[ Fig. 413. Palpation of a Movable Kidney, with the patient on her back. First step. The loin is grasped as here shown, to prevent the displaced kidney from slipping unnoticed back into its place at the beginning of palpation. Fig. 414. Palpation of a Movable Kidney, witi; patient on her back. Second step. Palpating the kid- ney with the right hand, while it is lield in displacement with the left hand. VARIOU8 MASSES WITIK )l 'l' M,1J( TUATION 275 shape of the Icklnoy iind is louder wIumi pressed upon. Pressure usually causes a desire to urinate, and it may cause pain running along the ureter to the bladder. The prolapsed kidney is usually somewhat enlarged. Unless adherent in its mal- position, it may ])e returned to its ])ed in the loin. This facility with which the kidney slips up into its bed when the patient is lying on her back, sometimes inter- feres with the diagnosis, for palpation then would show no displacement of the kidney. In order to prevent a prolapsed kidney from being pushed into place un- awares, during palpation in the vicinity, it is well to grasp the lumbar region firmly, as shown in Fig. 413. This fixes the kidney in its abnormal position, where it can be palpated by the fingers of the other hand, as shown in Fig. 414. Another way to examine a movable kidney in its lowest position, is to palpate the loin while the patient is standing. The patient must lean forward on some support in such a wav as to relax the abdominal muscles. 17. Tumor of Kidney. Such a mass may be traced up into the kidney region. If the tumor and kidney are prolapsed, they maybe returned to the loin, if not ad- herent. There are usually dragging pains in the loin, and bladder symptoms. Urinary examination may give decisive information. A very satisfactory method of palpating the kidney region for a mass, or for deep tenderness, is to use both hands, one behind and the other in front, the lumbar structures being caught between them (Fig. 166). 18. Perinepheritic Abscess, without cUstinct fluctuation. This may dissect down into the lower abdomen, and even into the pelvis, and still be so deeply situated or not to give definite fluctuation, except under anesthesia. The mass may be traced up into the kidney region. There is colon resonance over it. There is marked tenderness in the lumbar region, and usually decided swelling there. There is the history and the ordinary signs of kidney disturbance, associated with the general and local evidences of suppuration. 19. Psoas Abscess, without distinct fluctuation. This causes a deep seated mass in the lower abdomen, which may give no fluctuation until it approaches the surface in the neighborhood of Poupart's Ugament. As it is usually tubercular, the marked local tenderness and the high fever and chills of ordinary deep suppuration are gen- erally absent. A careful examination, however, will show more or less fixation of the thigh. When an attempt is made to move the thigh in any direction that pulls the psoas muscle, the movement is resisted. There are also other evidences of caries of the lumbar vertebrae. 20. Enlarged Liver or Solid Tumor of Liver. The liver occasionally becomes so enlarged from disease or abscess formation that its lower border is pushed into the right lower abdomen. The direct connection of the mass with the usual liver dull- ness may be demonstrated, and the lower border and left border of the mass has the shape of the liver and there is a history indicating liver disease. A tumor from the liver usually lies in front of the intestines and its connection with the liver may be directly shown by palpation and percussion. Also, there is a history of liver dis- turbance. 21. Movable Liver. Exceptionally the liver may be so movable that it sinks into the lower abdomen. The mass lies in front of the intestines, has the shape of the Hver and may be returned into the liver region unless adherent. 276 GYNECOLOGIC DIAGNOSIS 22. Tumor of Abdominal Wall (Fig. 124). This is a rare condition, and for that reason it is Hkely to be forgotten, resulting in a mistaken diagnosis. The distin- guishing signs of a tumor of the abdominal wall are given in the first part of this chapter (page 121). 23. Inflammatory Mass in Abdominal Wall. This presents about the same signs as a tumor of the wall, with evidences of inflammation added. 24. Tumor of Round Ligament. It arises somewhere in the course of the round ligament, either in the pelvic cavity or in the inguinal canal. If large, it necessarily produces great distortion of the parts. It may cause much confusion in diagnosis if the fact be not remembered that a tumor occasionally arises from this ligament. 25. Some Central Abdominal Mass. One of the firm masses mentioned as usually appearing in the central abdomen, may be displaced to one side or may become so large that it extends far over to both sides. 26. Mass from Opposite Side. Occasionally an enlarged organ or a tumor from one side, will become so much displaced as to appear to belong to the other side. ^»34/^P£A/lf/X Fig. 415. Double Pyosalpinx with adhe.sions. (Montgomery— Prncticnl Gynecology ) B. Mass, High in Right Side, Contains Fluid. 1. Uterus Displaced. The fluciuation may be duo to pregnancy or, very rarely, to pyometra or to homatometra. FLUCTUATING MASSES IN IllGHT SIDE 277 2. Pyosalpinx (Figs. 415, 416, 417). There is a tender mass in the tu])o-ovarian region, ^vith slight or well-marked Ihictuation. The mass is fixed and the uterus also is fixed. There may be a large amount of firm exudate or very little. There is usually a clear history of infection followed by the usual evidences of pelvic in- Fig. 416. Pyosalpinx wiUi uo adliesions. {KcWy— Operative Gynecology . Hammation, including persistent endometritis with discharge. If the trouble is gonorrhoeal, the symptoms may be mild, and if of long standing the pus-tube may not be very tender. But there is more tenderness and more thickening and fixation than occurs with hydrosalpinx or ovarian cyst or parovarian cyst. Fig. 417. Pyosalpinx with very extensive adhesions. (Kelly — Opera- tive Gynecology.) 3. Ovarian Abscess. This presents practically the same history and the same signs as a tubal abscess. In fact, it is sometimes impossible to say with absolute certainty whether the pus is in an enlarged tube or an enlarged ovary. As the former is the usual condition, we assume in a given case, that the pus is in the tube, 278 GYNECOLOGIC DIAGNOSIS unless there is something special pointing otherwise. Occasionally in an abscess in this region, the form can be made out as distinctly round (probably ovary) or dis- tinctly long and sausage-shaped (tubal). 4. Tubal Pregnancy. This presents the history and examination signs of an in- flammatory mass, with the history and progress of tubal pregnancy. There is, in R.T. R.L. R.O. L.O. R.L. Fig. 418. Right Hydrosalphinx. U. Uterus split open. R.T. Right Tube, distended with fluid (hydrosalphinx) . R.L. Round ligaments. R.O. Right ovary. (Keating and Coe — Clinical Gynecology .) the class of cases now under consideration, sufficient fluid blood encapsulated some- where to give fluctuation, either about the tube or in the posterior cul-de-sac. 5. Pelvic Tuberculosis. There are the signs of a chronic inflammatorj^ mass, "ndth a collection of fluid (tubercular pus), and the history and progress of the case pre- sent the characteristics of local tuberculosis, as explained in chapter xi. 6. Hydrosalpinx (Fig. 418). About the same as ovarian cyst except that it is oblong and extends from the uterus to the pelvic wall and is attached along the border of the broad ligament. The signs are much like those due to parovarian cyst, except that the hydrosalpinx is situ- ated high while still small. There nui}' or may not be a history of pelvic inflamma- tion at any time. Its intimate attach- ment to the uterine horn is an impor- tant diagnostic point. Fig. 419. Ovarian Cyst of Right side, dispiac- 7. OvaHan Or Parovarian Cyst. (Figs. iiig uterus to the Left.' (Montgomery— Prac«ca< .,„ Ac-.rw k. n i ,- ^ , Gynecology.) ' 419,420). A lluctuatmg uiass, somewliat FLUCTUATING MASSES IN RIGHT SIDE 279 movable, of slow growth, with no acute symptoms if not comphcatcd, unless caught in the pelvis, and there is considerable abdominal enlargement before xi^vy trouble- some symptoms appear. The mass is attached in the pelvis and, by further ex- amination, its attachment may l>e traced to the tubo-ovarian region. 8. Cystic Fibroid. The greater portion of the mass is usually solid and presents the characteristics of a uterine fibroid. 9. Large Perityphlitic Abscess. Presents the history of appendicitis with per- sistent septic symptoms, and the evidences of a pus collection in the vicinity of the caecum. 10. Cystic Tumor of Kidney. The tumor may be traced up toward the loin. It is freely movable usually, unless there has been inflammation about it. Good flue- Fig. 420. Graafian-FoUicle Cysts of the ovaries, which have become intraligamentary. (KeWy—Operativs Gynecology.) tuation is not obtained through a moderately thick abdominal wall, unless there is some large cavity or a number of small ones with very thin walls. The tumor may be made up of innumerable small cysts and yet, in the ordinary examination, appear as a solid tumor. Under anesthesia the fluctuation may usually be distinctly made out. Tenderness is slight unless there is complicating inflammation. The en- larged kidney is usually displaced downward considerably, so that there is room m the loin up into which it may be pushed. The colon hes over the mass, between it and the abnominal wall. This may not be apparent at first, the colon being flat- tened out against the wall and causing no resonance on percussion. The fact that the colon is over the mass is easily demonstrated by inflating the rectum and colon with air. This was necessary in the case of the tumor shown in Fig. 204 (see also Figs. 202 and 203). 280 GYNECOLOGIC DIAGNOSIS 11. Hydronephrosis and Hydro-ureter. Occasionally the kidney and ureter on one side will become very much dilated, forming a sac filled with fluid (urine). There is usually a history of kidney pains and bladder disturbance extending over a long period and varying much at different times. The characteristic feature is that the sac fills at times, producing a swelling with more or less tension and pain, and then after a variable time there is a discharge of a very large quantity of urine with disappearance of the swelling and relief of the symptoms. After a time the sac fills again and discharges. A crucial point in the diagnosis of such a condition is the coin- cidence of the disappearance of the swelling and the discharge of an extraordinarily large quantity of urine. Too much dependence should not be placed on the his- tory, as it is more or less uncertain and may lead to an erroneous conclusion. Be- fore the patient is subjected to operation, in cases where the symptoms are not urgent, she should be required to make daily measurements of the amount of the urine passed during one of the periods of appearance and disappearance of the swelling, in order that any marked increase in the amount of urine, as the swelling disappears or diminishes, may be known positively. 12. Pyonephrosis. When the dilated kidney or ureter becomes filled with pus, there is marked disturbance, with fever, chills, pains extending from kidney to blad- der, usually marked bladder disturbance and definite urinary findings. Palpation of the kidney and along the course of the ureter gives marked tenderness. An important feature in these cases of painful kidney trouble is the point-tenderness on deep pressure in the lumbar just over the kidney (Fig. 164). This helps to dif- ferentiate kidney -tenderness from tenderness due to appendiceal or other intra- peritoneal inflammation, which differentiation may in some cases be practically im- possible by palpation in front. Usually, however, careful palpation in front will show clearly that the tenderness is in the kidney and along the course of the ureter. 13. Perinephritic Abscess, large enough to give fluctuation. This may burrow into the pelvis or towards Poupart's ligament. It gives deep fluctuation and presents the symptoms and signs of deep suppuration in the kidney region. 14. Psoas Abscess, large enough to give fluctuation. This may burrow into the pelvis, or beneath Poupart 's ligament to the femoral opening. It presents fluctu- ation, both superficial and deep, and gives the symptoms and signs of tuberculosis of the lumbar vertebrae with involvment of the psoas muscle. 15. Dilated Qall=bladder. Occasionally the gall-bladder becomes so greatly en- larged and displaced, that it extends into the lower abdomen. The connection of the fluctuating mass with the liver may be traced, and there is a history of gall-stone disease or other liver disturbance. 16. Central Abdominal Affection. One of the cystic masses mentioned as usually appearing principally in the median fine, may be displaced to one side or may become so large that it extends far over to both sides. 17 Mass from Opposite Side. Occasionally a cystic mass from one side will be- come so much displeased that it appears to belong to the opposite side. Some months ago I operated on such a case. There was an ovarian cyst extending to the umbilicus. The history indicated that it had been unusually movable, occupying various positions in the lower abdomen. When I saw the patient she had been sick in bed several days with abdominal pains and evidences of a mild peritonitis. The MASSES HIGH IN LEP'T SIDE 281 large fluctuating mass occupied the left and central portions of the lower abdomen and pelvis. The small uterus was crowded into the posterior part of the pelvis iiehind the cyst. The cystic mass was not very tender, hut it was fixed immovably by adhesions. From its location there seemed no room for doulH that it arose from the left side. On opening the abdomen, however, I found that it was a light ovarian cyst which had fallen over to the left side in front of the uterus. The pedicle had become twisted, with resulting hemorrhage into the cyst and fil^rinous peritonitis about it. To the torsion of the pedicle, with the resulting hemorrhage and peritonitis, were due the acute symptoms and the recent fixation of the cyst. MASS HIGH, in Pelvis or Lower Al)(lomen, LEFT .Side. A. Mass or Induration FIRM. Same as on right side, substituting Sigmoid flexure for Caecum, and Spleen for Liver, and leaving out Appendicitis. B. Mass Contains FLUID. Same as on right side, substituting Cyst of Spleen for dilated Gall-Bladder, and leaving out Perityphilitic Abscess. MASS HIGH and in MEDIAN LINE IX PELVIS OR LOWER ABDOMEN OR CENTRAL ABDO.AIEN. A. Mass or Induration FIRM. Any of the solid masses mentioned as occurring in the Right or Left side, may extend to the Median line or across it. There are, however, certain firm masses that arise in or near the median line and, consequently, may be classed as belonging to this median region. 1. Solid Tumor of Uterus. Fibroid tumors are the most frequent cause of firm enlargement of the uterus, though occasionally a malignant tumor of the corpus uteri will cause marked enlargement. The characteristics of these have already been given. There may exceptionally be both carcinoma and fibroid (Fig. 421). 2. Abdominal Pregnancy and Lithopedion (Figs. 422, 423, 424). 3. Solid Tumors of Omentum, Small Intestine or Mesentery. These usually appear near the median line, and the signs vary with the location. The diag- nosis rests upon the presence of a mass presenting the symptoms and signs to be expected in a tumor from one of these structures, and for which no more-common disease would account. Such tumors usually are accompanied by gastro-intestinal symptoms. 4. Tumor of Pancreas. A deep-seated mass in the median line, accompanied by decided evidences of pancreatic disturbance, and presenting symptoms and signs for which nothin"; else will account. 282 GYNECOLOGIC DIAGNOSIS 5. Retroperitoneal Tumor (Fig. 201). It lies back of the intestines, is rather movable, more so than would be expected from a pancreatic tum.or, and is without evidences of disturbance of any particular organ. Fig. 421. Large Ma-ss in PelvLs formed by Uterine Fibroids and Carcinoma. (CuWen—Canca- of the Uterus.) 6. Enlarged Lymphatic Glands. This condition presents the evidences of a retroperitoneal or mesenteric mass, accompanied with a disease causing glandu- lar enlargement, such as Hodgkin's disease, or with recent ulceration in the in- testine (tubercular or typhoid). ADVANCED EXl'RAUTERINE PREGNANCY 283 7. Tubercular Peritonitis, without c !i () u g h fluitl to given fluctuation. Tuber- cular inflammation, with the exudate and resulting mass, may occur at any part of the peritoneal cavity, but is likely to extend into the median line, if not there primarily. The pa- tient presents the evidences of a chronic or subacute peritonitis with nothing else to account for it, and the presence of tuberculosis in the intestines or in the lungs. 8. Displaced Abdominal Organ. Several cases are Fig. 422. Extrauterine Pregnancy near full term. (Dudley- Practice of Gynecology.) Fig. 423. Extrauterine Pregnancy with Lithopedion, Showing the Lithopedion in situ. (KsWy— Operative Gynecology.) Fig. 424. Showing the Lithopedion removed, and also the site of the Tubal pregnancy. {KeWy— Operative GynecQlr ogy.) 284 GYNECOLOGIC DIAGNOSIS recorded in which a displaced organ, such as the kidney (Fig. 425) or the spleen, has led to an erroneous diagnosis and an erroneous operation. Fig. 425. The Kidney Displaced into the Pelvis. (Dudley— Prac- tice of Gynecology.) B. Mass, High and in Center, Contains Fluid. Any of the fluid masses mentioned as occurring in the Right or Left side, may extend to the Median line or beyond it. Fig. 426. A Large Cystic Fibroid. (Montgomery— Pwc/icff/ Gynecology.) FLUID MASSEf? IN CENTRAL I^OWER ARDOMEN 285 There are, liowevor, cei-laiiL (hict iKilini;- masses lliaL ai-is(! in (Ikj nu^diaii lino and hence may be said to belong to this region. 1. Pregnant Uterus. This may be any size, may be n(H'nial or abnormal, and the shape of the uterus maybe regular or irregular. 2. Cystic Fibroid (Fig. 426). It presents the evidences of a fil^roid along with fluctuation in a part of it. Where such a condition is found, be careful to exclude pregnancy complicating the fibroid. Fig. 427. Ovarian Cy.st with a long slender pedicle. (Montgomery— frac^ica? Gynecology.) 3. Distended Bladder (Fig. 140). This may cause much confusion in examina- tion and diagnosis. The diagnostic points have alread}^ been given. It has hap- pened that the unrecognized distended bladder ruptured with fatal results (Fig. 141). 4. Ovarian or Parovarian Cyst (Figs. 427, 428). The diagnostic points have been given briefly in this chapter, and are given in detail in chapter xii. 5. Ascites. For the differential diagnosis of ascites, see text and illustrations under Percussion in this chapter (page 157). 286 GYNECOLOGIC DIAGNOSIS Fig. 428. Dermoid Cyst filling front of pelvis and displacing the uteru? Daclcward. (Montgomery — Practical Gynecology .) 6. Ascites and Tumor (Fig. 429). The important percus- sion signs of ascites and tumor have already been mentioned and illustrated in this chapter (see Figs. 194, 195, 196.) 7. A Cystic Tumor of Omen= turn, Intestine or Mesentery. A considerable number of cystic tumors of the omentum and mesentery have been re- ported. Such tumors may cause much confusion in diag- nosis, unless it be kept in mind that they may be encountered. The symptoms and signs they present depend on the situa- Fig. 429. Ascites and Fibroid. The combination closely .simulated pregnancy. The abdomen was distended with a Fluid Mass having a Solid Mass inside, and the peculiarly shaped fibroid gave ballot tement. (Montgomery — Practical Gynecology.) TABLE ol' l»TA(iN(»sriC I'nINTS ^f^J tion, and may be worked out for the different situations l-)y a consideration of the surrounding structures and the signs that would Ukely result. The diagnosis depends largely on the exclusion of the more common conditions. 8. Pseudo-cyst of the Lesser Omental Cavity. This is usually preceded some months by an abdominal injury involving the pancreas. It is likely to be of rather slow growth, and the injury may be overlooked unless the history is carefully inquired into. In all cystic masses of doubtful character near the center of the abdomen, this should be thought of. 9. Cyst of Pancreas. . A true cyst of the pancreas may present nnich the same symptoms and signs as the pseudo-cyst of the lesser omental cavity resulting from an injury of the pancreas. I cannot take the space to give i-n detail the differential diagnosis of these various upper abdominal conditions. I wish simply to call at- tention to the conditions that may be encountered, and the presence or absence of which must be detern'.ined by the examiner through further .study. ■10. Cyst of Urachus. This and other rare abnormalities are occasionally met with. A cyst of the urachus is found in or near the median line, and between the peritoneum and the anterior abdominal wall. It may communicate with the um- bilicus, causing an intermittent discharge there, or with the bladder or with neither. POINTS in the DIFFERENTIAL DIAGNOSIS OF VARIOUS MASSES IN THE PELVIS OR LOWER ABDOMEN. The majority of mistakes in diagnosis are due not so much to want of knowledge as to lack of application of the knowledge possessed. A diagnosis in a difficult case implies (first) a careful examination, by which are obtained the essential facts of the case, and (second) correct reasoning and a logical conclusion, based on those facts. A mistake in diagnosis may be due to failure to get all the essential facts — some im- portant points being overlooked. In order to prevent this in the class of cases under consideration (presenting a mass in the pelvis or lower abdomen), I give the following table of points to be considered. In a difficult case, consult this table and notice whether or not you have obtained the information available on the various points mentioned. Examination Findings. ^^' Consistency of Uterus. 14. Tenderness of uterus. 15. Mobihty of uterus. 16. Discharge from uterus. 17. Discoloration of cervix or 1. Position of Mass. 2. Size. 3. Shape. 4. Consistency. 5. Tenderness. ^^^S^^^-. 6 Mobilitv ^^' I^slation of mass to tube and 7. Attachments. ovary. 8. Apparent point of origin. 19- Relation of mass to pelvic wall. 9. Relation to uterus. 20. Relation of mass to vaginal wail. 10. Position of uterus. 21. Bladder (full, distended, uri- 11. Size of uterus. nary incontinence, induration in 12. Shape of uterus. bladder, pain on pressure) . 288 GYNECOLOGIC DIAGNOSIS 22. Rectum (containing fecal masses, or indurated or painful on pres- sure) . 23. Mass elsewhere (arising from uterus or about tube or along colon.) 24. Colon or small intestine between mass and abdomen wall. 25. Outline of dullness. 26. Shifting (^f outhne of dullness. 27. Hard masses within a cystic mass. 28. Pulsation of mass, felt on exam- ination. 29. Fetal movements, felt on exam- ination. 30. Vascular murmur heard. 31. Fetal heart-sounds heard. 32. Fever present. 33. Emaciation or fat deposition. 34. Breast disturbance (tenderness, enlargement, enlarged veins with milk formation). 35. Evidence of disease of heart, lungs, liver, kidneys, gastrointes- tinal tract, spleen, pancreas, nerv- ous system. History and Subjective Symptoms. 36. Manner of onset, prominent sym- toms and apparent cause. 37. General course since. 38. Menstrual disturbance. 39. Intermenstrual bloody discharge. 40. Leucorrhoea. 41. Pain in lower abdomen or pelvis (pressure, aching, sharp pain) or about external genitals, or backache (sacral, lumbar, loin) or thigh pains. 42. Fever. 43. Disability. 44. Variation in- weight. 45. Abdominal enlargement. 46. Morning sickness, or persistent nausea or vomiting at other times. 47. Breast disturbance — pains, ten- tenderness, enlargement, pigmen- tation, enlarged veins, milk forma- tion. 48. Bladder or rectal disturbance, preceding or accompanying the trouble. 49. Evidence of disease of the heart, lungs, liver, kidneys, gastro- intestinal tract, spleen, pancreas, nervous system. Progress Under Observation. 50. Steady increase or decrease, or exacerbations, etc. If Examination Under Anesthesia Notice : 51. Exact position of mass. 52. Exact size and shape. 53. Consistency throughout. 54. Exact mobility. 55. All the attachments. 56. Point of origin. 57. Exact relation to adjacent organs, to uterus, to Fallopian tubes, to ovaries, to rectum, to colon. 58. Uterus — exact position, size, shape, consistency, (tenderness not appreciable), mobility, attach- ments. 59. It may be advantageous to make recto-abdominal examination also, 60. If cervix is suspicious of malig- nant disease, excise a piece for microscopic examination. If Necessary for Diagnosis, and Permissible Under the Conditions Present, Explore the Uterine Cavity : 61. With sound, to determine depth and direction. POINTS IN THE SPECULUM EXAMINATION 28y 62. With curet, to secure tissue for area, liard nodule) and presence of microscopic examination. retained placental remnants or pro- 63. With finger, to determine con- jecting polypoid growths, sistency of uterine wall (softened POINTS IN THE SPECULUM EXAMINATION. In the speculum examination, direct inspection is made of the vaginal wall and the cervix. Fig. 430. Primary Malignant Ulceration of the Vagina. {MontgoraeTy— Practical Gynecology.) Conditions of Vaginal Wall. The vaginal wall may present arterial congestion, venous congestion, bleeding areas or distinct ulceration. Arterial Congestion of the Vaginal Wall indicates inflammation, usually acute, or active irritation, as by an irritating discharge or pressary or other foreign body. The differential diagnosis of the various forms of vaginal inflammation has already been given in this chapter, when considering leucorrhoea (see page 177) . Occasionally there are cases of chronic vaginitis in which there is arterial congestion in spots. In 290 GYNECOLOGIC DIAGNOSIS such chronic cases there is Ukely to be infiltration and hypertrophy of the con- gested areas, giving rise to tlie condition l^nown as granular vaginitis. Venous Congestion of the Vaginal Wall should always arouse a suspicion of preg- nancy, for that is the most common cause. It may be caused, also, by a tumor or other pelvic mass that interferes with the vaginal circulation, or by extra-pelvic conditions that cause venous stasis in the pelvis, such as heart disease with faihng compensation. £^^- Fig. 431. Secondary Malignant Ulceration of the Vagina. In this ease there was a carcinoma of the en- dometrium, and the discharge caused an implantation carcinoma where the cervix came in constant contact with the posterior vaginal wall. {KeWy— Operative Oynecology) . Bleeding Areas on Vaginal Wall, without a distinct ulcer, are found principally in senile or adhesive vaginitis, which is described in chapter iv. A Distinct Ulcer on the Vaginal Wall may be simple, chancroidal, syphiUtic, tubercular or malignant. In the case of a malignant ulcer, it may be primary on the vaginal wall (Fig. 430) or it may be secondary (Fig. 431), the most common source of secondary malignant ulceration of the vaginal wall being carcinoma of the cervix uteri. ABNORMAT, 0(1NDITIONS OF THE CERVIX 291 Conditions of Cervix Uteri. The appearance of the normal virgin cervix is shown in Figs. 432 and 433. The appearance of the approximately normal cervix in the parous woman is shown in Fig. 434, and a cervix that has undergone the senile atrophy is shown in Fig. 435. Fig. 436 shows discharge from an unlacerated cervix, while Fig. 437 shows discharge Fig. 432. Fig. 4.3.3. Fig. 432 and 433, Varieties of Normal Cervix in the Virgin. Heitzmann — American Text-book of Obstetrics.) Fig. 434. Fig. 434, Cervix of Multipara. (Norris, after Fig. 435. A Senile Cervix, with upper part of vagina. (Edgar— Practice of Obstetrics.') Fig. 436. Discharge from seen through the speculum. Gynecology.) the Cervix Uteri, as (Massey — Conservative Fig. 437. Discharge, with I.iiceiation and Erosion of the Cervix. (Massey — Conservative Gynecology). Fig. 438. Erosion of the CerriS, witt a few scattered cysts. (H. MacNaughton- J ones— Diseases of Women.) 292 GYNECOLOGIC DIAGNOSIS (h-.-unjIai- ci-osii.ji :. 7ig. 439. Lacerations and Erosions of the Cervix. (Mann— American System of Gynecology.) LACERATION OF THE CERVIX 293 Fig. 440. Lacerations and Erosions of the Cervix. (Ma,nn— American System of Gynecology.) 294 GYNECOLOGIC DIAGNOSIS and laceration. Erosion of the cervix is a very common condition, being present to a greater or less extent in most cases where there is an irritating discharge. Fig. 438 shows erosion of the cervix, the shaded area extending out from the ex- ternal OS representing the red angry-looking erosion. A few small glandular cysts are also visible. Various appearances of lacerated cervix, as seen through the speculum, are shoT\TL in Figs. 439, 440. In a considerable proportion of cases, dis- tinct lips are noi at first apparent, the lacerated cervix having the appearance of a ball (Figs. 552, 441). In such a case, if the anterior and posterior portions of the cervix be caught with a forceps or tenaculum and brought together, as indicated in Fig. 442, the extent of the laceration becomes apparent. Fig. 441. Fig. 442. Figs. 441 and 442. Testing for the extent of the tear, in cases where the cervix has the appearance of a ball. The center of the anterior lip (A, Fig. 441), and of the posterior lip (Bj are each caught with a tenaculum and brought together, as indicated in Fig. 442. (B&\dy— American Text-book of Gynecology.) Fig. 44.3. Beginning Epithelioma of the Cervix. (Samp- son — Johns Hopkins Hospital Bulletin) Fig. 444. Beginning Carcinoma of the In- terior of the Cer\-ix. (Samp.^on— Jo/ni.5 Hopkins Hospital Bulletin ) IVlalignant disease of the cervix causes nianv thousands of deaths annually and yet in the beginning, it is entirely local and, when recognized early, can be com- pletely removed. The diagnosis is considered in detail in chapter ix. Here I wish to simply call attention to the fact that beginning malignant disease may make very little change in the general appearance of the cervix. Any suspicious area should be carefully investigated and, if necessary to a positive diagnosis, a small MALIGNANT DISEASE OF THE CERVIX 295 piece should be excised for microscopic examination. Beginning malignant disease of the cervix is shown in Figs. 443, 444, 445. Fig. 446 shows the cervix destroyed Fig. 445. Epithelioma of the C€r\'ix. The eerv'ix has been destroyed, leaving only an area of cancerous ulceration at the top of the vagina. (KeWy—Operativo (rynecology.) 296 GYNECOLOGIC DIAGNOSIS and drawn in by contracting tissue, so that no ulceration is visible through the spec- ulum. But in the vaginal palpation in this case distinct induration was felt in the Fig. 446. Epithelioma of the Cen-ix. The cer\-ix has been de- stroyed and the affected area has been drawn in, by the gradual con- traction of the infiltrated tissues, until no cancerous tissue can be seen. Palpation, however, shows that there is infiltration of the area enclosed within the dotted line. (_KeUy— Operative Gynecology). area bounded by the dotted line. Fig. 447 shows a case where the carcinoma has appeared in the form of a papillary growth. SIGNIFICANCE OF PAIX I.\ LOWER ABDOMEN 297 Fig. 447. Epithelioma of the Cerv-ix, appearing as a Papillarj' Growth. (Kelly — Operative Gynec- ology.) PAIN IN PELVIS OR LOWER ABDOMEN. Pain in the pelvis or lower abdomen may be due to: — 1. Salpingitis, acute or chronic. Pain referred to tubo-ovarian region (Fig. 148). History of preceding uterine inflammation, with cause for same. If chronic, his- toiy of preceding exacerbations. On abdominal palpation, tenderness in tubo- ovarian region. On vaginal and bimanual examination, there is found vaginal dis- charge (evidence of preceding uterine inflammation) and marked tendeness in tubal region. Mass is indurated, extending up to uterine horn and out to pelvic wall. Fixation of upper part of uterus and pain on movement of uterus. Absence of special signs of tubal pregnancy or of chronic oophoritis. Mass may be solid (consisting only of exudate or infiltration) or may give more or less fluctuation, due to serous fluid (hydrosalpinx) or to pus (pyosalpinx). All these conditions are in- cluded under the term salpingitis. 2. Oophoritis, acute or chronic. Acute or subacute inflammation of the ovary ordinarily presents practically the same diagnostic points as salpingitis, is usually associated with, and over-shadowed by, the salpingitis and is included under the general term "pelvic inflammation." There is however, one rather com- mon form of oophoritis not associated with salpingitis, namely, the cystic or cir- vhotic form. When not associated with salpingitis or peritoneal exudate, there is 298 GYNECOLOGIC DIAGNOSIS felt on bimanual examination, a tender mass in the tubo-ovarian region — rouaded, about the size of the ovarj or larrger, softened, with occasionally a fluctuating area, movable, often lying lower than ovary usually does (prolapse of ovary behind uterus) and when pressed upon produces a peculiar sickening pain. There is ab- sence of peritoneal exudate and there is no fixation. 3. Pelvic cellulitis. Signs same as in salpingitis except induration very hard (unless collection of pus) and occupying connective tissue areas, situated lower at side of uterus and intimately connected with uterus or pelvic wall. 4. Endometritis, acute or chronic. Pelvic pain shght, sense of weight and pres- sure in the pelvis. Uterine discharge, excessive menstruation, tenderness of uterus, no induration or marked tenderness outside uterus. 5. Backward displacement of Uterus. If uncomplicated, the pelvic pain is slight but there is a sense of pressure and weight. Body of uterus absent in front of cer- vix. Back of cervix can be felt a mass which, on further investigation, proves to be the bodj^ of the uterus. 6. Fibroid tumor of Uterus. Unless tumor is very large and chokes pelvis, pel- vic pain is slight but there is a sense of weight and pressure. Frequently uterine discharge and excessive menstruation. No history of uterine infection or attacks of pelvic inflammation. Firm mass flrmly attached to uterus, not tender, not movable separately from uterus, but uterus and mass movable together in pelvis (i. e., no fixation of uterus and mass to pelvic wall) except when tumor is so large as to fill pelvis. In deep seated fibroids, mass may appear as an enlarged uterus. 7. Cancer of Uterus. Leucorrhoea, with occasionally a streak of blood. No pain at first but later, when uterus is much enlarged (cancer of corpus) or infiltration in- volves parametrium (cancer of cervix), pain appears. If in the cervix, there is indurated area or an ulcer that resists treatment, find a piece should be excised for microscopic examination. If from body of uterus, there is a leucorrhoeal discharge or a blood-streaked discharge that resists treatment, and the interior of the uterus should be curetted and the scrapings examined microscopically. In the later stages there is a bleeding mass, yvith indurated margins, d site of cervix, or a bloody watery foul-smelUng discharge from the interior of the uterus. A bloody foul-smelling watery discharge, does not necessarily mean cancer. It may be due to a fibroid, the differential diagnosis being made by microscopic examina- tion of clippings or curettings, when necessary. 8. Painful Menstruation (dysmenorrhoea). Pain due to menstruation alone, occurs only at the menstrual periods, though pain from most any pelvic disease may be much increased at the menstrual period, on account of the menstrual congestion and increased nerve-sensitiveness. The various causes of dysmenorrhoea and the differential diagnosis, are given in chapter xiv. 9. Pregnancy, with Threatened Miscarriage. Pains are usually somewhat parox- ysmal, missed menses, morning sickness, pains in breasts, beginning softening of cervix, uterine body, enlarged and softened, elasticity of middle segment (Hegar's sign), bluish coloration of vaginal walls and cervix. 10. Incomplete Miscarriage. History of early pregnancy, pain and passing of blood clots or "pieces of flesh," followed by a bloody discharge and occasional pains. The pains are usually slight (unless infection has taken place), SIGNIFICANCE OF PAIN IN LOWER ABDOMEN 299 the principal symptom being the persistent bloody discharge. Cervix and body of uterus softened. Cervix open, and sometimes pieces of membrane and of blood- clost may be felt projecting out of it. 11. Tubal Pregnancy. Missed menses, morning sickness, uterus slightly en- larged and softened, tender mass in tubal region. Diagnosis on these signs not justi- fiable, unless previous examination of pelvis has shown it free from tubal or ovarian- inflammatory trouble. If rupture takes place, pain and tenderness are so marked and so severe at first as to preclude satisfactory palpation of tubo-ovarian regions. If hemorrhage is severe, pulse is affected. If slight, pain disappears and mass can be made out beside uterus or behind it. The signs at this stage (slight peritoneal hemorrhages and resulting peritoneal irritation and exudate) are the same as for acute salpingitis w'th exudate, with the following special features: — a. Bloody vaginal, discharge, beginning within a few days after onset of pain and continuing in an irregular way from one to several weeks. b. Only slight fever or none. With enough acute inflammation to cause such severe symptoms, there should be considerable and persistent fever, c. Evidence of internal hemorrhage, to a greater or less extent. d. Exaceibations of pain -without apparent cause and without decided elevation of temperatuie. e. Absence of recent intra-uterine pregnancy (miscarriage and infection are very common causes of ordinar}^ salpingitis). 12. Pelvic Tuberculosis. P^vidences of pelvic inflammation (tenderness, indura- tion or mass beside or behind the uterus or filling pelvis, fixation of uterus, fever and exacerbations), with the special features given for pelvic tuberculosis in chap- ter XI. 13. Tumor of Ovary, Broad Ligament or Fallopian Tube. A mass (usually soft, fluctuating) in tubo-ovarian region, not tender, usually freely movable. Not in- timately attached to uterus, no fixation of uterus unless mass is large enough to dis- place uterus 1o side of pelvis. Ovarian growths are usually freely movable and tend to rise out of the pelvis, while broad ligament growths are held firmly within the brofd ligament and cause pain and uterine displacement while still small. 14. Laceration of the Pelvic Floor. Loss of support in pelvic floor causes more or less dragging and pressure in pelvis (though rarely severe pain), present princi- pally when patient is on her feet, much relieved when she lies down. Feeling of weak- ness at pelvic outlet, and may be protrusion of parts (colpocele, cystocele, rectocele, prolapse of uterus). Examination js'hows marked loss of support in pelvic floor. 15. Acute Vaginitis. Pelvic pain slight and very low (more of pressure and weight and burning), free discharge, vulvar and urethral irritation. Examination shows purulent discharge and evidences of acute inflammation of vagina. There are a number of extra=genital diseases that may cause pain in the pelvis and lower abdomen and that may be confounded with gynecological affections, and that consequently must be taken into consideration in differential diagnosis. Among them may be mentioned the following: 16. Appendicitis. Pain more diffused through abdomen and about umbilicus at beginning of attack. Tenderness at McBurney's point, and no particular tender- ness over tube. Mass in appendix region, and not in tubo-ovarian region. Attacks 300 GYNECOLOGIC DIAGNOSIS associated with gastro-intestinal symptoms rather than with uterine symptoms, though pain may be \\orse at menstrual periods on account of menstrual congestion. Mass may involve both regions— if in virgin probably appendicitis, if in married wTJman probably salpingitis. 17. Mucous Colitis. Causes severe attacks of pain in lower abdomen and pelvis, and has frequently been mistaken for uterine or tubal or ovarian disease. Patients have been given pelvic treatment for months and years and have even had the ovaries removed when the trouble was none other than this peculiar affection of the colon. The affection is known by various names, such as membranous enteritis, tubular diarrhoea and mucous colic. Osier states: " It is a remarkable disease, to which attention has been paid for sev- eral centuries. It is an affection of the large bowel characterized by the production of a very tenacious, adherent mucous, which may be passed in long strings or as a continuous tubular membrane. I have twice had opportunity of seeing the mem- brane in situ, closely adherent to the mucosa of the colon, but capable of separation without any lesion of the surface. According to W. A. Edwards, 80 per cent, of the recorded adult cases have been in women. The cases are almost invariably seen in nervous or hysterical women or in men with neurasthenia. All grades of the affec- tion occur, from the passage of a slimy mucous like frog-spawn to large tubular casts a foot or more in length. Microscopically the casts are, as shown by Sir Andrew Clark, not fibrinous but mucoid and even the firmest consist of dense, opaque, trans- formed raucous. It is due to a derangement of the mucous glands of the colon, the nature of which is quite unknown. The disease persists for years, varying ex- tremely from time to time, and is characterized by paroxysms of pain in the abdo- men, tenderness, occasionally tenesmus, and the passage of flakes or long strings of mucous, sometimes of definite casts of the bowel. The attacks last for a day or in some cases for ten days or two weeeks. Mental emotions or worry of any sort seem particularly apt to bring on an attack. Occasionally errors in diet or dyspepsia precedes an outbreak. Membrane is not passed with every paroxysm, even when pains and cramps are severe. There are instances in which the morphia habit has been contracted on account of the pain. There may be marked nervous symptoms, and authors mention hysterical outbreaks, hypochondriasis and melancholia. The diagnosis is rarely doubtful (when this affection is in mind) but it is important not to mistake other substances for membranes, thus the external cuticle of asparagus and undigested portions of meat and sausage skins, sometimes assume forms not unlike mucous casts, but microscopical examination will quickly differentiate them." This affection may prove confusing when associated with endometritis or other pelvic lesion. The points in the differentiation of mucous colitis from a serious painful pelvic disease , are the character of the pain (resembling intestinal cramps and extending throughout the lower abdomen), the passage of characteristic masses of mucous- in some of the attacks and the absence of any palpable pelvic lesion to account for the symptoms. 18. Other Intestinal Affections — digestive disturbance, enteritis, colitis, dysen- tery, typhoid fever, chronic constipation (with distention and toxemia), intestinal tuberculosis. Each of these may cause pain in the lower abdomen and, if there SIGNIFICANCE OF PAIN IN LOWER ABDOMEN 301 happens to be accompanying uterine symptoms, may lead to a mistaken diagnosis. Pain is more widespread and variable. Tenderness on palpation is more general and ill-defined, all the lower abdomen being more or less tender and the tenderness may extend above the umbilicus and into the flanks. Uterine and tubo-ovarian region not especially tender. No palpable lesion in pelvis to account for symptoms. Special gastro-intestinal symptoms elicited on questioning. 19. Peritoneal Tuberculosis. This very closely resembles ordinary chronic pel- vic inflammation in its symptoms and course. The differential diagnostic points are given in chapter xi. 20. Kidney or Ureteral Affections — movable kidney, nephrolithiasis, pyone- phosis, ureteritis, and tuberculosis of kidney or ureter. Each of these affections causes attacks of pain, involving the lower abdomen and pelvis. Pain begins in kidney region and extends downward along ureter to bladder. There may or may not be accompanying bladder disturbance (frequent or painful urination, vesical tenesmus). On examination, tenderness in kidney region is elicited by accurate palpation of kidney and along ureter, and there may be displacement or enlarge- ment of kidney. On bimanual examination, there is tenderness in bladder or along ureter and no palpable lesion of genital organs sufficient to account for symptoms. There are pathological findings in the urine. 21. Bladder or Urethral Inflammation or Tumor. History of bladder symptoms (frequent or painful urination, vesical tenesmus, urinary changes.) On examina- tion, tenderness is confined to urethra, bladder or ureters, there are pathological findings in urine and no palpable lesion of genital organs sufficient to account for the symptoms. If the case is still doubtful, instrumental examination of urethra, bladder or ureters may give decisive information. 22. Rectal and Anal Diseases — proctitis, hemorrhoids, fissure, new growths. History of rectal symptoms (pain on defecation, discharge of mucus and perhaps blood at times, protrusion of hemorrhoidal mass). On examination, tenderness and other abnormalities are found about anus and extending up along course of rectum. No palpable lesion in genital organs to account for symptoms. 23. Nervous Diseases — transverse myelitis, neurasthenia,, hysteria, pelvic neu- ralgia. The history indicates disturbance of the nervous system, there are the special features of one of these nervous affections and there is no palpable lesion of genital organs sufficient to account for the symptoms. Pelvic tenderness is con- fined to the pelvic nerve strands or to the otherwise apparently normal ovaries. For thorough pelvic examination it may be necessaiy, in order to overcome mus- cular tension, to examine under anesthesia. 24. Coccygodynia (painful coccyx). The painful affections of this bone, either following injury or of spontaneous origin, are often mistaken for some genital or rectal affection. The pain is described by the patient as at the very end of spine, and may radiate from there into the pelvis or down the thigh. It is noticed especially in positions that occasion movement of the bone (the act of sitting or ris- ing, or straining at stool, or walking up or down stairs) or that cause pressure on the bone (resting on hard surface, riding on rough road). On examination with, the finger in the rectum and the thumb outside on the bone (Fig. 89), there is marked tenderness on palpation of the bone and pain on movement of same. There 302 GYNECOLOGIC DIAGNOSIS may be deformity, indicating previous injury or inflammation. The marked ten- j derness is limited to the region of the coccyx. There is no palpable lesion of the i genital organs to account for the symptoms. BACKACHE. Backache, either in the lumbar region or extending down over the sacrum, may be caused by most any of the conditions mentioned under "pain in the pelvis and lower abdomen. " It is not necessary to repeat them here. In addition, backache may be caused by affections of the muscles, nerves, Uga- ments or joints of this region, or by affections of the bones or spinal cord. REFLECTED PAINS. Reflected pains do not occupy as large a place in gynecologic symptomatology as formerly. We have come to look upon these distant pains in gynecological cases as usually an indication of some intercurrent or complicating trouble at the site of EndomelTilIS. ■Bladder » ^-•Oiaphrapuji Ovary Fig. 448. Showing the usual cause of Reflex Pains in tlie various regions. (Dana — Text-book of Nervous Diseases.) SIGNIFICANCE OF DISTURBANCES OF FUNCTION 303 the pain o-r of an abnormal condition of the nervous system, rather than as a direct reflex from the pelvic trouble. I think careful investigation will show this to be the case in the great majority of instances of so-called reflex pains. In rare cases, however, the connection between the distant pain and the pelvic lesion seems very close, as where, for example, a pain in the head or other situation is made to disappear by correction of a retrodisplacement of the uterus, only to re- appear as soon as the uterus returns to its malposition. When reflected pains do occur they are likely to be found as indicated in Fig. 448. DISTURBANCES OF FUNCTION. The various disturbances of function (amenorrhoea, menorrhagia, irregular men- struation, dymenorrhoea, dyspareunia, sterility) constitute important symptoms of disease in certain cases. They are considered in detail in chapter xiv, where the various causes, and consequePxtly the diagnostic significance, of each are given. 304 CHAPTER HI. GYNECOLOGIC TREATMENT. In Gynecologic Treatment the following therapeutic measures are employed: Rest. Complete Rest, in bed. Partial Rest, from work. Sexual Rest. Applications to Lower Abdomen and Exterior of Pelvis. Moist Heat. Hot Stupes. Hot Pastes. Hot Poultices. Hot Sitz-baths. Hot Moist Pelvic Pack. Dry Heat. Hot Water Bag. Japanese Stove. Hot Water Coil. Electrotherm. Hot Air Chamber. Hot Dry Pack. Cold Applications. Ice Bag. Cold Coil. Cold Sitz-bath. Counter-Irritant Applications. Mustard (poultice, plaster). Cantharides (plaster, collodion).. Tinct. Iodine. Applications to External Genitals, Vagina and Cervix. Douches. Concentrated Solutions. Powders. Tablets. Vaginal Suppositories. Tampons. Tampon-capsules. LIST OF THERAPEUTIC MEASURES 3C5 Pessaries. Submucous Injection of Substances. Local Blood-letting. Curet. Cautery. Electricity. X-Ra3\ Finsen Light. Radium. Intra-Uterine Treatment. Medicated Applications within uterus. Hot Water Irrigation. Curetment. Cauterization. Electricity. Cervical Dilatation. Vacuum Treatment. Applications within Rectum. Enemata, Low and High. Hot Water Irrigation. Applications to Lower Abdomen and Interior of Pelvis. Pelvic Massage. Pressure Treatment. Electricity. Applications to Body Generally. Bathing. Friction Rubbing (with alcohol, salt, brush, etc.) General Massage. Dress Corrections. Postural Methods and Exercise. Knee-Chest Posture. Trendelenburg Posture. General Exercise. Special Exercise. Internal Treatment. Medicines. Diet. Psycho-therapy. Operations. 50S GYNECOLOGIC TREATMENT REST. Complete rest in bed is necessary when acute inflammation is present and in acute exacerbations of chronic inflammation. In an acute attack of vaginitis, endometritis, salpingitis or acute pelvic perito- nitis, tlie patient should be put to bed and kept there until the pain and fever sub- side. When the inflammation is severe and accompanied by much pain, the patient should use the bed-pan and should not be permitted to get up to a vessel beside the bed. Also, rest in bed for a few days will temporarily diminish the pain of chronic inflammation and tlie backache and distress that accompany loss of support in the pelvic floor. It is a rule, with but few exceptions, that in pelvic disease strict rest in bed, com- bined with laxatives and hot vaginal douches and hot applications to lower abdomen, will in twenty-four to forty-eight hours relieve the pain to such an extent that the patient is comfortable. The exceptions to this rule are:— Active spreading inflammation of the peritoneum, A collection of pus with tension. Recurrent hemorrhage, as in tubal pregnancy. Threatened abortion. A tumor compressing pelvic nerves. Neuritis and neuralgia. In these conditions the pain may be persistent and severe in spite of absolute rest. By keeping these things in mind, the effect of rest becomes a help in differ- ential diagnosis in certain cases. Partial rest is advisable in many cases that do not require complete rest in bed. The work of some patients, requiring as it does much walking or long standing or constant running of the sewing machine or lifting of children, tends to aggravate and prolong certain pelvic affections and for that reason it may be necessary to have the patient stop work for a while, even though she can ill afford financially to do so. Again, it may be advisable to direct a vacation to some distant point for the patient who is dragged down by household duties or the care of children or office work or the exactions of society. The rest from care, the change of environment, the direction of the thoughts and activities into new channels, will in some cases do do more than anything else toward restoring tlie patient to health. Directions should of course be given for whatever additional therapeutic measures are neces- sary during the visit. Sexual rest is necessary in many cases, particularly in inflammatory troubles. In some cases coitus must be absolutely forbidden and in other cases restricted, as the marked congestion accompanying it is likely to aggravate the trouble. In acute inflammation it is rarely necessary to say anything on this point, as the painfulness of coitus itself prevents it. In sub-acute inflammations however and in chronic conditions aggravated by pelvic congestion, when the trouble resists treatment and it seems probable that coitus is interfering with the cure, it is advis- APf'fJCATIONS TO TIIK LOWER AlJboMEN 307 al^le to stop .sexual iiilcicoui'.sc or restrict it. Thi.s may be acconipli.shcd by one of three ways, as follows: a. Instructing the patient or her husband regarding it. This is .somewhat em- barrassing and not very effective, though it is sometimes the best plan. b. Use of vaginal tampons, the tampons to be worn continuously and changed only in the office. In this way the beneficial effect of tampons is .secured and at the same time coitus is restricted. The tampon-capsules when indicated for other pur- poses, may be used so as to accompUsh this object also — the patient being directed, on removing each tampon, to take a douche and immediately introduce the next one. c. Sending patient on a trip away from home. Here also the sexual rest is only incidental, though quite important in conditions aggravated by pelvic congestion. APPLICATIONS TO THE LOWER ABDOMEN AND EXTERIOR OF PELVIS. These applications are used to relieve pain and limit inflammation. MOIST HEAT. Hot stupes are made by folding a piece of flannel several times, making a pad large enough to cover the lower abdomen. This pad is wrung out of very hot water and quickly applied to the abdomen and covered with a piece of thin oilcloth or a heavy towel. The thin oilcloth is preferable, as it keeps in the heat and moisture better and is not so heavy. As soon as the pad begins to cool, another one is wrung from the hot water and slipped in place as the first is removed. If the stupes are changed frequently and thus kept hot, they are very effective in relieving pel- vic pain. They have some effect in all painful conditions, but the most marked effect is seen in the pain of inflammation. The efficiency of the hot stupes may be increased by adding one or two tablespoonfuls of turpentine to the hot water in the basin. To some patients, however, the odor of turpentine is disagreeable and disturbs the stomach and with such it should not be used. The disadvantages of hot stupes are that they have to be changed very frequently and that they soon get the bed- clothing damp. Hot pastes. There is a material for external use, consisting of an earthy silicate for a base and having incorporated glycerine and mild antiseptics with a pleasant odor. This is very convenient for application to the lower abdomen for it holds the heat and moisture well. This material, with slight variations, is put up by a number of firms and given different names (glykaolin, antiphlogistin, etc.). Under one of the tradenames, it may be purchased at any drug store in one or two pound cans. The methods of its application is as follows: Take oft' the lid and set the can in a pan of hot water on the stove until the paste is thoroughly heated. It is then thin enough to spread easily with a spatula or knife or spoon handle. It is spread directly on the skin in a thick layer (about i in. thick). The whole lower abdo- 308 GYNECOLOGIC TREATMENT men is covered with a thick layer of the hot paste, which is covered with a piece of flannel and outside of this is placed the hot-water bag or Japanese stove to keep it warm. The paste sticks tight to the skin at first, but after twent5'"-four hours usually there has been sufficient perspiration beneath it to loosen it and cause it to come off easily. It is then removed and a fresh layer applied immediately. A fresh application is made every twenty-four hours, as long as hot applications are desired. Flaxseed Poultice retains the heat well and is much used as a home remedy when hot applications are desired. It is not nearly as convenient nor cleanly as the hot pastes but is about as efficient if changed often and kept up for several days, and is often at hand when the other things are not available. The flaxseed poultice is made as follows: Take two parts of ground flaxseed (flaxseed meal) and five parts of boiling water and mix with constant stirring. When mixed, spread thick (^ in.) on a piece of thin muslin or cheese-cloth. Have the cloth large enough so that you can leave a margin on each side to fold over. The poultice should cover one-half the cloth and the other half can then be laid over after the margins are turned in. If a hot-water bag or Japanese stove is at hand put that over the poultice to keep it hot. Hot Sitz-bath. The patient sits in a small tub, preferably of special design, con- taining watsr enough to cover the hips, genitals and lower abdomen. The water should be as hot as the patient can stand without discomfort (105° to 115°). She should remain in the sitz-bath from twenty to thirty minutes and then be dried and put in bed. It may be repeated daily or several times daily, as found most bene- ficial. The hot sitz-bath is sedative in effect and relieves very much the pain of pelvic inflammation. In inflammation it should be used only in those cases where the patient may make the necessary movements without detriment. It is useful also in helping the onset of the menses in amenorrhoea or suppi-essed menses. Hot Moist Pelvic Pack. Instead of making the hot applications to the lower abdomen only, they may be extended all around the pelvis. The whole pelvis is encased in the hot stupe or compress, and over all a large piece of thin rubber cloth or table oilcloth is placed. A woolen blanket also is wrapped around the patient to keep in the heat and moisture. This may give much relief from the suffering in acute suppression of menses, in acute pelvic inflammation and in severe pelvic neuralgia. DRY HEAT. Hot=Water Bag. The hot-water bag produces almost the same effect as the hot stupes, and keeps hot a longer time without change and is much more convenient to manipulate. If the effect of moist heat is desired, a hot stupe may be applied and a hot- water bag placed over it to keep it warm. If no hot-water bag is at hand, a large flat bottle filled with hot water may be used. This should be securely corked and wrapped in a thick flannel cloth. If no suitable bottle is available, a plate, heated and wrapped in a flannel cloth, may be used, or a stove-lid or other article that will retain the heat. Japanese Stove. This consists of a small flat metal container, about the size of the hand, in which is burned a compressed powder resembhng charcoal. This HOT APPLICATIONS. COLD APPLICATIONS 309 little container may be purchased at the drug-store for a few cents and is very con- venient for applying dry heat or for keeping a moist application warm. If it is wished very hot, two or three sticks, instead of one, of the powder may be lighted and dropped in. If one stove is not large enough, two or three may be used. Hot=Water Coil. This consists of a coil of rubber tubing and a boiler, the former being attached to the latter by tubing in such a way as to cause a constant circu- lation of hot water through the coil. It is very nice but rather expensive. Electrotherm. This electric heating-pad is heated by a current through a cord, which is to be attached in the ordinary electric-light socket. This, like the other dry heat appliances, may be used alone for dry heat or over a moist application for moist heat. Iiot=Air Chamber. The apparatus is the same as that for applying hot dry heat to the joints or other parts of the body, the chamber for gynecological cases being made to fit about the pelvis and lower abdomen. The temperature that will be borne varies with individuals and also with the length of time employed. At first a temperature of 120° for twenty minutes will suffice. After a week or so the patient may bear a temperature of 135° to 150° for 45 minutes. The temperature should not be high enough to cause discomfort above a slight tingling of the skin. The air chamber may be heated with electric lights, instead of in the ordinary way. This is a convenient way and one in which the heat is easily regulated. The effect of the hot air chamber is to cause marked redness of the skin, free perspiration and a hastening of the absorption of chronic pelvic exudates. Cases of chronic pelvic inflammation are the ones suitable for treatment. In several cases, exudates were absorbed in 14 to 20 sittings. No bad after effects were noted. Cooling is allowed to take place gradually and the patient is then dried and lies in bed for an hour. It takes considerable time, about an hour to each patient, but after the apparatus is once started it may be left in the care of an experienced nurse. Without any special treatment about 90 per cent, or more of pelvic ex- udates tend to become absorbed, if the patient is kept quiet. This natural process is hastened by laxatives, hot douches and heat to the abdomen. This particular method of applying heat is about the most troublesome and expensive, except in hospitals where the apparatus is kept on hand or in homes where electricity is avail- able. In cases of persistent exudate without evidence of a remaining focus of in- fection, it is well to give this method a trial. Hot Dry Pack. Dry heat may be applied all around the pelvis by packing around it hot water bags or hot bottles or other containers for maintaining the heat, the skin being well protected by layers of flannel. COLD APPLICATIONS. In some cases cold gives more relief than heat, though the cases in which it will do so cannot be certainly determined without trial. It has been stated that cold gives more relief when the pain is due to active inflammation and the hot applica- tions in other cases. In my experience, that rule does not hold good. On the other hand, in the majority of cases, pelvic pain, inflammatory or otherwise; is 310 GYNECOLOGIC TREATMENT relieved more by hot applications than by cold. Consequently my rule is to use hot applications first and, if they fail to give relief, then the cold. There are several ways of applying cold. To get the best sedative effects it must, like the heat, be maintained continuously, or almost continuously, for sev- eral days. Ice Bag. The ordinary ice bag is a convenient and satisfactory method of ap- plying cold. If no regular ice bag can be secured, the ice may be put in a hot- water bag. The ordinary hot-water bag filled with ice does fairly well as a substitute for an ice bag but it is not as convenient, for the ice has to be broken into- very sma41 pieces. If no rubber bag of any kind is at hand, the broken ice may be wrapped in a towel and placed in a piece of table oilcloth, the edges and corners being pinned up so that no water can leak out. CoId= Water Coil. One end of the coil is attached to a vessel of ice water so that the water runs through it slowly and keeps it cold. The other end conducts the water from the coil to a waste bucket beside the bed. If the hydrant water is cold enough, the tube leading to the coil may be attached to the hydrant. Cool Sitz=bath. This is used, not as a sedative but as an active stimulant to the pelvic organs. It is taken the same as the hot sitz-baths except that the temper- ature of the water is 70^ to 50°, and the patient does not stay in so long — only five to twenty minutes. It may be given gradually, i. e., the water is tepid at first and gradually cooled to 60^ or 50°. In some cases in which amenorrhoea is due to local loss of tone or to imperfect development, the cool sitz-baths may prove more bene- ficial than the hot. They should, however, be given cautiously and in strong in- dividuals only and should not be continued unless good reaction comes on. As in a cool general bath, the reaction should be encouraged and increased by prompt drying and brisk rubbing. COUNTER-IRRITANT APPLICATIONS. Mustard Plaster. A mustard plaster or mustard poultice is applied over the lowei abdomen just long enough to produce marked redness of the skin. It should not be left on long enough to blister. This gives a quick and widespread counter-irri- tation of the skin and assists materially in relieving acute deep-seated pain. The effect is transitory however, and needs to be continued by the ordinaiy hot appli- cations. If there is smarting of the skin after removal of the mustard, apply a layer of vaseline and a thin cloth under the hot applications. The addition of tur- pentine to plain hot stupes is a form of counter-irritation, and in some cases assist very much in relieving pain. Of course, this should not be applied to the abdomen in a case where an abdominal operation may be necessary soon. Cantharides Plaster. Small fly blisters over areas of persistent pain often do much good in cases of chronic pelvic inflammation without marked lesion and in cases of pelvic neuralgia. The blister should be small, from, the size of a quarter to that of a dollar, and should be carefully protected from infection until healed. Cantharides Collodion is very convenient for making the small fly blisters. Paint it over the area which it is desired to blister and repeat after twenty-fouj- hours if no blister has appeared. VULVAR AND VAGINAL TREATMENT 311 Tincture of Iodine. This is painted over the ovarian region of the affected side once or twice daily until the skin becomes tender. Then it is stopped for a few days until the skin-tenderness subsides somewhat, when it is renewed. By vary- ing the application as indicated by its effect on the skin, a constant mild counter- irritation may be kept up for weeks, often with decided diminution of pain. APPLICATIONS TO EXTERNAL GENITALS, VAGINA AND CERVIX. VAGINAL DOUCHES. The vaginal douche is used for four purposes — for simple cleansing, for astrin- gent effect, for antiseptic effect and for the specific effect of hot water. Cleansing Douche. The simple cleansing douche is used when there is a trouble- some increase in the normal muco-epithelial discharge or when there is a muco- purulent discharge wdthout pain or evidence of inflammation or marked relaxation of the tissues. Plain boiled water comfortably warm (100^ to 105^) may be used, but if there is much discharge it is well to put a teaspoonful of ordinary salt or a teaspoonful of sodium bicarbonate to each pint of water, or the carbolic douche may be pre- scribed (see Formulae). The simple cleansing douche may be taken wdth the foun- tain syringe or with the bulb (Davidson) syringe. It may be taken with the patient lying in bed or in a sitting posture over a vessel. In all vaginal douches the point of the syringe nozzle should be so large that it cannot enter the cervical canal. Serious disturbance and even death has followed the accidental injection of the douche solution into the uterus. The point of the nozzle should be three-fourth inches in diameter, wdth the end closed and the openings at the sides. When it is necessary to use a slender nozzle (as in giving a douche to a virgin) it should be very short. Vaginal douches should be used only when there is some definite indications for them. In healthy women the constant use of douches or the routine use of them for indefinite periods, is not advisable. They are not required for mere cleanli- ness, in fact, they interfere in a measure with the normal germicidal vaginal con- tents, which nature has provided to keep the vagina in a healthy condition and to protect the structures above. Astringent Douche. The astringent douche is used when the vaginal walls are lax and atonic or in the various erosions and other chronic inflammatory lesions of the cervix and in cases where there is soft bleeding tissue about the cervix or vagina. As a mild astringent and sedative douche wdth some antiseptic effect, a solution of aluminum acetate is exceptionally efficient (see Formulae) . Dissolve the powder in boiling water, and then allow it to cool sufficienlly for the douche. It is rather difficult to dissolve, that from some manufacturers more so than from others. The aluminum acetate is excellent to use in connection with the hot douche, the last two quarts of the hot irrigating douche being saturated with it When a stronger astringent effect is desired, the zinc sulphate and alum douche (see Formulae) or the tannic acid douche (see Formulae) may be used. These strong astringent douches are used principally in cases of soft bleeding tissue in the 312 ■ GYNECOLOGIC TREATMENT vagina or in cancer of cervix or vaginal wall. They may be used also with benefit in relaxation of vaginal tissues and in erosions and other chronic inflammatory lesions of the cervix, in cases where it is impracticable to use the hot douche. Care must be taken that the solution does not irritate the vaginal wall. It is well to begin with a weak solution and advance to the stronger as toleration is established. Astringent douches should be taken with the patient in the horizontal posture, preferably with the hips elevated on the bed-pan, as described in the technique of the long hot douche (Fig 449). Antiseptic Douche. The antiseptic douche is used in those cases of purulent dis- charge or muco-purulent discharge in which the admixture of pus is so prominent that an active germicidal effect is important. One of the best of the germicides for making a strongly antiseptic douche is the only standby, hydrarg. bichloride, used in the strength of about 1-5000 or, where a weak antiseptic is desired, 1-10,000. Some state that it is dangerous to use such a strong antiseptic as a vaginal douche on account of the danger of poisoning. This is hardly probable however with the strength mentioned and under precautions. I have prescribed it freely for a num- ber of years and have noticed no untoward results. I am careful not to use it when there is a large raw surface in the vagina or when there is an opening communicat- ing with a large pelvic abscess cavity or when the cervical canal stands open so that the solution might easily pass into the uterus. Absorption from the intact vagina is not probable. In prescribing, it is well to have the concentrated solution colored (see Formulae) so no mistakes will arise, for it is a violent poison. Another efficient and very satisfactory douche is formol, 1-5,000 to 1-3,000. Formol, as purchased in the drug stores, is a 40 per cent, solution of formaldehyde gas. Formol is a very strong antiseptic and must be used in weak solution or it will cause irritation. Five to ten drops to two quarts of warm water is usually sufficient, though for special conditions the strength may be increased with some patients. Hot Vaginal Douche. The hot vaginal douche is cleansing and may be made antiseptic or astringent, but its special and distinct effects are the rehef of pain, the limitation of inflammation, the hastening of absorption of exudates and the toning up of relaxed tissues. These effects are brought about by the prolonged applica- tion of hot water to the vaginal walls and cervix. To get the best effect, it is essential that particular attention be given to certain details of its administration. These details are usually carried out in an incom- plete wa}^, for the importance of their full employment is not at all appreciated by the patient and as a rule onh^ partially by the physician. Hence, ordinarily, the hot douche amounts to little more than a cleansing douche, the specific effect of the heat being almost wholly missed. This is an important subject for, given properly, the hot douche is one of the most effective non-operative measures used in the treatment of gynecological diseases. Furthei'more, it is an inexpensive and simple measure, the necessary articles cost- ing but little, and the douche may be given to the patient by any woman of ordi- nar}'- intelligence, if definitely instructed. It has also the least possibilities of harm of the various methods of local treatment and is the least disturbing to the anatomy and physiology of the parts. The specific effect of the hot douche was recognized THE HOT VAGINAL DOUCHE 313 more than forty years ago by that prince of cHnical investigators, Dr. T. A. Emmet, and clearly set forth in his splendid work published in 1879, from which I make the following quotation. "It has been stated that the sympathetic system of nerves presides over nutri- tion and the organs of generation and that every blood-vessel, to the minutest ca- pillary, is covered by a network of nerve filaments communicating directly with the different ganglia. When nutrition is impaired, there is naturally a want of tone in the blood-vessels. It is only by exciting reflex action through these nerves that the necessary tonicity will be restored. "We have thi*ee agents for exciting this reflex action, viz., electricity, cold and heat. " Electricity exerts a decided effect during the time of the passage of the cur- rent, but the impression is too transitory and the agent is only to be relied upon as a valuable adjuvant. "Cold is a prompt excitor of reflex action, by which the vessels contract, but on reaction taking place the parts will become more congested than before, with both the arteries and veins distended. " Heat, unless at a temperature that would destroy the parts, does not act as promptly in causing this contraction as either electricity or cold. In fact, its immediate effect is to cause relaxation and to increase the congestion of the parts, but if its application be prolonged, reaction ensues and contraction takes place. In other words the reaction from heat is contraction. The capillaries are excited to increased action and as they contract from the stimulus of these nerves, the tonic effect extends to the coats of the larger vessels, their calibre in turn becomes les- sened and with this approach to healthy action the congestion is diminished. The popular belief is that heat relaxes and increases the congestion of the parts, and such indeed is the cas'e at first. But a hot poultice is never applied with the object of increasing the 'congestion, but, as any 'old wife' would express it, to draw the 'fire' or inflammation out — in other words it lessens the congestion by stimulating the blood-vessels to contract. That such is the effect, from the con- tinued use of a poultice, is familiar to everyone and is shown by the blanched and shriveled appearance of the tissues after its removal. The hands and arms of a washer-woman become swollen at first, from the increased flow of blood when in hot water, but the fact is quite as familiar that they afterwards become markedly shrivelled. "To place the hands in cold water will at once cause the skin to shrivel, as the ves- sels are stimulated to contract, but we are all familiar with the fact that reaction promptly comes on, and a larger quantity of blood returns to the parts than was driven out. The immediate effect of cold, therefore, is contraction, and with re action comes dilatation; but the reverse is true of heat, which causes at first dila- tation followed however by contraction. "With these practical points before us,we resort to the prolonged use of hot water, by vaginal injections, to gradually bring about the required contraction and tone in the pelvic vessels. Whenever inflammation exists we have congestion of the arterial capillaries. ....... .The congestion may be either venous or arterial. 314 GYNECOLOGIC TREATMENT This remedy Is not to be considered a ' cure all, ' but one of the most valuable adjuvants, under all circumstances; to other means. "If a vaginal injection has been properly administered, the mucous membrane Trill be found blanched in appearance, and the usual size of the canal lessened in calibre, as after the use of a strong astringent injection. As the patient lies on the back ^dth her hips elevated, the action of gravity will be brought into play, by which the veins will be rapidly emptied sufhciently to relieve the over-distension. When in this position also, the vagina "^ill become fully distended by the weight of water and kept so, since only the surplus amount can run off into the bed-pan beneath. The hot water T\'ill then be in contact T^ith everj' portion of the mucous membrane under which the capillaries lie. The vessels going to and from the cer- vix and body of the uterus pass along the sulcus on each side of the vagina, and their branches enclose the vagina in a complete network If then we are able to cause the vessels of the vagina to contract, through the stimulus of the hot water, we can directly or indirectly influence a large part of the pelvic circulation. It is most important to appreciate the necessity for elevating the hips, by which plan so large a portion of the venous blood becomes drawn off by gravitation. If the stimulus of the hot water is then applied, so as to cause the vessels to contract still more, we will, for a time at lea.st, have the pelvic circulation reduced almost to a natural condition. In order to allow the condition of contraction to be as pro- longed as possible, I generally direct the injection to be given at night, in bed, just as the patient is ready to retire. Thus, by constantly causing these vessels to con- tract, and by resorting to every other means of lessening the supply of blood in the pelvis, we will succeed eventually in securing a proper vascular tone. ''No plan of treatment could be more rational or appeal more forcibly to the good judgment of everyone. But, unfortunately, from a neglect of details, it is rare that the slightestbenefit is derived from these injections, although so many years have elapsed since the profession has. been fully instructed as to their mode of action. For fifteen years at least, I have been experimenting by different methods in the use of hot water, and have had during that time as large a number of cases as would be likely to be at the service of anyone, and I have arrived at the conclusion that it is an impossibility for a patient to give these injections to herself so as to derive their full benefit. Not the slightest advantage is received from them when adminis- tered T^ith the patient in the upright position, or, as is the usual method, while seated over a bidet, for, given thus, the water does not dilate the passage but re- turns along the nozzle of the syringe. I have found that the best method of all is to have the injections given while the patient is placed on her knees and elbows or chest. In this position we have the assistance both of gravity and the pressure of the atmosphere to empty the pelvic veins, while the water is able to act on a much larger surface of the vagina than it is when the patient is in any other position. But this position is a difficult one to assume, since those who are in the greatest need of hot water have not the strength to remain in it long enough to accomplish the purpose, and considerable difficulty is also experienced in keeping the patient dry. This latter difficulty, how^ever, can in a measure be overcome by using a funnel-shaped receptacle, with an india-rubber tube attached to the smaller end, THEORY OF THE HOT VAGINAL DOUCHE 315 the two sides being indented sufficiently to enable the patient to keep it in place by keeping the thighs together. But for the larger number of cases, the position on the back, with a bed-pan to elevate the hips, will be found the most convenient. Few women are so situated as to be unable to get someone to administer the in- jection properly, and the inconvenience of soliciting aid is a trifling one consider- ing the benefit to be derived from it, since experience has shown that, unless the details can be carried out fully, the process only involves a waste of time and a tax on the strength of the patient. "The temperature and quantity of water are to be varied according to circum- stances. When treating the early stages of inflammation, it is necessary that the temperature should be elevated rapidly from that of blood heat to 110^, or to as high a degree as can be borne by the patient, and that the injection should be often repeated. For ordinary use, a gallon of water at two or three degrees above blood-heat is generally sufficient, but the temperature must be maintained at the highest point by the addition of hot water from time to time. The hour of bed- time is usually the best in which to seek for the beneficial effects of hot water on the reflex system in allaying the local irritation, for prolonged vaginal injection at a high temperature "v\ill often, when gi^'en by an experienced hand, act with more promptness than an anodyne in allaying the nervousness and sleeplessness of an hysterical woman. I have frequently known a patient, after being well rubbed and having received an injection, to fall asleep before the nurse had com- pleted the process and to be so overcome with drow^siness as to be but little dis- turbed on removing the bed-pan. "In rare instances and from a condition I am unable to explain, cases are met with where a sensation of weight and an uncomfortable feehng are experienced after an injection of water at the usual temperature. In some instances so much disturbance resulted that occasionally I was obliged to abandon its use. But I have long since ascertained that the injection is well borne at a lower temperature, generally about 95^, and that after a week or two the temperature can be gradually increased. "This ' cooking process, ' as it has been facetiously termed, is rendered easier by the use of ivory or some other nonconducting material for the nozzle of the syringe, since the patient suffers more discomfort from the heated metal surface of the or- dinary nozzle coming in contact with the outlet of the vagina than from any de- gree of heat in the water which it is advisable to employ. "To the injection (generally to the last pint) may be added glycerine, chlorate of potash, chloride of sodium, carbonate of soda, borax, castile soap, sulphate of copper, muriate of ammonia, brewer's yeast, permanganate of potassa, carboHc acid or any other remedy w^hich may seem to be indicated. "As the patient improves in health, the quantity of water for the injection may be lessened and the temperature gradually lowered and then discontinued. But for some months it would be prudent, for a few days after each period, to resume the injections at a degree or two above blood heat, and to have recourse to them whenever their use should seem indicated to counteract the effect of some impru- dence. "I do not claimx to be the first person under whose direction a vagina was ever 316 GYNECOLOGIC TREATMENT washed out with warm water, but I do claim to be the first to use the agent in a systematic jnanner, for the treatment of the diseases of women, and to have done so with a definite purpose."* Directions for the Hot Vaginal Douche. In prescribing the hot douche, take pains to give exphcit directions on the fol- lowing points: — Fig. 449. Patient arranged for the Long Hot Vaginal Douche. Notice that the patient's hips are elevated and that the douche-pan has an outlet tube leading into a bucket beside the bed. The douche-nozzle has a thick end and the openings are at the side, so that there is no possiblity of the water being forced into the uterine cavity. The douche-bag may be hung at any height required to give the desired rate of flow. 1. Articles Required. Direct the patient to buy a yard of thin oilcloth, a douche- pan, a fountain syringe, a bath-thermometer and a four-ounce bottle of lysol. Principles and Practice of Gynecology, by Thomas ,\(klis EmiucI, M. P. DIRECTIONS FOR THE HOT VAGINAL DOUCHE 317 The patient wishes the most effective treatment, not lialf-way measm-cs. These articles cost but Uttle and are necessary to the proper cure of the case. The piece of oilcloth is to be phiced under the douche pan to thoroughly protect the bed. It does very well. A piece of white rubl)er cloth is nicer but a little more expensive. A very convenient form of douche=pan is that shown in Fig. 449. It should have an opening for attachment of rubber tubing to conduct the water to a vessel beside the bed, so that when desired, several gallons of water may be used without empty- ing the douche-pan. This pan holds a good large quantity of water and is easily cleansed, and by closing the outlet with the screw, cap it may be used as an ordinary bed-pan. A douche-pan of this or some similar style can be purchased for a small amount and is just as much a necessity in the proper treatment of the case as med- icines that cost more. The fountain syringe should be of good size (3 or 4 qts.), the syringe-nozzle hav- ing an end three-fourth inches in diameter and with the openings at the sides (Fig. 449). The nozzle is kept in 2 per cent, lysol solution (two teaspoonfuls to a pint of boiled water) when not in use. Immediately after use each time, it is washed out "^dth a stream of water and then dropped into the antiseptic solution. The bath=thermometer should register as high as 120F. It is kept wrapped in a clean towel. Each time before use it is cleansed in the lysol solution. After use it is again cleansed in the lysol solution, dried and wrapped in towel. The antiseptic is used for cleansing the douche-nozzle and the thermometer, and for mixing Tvith the last two quarts of the douche water when it is desirable to do so. Any antiseptic desired may be used. Lysol is easily obtained, may be mixed in approximately the required proportions very easily, does not corrode when mixed in a metal vessel, is of such color and odor that it is not likely to be mistaken for something else and does about as well as anything so far as antiseptic effect is concerned. For a douche use ^ per cent, (one teaspoonful to the quart). If an astringent effect is desired, use alum (two teaspoonfuls to the last two quarts) or aluminum acetate (one teaspoonful to the last two quarts) , instead of the lysol. If a still stronger astringent effect is desired, the zinc sulphate douche or the tannic acid douche may be used. The formulae for these various douches are given in the Appendix. 2. Have some one give the douche as follows: — Scald out the douche-bag and tubing "v\ith boiling water and hang it about three feet above the level of the bed. Get a tea-kettle of boiling water and a large pitcher of warm water, as waim as the douche may be comfortably begun with (about 105° by the bath-thermometer). Put the piece of thin oilcloth on the bed, and on this an ironing board. Put the douche-pan on the lower part of the board and a quilt on the upper part, to make it comfortable for the patient, and a pillow for her head. If the upper edge of the douche-pan is uncomfortable, cover it with a folded towel. The tube of the douche- pan leads into a bucket beside the bed. When the patient is arranged, the hips should be considerably higher than the rest of the body (Fig. 437). Take the douche-nozzle out of the lysol solution, rinse off the lysol in the pitcher of douche-water, attach the nozzle to the douche tubing and introduce it into the vagina. Pour some of the warm water from the 3 IS GYNECOLOGIC TREATMENT pitcher into the douche-bag and allow it to run. If some air runs from the douche- tube into the vagina, that is beneficial for it helps to separate the walls. As the patient can take the water warmer and warmer increase the temperature, bring- ing it up to 115^ if not too uncomfortable. Keep up the hot irrigation, ordinarily, for thirty minutes or more, using as much water as necessary to maintain the irrigation for that length of time. The water runs slowly (only two or three feet elevation) and three or four gallons is usually enough. 3. If it is desired to make the latter part of the douche especially astringent, as when the parts are relaxed and atonic, a suitable chemical is added. The alum- inum acetate is excellent for this purpose, a teaspoonful of the powder being dis- solved in the last two quarts of the irrigating fluid. If a strong antiseptic effect is needed, as in a case of purulent discharge, the required antiseptic is added to the last two quarts of the hot water. In inflammation (subacute or chronic) considerable additional benefit is secured by introducing to the top of the vagina, immediately after the douche, a vaginal capsule containing a tampon with the upper end saturated Vvdth some glycerine preparation (ichthyol-glycerine or boro-glycerine) . This tampon is left in place from twelve to twenty-four hours, when it is removed and the douche repeated. This is an excellent method of treating subacute or chronic pelvic inflammation and also acute exacerbations of the same. 4. After the douche, the patient slides over to another part of the bed while the douche pan, etc., is being removed, and should remain quiet for at least an hour. 5. The frequency with which the douche should be repeated varies with the case. In chronic inflammation, when the patient is up and at work and suffering but little, once a day may be sufficient. In such a case the preferable time is in the evening, as the patient is then in bed for several hours afterwards. In cases of more severity or where the one douche does not produce satisfactory results, a douche in the forenoon may be added — the patient remaining in bed at least one hour afterward. In the cases where the patient is confined to bed, the douche is given, ordinarily twice daily. In severe cases of acute pelvic inflammation, after it is seen that the uterus is clean and draining and any other focus of infection opened, it may be beneficial to give the hot douche every six hours and in some exceptional cases, it is advisable to keep up an almost constant irrigation of the parts for some days. 6. This hot vaginal douche, with its specific effect, is beneficial in practically all inflammatory conditions of the pelvis, in relaxation and want of tone in the pelvic tissues, in pelvic congestion and in pelvic neuralgia. In these conditions it must not be depended on to the exclusion of other necessary measures, operative and non-operative, but it is to be used in conjunction with these, as indicated by the requirements of the particular case. Where many gynecological cases are treated, it is well to have a printed slip to give each patient who is to take the douche, setting forth definitely, in a few plain words, the necessary directions. By having this to refer to, the person who gives the douche will give it much more nearly as it should be given and therefore- much more effectively. LOCAL APPLICATIONS 319 CONCENTRATED SOLUTIONS. Before taking up the details of the office treatment of gynecological diseases, it would be well to get a clear idea of what good can be done and what harm can be done by such treatment. The importance of ordinary office treatment is, on the whole, still rated much above its actual value. This statement applies especially to the application of medicines to the vaginal walls, to he cervix and to the interior of the uterus. In some affections for which this method of t.eatment is generally and persistently employed, it does no good and much harm. There is, however, no warrant for those wholesale condemnatory statements made from time to time which, reduced to their essence, mean that when any pel- vic disturbance is severe enough to require treatment, it requires operation. Such teaching is very far from the truth and is almost, if not fully, as erroneous in theor}' and deplorable in results as the former teaching that "local treatment" was the most important measure in the handling of patients with pelvic disease. Happily the treatment of gynecological diseases is no longer based upon obscure theories and opinions empirically expressed, but upon the rational application of known remedies to demonstrated pathological conditions. Though there is still much to be learned and much that is obscure, as there always will be about a subject so inti- mately connected with the mysterious processes of life, the essential features of most of the diseases and the main effects of the principal methods of treatment are open to the understanding of all who will give the necessary time and study to the subject. Critically reviewing the demonstrated pathological changes present in the vari- ous gjmecological affections, it is evident that in a considerable proportion of the serious diseases, effective treatment is necessarily operative, for the abnormal changes are of such nature that they can be influenced only by direct handling and treatment of the affected organs. On the other hand, there are many conditions that may be much influenced by non-operative measures carried out at home, such as attention to general health, internal medicine, special exercises, posture, hot or cold external applications, hot vaginal douches, etc., etc. Much effect is exer- cised also over certain conditions, by local treatment in the office — pessaries, tam- pons, packings, pressure treatment, massage, dilatation and various medicinal applications to the vagina or cervix or within the uterus. No one of these methods should be used until sufficient knowledge has been obtained to show what the principal effects of that method are and in what con- ditions we may reasonably expect decided benefit from such effects. The method just now under consideration is the application of concentrated solutions to the cervix uteri, the vaginal wall or the external genitals. What good can such applications do? 1. Tkey may exercise an antiseptic or an astringent or an anesthetic or an irri- tating effect, limited to the surface on which they are applied. 2. They may destroy tissue (cautery). 320 GYNECOLOGIC TREATMENT 3. They may draw off fluid from tissues adjacent to the vaginal vault (hygro- scopic effect), as in the use of glycerine in various combinations. This may diminish the pain (interstitial pressure) of an inflammatory or edematous infil- tration and possibly assist nature in limiting the inflammation and hastening absorption. This effect is very desirable, but in acute and subacute cases its bene- ficial effect is more than overbalanced by the trips to the office. In such cases the effect may be more advantageously secured by having the tampon-capsules used at home, immediately after the douche. Occasionally, in the case of a chronic exudate, when the patient can get about without disturbance, it may be used with decided effect in office work. 4. They may possibly influence deep pains by counter-irritation at the vaginal vault. This is applicable only in cases of chronic exudate or pelvic neuralgia, and even in these it is of doubtful utility. Whether the decided relief of pain that sometim.es follows counter-irritation at the vaginal vault is due to the mechanical drawing of the blood from the adjacent tissues to the dilated vessels of the vaginal surface, or to a reflex deep anemia from the irritation of surface nerve-filaments, or to a purely sensory effect on the deeper nerves by irritation of the corresponding superficial nerves, I am not prepared to say. Possibly it is not due to any of these but to some other factor in the treatment (pressure, cleansing, posture) . Formerly much importance was attached to counter-irritation at the vagina] vault, and a woman with pelvic inflammation could hardly be considered initiated into treatment until the vaginal vault and cervix had been painted with Churchill's tincture of iodine. It is not so often used now, for we have more effective measures. What harm can such applications do? 1. May cause the patient to come to the ofl&ce when the dressing and coming do more harm than the application does good. This is true of all acute inflammations (even vaginal and vulvar) and of practically all subacute, inflammations of the uterus and deep pelvic structures. 2. May cause postponement of effective treatment, by holding out false hope, until the disease is much more difficult of cure or is past cure. This applies to chronic inflammations of the corpus uteri and peritoneal structures, to deep-seated inflammatory troubles of the cervix uteri and to beginning cancer of the uterus. 3. May convert a neurasthenic or hysteric into a confirmed invalid by fixing at. tention upon, and exaggerating the importance of, some trivial local disturbance. In such patients the frequent calling of the attention to some minor disturbance in any part of the body is deleterious and particularly so if the disturbance is in the genital tract, for the importance of minor disturbances there is greatly over- rated in the minds of people generally. For this reason, in patients with neuras- thenic or hysteric tendency, I rnake it a point to avoid repeated local treatments, even in some conditions where otherwise I would feel that they might be beneficial. Occasionally local treatment of an unimportant lesion two or three times, princi- pally for psychic effect and to gain the patient's confidence by letting her see that you appreciate all that is there, is beneficial. Usually, however, the same effect is better accomplished by a thorough examination and then an unequivocal dis- missal of those organs from the list of damaged structures. VARIOUS SOLUTIONS USED 321 The concentrated solutions used for application to the vaginal walls or cervix, are applied through a speculum by means of a pledget of cotton held with a uterine dressing forceps, or by means of a cotton- wrapped applicator. These solutions may be divided into several groups, according to effects. I do not give all the solutions under each group but only some well known examples. Solutions Used. !. Antiseptic and astringent solutions. Protargol Sol. 2% to 10%. Argja-ol Sol. 20% to 40%. Silver Nitrate Sol. 2% to 10%. Bichloride Sol. 1 to 500. Tinct. Iodine. Copper Sulphate Sol. 10%. Adrenalin Chloride Sol. 1-1000. Liq. Ferri Subsulphatis. Silver Nitrate solution is the one former .y most commonly used as an antiseptic apphcation to the genital tract. It is still used largely and with excellent effect, though there are some other preparations with the same effect and mthout the pain on apphcation and the discoloration of the clothing incident to the use of silver nitrate. Silver nitrate is the pioneer of the silver preparations. It is used in the treatment of vulvitis, vaginitis, erosion and ulcer about cervix, endocervicitis and endometritis. The strength used for vulva and vagina is usually 2 per cent, to 4 per cent., the weaker being used at first when the parts are particularly sen- sitive and the stronger later as the sensitiveness becomes less. A sensitive in- flamed surface or an abrasion or ulcer is usually much diminished in sensitiveness after one or two appUcations, and the application seems also to stimulate repair. For application to an eroded area or an ulcer on the cervix, 4 per cent, to 10 per cent, is used to stimulate repair. During the last few years a number of silver preparations have been put forward as superior to silver nitrate for local application. Protargol and Arg}^rol are two that have stood the test of extensive use. They have about the same or perhaps a better effect than silver nitrate, do not irritate so much and do not form perma- nent stains on the clothing and skin. The protargol is used in the same strength as silver nitrate. The argyrol must be used much stronger, 20 per cent, to 40 per cent. It is the least irritating of the silver preparations. The bichloride solution is strongly antiseptic and mildly astringent. Tincture of iodine (either the ordinary tincture or Churchill's tincture) is a use- ful antiseptic and stimulant to chronically inflamed areas or to erosions or ulcers. It was formerly much used as a counter-irritant application to the vaginal vault in chronic pelvic inflammation, but more effective measures for the treatment of this disease are now available. The copper sulphate solution is used to check bleeding and to stimulate healthy 322 GYNECOLOGIC TREATMENT cell action in eroded and ulcerated areas. It has a tendency to check bleeding from all ulcers except those due to beginning malignant disease. Consequently it is helpful in the differential diagnosis of a maUgnant ulcer, as explained in chapter ix. Liq. Ferri Subsulphatis maj^ be used when a strong hemostatic application is needed for a bleeding area. Adrenalin affects different parts of the mucosa of the genital tract in a different manner. It seems, in some cases at least, to have no effect on the mucosa of the vagina, but a pronounced effect on that of the uterus. 2. Cauterizing Solutions. Carbolic Acid 95%. Iodized Phenol. Nitric Acid— C. P. Carbolic acid is employed as a cauterant application to unhealthy ulcers on thft cervix or vaginal wall, particularly chancroidal ulcers. lodized-phenol (see Formulae) is a milder cauterant, more superficial and less irritating than carbolic acid and also less effective. Nitric acid is a very deep and painful cauterant. It is now seldom used, as carboUc acid is effective and is easier handled and causes less subsequent disturbance, 3. Hygroscopic Solutions. Glycerine. Boro-glycerine (Boric acid 50%). Carbol-glycerine (Carbohc acid 2%). Ichthyol-glycerine (Ichthyol 10%). Protargol-glycerine (Protargol 10%). Tannic-acid-glycerine (Tannic acid 10%). The glycerine preparations are used for the hygroscopic (water-extracting) effecf of the glycerine and also for the special effect of the particular drug incorporated with the glycerine. The application is made by soaking one end of a tampon in the desired glycerine preparation and then introducing it through the speculum into the upper part of the vagina, the medicated end being placed against the cer- vix. These glycerine tampons are used particularly in acute and chronic inflam- matory conditions in the pelvis. They seem to assist materially in diminishing the pain and soreness and they certainly exercise a decided effect on the adjacent tis.sue fluids, for the patients often remark on the large amount of water which comes from the vagina when using these glycerine tampons. 4. Anesthetic Solutions. Cocaine Sol. 10%. Cocaine Sol. i% (for hypodermic injection). Eucaine Sol. Chloretone Sol. VARIOUS POWDERS USED 323 The 10 per cent, cocaine solution is used for local application to painful sores or abrasions, to diminish pain during examination or cauterization. The y per cent, cocaine solution is used as a subcutaneous or submucous in- jection, for removing small growths or pieces of tissue for microscopic examination. POWDERS. Powders may be applied by means of the powder blower or they may be placed on a cotton or gauze tampon, which is then placed in the upper part of the vagina Powders innumerable have been used for this purpose, and as a rule any powder that is a good antiseptic application for wounds is good also as a vaginal applica- tion. Powders are used principally for the antiseptic and drying effect or for an anes- thetic effect. 1. Antiseptic and Drying. Pulv. Boric Acid. Xeroform and Boric Acid (1 to 4). Bismuth Subnitrate. Bolus Alba. Aristol. Pulverized boric acid is used as a mild antiseptic and drjang powder. It. is bland and can hardly cause irritation even with children. Xeroform and boric acid (1 to 4) is preferable when a stronger antiseptic powder is desired, in fact, it is the powder I ordinarily use, except when some special astringent or anesthetic effect is desired. Xeroform has proven a very satisfactory substitute for iodo- form. Its action in stimulating healthy granulation, is very much like iodoform and it has practically no odor. It is I think just as effective, if not more so, than the other iodoform substitutes and less expensive. Bolus Alba (the ordinary yeast germs dried) has been highly recommended as a vaginal application in cases of leucorrhoea, with the idea that the yeast fungi in- hibit the growth of other bacteria. Gonorrhoeal infections are probably favor- ably influenced by this powder. Ceriviscine, a special preparation of the dried yeast plant, has been put upon the American market and numerous favorable re- sults have been reported. 2. Anesthetic powders. Orthofoim, Xeroform and Boric Acid (1-1-4). Chloretone, Xeroform and Boric Acid (1-1-4). Orthoform is a powder that is decidedly anesthetic and for that reason is advan- tageously combined with powders used in the treatment of painful affections of ex- ternal genitals. Vagina and cervix. The anesthetic effect is, of course, most marked when the powder is used pure, but, Uke cocaine, it has a devitalizing effect on poorly 324 GYNECOLOGIC TREATMENT nourished tissues and may cause superficial sloughing if used too strong. I have had such an experience with it in treating superficial abrasions due to senile pru- ritis vulvae — the orthoform, when dusted on pure, causing the abrasions to become very extensive instead of smaller. A similar experience, in a patient past the menopause, was related to me by one of my colleagues. Chloretone can be used to advantage whenever there is pruritis or a sense of soreness in the vagina or about the external genitals. It is very satisfactory as a dusting powder to painful ulcers, chancroidal and otherwise. As a dusting powder, it is diluted with a bland powder and combined with an antiseptic powder as above indicated. TABLETS. Compressed tablets containing antiseptic or astringent or anesthetic drugs, are put up for vaginal use. They may be introduced to the upper part of the vagina by the patient, either following a douche or without a douche, once or twice daily or more often as directed by the physician. Tablets of various formulae for vaginal use may be obtained. Several of them are given in the Appendix. They are very convenient in cases where it is desir- able to have the patient use some drug between the office treatments or where the patient can not come to the physician or be seen by him often enough for regular treatment. They are not as effective, however, as powder apphcations made with speculum exposure of the affected area and held in place by a tampon, as in office treatment. In prescribing tablets use only those put up by a reliable house, so that you can depend on the stated formula and know just what you are using. The effect of these tablets, dissolved in the vagina, as of other vaginal medica- tion, is of course only local (limited to superficial effect on the vagina and cervix) and has practically no influence on deep-seated or serious vaginal or uterine or peri- uterine lesions. Tablets of various shapes and alleged formulae and called by fancy names, are put up for vaginal use by patent medicine venders and peddled from house to house by women agents. They are put forth as wonderful discov- eries that will cure all ''female diseases," and Uke other alleged "wonderful dis- coveries" they deceive many a poor woman with unfounded hopes, the falseness of which in serious diseases she of cen discovers only when the disease is past cure. It is another case of "blind leading the blind" or, worse still, of avarice leading the blind. VAGINAL SUPPOSITORIES AND CONES, Vaginal suppositories furnish another method of applying medicine to the va- ginal wall and cervix. In vaginal suppositories, the active ingredient is incorporated with coca butter or othei- suitable material which melts in the vagina. Vaginal suppositories are used principally in the treatment of chronic vaginitis in children, in cases in which it is difficult or impracticable to employ the ordinary and more effective methods of vaginal treatment. Formulae of vaginal suppositories are given in the Ap pendix- USE OP TAMPO^S 325 TAMPONS. A vaginal tampon is simply a piece of absorbent cotton or common cotton or wool or gauze, of the desired size and shape, with a short string attached, so that the tampon may be removed from the vagina by the patient after a specified time. One way to make a cotton tampon is to take a rather thick piece of cotton (common cotton or absorbent cotton) of the required length and width and thick- ness and tie one end of a strong string firmly about the middle. Fold the cotton at the place where the string is tied. This brings the free ends together. If it is de- sired to use a solution, the free ends are dipped in it. If it is desired to use powder, the free ends are spread out so as to make a depression in which the powder is placed. This end of the tampon is then caught \\'ith the long uterine dressing forceps and carried up to the cervix. Leave the string long enough so that the end will project from the vagina, that the patient may easily catch it and remove the tampon at the end of tw^elve to twenty-four hours as directed. It is well to make the string into a loop, as indicated in Fig. 4.50. Tampons made of surgical wool are preferable when the principal effect desired is support, as they are much more elastic than the cotton and retain their elasticity longer. In some cases the wool proves to be irritating to the vaginal walls. To prevent this and yet secure the springyness imparted by the wool, the wool tampon may be covered with a thin layer of common cotton. It is a good plan to keep prepared, ready for use, a number of tampons of different sizes. They may be prepared during leisure and they are then ready when needed, and thus is saved considerable time and inconvenience. When the vagina is tamponed with a strip of gauze or ■v\ith cotton balls without strings, it is referred to as a vaginal tamponade. I have included all these pack- ings under the general term "tampons." Tampons of cotton or wool or gauze or vaginal packings of the same, are used for the following purposes. 1. To secure the effect of drugs incorporated in the gauze or cotton or held in place by them. 2. To occlude the vagina after operations in its upper part. 3. To stop hemorrhage. 4. To keep inflamed surfaces separated. 5. To support the pelvic organs. Tampons are much used for holding medicine against the cervix and vaginal vault. If the medicine is in solution, for example, one of the glycerine prepar- ations, the end of the tampon is dipped into the solution and then applied to the vaginal vault and left there, to be removed by the patient after twelve to twenty- four hours. If the medicine is a powder, it is dusted freely about the cervix and some of it is placed on the end of the tampon, which is introduced as before. When used to occlude the vagina after an operation, the gauze or cotton is simply a surgical dressing, the same as when applied to an external wound. The gauze or cotton may be simply sterile or it may be impregnated with some antiseptic, as in bichloride gauze, iodoform gauze, etc. 326 GYNECOLOGIC TREATMENT When gauze or cotton is used to check hemorrhage it should first be wet in some antiseptic solution and then squeezed as dry as possible before being packed into Fig. 450. Preparation of Tampons, a. A piece of cotton of the required size with a strong string tied about the middle and also a loop tied. b. The same, with the ends folded up preparatory to receiving powder in the hollow formed there or to being dipped into an application-solution, c. Another satisfactory way of making a tampon. The piece of cotton is folded and the ends are tied together and the string looped, d. .\ small bowl containing tampons ready for use. the vagina. Used in thi« way it makes a much more effective hemostatic than when used perfectly dry. USE OF TAMPON-CAPSULES 327 For keeping inflamed surfaces separated, l:iiiipons of cotton or gauze-strips are used in the various forms of vaginitis. To support the uterus or hold it in position, dry gauze or cotton or wool is used. Wool has more "spring" in it than cotton or gauze, consequently a wool tani])()n is the best in cases where only support is required. Sometimes the wool tampon irritates the vagina, in which case it may be covered with a thin layer of cotton as before mentioned. When cotton is used for supporting tampons, ordinary cotton is better than absorbent cotton, as the latter absorbs fluids rapidly and soon loses its elasticity. A tampon or tamponade for support should be put in with the patient in the Sims posture or in the knee-chest posture. Fig. 451. Tampon-Capsules. a. Large size. b. Small size. c. The cap removed, showmg the tampon. d. A tampon-capsule prepared, ready for introduction. The cap was removed and the medicme poured into tne cap, which was then replaced. The dark ichthyol mixture shows through the transparent cap. TAMPON-CAPSULES. Ordinarily, all tampons are introduced by the physician. When, however, it is advisable that tampons be applied at home by the patient, between the office visits or in conditions in which the patient can not well come to the office, the tampon- capsule may be used. The tampon-capsule is a large capsule of special design containing a plain wool tampon with a string attached. There are two sizes (Fig. 451). They come in boxes of a dozen and may be purchased from the diuggist or wholesale drug-houses. They are convenient for use immediately after the hot douche, to secure hygroscopic effect. Just before use, the patient removes the cap 328 GYNECOLOGIC TREATMENT from the capsule, pours in about a half a teaspoonful of any desired medicine (usually boro-glycerine or ichthyol-glycerine), replaces the cap and introduces the capsule, medicated end first, up to the vaginal vault. Here the capsule soon melts, liberating the medicine and tampon, and the latter holds theformer in place. PESSARIES. Pessaries are appliances for introduction into the vagina for the purpose of hold- ing the uterus or vaginal wall in proper position. They are made of hard rubber or soft rubber, usually the former. Those made of soft rubber are generall}^ hol- low and contain air or flexible mre. Occasionally a pessary is made of glass or block-tin or some other material. Pessaries are used principally for the following affections. For Backward Displacement of the Uterus. For Prolapse of the Uterus. For Prolapse of the Anterior or Posterior Vaginal Wall. For Backward Displacement of Uterus. In retrodisplacement of the uterus the pessary is used after replacement, to held the uterus in proper position. Occasionally a pessary is used to support the uterus somewhat when complete replacement is not practicable. Varieties Used. nnumerable forms have been recommended, and to attempt to mention all of them would be a waste of time. The following four varieties are the principal ones used at present in the treatment of retrodisplacement, and they are sufficient in practically all cases in which a pessary is the preferable method of treatment. Fig. 452. A. Tlie Hodge Pessary. B. Tlie Albert Smith Pessary. C. The Thomas Pessary. 1. Hodge Pessary (Fig. 452, A). This pessary, devised by Hugh L. Hodge, Professor of Diseases of Women in the University of Pennsylvania from 1835 to 1863, may be taken as the type of the hard-rul)ber ring pessaries. It is the original model from which nearly all other pessaries of that character descended. It is PESSARIES FOR RETRODISPLACEMENT 329 stil much used and, as explained later, is the most suitable one for certain con- ditions. 2. Albert Smith Pessary (Fig. 452, B). Albert H. Smith modified the Hodge Pessary in two important particulars. He narrowed the anterior end so that it fits well up into the narrow portion of the pubic arch, the point projecting slightly into the arch. This tends to keep the pessary from turning or slipping about in the vagina and at the same time causes the anterior part of the pessary to lie higher — SO that it is out of the way and does not interfere with coitus or with the introduc- tion of a douche-nozzle. His other modification was a lengthening of the posterior arm of the pessary. This pushes the posterior vaginal fornix further upward and backward, thus increasing the ability of the pessary to hold the cervix uteri well back in the pelvis. 3. Thomas Pessary (Fig. 452, C), sometimes called the Smith-Thomas pessary. T. Gaillard Thomas modified the Smith pessary(which was itself a modification of the Hodge pessary) by thickening the posterior end into a bulbous enlargement. This distributes the pressure over a larger surface of the posterior fornix, and in that way tends to prevent pressure injury of the vaginal vault at that point. 4. Inflated Ring Pessary, to be described later. Action of the Pessary. The action of the Hodge pessary and its modifications, as ordinaiily used in a ease of retrodisplacement, is to hold the cervix back in the hollow of the sacrum. As long as the cervix is held well back in the pelvis, the fundus uteri will stay forward where it belongs. The pessary holds the cervix uteri back in place by holding back the posterior vaginal vault (to which the cervix is closely attached! and also by pushing upward and backward on the sacro-uterine ligaments, thus [— — - ■ iA'M^^ abi1ft«*iseases o/ Women.) 330 GYNECOLOGIC TREATMENT replaced, if we keep the cervix well back in the pelvic cavity, that is, a certain distance from the vaginal outlet, the fundus will stay forward (Fig. 453). Sup- pose then that we introduce a straight stick that reaches from the public arch to the posterior vaginal vault. Now as long as the anterior end of the stick is sup- ported by the pubic arch, neither the posterior vaginal fornix nor the cervix, which is closely attached to it, can approach the vaginal outlet. The cervix can move up and down through a small arc, but it can not come any nearer the vaginal outlet and consequently as the cervix is held well back in the pelvis the fundus uteri stays forward. This is practically the action of the pessary. It takes its fixed point of support from the pubic arch (the soft tissues intervening) , being held up against the narrow part of the arch by the pelvic floor. As long as the anterior end of the pessary is properly supported (held stationary) the posterior end holds the posterior vaginal vault and the attached cervix well back in the pelvis. The ring shape of the pes- sary and the various curves are simply to adjust it comfortably to the adjacent structures. The open ring permits the pessary to lie up well out of the way in the lateral angles of the vaginal canal and also permits the cervix to project through the pessary and the uterine secretions to flow outward without hindrance. The marked upward bend of the posterior portion of the pessary increases its ability to push the posterior vaginal fornix upward and backward and put the sacro-uterine ligaments on the stretch. The long upward curve of the front part of the pessary with the narrow anterior end permits the anterior end to lie up out of the way in the narrow part of the arch, and also furnishes a slope against which the perineum and front part of the pelvic floor acts advantageously, helping to support the pes- sary in both an upward and backward direction and thus taking some of the pres- sure off the extreme anterior end. If all the pressure on the pessary were trans- mitted to the very end, it would cause pain by pinching the soft tissues between the pessary and the bony arch. With the long steep upward curve, however, a largo part of the downward and forward pressure is borne by the pelvic floor. The little transverse notch or downward dip at the anterior end of the pessary is to prevent pressure on the urethra as the pessary lies well up in the angle of the pubic arch. The two principal factors in the support of such a pessary are the pubic arch and the pelvic floor. As to just, which furnishes the most support, it is hard to say — probably there is much variation in different cases, depending on the con- formation of the parts and the shape of the pessary. When the pelvic floor is severely torn it permits the pessary to sink lower in the pelvis. The anterior narrow end lies at a wide part of the arch, a part too wide to furnish support for it and it slips outside a short distance. This permits the cervix to come forward and then 'the fundus goes backward. Now in such a case, if we use a pessary with a wider anterior end (e. g., the regular Hodge pessary) it, being wider, impinges on the sides of the arch and holds the cervix back where it belongs. In very severe laceration, the marked relaxation of the pelvic floor allows the pes- sary to come so low — to such a very wide part of the arch — that not even the Hodge pessary will stay in. In such a case some temporary relief may be given by other styles of pessary to bo mentionoc] later. KIND OF PESSARY REQUIRED IN VARIOUS CONDITIONS 331 Selection of Pessary. The selection of the pessary best adapted to a i^articulur case concerns the style, size and special modifications. As to style or form, in retrodisp acement I prefer the Tliomas pessary in all but exceptional cases. The advantages of this form are: — a. Narrow anterior end that lies well up out of the way. There is little or no interference with coitus or with the introduction of the douche-nozzle. b. Long steep anterior slope on which the pelvic floor can act to advantage in assisting in the support of the pessary. c. Long posterior arm, which tends to keep the posterior vaginal fornix well up. d. Thick posterior end, which distributes the pressure over a wide surface of the posterior vaginal fornix and thus prevents injurious pressure or ulceration at any point. The exceptional cases in which the Thomas pessary is not satisfactory, are as follows: — 1. Where there is a severe laceration of the pelvic floor. In these cases a pes- sary with a wider anterior end is required, as previously explained. Here the regular Hodge pessary is usually the preferable one. In lacerations of extreme severity, where the parts are so relaxed that neither the Hodge or Smith or Thomas pessary Avill stay in, the inflated ring pessary or one of the other forms mentioned under prolapse may give some temporary relief. For permanent relief in such a case operative measures are required. 2. Where the posterior vaginal fornix is too small or shallow to accommodate the large bulbous end. In such a case the Smith or the Hodge pessaiy may be used. In each of these the posterior bar is of small diameter and will fit into a small posterior fornix. If the pelvic floor is not too badly torn the Smith pessary is the preferable one of the two, as it has the narrow anterior end and the long pos- terior arm. 3. When there are painful inflammatory lesions about the uterus or a prolapsed and tender ovary. In some of these cases the pessary may be worn without dis- comfort after the parts have been held in place by tampons for a few days. In others, the tenderness persists and any form of pessary which pushes well up be- hind the cervix causes pain and hence can not be worn. In such cases the inflated ring pessary sometimes gives considerable relief by diminishing the dragging of the heavy uterus on the inflamed adnexa and broad ligaments. As a rule, however, in such cases time spent with pessaries is time wasted, as far as any permanent relief is concerned. As to the size of pessary to be selected, the approximate length may be deter- mined by measuring with the examining fingers the distance from the posterior vaginal vault (pushed well up) to the pubic arch. The length of the pessar}' should be a trifle less than this. The width of pessary which the vagina will ac- commodate may be determined approximately by the apparent roominess of the \^agina as felt on vaginal palpation. A special maneuver for this purpose is to in- troduce the two examining fingers to the upper part of tlie vagina, separate them laterally as far ns the vaginal walls will permit and then withdraw them in the 332 GYNECOLOGIC TREATMENT antero-posterior diameter (the largest diameter of the vaginal outlet), retaining them as nearly as possible in the original position. However, the size of pessary that will keep the uterus in position with the least discomfort can be determined certainly only by trial, and several pessaries may have to be worn for a short time before the most satisfactory one for that partic- ular case is settled upon. A pessary that is too small, fails to hold the uterus in position and tends to slip out. A pessary that is too large, causes pain. It is better to give too small than too large a pessary, as the latter may cause severe pain after it has been in place a day or two, and if the patient is a long way from the physician and cannot succeed in removing the pessary herself, she may experience much suffering. The special modifications refer to slight changes in shape from the regular form, occasionally required to make the pessary more comfortable or more satisfactory in retaining the uterus in position. 1. General Narrowing of the pessary. The pessaries as purchased maintain a ratio between the width and the length (the longer the pessary the wider it is). As a rule this is desirable. In some cases, however, the vaginal opening is too small to admit a pessary of sufficient length. To overcome this difficulty drop the pessary in hot water for a moment, until it becomes slightly pliable, then remove it with a forceps, grasp it with a towel and squeeze it so as to narrow it laterally to the required extent, and hold it thus until it cools. The cooling may be hastened by holding it in cold water. Do not keep it very long in the hot water or it will become so pliable that it flattens into a simple ring, and all the characteristic curves are lost. 2. Local Bending. Occasionally it is desired to bend a hard-rubber pessary at some particular point, so as to change an ordinary curve to an unusual one or to change one form of pessary to resemble another form, which is needed but is not on hand. To make these local bendings, coat that part of the pessary to be bent lib- erally with vaseline or other ointment and hold it high above the flame of an alcohol lamp orBunsen burner. Hold it close enough to the flame to heat the pessary well at the exact area it is desired to bend but not close enough to burn off the ointment. In a few moments the pessary is softened sufficiently to permit bending. If the pessary is brought too close to the flame, it is burned and the smooth surface roughened. In 1859, J. Marion Sims introduced the block-tin modification of the Hodge pes- sary, the advantage of this material being that it is sufficiently pliable to be moulded to any shape and yet firm enough to hold the shape given it. The block-tin pes- sary was the favorite with Dr. T. A. Emmet and was highly recommended by him, but it is not so frequently used at the present time. Ordinarily the hard-rubber pessary is preferable.. Pessary Used Only After Replacement. The pessary is ordinarily not used until the uterus has been brought forward. The pessary is not, as many suppose, used to push the fundus uteri forward, neither is it used to prop the fundus forward. The pessary has nothing to do THE INTRODUCTION OF THE PESSARY 333 directly with this part of the uterus. All the pessary does is to hold the cervix well back in the pelvis, as previously explained, and then in the ordinary state of affairs the fundus must stay forward. There are some exceptions to the rule that a pessary is used only after replace- ment. In some cases of roomy pelvis, in which it is difficult to raise a movable fundus uteri because it gets out of reach, a pessary may be used somewhat as an extension to the finger, to help raise the fundus within reach of the abdominal fingers. Hodge, in describing the use of his pessary, mentions it as a lever for re- placing the uterus. He directs that the pessary be introduced and then by de- pressing the anterior end, the posterior end is thrown upward carrying the fundus with it. This is called the lever action of the pessary, the pelvic floor serving as the fulcrum, and he refers to his pessary as the " lever pessary. " But this action of this pessary is seldom employed now, as there are more effective methods of re- placement. Again, in a case of movable uterus which can not be brought forward satisfac- torily, if a pessary be introduced and the patient instructed to take the knee-chest posture twice daily, the uterus may be found forward at the next examination a few days later Again, in some cases where the uterus can be raised considerably but can not be brought forward, a pessary introduced and worn just as if the uterus were forward, will, in conjunction ^\ith the knee-chest posture morning and evening, give the patient some relief — indicating that in that particular case the symptoms are due not so much to backward displacement yer se as to the sinking of the uterus with the consequent disturbance of the circulation, which is relieved by the pessary in spite of the fact that the uterus is still in retrodisplacement. It is this holding up of the heavy uterus and the relief of the slight prolapse complicating the retro- displacement, that accounts for the decided relief often secured by the use of the inflated ring pessary in cases of unreplaced retrodisplaced uterus. Introduction of the Pessary. Ordinarily the pessary is introduced with the patient in the dorsal posture, immediately after the uterus has been brought forward by bimanual reposition as described in chapter vii. Before introducing a pessary, cleanse it thoroughly in an antiseptic solution and then lubricate it with a suitable ointment. In introducing it into the vaginal open- ing, if the opening seems rather small, put one finger in the vagina and depress the perineum strongly to make room for the pessary. Remember, in introducing a pessary or speculum or the examining fingers into the vagina, if the opening seems small and more room is desired, the pressure must always be made backward, de- pressing the perineum. The least pressure forward will pinch the tissues against the pubic arch. The introduction or placing of the pessary is carried out as follows: Hold the pessary by the anterior end, depress the perineum well with one finger (Fig. 454) and introduce the posterior end with the breadth of the pessary lying in the an- 334 GYNECOLOGIC TREATMENT tero-posterior diameter, which is the largest diameter of the opening. The pes- sary should be held somewhat obliquely so as not to make painful pressure on the urethra (Fig. 455). When the pessary is about half way in (Fig. 456) turn it so Fig. 454. Introducing the Pejsary. pressing the perineum. First step — de- ^ Fig. 455. Introducing the Pe.ssary tluougli the vaginal opening. The width of the pessary lies in the antero-posterior diameter of the opening, which is the long diameter, but is turned somewhat oblique- ly to avoid the urethra. that the breadth of the pessary lies laterally (Fig. 457) and the posterior arm is directed upward. Then push the pessary along until it will not go any further. It stops because the posterior end is against the anterior lip of the cervix. Then introduce a finger into the vagina beneath the pessary, catch the posterior bar with the finger tip (Fig. 458) and depress it (Fig. 459) and then push the pessary past the cervix. Fig. 453 shows the pessary in place. THE INTRODUCTION OF THE PESSARY 335 After the pessary is in place it is well to have the patient walk about the room a little, to see if tliere is any discomfort. If there is any decided ])ain or marked discomfort, try a smaller size or another form. In those cases in which it is necessary to use the knee-chest posture to effect re- Fig. 456. Introducing the Pessary. The pessary is now well within the vagina and ready for turning. Fig. 457. Introducing the Pessary. The pessary is turned so the width lies transversely, for the transverse diameter is the long diameter of the vaginal canal, though not of the vaginal entrance. The pessary is then pushed in until its further progress is stopped by the cervix. position and also in those cases in which it is thought advisable to use a pessary even though the uterus can not be brought well forward, it is advisable to intro- duce the pessary with the patient in the knee-chest posture. 336 GYNECOLOGIC TREATMENT Instructions to Patient with Pessary. The care of a patient having a pessary in place, includes the following points: — Visits to the Physician. When the pessary is introduced the patient is directed to leturn in about three days. If the pessary is proving satisfactory then, she need not return again for a week. If everything is going well at this third visit, she need not return, except once every four to six weeks to have the pessary re- moved and thoroughly cleansed and replaced. Fig. 458. Introducing the Pessary. The inde.K finger is passed to tiie top of the posterior end, whicli is tliea depressed until it can be pushed past the cervix, as shown in Fig. 459. There is always more or less uncertainty for the first week or so, as to just how the pelvic structures will accommodate themselves to a pessary. For that reason it is well to instruct the patient to return at once if any unusual pain is felt or if the pessary appears to slip out of position. But the patient should return in three or four days, even though she has no particular disturbance, for the uterus may have settled back into its old malposition. DIRECTIONS TO PATIENT ^^ ITU PESSARY 337 At this second visit, inquire if the patient has noticed any protrusion or slipping of the pessary or has luid any pain or cU.sconifort from the pessary. A pessaiT which is entirely satisfactory should give little or no sensation of its presence, in fact, in most cases the patient \\ould not know the pessary was there if she were not told. Inquire also how much she has been relieved from the previous dis- comfort, for which the pessary was introduced. Ascertain by examination if the pessary is in proper position and if it holds the uterus in proper position. If so do not disturl) the pessary but direct the patient to return in a week. If the uterus r Fig. 439. Introducing the Pessarv. The posterior end depressed and being pushed past the cervix. Thr pessary is shown in place in Fig. 453. is out of position, remove the pessary, replace the uterus and introduce anothei pessary, better adapted to the case, and again direct the patient to return in three days, when another examination is to be made. When the pessary is found satisfactory at the second and third visits, it is to be assumed that it will prove satisfactory right along, and as long as the patient feels well she need not return, except every month or six weeks as above indiceted. 3;Jg GYNECOT.OGIC TREATMENT This return at regular intervals of a few weeks is important in every case (though, exceptionally, the interval may be longer) for three reasons — (a) because the pes- sary is liable to accumulate concretions that may prove irritating, (b) because long-continued pressure may produce ulceration at some point in the posterior vaginal fornix and (c) because it is important to know whether the pessary is doing the work it is used for, and if everything is going as it should. Injurious pressure on the wall is indicated by a distinct groove or ridge with infiltration in the affected area. When such is present, the pessary should be left out for a few weeks or a dif- ferent form used. If necessary to leave the pessary out for a time and trouble is experienced from the uterus returning to its malposition, packing in the knee- chest posture or in the Sims posture may be employed during this interval. In many cases, however, a resort to the knee-chest posture night and morning is all that is necessary. Douches. The patient wearing a pessary should take a vaginal douche every day or every few days. If the discharge is very free it may be advisable to take two or three douches daily. If there is practically no discharge two douches weekly may be sufficient. Ordinarily the patient is directed to take a douche once daily or every other day. The kind of douche to be taken varies with the condi- tions present — a large hot douche or an astringent douche when the indications previously given for them are present. When there are no special indications, I usually prescribe the bichloride douche or the aluminum acetate douche (see Formulae). Knee-chest Posture. The knee-chest posture (Fig. 469) taken by the patient night and morning, is very useful in those cases in which the uterus tends to return to its old position or in which the patient complains of downward pressure in the pelvis. It causes the patient some inconvenience and is not necessary when the pessary holds the uterus well up and entirely relieves the symptoms. But in many cases of damaged pelvic floor, its use along with the pessary is very advan- tageous. The activity of the patient need not be cm-tailed on account of the pessary. The pessary is meant to hold the uterus in proper position and restore the patient to comparative health, so that she can pursue her usual activities without disturb- ance. If the patient cannot pursue her usual activities, after the pessary has been worn a month or two, the pessary has failed of its purpose, and some more effective method of treatment is indicated. As to coitus, the fact that a pessary is being worn is no bar to sexual intercourse. With the Thomas pessary and the Smith pessary, the anterior end lies so high in that it interferes but little, if at all. Even with the Hodge pessary, coitus may, in some cases, be accomplished with but little inconvenience. Coitus, however, causes marked pelvic congestion and this increases the liability of discomfort re- sulting from the pressure of the pessary. Consequently for the first few weeks, while the pessary is on trial so to speak, coitus had best be discontinued. Later, after the uterus has been sometime in its proper position and the pelvic structures are adjusted to the pessary, no restriction in. this direction is necessary ordinarily. In some cases, the replacement of the uterus and wearing of the pessary is car- ried out principally to increase the chance of pregnancy, and in such cases coitus WHEN TO I)1S(\\KI) PESSARY 339 is permissible from the first. It is well to mention this fact to the patient or her husband, as otherwise it may be thought that coitus is not possible while the pes- sary is in place. If pregnancy should develop, the pessary should be worn just the same until the uterus has become large enough to prevent its sinking back into the pelvis. The douche should then be taken only warm — not hot, for a hot douche may excite uterine contractions and lead to miscarriage. Usually along in the third or fourth month the pessary is taken out, as it is of no further use and if left in longer it might cause irritation and disturbance. Occasionally a pessary excites pain shortly after pregnancy takes place. If so, it should be removed, the patient being directed to take the knee-chest posture two or three times daily, to keep the fundus uteri forward. Tampons or tamponade of the vagina to keep the uterus forward is not advisable in these cases, as it might lead to miscarriage. When to Discard the Pessary. The time at which the pessary may be discarded varies much in different cases, and in each case is more or less a matter of trial. A very good rule is to leave out the pessary after the uterus has remained in position continuously for three or four months. Direct the patient to return in two or three days. If the uterus has re- turned to its old backward position, replace it and use the pessary again for several months. If the uterus maintains its forward position with the pessary out, direct the patient to return again in two weeks. If then the uterus is in proper position and the patient feeling well she may be discharged, being directed to return if symp- toms should at any time reappear. In some cases the pessary may be permanently discontinued in three or four months, but in more cases it must be worn for six months or a year, while in cer- tain cases, it must be worn a still longer time or even indefinitely. If after the pessary is removed, the uterus shows a tendency to go backward, it is well to have the patient take the knee-chest posture occasionally for some months. The Inflated Ring Pessary. The action of the inflated ring pessary (Fig. 460, B) is principally to raise the uterus and adjacent tissues somewhat and to support them. It has no particular action in holding the cervix well back in the pelvis nor in maintaining the uterus in a proper forward position . Consequently the field of usefulness of this par- ticular form of pessary is in those cases in which the uterus cannot be gotten into the forward position or can not be maintained there. The simple supporting of the uterus, thus overcoming the slight prolapse which is present in most cases of retrodisplacement, often gives the patient much relief, though the retrodisplace- ment has not been corrected. On the other hand, such a pessary is sometimes used by the physician or by the patient on her own responsibility (this form of pessary being frequently adver- 340 GYNECOLOGIC TREATMENT tised to the laity), in cases wliere complete replacement could be easily accom- plished. In such a case, complete replacement with the subsequent use of the Thomas or Hodge pessary would tend to effect a cure, while the effect of the in- flated ring pessary is imperfect and only temporary. In the cases in which the inflated ring pessary is useful, some radical measures are usually preferable and the pessary is simply a temporary expedient to make the patient more comfortable while she is getting ready for operation. Some pa- tients, however, prefer to wear the pessary indefinitely, even though it affords only partial relief, rather than submit to any operative measure. This pessary requires a douche every day and should be removed and cleansed at least every week. It requires more care to prevent incrustation and irritation. The patient can usually remove and reintroduce the pessary satisfactorily herself after a little practice. Just before introducing it, the patient should take the knee-chest posture for a few minutes. Then lying on her back or side she intro- duces the pessary, which has been previously cleansed and lubricated. When coitus is desired, the pessary may be taken out in the evening and left out until morning. If desired a loop of strong string may be attached to the pessary to facilitate its removal. If the pessary becomes deflated, it may be reinflated with a hypodermic syringe, the needle being introduced through the thick spot designed for that purpose. A pessary of about this form is made of hard rubber (Fig. 460, C) and is used in the same way. It does not become deflated and is less hkely to accumulate in- crustation and irritate the vaginal wall. It is unyielding, however, and for that reason is more hkely to produce painful pressure at some point. Also a smaller size must be used, for this pessary cannot be compressed, as the inflated rubber pessary can, to pass the vaginal orifice. Fig, 460. A. Flexible Ring Pessary. B. Inflated Ring Pessary. C. Hard Rubber Disk Pessary. 5. Flexible Ring Pessary. The flexible-rubber ring (Fig. 460, A) is sometimes preferable to the inflated ring, particularly in cases where there is very free dis- charge. The opening being larger, the free discharge escapes easier and conse- quently there is less retention and irritation. Pessaries for Prolapse of Uterus. The treatment for prolapse is to raise the uterus and maintain the fundus in a forward position. The pessary that accomplishes this in a case of retrodisplace- ment is likewise beneficial in a case in which the prolapse is the principal feature. PESSARIES FOR PROLAPSE OF UTERUS 341 Consequently, in the milder grades of prolapse, a Thomas or Smith or Hodge pessary may be all that is necessary to maintain the uterus in its proper position. In many cases of prolapse, however, more so than in retrodisplacement, the pelvic floor has been torn so much that this form of pessary will not stay in satis- factorily. In such a case, a large inflated rubber-ring pessary may be introduced and then turned so it will not slip out. This does not hold the cervix back in the pelvis and the fundus forward, but it does plug the vaginal opening so the redun- dant vaginal wall and the uterus can not prolapse to the former extent. If the pessary tends to protrude, a pad over the genitals, with a firm T-bandage, may keep it in place comfortably. 6. Menge Pessary., A large thick hard rubber ring, turned crosswise of the vaginal opening, will plug the opening effectually for a short time. But when the patient walks about for a few hours the ring shifts about until its edge comes to the wide relaxed vaginal opening and then it slips out. The Menge pessary (Fig. 461) has a central stem which prevents the pessary from turning when once in place. To intro- duce this pessary, the de- tachable stem is removed, (Fig. 461-B), the thick ring introduced and turned squarely across the vaginal opening with the hole in the cross-bar directed ^^^' ^^i"^- Fig. 461-A. Fig. 461. The Menge Pessary. A. The pessary with the stem in place. B. The pessary with the stem de- tached from the rng portion of the pessary, preparatory to introduction of the latter. After the ring portion has been introduced, the stem is fastened in place as shown in A. The stem lies in the vaginal canal, and keeps the ring from turning into any position that will allow it to slip out. toward the opening. While the ring is held in this position, the stem is fast- ened in place. The stem holds the ring in proper position, so that it (the ring) blocks the canal and prevents complete prolapse. This pessary has proven exceedingly useful in severe cases, where operation was inadvisable or was refused or where temporary relief was required while the patient was waiting for operation. 7. Cup and Belt Pessary (Fig. 462). This is another form of pessary that has given much relief in the three classes of cases just mentioned. It does not depend at all for support on the tissues of the pelvic floor or vaginal outlet, and hence is suitable in cases where even the Menge pessary is expelled or is unsatisfactory on account of painful pressure. It obtains its support from a belt about the abdo- men. There are various forms, one of which may be preferred by one patient and another by another. In many cases of prolapse in elderly women with practically no support at the 342 GYNECOLOGIC TREATMENT A B CD Fig. 462. A. Cup and Belt Pessary. B, C, D. Different of Cups that may be used. Fig. 463. Gehruiig's Ante- version Pessary, which is very useful in Cystocele. (Hirst — Diseases of Women.) pelvis roomy and the cervix so small that it does not stay in the cup well. Ordinarily, however, the cup is preferable, as it holds the cervix well back and up in the pelvis and thus keeps the vaginal wall' on the stretch without making uncomfortable pressure on adjacent organs. Pessaries for Cystocele. In many cases of cysto- cele much relief may be given by the use of one of pelvic outlet, this pessary has given great relief, even permitting the patient to work hard with comparatively little discomfort. Of course this is only a makeshift, giving temporary relief, and curative operative measures are preferable in suitable cases. But some of these women are not in fit physical condition for operation and others refuse operation, preferring to get along. with a fairly satisfactory pessary. A modification of the cup and belt pes- sary is made by substituting a ball for the cup. This form is more useful than the cup in some cases, particularly when the vaginal walls are very redundant and the Fig. 464, Introdlioing the Gehrung Pessary, o/ Womtn.) {Rmi— Diseases PESSARIES FOR CYSTOCELE 343 the forms of pessary already described, the maintaining of the cervix well upward and backward doing away temporarily with the cystocele. In other cases the cystocele is the principal feature and gives trouble in spite of tlu; maintenance of the uterus in approximately correct position. In such cases, operation as a a Fig. 465. Skene's Cystocele Pessary The first figure Ca) shows the outline of the pessary, and the second figure shows the pessary in place supporting the anterior vaginal wall. (Ashton — Practice of Gynecology.) rule is indicated. In cases where operation is not advisable or where tempo- rary relief is desired while the patient is waiting for operation, one of the follow- ing pessaries may prove useful. 8. Qehrung's Anteversion Pessary. This pessary, devised by Dr. E. C. Gehrung, of St. Louis, is the most effective form yet presented for the treatment of cystocele. Fig. 463 shows the shape of the pessary and also the relation it bears to the uterus when in place. The method of its introduction is shown in Fig. 464. 9. Skene's Cystocele Pessary. This has been extensively used for cystocele and is very satisfactory in many cases. The form of the pessary and also its action when in place, are shown in Fig. 465. 10. Globe Pessary (Fig. 466). This puts the relaxed vaginal walls on the stretch and prevents prolapse of the bladder, but is likely to make uncomfortable pressure on surrounding structures. In cases where it is satisfactory except that it slips out, it may be held in place by a firm pad and T-bandage. Fig. 466. Globe Pessarj', with cord attached so that the patient may remove it as necessarj'. (Hirst — Diseases of Women). Other Kinds of Pessaries. There are many other forms of pessaries in use, but to mention all of these vari- ous kinds would only cause confusion. It is better to learn to use a few well than 344 GYNECOLOGIC TREATMENT to be tr3T.iig all of the fanciful shapes devised. The styles already mentioned, if intelligently used, \^-ill answer the purpose in practically all cases in which the use of a pessary is the preferable method of treatment. SUBMUCOUS INJECTION OF PARAFFIN. The submucous injection of paraffin has been successfully emploj^ed in some cases of incontinence of urine and also in certain cases of prolapse of the uterus or vagina. However, it is held by Stolz, who speaks from considerable experimental and clinical experience, that plastic operation are far preferable. In cases of pro- lapse of the uterus or vaginal wall in which operation is not advisable, pessaries are as a rule preferable to paraffin injections. The use of the latter is in a measure experimental and is accompanied ^^ith danger of embolism and should be used only after careful study and under special precautions. LOCAL BLOOD-LETTING. In cases of chronic inflammation and congestion of the cervix, particularly where there is much cystic change, some benefit may be derived from multiple punctures of the cervix with a bistory-point. This causes free bleeding from the chronically congested cervix, and at the same time opens and evacuates man}' small cysts. The drainage of blood and serum from the cervix may be prolonged by the use of a warm (not hot) douche within an hour or two afterward. The punctures into the cervix for an eighth to a quarter of an inch cause no particular pain. The adjacent vaginal wall, however, is sensitive to puncture or grasping with tenactilum-forceps, and hence should be carefully avoided. Before making multiple punctures in the cervix, be careful to determine exactly the cause of the chronic congestion. It may be due to pregnancy, which would of course contra-indicate multiple puncture. THE CURET. The sharp curet is used, in the treatment of affections of the vulva and vagina and cervix, for the following purposes. To remove infected or otherwise diseased tissue. To stimulate healthy granulation. To secure specimens for microscopic examination. Its principal use is in the treatment and diagnosis of chronic ulcers. The occa- sional curetting away of the unhealthy granulations of an indolent ulcer, does much to assist in its healing and also furnishes tissue for microscopic examination in doubtful cases. Occasionally also a thorough curetting of the interior of a chronically inflamed cervix v.'ill be beneficial. Before using the curet, the surfaces should be anesthetized partially, l)v a pledget of cotton soaked in a 20 per cent, solution cocaine being laid on the surface for five minutes. THE X-KAV TKEATMENT 34?. THE CAUTERY. The Paquelin thermo-caiitery or the electric cautery is useful, on the surfaces under consideration, for the following purposes: To destro}" the virus in a chancroid. To destroy unhealthy granulations or infected tissue. To excise small growths (condylomata, etc.). To destro}" retention cj'sts in the cervix. Before using the cautery, the parts are usually anesthetized by the local applica- tion of a 20 per cent, cocaine solution on a pledget of cotton or, in the case of a growth, by the hypodermic injection of a § per cent, cocaine solution under the base. ELECTRICITY. The uses of electricity (galvanic current, faradic current), as applied to the ex- ternal genitals and vagina and cervix, are principally two — first, as the electric cautery for destroying diseased tissue or excising growths and, second, as a seda- tive for relieving persistent itching or pain. The details of the application of elec- tricity in gynecological work are given further along, under Intra-uterine Treatment. X-RAY TREATMENT. The X-Ray treatment has not fulfilled expectation as to curative effects in malignant disease. ■fhe present status of the subject is w^ell summed up by Dr. Wm. B. Coley of New York, who reports on the results of his experience with this agent in the treatment of 167 cases of malignant disease, and reviews the reports of other series of cases. He states (Annals of Surgery, August, 1906) that the results of X-Ray treatment of malignant tumors up to the present time have proven as follows: — • ''1. That the X-Ray exerts a powerful influence upon cancer cells of all vari- eties, but most marked in cases of cutaneous cancer. 2. In some cases, chiefly in superficial epithelioma, the entire tumor may dis- appear, probably by reason of fatty degeneration of the tumor cells, with subse- quent absorption. 3. In a much smaller number of cases of deep-seated tumors, chieflj'' cancer of the breast and glandular sarcoma, tumors have disappeared under prolonged X-Ray treatment. In nearly every one of these cases, however, that has been traced to final results, there has been a local or general return of the disease within a few months to two years. 4. In view of this practically constant tendency to early recurrence and, fur- thermore, in the absence of any reported cases well beyond three years, the method should never be used except in inoperable cases, or as a prophylactic after opera- tion, as a possible, though not yet proven, means of avoiding recurrence. 5. The use of the X-Ray as a preoperative measure in other than cutaneous cancer is contradicted, (l)because that agent has not yet proven to be curative 346 GYNECOLOGIC TREATMENT and (2) because of serious risks of an. extension of the disease to inaccessible glands or to other regions by metastases during the period required for a trial." Even in the superficial malignant tumors, it is safer to. excise the growth and then use the X-Ray, rather than to trust entirely to the latter. In certain intractable non=malignant affections the X-Ray has produced most satisfactory results. In severe pruritus vulvae presisting in spite of many other measures, this treatment has affected a cure. In tuberculosis of the vulva, in ulcus rodens and in chronic eczema it has proven exceedingly beneficial. In any chronic ulceration or infiltration that resists other measures, this treatment may be given a thor- ough trial with good prospect of relief. It must, of course, be applied in the proper way, according to the indications in that case and by a physician who has made a real study of the subject. A large proportion of the so-called X-Ray In- stitutes and Laboratories, so generously advertised in the newspapers, are simply X-Ray fakes. THE FINSEN LIGHT. Much has been claimed for the Finsen Light and allied ray-treatment in gyne- cological work, and many cases indicating beneficial result ; have been reported. But most of the reports that have come to my notice have seemed to be the result of enthusiastic seeking for good results rather than critical analysis of cases and effects. In superficial tuberculosis and in other non-malignant chronic ulcerations, it may be used with great benefit. But further than that its use is still in the stage of experimentation. No time should be wasted with it in operable cases of malignant disease. RADIUM. The employment of radio-active substances in the treatment of various forms of ulceration about the genitals, is still experimental. Some clinical results have been reported, but not in a way that gives much confidence as to lasting benefit. While it is advisable to continue experimentation to determine the therapeutic value of radio-activity, it should not displace the recognized and well-tried thera- peutic measures. The so-called ''wonderful cures" of serious diseases by radium, so widely heralded in the daily press, may, as far as any real evidence that has come to my notice, be set down as the wonderful fancies of an enthusiast or the wonderful lies of a faker. INTRA-UTERINE TREATMENT. MEDICATED APPLICATIONS WITHIN THE UTERUS. Effects, Good and Bad. What good can intra-uterine applications do? They may exercise uu antiseptic, astringent or anesthetic efTect. They may destroy diseased tissue. They may exercise a hygroscopic effect. EFFECTS OF INTRA-UTERINE APPLICATIONS ;^47 1. They may exercise an antiseptic or astringent or anesthetic effect, limited to the surface to which they arc applied. Ovviiif;- to peculiarities in liie luiturc and situation of the endometrium, an intra-utcrine application of an antiseptic does not ordinarily have much influence in checkini-; the activity of bacteria that hav(^ gained a foothold there. The three most important influences limiting l)acterial penetration into the uterine wall are (a) an intact epithelial surface, (b) the bac- teriacidal influence of leucocytes and blood serum and lymph, and (c) the absence of irri ation (toxic, chemical, mechanical) within the cavity. In a patient with bacterial invasion of the endometrium, after the uterus has been cleared of placental remnants and good drainage secured (removal of toxic, chemical and mechanical irritation) the issue depends almost wholly on the bac- teriacidal and antitoxic influence of the leucocytes, blood serum and lymph. The efficacy of any therapeutic measure employed must l)e judged largely by its in- fluence on this battle beneath the surface, rather than by any superficial effect. The beneficial effect of killing a few bacteria upon the surface is more than over- balanced by the local disturbance whicli the application occasions. It adds irri- tation to the already great irritation from the bacteria and their products, and it opens up new avenues for invasion, by abrasion of the protecting epithelial cover- ing. In chronic cases, the bad effect of such applications is not great, because nature has the process well limited, but occasionally, even in these cases, there will be considerable disturbance following the application, due to immediate ex- tension of the infection deeper into the uterine wall or into the tubes or para- metrium. In the acute and subacute stages of bacterial invasion of the uterus (puerperal or nonpuerperal) an intra-uterine application very frequently causes an aggravation of the trouble, as evidenced by a chill and a sharp rise of temper- ature within a few hours. It may, I think, be stated as a general proposition, that intra-uterine applica- tions for antiseptic effect, in the acute, subacute or chronic stages of l^acterial in- vasion, do more harm than good. The harm is due, not to the presence of the anti- septic, but to the abrasions of the endometrium incident to the application. If the antiseptic effect could be secured without these minute traumatisms, which are incident to the introduction of any instrument within tlie cavity, the applications might be beneficial, provided they are made in an aseptic way. There is one method that promises something along this line, namely, the use of uterine suppositories, of such consistency that they can not abrade the surface of the endometrium. The use of an astringent intra-uterine application is advisable in certain excep- tional cases of persistent bleeding or free discharge from the endcmetiium, not dependent on l^acterial invasion or a new growth. There are many cases of l^leed- ing (especially menorrhagia) due simply to chronic congestion and hyperplasia of endometrium. It is principally in those dependent on subinvolution and which have not been relieved by internal treatment (laxatives, general tonics, uterine astringents) and hot vaginal irrigation and other measures directed towards dimin- ishing the pelvic atony and congestion, that local astringent applications are of service. 348 GYNECOLOGIC TREATMENT In most of these persistent cases it is preferable to remove the thickened en- dometrium with the curet. But in some cases the symptoms are hardly sufficient to demand curetment, or the patient objects to it. In such a case a few astringent applications to the endometrium; made under proper precautions, may do much good without doing damage. A few abrasions of the epithelium by an aseptic application in such a case, are of less consequence than when made in an infected cavity where there are bacteria ready to enter the abrasions. Also the chemical and mechanical irritation is better borne because there is no deep-seated bacterial activity. Occasionally such an application is indicated in the simple hyperplastic endometritis in a virgin. But the discomforts and difficulties of a satisfactory intra-uterine application in the A'irgin are such that when intra-uterine treatment is necessary, thorough dilatation under anesthesia and curetment is usually the preferable method. In infective endometritis, the application will probably do more harm than good, except in those old cases in which the bacteria are dead or so attenuated that the condition is practically one of simple endometritis. In bleeding due to fibroids or malignant disease, astringent applications exer- cise no influence over the course of the disease, and may cause infection and thus increase the danger of the necessary operation. For temporary control of bleed- ing while waiting for operation, general measures and internal medication and firm vaginal packing will nearly alwaj^s suffice. For the inoperable cases, other methods more effective are at our disposal. An anesthetic application, such as cocaine or orthoform, is useful when applied about a sensitive internal os, preceding dilatation of the same. The pain is usually considerably diminished. Applications of anesthetic substances to the endo- metrium proper are of httle benefit and present the dangers common to all intra- uterine applications. 2. They may destroy diseased tissues. This will be spoken of under cauteriza- tion. 3. They may exercise a hygroscopic effect. This effect, secured by the small amount of hygroscopic material retained in the uterus, is so slight that intra- uterine applications for this purpose are not advisable. What harm can intra-uterine applications do? Same that vaginal applications may, and also: May carry infection into the uterus. May increase bacterial disturbance already in the uterus. 1. They may cause the same harmful effects that vaginal applications maj'. That is, they may (a) cause patient to come to office when she should be resting at home, (b) cause postponement of effective treatment until the disease is past cure and (cj convert a neurasthenic or hysteric individual into a confirmed invalid by fixing attention on some trivial local disturbance. 2. They may carry infection into the uterus and change some simple disturb- ance into a very serious one. This has happened many times and constitutes One of the most serious objections to intra-uterine applications. By taking proper care of the cervical canal with an antiseptic, infection can usually be avoided. HOW TO MAKE INTRA-UTERINE API'IJCATIONS 34v But even with this care, infection ma}' he carried in from an apparently lieahhy cervix. It is an ever-present (hmger and must be over-hahinccd hy tlie probable benefit in the particular case, before an intra-uterine application is advisable. 3. They may increase a bacterial disturbance already in the uterus, as previ- ously explained. Methods of Intra-Uterine Application. 1. With Cotton-wrapped Applicator. An intra-uterine application is made liy wrapping, with disinfected fingers, a small amount of absorbent cotton about the end of an applicator (Fig. 467, b), saturating the cotton with the desired medicine and then carefully introducing it through the cleansed and dilated cervical canal into the cavity of the corpus uteri. In making an intra-uterine application, the same antiseptic care must be observed as in sounding the uterus. It is well to prepare a number of cotton-wrapped aluminum applicators (Fig. 467, c) and have them in sterile wide-mouthed bottles (Fig. 467), some dry steri- lized and others in some of the solutions frequently used. Then you can be cer- tain that the cotton on your applicators is sterile, as it is very likely not to be if it is twisted on hurriedly during the office treatment, for it is difficult to steri lize the fingers and keep them sterile. 2. With Gauze. Another method and a very effective one for bringing medi- cine in contact with the endometrium, is to soak the end of a small strip of anti- septic gauze in the medicine and carry it into the uterus and leave it there. The remaining part of the gauze is packed against the cervix to hold the uterine portion in place. The other end of the gauze is brought near the vaginal outlet so that the patient may remove it after several hours. 3. Slippery =Elm Applicator. A method somewhat similar to the last mentioned, is the use of a small slippery-elm tent, sterilized and dipped in the medicine and carried into the cavity and left there. A string is attached by which the patient can remove it as directed. My colleague. Dr. Frank A. Glasgow, thinks very highly of this device, and for many years has used it almost exclusively in intra- uterine applications. 4. Uterine Suppositories, or soluble uterine bougies, furnish another method of applying medicine to the endometrium. Protargol and iodoform are the medi- cines usually incorporated in them. It is possible that there will be worked out along this line, a method of making effective antiseptic and astringent applications without mechanical disturbance of the endometrium. If so this might prove of decided help in the treatment of bacterial invasion, in both the acute and chronic stages. It seems to me that more will be accomplished in this direction by using the penetrating antiseptics, such as collargolum or Crede's ointment, than by the use of the surface antiseptics usually employed. The injection of medicines into the uterine cavity by means of the intra-uterine syringe, I can not recommend. Its danger outweighs its advantages. 850 GYNECOLOGIC TREATMENT For What Effects Indicated. As pre^dously explained, the only intra-uterine applications advisable ordinarily are those for an astringent or anesthetic effect in the non-infected uterus, anci even these only in exceptional cases and for a short time. Fig. 467. Applicators for Intrauterine Treatment, a. The ordinary handled applicator, b. The same wrapped with cotton, preparatory to dipping it into the medit-ine to be applied withiin the uterus, c. Plain aluminum wire applicator, nine inches long. d. The same wrapped with cotton. The jar contains prepared applicators like (d), and is ready to receive the solution in which they are to be kept. MEbUUNES FOR INTRA-U TEUINE APlM,lCATION 351 Long continued intra-uterine applications do little or no good and may do much harm. They may cause the inflammation to extend deeper into the uterine wall or into the parametrium or into the Fallopian tubes. If no decided l)eneficial effect is apparent from a few applications, made at intervals of several days, they should be discontinued and more effective measures employed. Medicines Used for Intrauterine Application. The medicines used for astringent effect are: — Protargol, 5 to 10%. Formol, 20 to 40%. Iodized Phenol (Tinct. iodine and carbolic acid, equal parts) Carbolic Acid, 10 to 95%. Copper Sulphate, 10%. Adrenalin Chloride, 1-1000. The medicines used for anesthetic effect are: — Cocaine Hydrochlarate, 10 to 20%. Orthoform. Chloretone. Local anesthetic appHcations are seldom used within the uterus. About the only indication is for the diminution of pain due to dilatation of the cervical canal. A few minutes before the dilatation an application of the desired local anesthetic is made along the canal, especially about the internal os which is the most sensitive part. HOT WATER IRRIGATION. Intra-uterine irrigation is employed in the treatment of acute endometritis, par- ticularly that form caused by infection following labor or abortion. With the same antiseptic precautions as for sounding the uterus, the double current irrigat- ing tube is introduced into the uterine cavity and a large amount (half a gallon to a gallon) of hot sterile water, or normal salt solution, is allowed to pass slowly through the uterus. This removes mechanically a large amount of the infective material and the effect of the hot water is beneficial in tending to allay the inflam- mation. In some cases of puerperal sepsis, this irrigation is sufficient to check the trouble, but in other cases there remains infected material that must be removed by the finger or curet. One thorough irrigation is usually all that is advisable, provided the uterine cavity drains well. Of course if there is distinct retention ol pus within the uterus then the cervix must be opened and the pus washed out as often as such retention occurs. Intra-uterine irrigation has been used also in the treatment of acute gonorrhoeal endometritis but the effect was not such as to encourage its use. Prolonged hot intra-uterine irrigation has been used also in the treatment of chronic endometritis with decided benefit in some cases. In the uterus not rec- cently pregnant, the cervix may require considerable dilatation before it will admit the irrigating tube. The required dilatation can usually be easily accomplished by using the graduated cervical dilators, of hard rubber or metal. 352 GYNECOLOGIC TREATMEXT In addition to the dangers incident to all intra-uterine manipulations (irrita- tion, abrasions, infection), irrigation presents the danger of fluid extending into the tubes and out into the peritoneal cavity. To avoid this, the return-flow must be unobstructed and the irrigating receptacle not more than two feet above the uterus. In puerperal infection, after the uterus is thoroughly cleansed of placental rem- nants and infected clots, and free drainage is secured, the less intra-uterine inter- ference for irrigation or other cause, the better as a rule. In chronic endometritis the treatment by intra-uterine hot water irrigation is still on trial. The indications so far are that in the cases really requiring intra- uterine treatment, more effective methods are preferable. CURETMENT. The use of the curet within the uterus in office work is very limited. It is used nearly altogether for diagnostic purposes, though occasionally in a case of hyper- trophic endometritis with a wide cervical canal, it may be advisable to curet suf- ficiently to remove a large part of the endometrium and secure a therapeutic effect. The precautions are the same as for sounding the uterus. Usually the Sims posture T\ill be found most convenient. Regular curetment under anesthesia, properly carried out in suitable cases, is one of the most beneficial of gj^necologic therapeutic measures. By it, the chron- ically diseased endometrium may be largely removed. This stops the bleeding and leaves the surface in a good condition for the rapid regeneration of a compar- atively healthy endometrium (Figs. 589, 590, 591). In practically all cases of chronic uterine bleeding or free discharge, in which the trouble is not amenable to a few intra-uterine applications, regular curetment under anesthesia is indicated both for therapeutic effect and for diagnosis. Regular curetment is considered in detail in chapter vi, under Chronic Endometritis. CAUTERIZATION OF ENDOMETRIUM. Destruction of the endometrium b}- cauterization was formerly much practiced in cases of persistent bleeding or discharge. It has been found, however, that in all but exceptional cases, a curetment is more effective and leaves the uterus in better condition for the regeneration of a healthy endometrium, as explained and illustrated in chapter vi. In cases where curetment can not be carried out or is not effective, cauteriza- tion may be employed. For accomplishing this there are three methods — by chemicals, by steam, by electricity. Cauterization of Endometrium by Chemicals. Chloride of zinc was formerly much used, as was also nitric acid. The effect of these strong deeply cauterizing agents in many cases was to destroy the endometrium beyond the possibility of satisfactory regeneration (see Fig. 592), the interior of the uterus being in many cases converted into a mass of scar tissue. Carbolic acid (95%) does very well as a superficial cauterant, but it does not cauterize deeply enough to approach in effectiveness curetment as a means of re- CAUTERIZATION. ELECTRICITY 353 moving a diseased and bleeding endometrium. When a superficial effect only is required, it does very well, applied as an ordinary medicated iutra-utei-inc aj)pli- cation. Care is necessary, however, to avoid cauterizing the vaginal wall and also to avoid concentrating the effect in the narrow part of the cervical caiud, near the internal os, with almost no effect above. This is avoided by having the cervical canal well dilated, so the charged applicator will pass in easily. The stronger formol solutions (30% to 50%) have a superficial cauterizing effect. Cauterization of Endometrium by Steam. By means of the Pincus apparatus, the intra-uterine application of steam has been made practical. A thorough curetment (under anesthesia) precedes the application of steam. Then the steam, under the control of the Pincus apparatus, is applied for a few seconds. This cau- terizes the interior of the uterus, and stops metrorrhagia in some cases where other measures, including repeated curetment, have failed. It is a dangerous measure, however, and is not suitable for general u.se. It has caused deaths, also atresia of the uterine canal necessitating suVjsequent hysterec- tomy. It is not to be used as a substitute for curetment or other less dangerous measures, but is to be employed only as a substitute for hysterectomy in cases of persistent metrorrhagia due to a non-malignant pathological process in the en- dometrium. Cauterization of Endometrium by Electricity. This is often very effective where a mild cauterizing effect is desired, to check a persistent menorrhagia or metror- rhagia not dependent on malignant disease nor active infection. The treatments may be given in the office easily and with but little d scomfort to the patient in suitable cases. Where curetment is not required for diagnosis, electricity may in some cases be uced as an effective substitute for it, and anesthesia thus avoided. The details of the application of electricity in this and other cases are given below. ELECTRICITY. Electricity is a useful method of treatment which has fallen into disrepute be- cause too much was expected of it and claimed for it. The manner of its presen- tation was confusing and, with the small results, discouraging. It was put forward as a wonderful cure-all, with a mysterious source, action and effect. Its clinical use and understanding supposedly necessitated the perusal of volumes of explana- tions — sensible and absurd, chemical, physical, physiological and psychical. By the time the reader had made good progress into the explanations, he was so be- wildered and befuddled that the only tangible conclusion he could reach was that it was a wonderful remedy and must certainly produce wonderful results for what- ever used. When the actual clinical results were viewed in the same way that results from therapeutic measures without mysterious trimmings were vie.i\'e(l, it was found that many of the strongest claims were without foundation in fact. Because of this conspicuous failure in certain particulars, some have been led to the mistaken idea that it is a total failure as a therapeutic agent. Less of mystery and finely-spun theorizing and more of common sense and critical testing of results 354 GYNECOLOGIC TREATMENT by reliable methods, have shown that its usefulness in strictly gynecologj^ai ofibes is very limited, but within those hmits it is effective. Apparatus Required. It is necessary to have an electrical table-plate or switch-board arranged for de- Uvering, controlhng and measuring the current, and a separate converter for the cautery. The current itself is preferably supphed from a suitable street current, if that is available. In places where there is no street current, dependence must be placed in cells of suitable character and number, placed in the basement or else- where. Electrodes. There should be one large abdominal electrode made of sponge or some satisfactory substitute. Just before using each time the surface of the elec- trode may be covered with a layer of absorbent cotton, which keeps it from direct contact with the skin of the patient and thus does away with any possibility of contamination from one person to another. By using a wide thick piece of ab- sorbent cotton, the contact surface of the electrode may be increased as desired. This increase in contact surface is very useful for the abdominal electrode when giving strong currents. Two vaginal electrodes, one monopolar and one bipolar, are required. These may be used also as rectal electrodes. Two intra-uterine electrodes, one monopolar, and one bipolar, are required. They must be so constructed that they can be sterilized each time before use. The intra-uterine electrodes may be used also as urethral electrodes. A very convenient set of monopolar electrodes is that of Goelet's. There are three sizes in order to make them effective in the treatment of cervical stenosis and persistent menorrhagia and metrorrhagia. In the treatment of persistent uterine bleeding the effect desired is a mild cau- terization of the endometrium. This is secured as later explained by a current of 30 to 40 m. a., the intra-uterine electrode being the positive pole. When the posi- itive pole is composed of copper it is corroded by the current and there is secured some cataphoresis — that is, the copper salts are projected slightly into the adja- cent tissues, increasing the beneficial effect. For regular cautery work (excision of growths, etc.) it is necessary to have a cautery handle with two cautery points, one point knife-like, for cutting, and the other cone-shaped for touching surfaces superficially. Rules of Application. 1. Study your electrical. outfit and experiment with it until you are acquainted with all its component parts and know by experience what it will do under ordi- nary circumstances. You can not get this knowledge by reading a description of the apparatus and the directions for operating it. It can be acquired only by actually handling and experimenting with it. 2. Wherever an electrode is to be applied to the skin, the skin and the electrode should be well moistened. If this precaution is not taken, there will be consider- able pain and not much current, for the dry skin is a poor conductor of electricity. RULES FOR THE APPLICATION OF ELECTRICITY 355 See that there is no current until everything is in place. Adjust the electrodes in place before connecting them with tiie battery. When connecting them with the battery see that the current is entirely shut off. 3. After the electrodes are in place and connected by the conducting cords with the battery, then by means of the current controller turn the current on very grad= ually. If the patient complains of pain while there is only a small current, it means that there is poor contact or too small an area of contact between one of the electrodes and the patient. If the indicator of the milliamperemeter fails to move up, it means that there is a break somewhere and that there is no current passing between the electrodes. Turn on only a very small current until it is seen that everything is working nicely and then the strength may be gradually increased to the desired amount. 4. Indifferent electrode. In all pelvic applications, where two electrodes are used, the larger electrode is placed on the lower abdomen or on the back in the lumbar or sacral region. It is disposed in relation to the active electrode so that the current will pass through the affected tissues. Consequently, in most cases it is placed over the lower abdomen. This large electrode is called the indifferent electrode because there is no particular effect near it. It must be large enough (must spread over enough skin surface), to carry the required strength of current without marked irritation of the surface. If the contact area is too small for the strength of current, the skin becomes very red and the patient complains of ting- ling or burning. In cases where a counter-irritant effect on the skin is desired, a strong current with an undersized electrode may be used for that purpose. Ordi- narily, however, the indifferent electrode should be so large that there is no effect on the skin beyond a slight tingling and a temporary redness. If any metal part of an abdominal electrode comes in contact with the skin, while a strong current is passing, it will cause a burn and resulting blister. 5. The active electrode is the internal one, the one in the uterus or vagina or urethra or rectum as the case may be. If the application is wholly external, the smaller of the two electrodes is the active one and is usually placed nearest the seat of the lesion or the pain (the external applications are usually made for pain), the larger electrode (indifferent electrode) being placed opposite on the abdomen or on the back. The internal electrodes (intra-uterine, vaginal, urethral, rectal) are ordinarily used bare so that the metal comes in direct contact with the adjacent surface. In cases of vagino-abdominal or vagino-dorsal application in which it is desired to use a strong current, the vaginal electrode is wrapped with absorbent cotton which is well moistened before introduction. By increasing the amount of the wrapping, the contact surface of the vaginal electrode (and consequently the strength of the current that may be used without discomfort) may be increased as desired. 6. The active electrode is the positive pole when it is giving the current to the other one, it is the negative pole when it is receiving the current fromthe other one. The active electrode is made positive or negative as desired by means of the pole changer. 7. The local effects of the positive pole are to diminish the amount of blood in 356 GYNECOLOGIC TREATMENT the immediately adjacent tissues (checks hemorrhage and lessens congestion) and to relieve pain. It is used to check uterine bleeding due to endometritis, subin- volution, or fibroids, and to relieve pain due to congestion, old inflammatory trouble or neuralgia. The local effects of the negative pole are to increase the amount of blood in the immediately adjacent tissues. Consequently, it causes active congestion, in- creases functional activity, increases growth and hastens the absorption of chronic exudates. It is used in cases of amenorrhoea, scanty menstruation, poor devel- opment of uterus or ovaries, and for plastic or serous exudates remaining in the pelvis after acute symptoms have long subsided. The relative quality of action of the two poles is about the same for both the galvanic and faradic currents. 8. With the faradic current, one may use either the primary or secondary current. The primary current is more stimulating and is used to overcome relaxation of tissues and to increase functional activity. The secondary current is more sedative in its effect and is used to relieve pain due either to congestion or to neuralgic conditions. With the faradic current there is another disposition of the poles, namely, the placing of the two close to- gether in the same electrode. This constitutes the bipolar electrode. Used with the secondary current, it is especially effective in reheving local pain. 9. The various locations of the electrodes for pelvic treatment may be desig- nated as follows.* On External Surfaces — Dorso-abdominal, Sacro-abdominal, Perineo-abdom- inal, Perineo-dorsal. In Vagina — Vagino-abdominal, Vagino-dorsal, Bipolar vaginal. In Uterus — Intrauterine-abdominal, Intrauterine-dorsal, Bipolar intrauterine,- In Rectum — Recto-abdominal, Recto-dorsal, Bipolar rectal. In Urethra — Urethro-abdominal, Urethro-dorsal, Bipolar urethral. Other methods of application such as general galvanization and general faradiza- tion and appUcations of static electricity, while frequently useful in the treatment of certain conditions associated with gynecological diseases, belong to general medicine and will not be described here. 10. Manner of using electricity for the different affections. a. For uterine bleeding (menorrhagia or metrorrhagia), uterine leucorrhoea or chronic congestion, use the galvanic current, positive pole in uterus, strength of current 20 to 50 m. a., duration five to ten minutes, and repeat once a week or twice a week or every other day as necessary. b. For amenorrhoea, scanty menstruation, poorly developed uterus, atonic conditions of uterus or vagina or pelvic floor muscles or sphincter ani (when re- paired after long non-use) or sphincter vesicae (when weak from damage in par- turition or other cause), use the galvanic current, negative pole in uterus, strength of current 20 to 50 m. a., duration five to ten minutes, and repeat once a week or twice a week or every other day as necessary. Use faradic current, primary current and negative pole in uterus. Use faradic current, primary current and negative pole in vagina. Use faradic current, bipolar application in uterus or vagina. RULES FOR THE APPLICATION OF ELECTRICITY 357 In all cases be very careful to exclude pregnancy before using this treatment. When treating for atony of the sphincter ani and accessory muscles, the vaginal electrodes may be used as rectal, the active portion of the electrode being placed so as to direct the current through the affected muscles. When treating for imper- fect control of the urine, the intra-uterine electrodes may be used as urethral. c. To overcome stenosis of cervical canal, use galvanic current, negative pole, strength of current 5 to 10 m. a., duration 10 to 20 minutes and use twice, with a 3 to 5 day interval, just before the menstrual time, when no chance of pregnancy. The electrode is introduced to the stenosis and then the current turned on grad- ually. The effect of the negative pole is to cause congestion and softening of the tissues. The electrode is kept gently pressed against the area. It gradually advances as the tissues in front of it soften. d. To relieve pain due to dysmenorrhoea, chronic pelvic inflammation or con- gestion, use the positive pole in the uterus or vagina with galvanic or faradic cur- rent. Also faradic bipolar application with secondary current. If due to ane- mia, poor development or poor functional activity, use the negative pole in uterus or vagina with galvanic or faradic secondary current. Also faradic bipolar appli- cation in uterus or vagina with secondary current. If without distinct local lesion, i. e., coming under the class styled neuralgic, try the different methods. The far- adic bipolar application with secondary current is especially effective in relieving localized pain, when the electrode can be brought close to the painful area. The advice to try the different methods is applicable, in a measure, in nearly all appli- cations of electricity to gynecological treatment, when the method first used does not produce the desired result. Each case is to some extent, a "mixed case," i. e., there are several separate, and sometimes opposed, factors at work and it is often difficult to say which is the predominating one. e. For excision or destruction of tissue, such as small condylomata about the external genitals, caruncle about the urethra, persistent erosion about the cervix, small cervical cysts, cervical polypi, etc., the cautery is employed. Use the cautery-knife for excising papillomata and puncturing cysts, and the cone-shaped cautery-point for searing areas requiring such treatment. If on a sensitive surface, as on the external genitals or on the vaginal wall, apply a 20 per cent, cocaine solution or inject a J per cent, cocaine solution at the base of the involved tissue. 11. The desired effect should be obtained with as little local disturbance as pos- sible — that is, in a case where the desired result can be obtained by dorso-abdom- inal applications (as in some cases of general pelvic pain due to chronic pelvic in- flammation, pelvic neuralgia, etc.) these should be used in preference to vaginal or intra-uterine applications, especially in the case of unmarried women. On the same principal, an intra-uterine application is not used when a vag'nal application will suffice. Furthermore the strength of the application should not be such as to cause pain, the limit for that particular patient being found by gradual increase of the current strength by means of tho controller (rheostat). Start with a very slight current, barely enough to move the indicator, until it is seen that everj'thing is working smoothl}'. Then increase very gradually as the patient becomes accustomed to the current. This special care to give not the slightest discomfort is particularly 358 GYNECOLOGIC TREATMENT important at the first application, as some patients are very uneasy when under treatment by electricity until it has been demonstrated to them that there is no pain or shock. The duration of the application should not be sufficient to cause fatigue or much subsequent irritation, the usual duration being 10 to 20 minutes. The frequency of the application varies very much in different cases. The milder application may be made twice a week or every other day or even every day for special indications. The stronger currents should be applied less frequently, as once a week or every ten days or two weeks. 12. Strict attention should be given to cleanliness. The electrodes for internal use (intra-uterine, vaginal, urethral, rectal) are sterilized and used under the same strict precautions as other instruments for the same localities. 13. Remember that electricity is not a cure=all. It is only one of our many re- sources. Some affections in some patients are benefitted by it. Many are not benefitted. Our duty in each case of disease is to cure the patient, or give her re- lief, by the safest and most effective means. Consequently in those cases where electricity promises the best results it should be given a thorough trial, but in those cases for which we have better means no time should be wasted with it. CERVICAL DILATATION. The thorough dilatation under anesthesia which precedes curetment is con- sidered in chapter vi. Partial dilatation in the office may give considerable relief in cases of dysmenor- rhoea and it is used also in the treatment of sterility. The methods of making partial dilatation are given in chapter i and in chapter xiv. VACUUM TREATMENT. Suction has been applied to the uterine cavity by means of an apparatus fitting over the cervix and extending into the cavity. By means of a suction pump the uterine secretion is drawn out and a partial vacumn created, causing passive con- gestion of the endometrium. It is an application of Bier's "congestion treat- ment, " which has been found so useful in certain general surgical affections. It has been used principally in the treatment of chronic endometritis. The reported cases show that the treatment must be long continued and the results finally secured are apparently no better, if as good, as those given by the more common and less tedious therapeutic methods. APPLICATIONS WITHIN RECTUM. ENEMATA, LOW AND HIGH. The use of low enemata for emptying the rectum is so common and well known as to require no description. It may be well, however, to point out that in all pain- ful affections of the rectum, an enema of two to four ounces of olive oil or sweet oil, with or without the addition of a pint of plain water, is preferable to the soap-water enema ordinarily employed. PELVIC TREATMENT PER RECTUM ;^59 High enemata are useful in several ways. Plain water or soap-water or medi- cated solutions are used in this way to secure bowel movement in obstinate cases. Normal saline solution is thus used after serious operations, to relieve thirst, to aid the kidney action and to sustain the heart, ^'arious nutrient mixtures are used as hiirh enemata to nourish the patient in certain classes of cases. It is in the after-treatment of .serious operative cases that high enemata are prin- cipally employed in gj'necological work. The indications for their employment are given under After-treatment of Operative Cases (chapter xvi) and formulae for the same are given in the Appendix. HOT WATER IRRIGATION OF RECTUM. The use of hot water or hot saline solution in the rectum has been found useful in two classes of gjmecological cases, first, those presenting a large mass of inflam- matory exudate that resists absorption and, second, those presenting acute gen- eral peritonitis. For Pelvic Exudate. In these cases the effect desired is the same as that sought by the long hot vaginal douche, namely, the long application of moist heat in the immediate vicinity of the mass of exudate. In some cases the hot water may be brought closer to the mass and made more effective by rectal irrigation than by vaginal irrigation. The rectal douche must differ, however, in some particulars from the vaginal douche. On account of the sphincter ani muscle, a double irri- gating tube should be used. Again, the rectal mucosa is easily irritated and, furthermore, it is an absorbent surface, hence no strong antiseptic solution is per- missible there. The irrigating fluid should be simply plain water or normal saline solution. For Sepsis. Here the effect desired is absorption of the saline solution into the general circulation, for aiding the kidneys and heart, and also to some extent absorption of the saline into the peritoneal cavity and out with the drainage, instead of absorption of septic material from the cavity into the general circu- lation. For details, see Treatment of Acute Pelvic Inflammation (chapter x). APPLICATIONS TO THE LOWER ABDOMEN AND INTERIOR OF PELVIS. PELVIC MASSAGE. Pelvic massage is the application of the principles of massage to the intrapelvic structures. The effects to be attained are: Correction of displacement of the uterus, tubes and ovaries. Stretching of adhesions and infiltrated tissues. Improvement of pelvic circulation (lymph and blood). Absorption of chronic exudates. Details of Application. I think the best way to introduce this important therapeutic method is to con- sider it as a continuation of, or addition to, the ordinary bimanual examination. 3Q0 GYXECOLOGIC TREATMENT When there is displacement of the uterus, with or without adhesions, the bimanual examination, by which the diagnosis is estabUshed, has also a therapeutic value. Take, for example, a case of retrodisplacement in which the uterus can be brought forward but vdW not stay there. By bringing the uterus forward in the bimanual examination, the diagnosis of movable retrodisplacement is established. Then search is made to discover why the uterus will not stay forward. Suppose it is found that the anterior vaginal wall or vesico-vaginal septum is shortened, as sometimes happens. Whether this is a, primary or secondary change is not of so much importance as to the fact that it exists, and constantly keeps the cervix so far forward that the fundus uteri tends to go backward. Of course, when in the bimanual examination the fundus is brought forward, the cervix is pushed back- ward and upward and the fundus is at the same time bent forward over the tips of the examining fingers in the anterior fornix, to take out any flexion in the body of the uterus. Now, if instead of ceasing this intra-pelvic work as soon as the diagnosis is estab- lished, we continue to stretch the shortened vesico-vaginal septum, a decided therapeutic effect tending to permanent correction of the displacement is secured. The contracted tissues anterior to the cervix are made tense and stretched even up to the point of painfulness, and we endeavor all the time to place the cervix farther back in the pelvis as the tissues gi-adualty yield. Force sufficient to damage the tissues or cause severe pain should not be used, the object being to gradually lengthen the tissues as much as possible without damage. In doing this we per- form one of the important manipulations of pelvic massage, namely, stretching. This stretching may be done with the vaginal fingers alone, but the holding of the fundus uteri well forward at the same time, with the fingers of the abdominal hand, makes it more effective. There may be a restricting band running obliquely toward one obturator foramen, or transvei-sety toward the pelvic wall in the base of the broad ligament. Whatever the direction of the band, it is to be stretched. This process of stretching is somewhat painful and maj' be followed by a sense of fullness and pain in the stretched structures. It has been found by experience that these discomforts are climinished and the softening and stretching of the tense tissues facilitated by sweeping pressure, so directed as to work the lymph and venous blood out of the tissues toward the pelvic wall. This permits the more rapid entrance of fresh blood and hastens the absorption of serous and cellular in- fi'tration. This sweeping pressure is applied by the finger-tips or the knuckles of the abdominal hand, worked far down into the pelvis to the tissues under treat- ment. The fingers of the abdominal hand depress the abdominal wall to the af- fected tissues, which tissues are, at the same time, raised as much as possible by the vaginal fingers. The infiltrated tissues are now compressed between the va- ginal and abdominal fingers. The abdominal fingers, still keeping up the pressure, are made to describe a small circle or ellipse. In the lower part of the circle, which lias directly over the ti.ssues under treatment and where the direction of movement is from within outward, the strong pressure is made. In this movement, the ab- dominal fingers remain at the same spot on the skin. This is essential for, if the pressure is relaxed enough to allow the fingers to slip over the abdominal surface, no deep effect can be obtained. The skin is freely movable over the deeper struc- DETAILS OF PELVIC MASSAGE :ni\ tures of the abdominal wall, and one point can easily be carried through the small circle described. In some cases, where the abdominal wall is very thin and lax, the whole thickness of the wall may follow the fingers to some extent. The va- ginal fingers are not moved in the least. They remain perfectly stationary, being required only to elevate the infiltrated area so that it can l)e subjected to com- pression by the fingers above. The application of this sweeping pressure, as just described, constitutes that other important manipulation of massage known as kneading. These two manipulations, stretching and kneading of shortened and infiltrated tissues or of adhesions, constitute the essentials of pelvic massage in ordinary cases. Whether the infiltrated area or the tense band is at the lower part of the broad ligament or the upper part, whether it binds the uterus backward or forward or laterally or holds an ovary or tube in abnormal position, the principles of manip- ulation are the same, namely, to stretch the adhesions or shortened tissues and to work the lymph and venous blood out of them towards the pelvic wall. The clothing must be well loosened so that there is no constriction forcing the intes- tines into the pelvis. The bladder and rectum should be empty — therefore direct the patient to take an enema an hour or two before coming for treatment and to empty the bladder just before treatment. The manipulations must always be gentle at first, gradually increasing in force as the tenderness diminishes. Painful points should not be passed over directly or carelessly but circled about and approached gradually. As to the length of the seance and the frequency of repetition, the ph3-sician is guided b}^ the conditions present and the effect produced. The idea is to stretch the tissues and remove infiltration as quickly as po.ssible, but if too much force is used or the seance made too long the resulting irritation may increase rather than diminish the infiltration. The treatments should be far enough separated so that the irritation from one, as evidenced by pain and soreness, has largely subsided before the next is given. This, of course, will varj^ much in different cases. A seance of five or ten minutes repeated from every second day to e^'ery other week, are about the requirements. The cases must be carefully selected, and if no decided benefit is apparent after a few treatments, they are stopped and more effective measures employed. Of course, other measures are to be used in conjunction with this treatment as indicated — general measures, internal treatment, hot vaginal douches, pessaries, etc. Indications for Pelvic Massage. Pelvic massage is of benefit principally in cases of uterine displacement accom- panied by the sequelae of a pelvic cellulitis (real parametritis) or by old peritoneal adhesions without active pelvic inflammation. It is useful also in some cases of the same connective tissue or peritoneal inflammatory sequelae without important displacement of the uterus, the improvement in these cases being due probably to the removal of cellular infiltration and stasis-edema of the tissues, the relief from pressure of constricting peritoneal bands and the improvement of the lymph and blood circulation in the pelvis. It is useful also in exceptional cases of a per- 362 GYNECOLOGIC TREATMENT sistent large mass of exudate, but only where all active inflammation has disap- peared and nature has failed to make the usual prompt removal of exudate when it is no longer needed for limiting purposes. Inflammation of the connective tissue in this region, as in other regions, runs its course rather rapidly, ending in resolution or in the formation of an abscess which is opened or opens itself. In either case the active inflammation soon subsides, leaving no persistent focus of active inflammation, but only the sequelae, consist- ing principally of scar tissue and cellular infiltration and the circulatory disturb- ance of lymph and blood resulting therefrom. These are just the conditions most susceptible to improvement by massage. Furthermore, in this condition com- paratively Uttle can be accompHshed by operative work. There is no focus of per- sistent inflammation to be excised, no intra-peritoneal mass of exudate to be re- moved, no intra-peritoneal bands to be broken. The cellular infiltration and the bands of scar tissue lie under the peritoneum among important vessels and nerves and other structures, and are of such nature and so situated, that their excision is not, ordinarily, desirable nor practicable. Allied to these cases, as regards their suitableness for massage, are the cases of retrodisplacement without infection in which the persistence of the displacement seems to be due, to considerable extent at least, to a shortening of the upper pos- terior part of the broad ligament. This is found in certain troublesome cases of retrodisplacement in wornen who have never been pregnant. It constitutes the cause of failure in some cases submitted to the ordinary operative procedures for retrodisplacement. It is not effected by such measures unless the involved tis- sues are directly divided or over-stretched at the time, and this must be done care- fully or important structures will be injured. In some cases this contraction is hardly appreciable during the operative work, the uterus coming forward without much resistance, but the constant slight pull maintained by this tense tissue is sufficient to gradually draw the uterus back again into retrodisplacement. In cases of retrodisplacement, the intra-pelvic conditions should be carefully studied by bimanual examination, to determine just what holds the uterus backward or what causes it to go backward after replacement. On the other hand, when an infectious process attacks the Fallopian tubes there is liable to remain a focus of persistent inflammation, the same as there does in the appendix. It may be walled off so as to remain in a measure quiescent for weeks or months at a time, but every once in a while it is stirred up by extra exertion or some other circumstance that increases the local irritation or diminishes the local resistance. It is evident that in such a condition (salpingitis), stretching or kneading of the involved tissue would only cause an increase of the inflammation and of the resulting exudate and disturbance. The proper tr.eatment in such a ca,se is to re- move the focus of persistent inflammation, and this is accomplished by the removal of the diseased tube oi' ovary and, as far as practicable, of the accompanying peri- toneal exudate. Just a word as to the term " parametritis, " for it looms up large in nearly all arti- cles on pelvic massage. The connective tissue about the uterus and extending out into the broad ligaments and sacro-uterine ligaments, is often spoken of collect- ively as the "parametrium" — a very convenient term, for it is much shorter than INDICATIONS FOR PELVIC MASSAGE 363 "pelvic connective tissue" or "peri-uterine connective tissue," with whidi it is synonymous. Inflammation of the connective tissue about the uterus (pelvic cellulitis) is often spoken of as "parametritis." So far so good, for this also is a convenient term, but with its extended use, confusion has crept in. In the first place, it is very similar in sound and appearance to the term "perimet- ritis," which means inflamnuitionof the tissues around the uterus, more especially, however of the peritoneum and adnexa (tubes and ovaries). So, even with a per- fectly clear idea of the limitation of parametritis, it may be confounded by the hearer or reader with the very similar sounding and appearing word "perimetri- tis," which means almost the opposite. In the second place, the term paramet- ritis is used loosely b}^ some writers and speakers, which has led to ambiguity and much difference of opinion as to the efficiency of pelvic massage and other methods of treatment in pelvic inflammatory troubles. There seems to be a tendency to apply the term parametritis to every thickening or induration around the uterus. This is inexact and leads to misunderstanding and confusion. If persisted in to any great extent, it will necessitate the dropping of this very useful and con- venient term. In speaking to my classes I usually employ the less convenient term "pelvic cellulitis," because only one meaning can be attached to it. In regard to pelvic massage, so much has been claimed for it and on the other hand so much has been said against it, that the beginner is very liable to be misled by one sided reading or confused by the vigorous promulgation of conflicting views. The markedly denunciatory statements indulged in on each side are in many cases the result of one-sided experience. One physician prefers operative treat- ment, uses it exclusively and denounces massage, about which he knows little or nothing. Another physician favors massage, uses it exclusively and denounces operative treatment, about, which he knows little or nothing. Of course, such a state of affairs should not exist, but the fact remains that it does exist, not only in regard to this subject but also in regard to other important subjects. It is so flat- tering to one's vanity to give a sweeping opinion on a subject of importance and so easy to find auditors, that many persons make broad statements without proper thought and investigation. Such opinions are of course worthless, but the fact that they are worthless is often not known to th'osewho hear and read them, and the situation is thus complicated and the truth obscured. Differences of results and consequently differences of opinion will always exist on account of differences in physicians and patients, but we should always be ready to consider a subject in a rational way and without prejudice. Persons and conditions vary so much and there are so many sources of error that we must advance cautiously from the well established to the comparatively unknown. When however a method of treat- ment is, from its demonstrated effect, rationally applicable to a known patho- logical condition, and hundreds of thoroughly reliable physicians in various parts of the world have secured good results by practical application of the method, there is no reason why it should not be used where the necessary skill and dis- crimination can be obtained. A method is not condemned because some have employed it as a cure-all, when in fact it is applicable to only a small proportion of the conditions met with, or because some have used it in conditions where it was contra-indicated and have thereby done harm, or because some who were unworthy 364 GYNECOLOGIC TREATMENT the name of physician have used it as a cloak for criminal practices, just as the same or similar creatures have used other well-established therapeutic measures. Pelvic massage has its strict indications and contra-indications, just as has every other therapeutic measure. Its application requires much discrimination in the selection of cases and much skill in the pelvic manipulations and then a large fund of patience and perseverence. Used with skill and care in conjunction with the other measures, it has, in certain conditions already indicated, restored the patient from a condition of chronic invalidism to health, and to a condition much nearer anatomical and physiological cure than could have been secured by a cut- ting operation. In other cases the patient is not cured, but the intra-pelvic con- dition is so far improved that she is made fairly comfortable and able to get along. In still other cases it does no good and is a waste of time, and serves to postpone the employment of measures that would be effective in restoring the patient's health. Contra=Indications to Pelvic Massage. When there is marked tenderness or where there is marked hyperesthesia of the pelvic organs or of the vagina or of the external genitals, pelvic massage is contra- indicated. It is contra-indicated also in the presence of: — Acute inflammation. A collection of pus. Active salpingitis. Pelvic tuberculosis. Malignant disease. Pregnancy, PRESSURE TREATMENT. The effects sought by pressure treatment are (a) to hasten the absorption of a chronic exudate in the pelvis, (b) to assist in stretching adhesions or infiltrated tissues and (c) to assist in raising a displaced uterus. The articles required are (a) two strong colpeurynters connected by a stop- cock, (b) two pounds of mercury, (c) bag of fiine shot weighing three pounds, with an elastic bandage for fastening same to the lower abdomen. The empty col- peurynter is introduced into the vagina, the patient's hips elevated, the shot-bag applied to the lower abdomen, and the mercury run into the vaginal colpeurynter in sufficient quantity to make the desired pressure. Details of Application. The bladder and rectum must be empty. With the patient in the dorsal pos- ture on a bed or table, one colpeurynter (detached from the other and empty) is cleansed, lubricated, folded, grasped with a uterine dressing forceps and intro- duced to that portion of the vaginal vault nearest the exudate. The patient then takes the position to be maintained during the treatment — on her back, if the ex- udate is behind the uterus, or on the side corresponding to the exudate if it is on one side of the uterus — and the shot-bag is placed on the lower abdomen and so INDICATIONS rOR PRESSURE TREATMENT 365 fastened by a bandage or elastic belt that it will maintain the counter-pressure in the direction of the exudate when the patient's hips are elevated. The foot of the bed is then raised about eighteen inches and the hips are still further elevated by one or two folded pillows placed under them. The other colpeurynter, contain- ing the two pounds of mercury, is connected with the colpeurynter tube extending out of the vagina and the stop-cock is opened sufficiently to permit a small stream of mercury to flow into the vaginal colpeurynter at the vaginal vault. From one to two pounds of mercury is allowed to flow into the vaginal colpeurynter, de- pending on the absence of pain. There should not be enough pressure to cause much pain. The treatments are given daily and at first should not last more than half an hour, to be soon increased to one hour. Later, if well borne, the treatment may be kept up for several hours at a time — in fact, may be continued the greater part of the day with intervals of rest. Indications and Contra=Indications. Indications. Pressure treatment is applicable principally in cases of adherent retro-displacement of the uterus and in cases of chronic pelvic inflammation in which the exudate is in the cul-de-sac of Douglas cr in the broad ligament or in which there are adhesions low in the pelvis. Contra=indications. When the exudate is situated high, above the fundus uteri or about the tubes, this treatment is not satisfactory. When severe pain is caused by the pressure, the treatment must be discon- tinued, as there is danger of starting up active inflammation or disseminating an unrecognized focus of active infection. It is contra-indicated also in the presence of:— Acute inflammation. A collection of pus. Active salpingitis. Pelvic tuberculosis. Malignant disease. Pregnancy. APPLICATIONS TO BODY GENERALLY. BATHING. Regular bathing for hygienic purposes is necessary to keep the patient in good general health. Also hot baths or cold baths may be required for their special effect on the patient's nervous system. The hydrotherapeutic methods particularly useful in gynecological cases (va- ginal douches, moist applications to lower abdomen, sitz baths) have already been described. FRICTION RUBBING. Friction rubbing of the general body surface with alcohol or salt or a brush or a rough towel, which the neurologists have found so extremely useful in atonic 366 GYNECOLOGIC TREATMENT conditions of the nervous system and of the body generally, is often indicated in gynecological cases. The fact that the patient is under treatment for some pelvic disease should not prevent her receiving such other treatment as is necessary. After operation for pelvic disease which has caused marked deterioration of the general health, it is important to employ general measures in conjunction with the local measures in order to complete the restoration to health. The detailed consideration of these various general measures would take up too much room and would be somewhat out of place in a work of this character. I must content myself with calling attention to the importance of their intelligent use in gynecological cases. GENERAL MASSAGE. General massage also is invaluable in the treatment of certain conditions of physi- cal depression caused by or associated with pelvic disease. The cases referred to are those in which the vital forces are apparently " wornout " by long suffering, chronic septic absorption, autointoxication or faulty metabolism. The object is to produce a general tonic effect upon the muscular, circulatory, nervous, diges- tive, respiratory and execretory systems. General massage, like other general measures, belongs to general medicine and its description is not called for here. Pelvic massage has already been considered. DRESS CORRECTION. It is not my purpose to take up in a general way the subject of dress as it relates to health. I want simply to mention two things that have a bearing on the treat- ment of pelvic disease. 1. Constriction at the waist. By this constriction the abdominal contents are forced downward towards the pelvis, and thus the pelvic contents are sub- jected to abnormal pressure. This abnormal pressure interferes with the circu- lation in the various pelvic organs, causing poor nutrition and chronic congestion. This injurious pressure helps to bring about the following abnormal conditions. In the young woman, the nutrition may be so interfered with that perfect develop- ment is not attained. In the adult, the chronic pressure and congestion tends to cause chronic endometritis, displacements of the uterus and chronic irritation and enlargement of the ovaries. Following parturition, the persistent congestion tends to cause subinvolution and chronic endometritis. In laceration of the pel- vic floor, the pernicious effects of the laceration are much increased by the con- stant strong downward pressure of the abdominal contents. In retrodisplacc- ments of the uterus, the fundus uteri is forced still further into the abnormal posi- tion by this downward pros»i;re from above, and the ovaries also are forced down beside the displaced uterus. In prolapse, the structures are constantly forced further and further out of the pelvis and, in addition, there is caused a general splanchnoptosis. This tendency of waist constriction to cause permanent dis- placement of various abdominal organs, adds many abdominal symptoms to those of the pelvic disturbance. THE KNEE-CHEST POSTURE 367 2. Dragging weight at the waist line. To support heavy skirts by means of a string tied around the waist is fully as injurious as tlie wearing of the avei'age corset. The hea^•y skirts drag down the abdominal organs towards the pelvis and produce injurious pressure on the pelvic organs. To prevent these injurious effects, all constriction should be removed from about the waist and the clothing should be supported from the shoulders, as has been insisted upon so strongly by those who have given much careful study to the relation of the clothing to bodily health, strength and l^eauty. This is advisable in well persons, Init is imperatively important in those suffering with pelvic disorders. Any "corset" or "support" or "stay" that is used, should make no firm constriction above the iliac crests. Some are so arranged that they not only cause no waist-constriction, but really give some support to the lower abdomen and hence are beneficial in cases requiring support. POSTURAL METHODS AND EXERCISE. KNEE-CHEST POSTURE. The patient supports herself on the knees and chest (Fig. 468) . The head rests on a pillow, with the face turned to one side, and the breasts are brought as closely as possil)le against the table. The clothing must be well loosened about the ab- domen. The thighs should be vertical. Unless particular attention is given to the latter point the patient's hips will be too far forward or too far backward, thus Fig. 468. The Knee-chest Posture. The thighs should be perpendicular and the breasts should be brought against the table. All constriction about the waist must be removed. 368 GYNECOLOGIC TREATMENT losing a large part of the desired elevation. This position may be maintained for from one to ten minutes. The effect of this posture is to temporarily take all downward pressure off the pelvic organs and permit them to gravitate toward the abdominal cavity (Fig. 469). The downward pressure on the pelvic organs is for the time being relieved, the local circulation is greatly improved and a movable retrodisplaced fundus uteri tends to gravitate forward towards the normal position. The effect is much Fig. 469. The Knee-chest Posture, showing the pelvic structures in outhne and illustrating the tendency of the uterus andadnexa to gravitate forward. (Montgomerj'— Practical Gynecology.) Fig. 470. The Knee-chest Posture, with the patient draped ready for packing or other treatment. INI)I inflammatory infiltration diminished. This class of remedies is beneficial in all conditions of chronic uterine congestion and hemorrhagic tendency, except those connected with pregnancy. 2. Laxatives. It is difficult to appreciate the full value of laxatives in the treatment of patients with pelvic disease until the marked benefit due to them becomes a matter of personal observation through years of experience. The in- telligent and systematic use of saline purgatives in acute inflammatory conditions and of the milder laxatives (cascara sagrada, etc.) in chronic pelvic disaeses is one of the greatest aids in restoring the organs to their normal condition, where such restoration can be accomplished by minor measures, and in preparing the struc- tures for successful operative work in the cases where operation is necessary. A constantly loaded rectum and colon chokes the pelvis mechanically, causes chronic pelvic congestion, both liy direct pressure and l>y irritation and also In- contributing to an atonic condition of the pelvic tissues, and depresses the gen- eral health ])y auto-intoxication from the intestinal contents. 3. Sedatives. In various conditions sedatives are required, either on account of local pain or because of marked general nervousness. The various prepara- tions in common use are given in the Appendix. In ordinary pelvic distress, con- sisting of a mixture of pain and pressure and fullness, the preparations containing viburnum prunifolium usually give some relief. If there is simply general ner- vousness and sleeplessness, sodium bromide is effective. If there is associated bladder irritability, hyoscyamus in combination with potassium citrate or other alkaline tends to lessen the vesical tenesmus. When there is severe pain, stronger analgesics are required, for example, codeine in combination with phenacetine, and if there is still no relief it may be necessary to give morphine. The lattei-, when given at all, should be given in such form that the patient does not know what she is taking. For that reason it is preferable to give it in a capsule in com- bination with some indifferent substance rather than in the usual small tablets, the contents of which are at once surmised by most patients. 4. Tonics. Tonics containing iron are, of course, indicated in anemic patients, and it is usually advisable to give also some one or more of the general tonics, such as strychnia, quinine, arsenic, etc. 5. Organo=therapy. The use of animal extracts or dessicated tissue from vari- ous glands, has not proven of as much value in gynecological cases as some at first 372 GYNECOLOGIC TREATMENT hoped for. However, the administration of dessicated ovarian tissue or corpus luteum tissue is undoubtedly of vahie in a large proportion of the cases of de- struction of the ovaries by operation or disease. Also, in some cases of excessive nervous disturbance during and immediately following the natural menopause, it has given marked relief after other measures failed. In order to secure the de- sired effect the remedy must be given continuously over a period of several weeks or months. Thyroid extract administered in cases of fibro-myoma, while it has led to some remarkable reported effects, is on the whole probably not as effective as ergotin when the latter is given with the same care and persistence. 6. Serum Therapy. In various infective processes much good may be accomplished by the injection of bacterial products which inhibit the growth of the corresponding bacteria. The most striking and certain effects are seen in the cure of diphtheria by diphtheria antitoxin and the prevention of tetanus by antitetanic serum. Antistreptococcic serum in its various modifications has proven beneficial in cases of puerperal infection and other forms of streptococcus infection and of mixed (staphylococcus and streptococcus) infection. In some cases the effect is very pronounced, apparently saving the patient's life, while in other cases there is ap- parently no effect. It is worthy of a thorough trial in severe cases, as explained under Acute Pelvic Inflammation (see chapter x.). Opsonic Treatment. The object of this treatment is to increase the destruction of invading bacteria by the white blood-corpuscles (leucocytes). The power of the leucoc^'tes to take in and destroy bacteria (phagocytosis) has long been known, through the investigation of Metchnikoff. Within the last few years much additional information regarding phagocytosis has been acquired. Various facts have been brought out by different investigators, but it is largely through the work of A. E. Wright, of England, that the subject has been developed to the point where a definite therapeutic method has resulted. The essential features of the opsonic theory and treatment may be summarized briefly as follows: a. Leucocytes, freed from the serum and mixed with bacteria, have no phago- cytic power. When blood-serum is added to the mixture, phagocytosis begins. This difference is due to some substance in the serum that combines with that par- ticular class of bacteria, and prepares the bacteria for ingestion by the leucocytes. This is designated as an "opsonic" effect (from opsone — I cater for or prepare food for), and the substance that thus prepares the bacteria is called an "opsonin." b. The opsonic power of a patient's blood-serum, for the particular bacteria causing the illness, may be definitely measured by bacteriologic methods. This is then compared with the opsonic power of the blood-serum of a normal individual for the same bacteria. In this way is secured the "opsonic index" (relative opsonic power) of the patient's blood. c. When the opsonic index is low (poor resistance to the invading bacteria), it may be increased by the subcutaneous injection of devitalized cultures of the infecting organism. The toxic principle contained in the bacterial bodies, when brought in contact with the blood-serum, increases the opsonizing power of the DIET. PSYCHO-THERAPY 373 serum for that particular kind of bacteria. Thus the opsonic index of the patient's blood may be raised to normal, and then the growth of the infecting micro- organism is checked and the lesion heals. The injection of this "bacterial vaccine," as the devitahzed culture is sometimes called, is repeated at certain intervals, depending on the nature of the trouble and the demonstrated effect of each injection on the patient's opsonic index. d. So far, this treatment has proven most effective in localized infections, such as furunculosis, acne, persisting sinuses, tuberculosis in all forms and internal sup- purative lesions. Striking results have been reported in tubercular adenitis and tubercular cystitis — two lesions that often persist in spite of every other thera- peutic measure. Some effec-t has been secured also in tlic^se diseases in whicli the bacteria are in the blood, for example, in general sepsis from staphylococci or streptococci. The accurate employment of opsonic therapy requires the services of a skilled pathologist and a laboratory. The method is full of promise in a wide range of chronic and acute infections, but it is still in the experimental stage. 7. Special Medication. In many patients with pelvic disease there are com- plicating or associated disturbances that rec}uire treatment, such as disease of the stomach, liver, lungs, kidneys, etc. Care should be taken that such coincident affections be not overlooked for they, as well as the pelvic lesion, must receive proper treatment in order to restore the patient to health. DIET. A comprehension of the principles of proper diet and an intelligent employ- ment of the same is necessary in overcoming malnutrition and in rescueing pa~ tients from the depraved general health occasioned by certain pelvic diseases. In this connection, however, the diet has to do primarily with the general nutri- tion and only remotely with the pelvic lesion. The principal way in which the details of diet enter directly into the treatment of pelvic lesions is in the after- care of operative cases, consequently, such details of diet as I think best to take space for will be given in chapter xvi. PSYCHO-THERAPY. Many nervous affections require psycho-therapy, such as competent and dis- criminating neurologists are using more and more. This subject has been care- fully investigated in recent years by reliable physiologists and clinicians, and methods of treatment have been worked out which, in conjunction with neces- sary medication or operative measures, will greatly has ten the cure in many cases, and will restore to health some patients otherwise incurable. OPERATIONS. Careful anatomical and pathological investigations have demonstrated that many pelvic lesions are of such nature and so situated that a cure can be effected 374 GYNECOLOGIC TREATMENT by nothing short of operative treatment, with its direct handling of the diseased tissues and extirpation of the hopelessly damaged. In some cases this is evident from the very nature of the lesion, as in the case of malignant disease and tumors generally. On the other hand, in many inflam- matory lesions the question as to whether or not operative treatment will be neces- sary can be answered decisively only after nature, with the aid of minor meas- ures, has been given a thorough trial. The operative measures indicated in the various affections will be mentioned in the appropriate chapters. 375 CHAPTER ly. DISEASES OF THE EXTERNAL GENITALS AND VAGINA. POINTS IN ANATOMY, EXTERNAL GENITALS. The external genitals (Figs. 42, 208), called also the vulva and the pudenda, in- clude the following structures: Mons Veneris. Labia Majora. Labia Minora. Clitoris. Vestibule. Vulvo-vaginal Glands. Hymen. . The mons veneris (Figs. 1, 3, 30) is simply a pad of subcutaneous fat lying over the symphysis pubis. The triangular area which it forms is covered with hair after puberty. The base of the triangle is represented by a slight groove at the lower limit of the hypogastric region, and the lower portion is continuous ^^•ith the labia majora. Examination of a microscopic section through this region shows the usual characteristics of skin, i. e., many layers of squamous epithelial cells (the deepest being cubical and the most superficial being flattened and horny) placed on loose connective tissue, and presenting hairs, sebaceous glands and sweat glands. A little deeper there is much fat, which is penetrated and held together by fibrous septa that divide it into lodules. There are also many elastic fibers. The labia majora (Figs. 42, 43, 208) are two cutaneous folds which extend, one on either side, around the vaginal opening. They are appar- ently continuations of the mons veneris and, passing backward, end by joining the perineum. The external surface of each labium majus presents the ordinary characteristics of integument. Each labium is limited exter- nally by the genito-crural fold and corresponds to that side of the scrotum in the male. The round ligament, coming through the inguinal canal of each side, terminates in the upper part of the labium majus of that side. Some- times a distinct canal remains open for some distance along the round ligament. This is know^n as the canal of Nuck, and through it a hernia may take place into the labium, constituting a labial hernia. This is known also as a pudendal hernia. The hernial c(mtents may be intestine or omentum or ovary or even the uterus. 376 DISEASES OF EXTERNAL GENITALS AND VAGINA Occasionally the canal of Nuck is shut off from the peritoneal cavity, and the sac thus formed fills with fluid, giving rise to pudendal hydrocele or " hydrocele of the canal of Nuck." The inner surface of each labium majus is smooth and of a pink- ish color. It has largely lost one of the characteristics of integument — the hairs — only a few fine hairs being found here. In children the labia majora are very small and the labia minora project be- tween them. As puberty is approached the external labia become larger and meet in the median line. At puberty they, in common with the mons veneris, become covered with hair. A little later in life, particularly in married women, the labia minora become enlarged so much that they project forward, separating the labia majora. In old age the labia undergo marked diminution in size and prominence, the shrinking being due largely to absorption of the fat. Microscopic examination of a section of a labium majus shows the same structures found in the mons veneris, the only difference being that on the inner surface of the labium there are only a few hairs, and they are small. There are, however, many sebaceous glands. There are also, of course, the arteries, veins and other structures found in cutaneous and subcutaneous tissues. The connective tissue is rich in elastic fibers, and still deeper there is the thick deposit of fat that gives the labium its prominence. The veins are numerous and large, and become much distended when there is intra-pelvic pressure, as in pregnancy or a tumor. Under such circumstances, a wound of the labium may lead to serious and even fatal hemorrhage. The labia minora, (Figs. 208, 212, 214), or nymphae, are two dehcate muco-cutaneous folds lying between the labia majora, one on each side of the vaginal opening. Each labium minus apparently grows from, or is a secondary fold of, the upper and inner portion of the labium majus of that side. In stout women the nymphae are normally concealed by the labia majora. Ordinarily, particularly in married women, they project slightly, l^'requently they are somewhat enlarged and project half an inch or more. The enlargement is usually not exactly symmetrical, and in some cases it is confined to one labium. In a valuable article on these enlargements of the labia minora, Dickinson upholds the idea that whenever the enlargement is marked it is proof of excessive irritation of the labium. It is stated that among the Hot- tentots, owing to certain treatment practiced in childhood, the labia minora often becomes excessively developed and hang like a thick apron between the thighs (Fi"-. 268). The labia minora begin just below the anterior junction of the labia majora as double folds which pass above and below the clitoris (Fig. 214) The folds that join above the clitoris form the prepuce of the same. The labium minus of each side then descends along the inner side of the labium majus and blends with laljium majus about the junction of the middle and lower third. The posterior extremeties of the laljia minora are united by a delicate fold which extends between them- just within the posterior margin of the vulvar orifice, forming the fourchette. When the labia are separated, the fourchette is made tense and between it and the hymen is a small depression called, from its boat-like shape, the "fossa navicularis." This delicate fourchette is, except in rare cases, torn at child-birth, and in some cases is obliterated even Ijy sexual intercourse. It is best seen in the virgin. POINTS IN ANATOMY OF EXTERNAL GENITALS 377 There has been much dispute as to whether the inner surfaces of the labia minora are covered by integument or mucous membrane. The covering presents some of the characteristics of each. It is a transional form of covering and represents one step in the several changes which take place from the labia majora to the external surface of the cervix. The outer surfaces of the labia majora are ordinary integu- ment. On the inner surfaces of the same structures, the hairs are much reduced in size and number. On the lal)ia minora, the hairs are absent, though the sebace- ous glands are still present. On the vestibule, only a few glands remain and tlie thinning of the epithelium is more marked. In the vagina, all glands disappear (it being now generally held that there are no glands in the normal vagina) and the epithelium becomes thinner and the papillae less marked. Over the vaginal portion of the cervix the papillae have almost disappeared. 80 there is a gradual transition from ordinary integument, with a thick epithelial layer and hairs and sebaceous glands and sweat glands and marked papillae, to a thin epithelial layer without hairs or glands and almost without papillae. When the vaginal wall is turned out for a long time, as in prolapse, and exposed to friction by the clothing, the epithelial layer becomes much thickened, and if the surface is kept dry it be- comes horny like the external integument. The labia minora have many small folds, giving a very uneven surface. Ex- amination of a section of a labium minus shows numerous epithelial depressions, owing to the much folded surface. The bands and nests of epithelial cells seen in such a section are simply oblique cuts of normal folds and ingrowths. The labia minora are very rich in blood vessels, especially veins, so much so that the struc- ture partakes of the nature of erectile tissue. They are also rich in lymphatics and nerves. The clitoris (Figs. 1, 208, 224, 488) is the analogue of the penis in the male, and is situated just below the anterior junction of the labia majora. It is a small erectile organ richly supplied with blood and nerves, and is attached to the sides of the pubic arch by its crura. In both the clitoris and the labia minora there are special nerve endings. Examination of a section of the chtoris shows the erectile nature of the structure. During sextual excitement the clitoris fills with blood and becomes swollen and firmer. It is supposed to be the most sensitive of all the genital organs to sexual contact, and on this account excision of the clitoris (clitoridectomy) was proposed and carried out for the relief of disturbances depending on sexual hyperesthesia, but the results were not such as to recommend the operation, and it is now rarely practiced. The vestibule (Figs. 44, 208, 213, 214) is an elliptical area situated between the labia minora. The sides are formed by the labia minora, the anterior end ex- lends to the clitoris, and the posterior end is formed by the junction of the labia majora. Into this vestibule four canals open — the urethra, the vagina and the duct of the vulvo-vaginal gland of each side. The urethral opening, the meatus urinarius, is situated just above the vaginal orifice (Fig. 214). In the nullipara it is small and round. In the multipara it is larger and somewhat star-shaped, and there is often some pouting or projection of the urethral mucosa. This change is due to the SAvelling and distortion during labor, from which the parts never" 378 DISEASES OF EXTERNAL GENITALS AND VAGINA return absolutdr to their former condition. The floor of the vestibule is formed of several layers of squamous epithehum and under this the subepithelial con- nective tissue. There are a few glands, some of which at times become enlarged. Fig. 472. Indicating the line of di\-ision of the urethra to give the ^'iew shown in Fig. 47-3. (Dudley — Practice of Gynecology ) Fig. 474. Cross-section of the Uretbra, showing the periurethral ducts (Skene's glands). L'. Urethra. A. Periurethral Ducts. (Dudley — Practice of Gynecology.') Fig. 473. The Urethra di\-ided so as to show the openings of Skene's glands. The openings are situated just within the meatus, one on either side. (Dudley.) The MEATUS UEI- NARius, as well as the urethra, is lined with stratified squa- mous epithehum on a ba-sis of connect- ive tissue rich in cells. This comiect- ive tissue of the meat u s and the urethra presents usually many typic- al lympl nodules of microscopic size. Just within the meatus, near the posterior wall, are X^ the openings of two divertula, one on either side. They are known as Skene's ducts or Skene's glands. The}^ are called also "periurethral ducts." Their size and shape and location are shown in Figs. 472, 473, 474, 475. They are important in that gonorrboeal infection may extend into them and persist there indefinitely. Just back of the lining of \ Fig. 475. This gives a clear idea of the size and relation of the periurethral ducti (Skene's gland.s). The floor of the urethra has been divided longitudinally, the end of tl'.e urethra raised and a probe introduced into each of the periureth-al ducts. (Skene— i>ise««e3 of Women.) THE VULVO-VAGINAL GLANDS 379 the vestibule there are two masses of veins, one on cither side of the vaginal orifice, called the bulbs of the vestibule (Fig. 476). The bulbi vestibuli lie just in front of the anterior layer of the triangular ligament. They are supposed to correspond to the corpus spongiosum of the male. In wounds of this region, or in operations, if these vascular bulbs are injured there is troublesome bleeding. The vulvo=vaginal glands are two glands situated beside the vaginal entrance, one on either side (Fig. 49) . They correspond to Cowper's glands in the male, though their relations to the triangular ligament is not so clearly defined, appar- ently varying some in different cases. They lie, as a rule, behind the anterior Fig. 476. The Veins of the External Genitals, including the "bulb of the vestibule," on the left side. V. Vagina. M. Meatus 1. Left venous "bulb." {Savage— A7iat07H!j o/ Pelvic Organs.) layer of the ligament, and may lie behind or in front of the posterior layer. Each gland lies very close to the lower end of the venous bulb of that side. The gland is a small reddish body about the size of a bean, and belongs to the racemose variety of glands. Its secretion is discharged through a small duct which opens just in front of the hymen, about the junction of the lower with the middle third of the side of the vaginal orifice. When the gland is normal, this opening has to be looked for rather carefully to be seen. When the gland has once become in- flamed, the opening is easily seen, for it is larger and is usually surrounded by a small reddened area. The mucous secretion of the gland acts as a simple lubri- cant to the parts and is discharged during sexual excitement. When inflamed, the gland is felt as a hard tender mass beside the vaginal opening Fig. (51), 38'J DISEASES OF EXTERNAL GENITALS AND VAGINA The hymen (Figs. 208, 209) is a circular or crescentic fold of mucosa and sub- mucous connective tissue, situated at the vaginal entrance and partially closing the same (Fig. 208). The shape of the hymen and the opening in it varies much in different persons. Fig. 209 shows several forms. The crescentic hymen and the circular hymen are the usual forms. The fimbriated h3^men has a dentated or fringe-like margin. The cribriform hymen presents a number of small holes. In certain cases of malformation, the hymen is absent. In other cases it closed entirely (imperforate hymen). The hymen is usually ruptured at the first sexual intercourse. In some cases "rupture of the hymen" amounts to nothing more than stretching, with slight abrasion. In other cases there is distinct tearing, with considerable pain and some bleeding. In rare cases there may be persistent and even serious bleed- ing. In some cases the hymen is so rigid or tender as to prevent coitus. Long- PL a~E v. Fig. 477. The Arteries and Nerve s of the external genitals. (Savage -Anatomy of Pelvic Organs.) continued sexual intercourse stretches the hymen until it is not at all prominent. Much medico-legal importance has been attached to the condition of the hymen, and, ordinarily, it is a decided help in determining whether or not coitus has taken place. But it is a well-established fact that an intact hymen is not absolute proof of virginity, nor is an apparently ruptured or stretched hymen absolute proof of sexual intercourse. Childbirth destroys the hymen as an intact ring. Usually after parturition there are only irregular tags of tissue left, the result of tearing and sloughing about the vaginal entrance. These irregular tags of tissue surrounding the vaginal POINTS IN ANATOMY OF VACINA 3S1 orifice are known as "canmculae myrtiformes," and result from child-birth only, not from sexual intercourse. Coitus does not usually destroy the hymen, l)ut simply tears it slightly and stretches it. The IJLOOD SUPPLY of the external genitals (Fig. 477) comes principally from the internal pudic artery, one of the terminal branches of the anterior trunk of the internal iliac. The LYMPHATICS EMPTY into the inguinal glands. Poirier calls attention to the fact that the lymphatics from the clitoris extend into the deep pelvic glands. Consequently in carcinoma of the clitoris proper (not its prepuce), the glands within the pelvis are soon involved. The NERVE SUPPLY (Fig. 477) comes principally from branches of the pudic and small sciatic nerves. In certain painful affec- tions of the external genitals, the pudic nerve is sometimes d'vided or resected to afford relief. VAGINA. The vagina is a musculo-membraneous canal extending from the vulva to the neck of the ute- rus, around which it is attached. It lies between the bladder and the rectum (Figs. 1 and 3). Its size and shape are very variable and it is capable of gi'eat distension, as is seen when the child passes through it in labor. The length of the vagina is ordinarily three to four inches along its anterior wall, and five to six inches along its posterior wall. It is constricted at its lower end, where it is partially closed by the hymen, and becomes dilated towards the uterine extremity. Normally the anterior and posterior vaginal walls lie in contact, and on cross-section the cavity is represented by a slit having somewhat the shape of the letter H (Fig. 478). The wide diameter of the vagina, some distance up the canal, is the transverse diameter, but the wide diameter of the vulvar cleft is the antero-posterior diameter. Furthermore, the anterior end of the vagina lies so far up in the narrow part of the Fig. 478. Cross-section of the Pelvic Structures, showing the rela- tions of the Urethra, Vagina, Rectum and Levator Ani Muscles. Notice how the vaginal walls fold so that the shape of the cavity approximates the letter H. Ur. Urethra. Va. Vagina. R. Rectum. L. Levator ani muscle. (Savage -Anatomy of Pelvic Organs.) pubic arch (in patients where the perineum has not been damaged) that there is not much room laterally. Consequently in introducing the speculum, the preferable way is to introduce one finger into the vaginal opening and press the perineum well back (Fig. 92), so that the vaginal opening is stretched antero-posteriorly and made to correspond in a measure with the vulvar . cleft, and then introduce the speculum obliquely as shown in Figs. 92 and 93. When the speculum is well past the entrance, so that it may be used to depress the perineum, it is then turned with its width in the transverse diameter of the vaginal canal (Fig. 94) and introduced all the way. From my 382 DISEASES OF EXTERNAL GENITALS AND VAGINA experience, I think this is decidedly the preferable way of introducing the specu- lum, when the perineum is intact -and resisting. I consider erroneous the state- ment by some authorities that the speculum should be introduced with the wide diameter transversely, " because the wide diameter of the vaginal canal is trans- verse." The speculum must first pass the vulvar cleft and vaginal entrance, and we must deal with the conditions found there before accommodating the speculum to the wide diameter of the canal proper. Of course, in a large propor- tion of cases the perineum is lax from damage and the primary anatomical rela- tions are destroyed, and the speculum may be introduced in any way without resistence. Relations. Fig. 1 shows the angle which the axis of the uterus normally bears to the axis of the vagina. The upper end of the vagina surrounds the lower end of the uterus. That portion of the cervix uteri projecting into the vagina is known as the vaginal portion (portio vaginalis). The attachment of the vagina extends higher on the posterior wall of the cervix than on the anterior. The vaginal mucosa is continued on the cervix as far as the external os. The upper end of the vagina is termed the "vaginal vault." The term "fornix" is also much used, the anterior fornix being that portion of the vault in front of the cervix, and the posterior fornix being that portion lying behind the cervix, and the right and left lateral fornix lying to the right and left respectively. With the for uterus in normal position, the posterior fornix is much deeper than the anterior, for the vaginal wall is attached higher on the posterior surface of the cervix than on the anterior. The vagina is surrounded by important structures. The anterior wall is in con- tact with the urethra and the base of the bladder (Fig. 1). The vaginal wall and bladder wall and the tissue lying between them, constitute the vesico-vaginal sep- tum. The posterior wall for the lower three-fourths of its extent is attached to the anterior wall of the rectum, except the very lowest portion, which is separated from the rectal wall by the perineum. The vaginal and rectal walls and the tissue lying between them, constitute the recto-vaginal septum. The upper fourth of the posterior wall is separated from the rectum by the recto-uterine pouch of peritoneum, known as the "cul-de-sac of Douglas" (Figs. 3 and 4). The sides of the vagina give attachment to fibers from the levator ani muscles and the recto-vesical fascia. Structure. The wall of the vagina presents three layers — an external connective tissue layer, a middle muscular layer and an inner mucous layer. The connective TISSUE layer serves to attach the vagina to the adjacent organs. It contains the external plexus of veins, and is composed of connective tissue filled with lymphatics and blood vessels, the veins being especially numerous. The attachment of the vagina anteriorly is firm in the lower third, where it is attached to the in-ethra. It is more loosely attached to the bladder in the middle and upper third, particu- larly the latter, and is easily separated in operating. The MUSCULAR LAYER contains involuntary muscle fibers arranged in bundles without distinct strata. Some of the bundles are longitudinal, some transverse and some oblique. The muscular layer is thicker at the lower than at the upper end. THE VAGINAL MUCOSA 'SfiS The MUCOUS layer, or the lining of tlie vagina, is apparently a modified epi- dermis. It presents on the surface the usual layer of squamous epithelium several cells thick and, beneath this, connective tissue rich in cells. The glands have all disappeared and the papillae are much smaller than are encountered in the ex- ternal genitals. The vagina normally contains no glands. The secretion found in the vagina comes from the cervix and the endometrium, principally the former. The vaginal walls are kept constantly moist with the secretion, and consequently the epithelium desquamates before it advances so far in the process of cornification as is seen in integument. In cases of prolapse, where the vagina is turned outside the vulva and is subjected to fridtion of the clothing and is kept dry by contact with the same, it becomes more like ordinary epidermis and shows well-marked keratin changes. The mucosa (epithelium and connective tissue immediately under it) is attached to the muscular coat by a submucous layer of loose connective tissue which is very rich in interlacing veins, about some of which are bundles of muscular fibres, forming a kind of cavernous tissue. The vaginal mucosa is thrown into numerous large folds called "rugae." Extending longitudinally along both the anterior and the posterior wall of the vagina is a prominent ridge, best marked in the virgin. These ridges are known as the "columns" of the vagina, and from them the rugae extend laterally. The columns and rugae become more or less obliterated by child-birth, so that in many multipara the vaginal walls are almost smooth. Vessels and Nerves. The blood supply of the vagina comes from the anterior trunk of the internal iliac, through the vaginal, uterine, middle hemorrhoidal and internal pudic arteries. These anastamose freely in the vaginal wall. The veins of the vagina are arranged principally in two plexuses that form complete vasculai* sheaths around the canal. One plexus is external to the muscular layer, while the other lies just beneath the mucosa. These veins form an intricate network and communicate freely with the plexuses of the other organs and with the plexuses of the broad ligament. The lymphatics from the lower third of the vagina, it is generally held, join those from the external genitals and empty into the inguinal glands. But Poirier, who has made a special study of the subject, claims that all the lymphatics of the va- gina empty into the pelvic glands and that when an injection of the vaginal lymph- atics is made, even just within the hymen, no injection material passes to the inguinal glands except through some anastomosing channels. The lymphatics from the middle third of the vagina empty into the hypogastric glands. Those from the upper third join with the lymphatics of the cervix uteri and pass to the iliac glands. The NEEVE SUPPLY of the vagina comes from pelvic plexus of each side. Jiy4 DISEASES OF EXTERNAL GENITALS AND VAGINA CLASSIFICATION OF DISEASES Of The External Genitals and Vagina. Gonorrhoea. Other Inflammatory Diseases of the Vulva — Simple Vulvitis, Folli- cular Vulvitis, Erysipelas, Cellulitis, Gangrene, Diphtheria, Eczema, Intertrigo, Herpes, Prurigo, Parasitic Diseases. Other Inflammatory Diseases of the Vagina — Simple Vaginitis, Para- sitic Vaginitis, Diphtheritic Vaginitis, Emphysematous Vaginitis, Ad- hesive Vaginitis. Ulcers of Vulva and Vagina — Simple Ulcer, Chancroid, Syphilis, Tu- berculosis, Malignant Disease, Ulcus Rodens Vulvae. Urethral Affections — Urethritis, Peri-urethral Abscess, Prolapse o: Urethral Mucosa, Urethral Caruncle. Vulvo-vaginal Gland Affections — Inflammation, Abscess, Sinus, Cyst. Non-malignant Growths and Swellings — Condylomata, Cysts, Fibro- mata, Lipomata, Stasis Hypertrophy, Elephantiasis, Pudendal Hernia, Pudendal Hydrocele, Hematoma, Varicose Veins. Injuries of Vulva and Vagina. Miscellaneous Affections — Kraurosis Vulvae, Pruritis Vulvae, Hyper- esthesia of Vaginal Entrance, Adhesions of Prepuce and Labia. (The more pronounced Malformations are considered in chapter xiii.) GONORRHOEA. Gonorrhoea is inflammation of the genital organs produced by the gonococcus. The term, when not qualified, is understood to mean gonorrhoeal inflammation of the vulva, vagina and urethra, i. e., gonorrhoeal vulvitis, vaginitis and urethritis. If the process extends into the uterus or Fallopian tubes or bladder, it causes com- plications known respectively as gonorrhoeal endometritis, gonorrhoeal salpingitis and gonorrhoeal cystitis. Gonorrhoea is sometimes referred to as "specific" vaginitis or vulvitis or urethritis. ETIOLOGY. Gonorrhoea is caused by contact of the affected organs with a gonorrhoeal dis- charge, usually in sexual intercourse. The infecting germ (the gonococcus) is a diplococcus, easily stained, and is found in large numbers in the pus cells of all acute gonorrhoeal discharges (Fig. 479). In chronic gonorrhoeal discharges it is GONORRHOEA 3g5 not found so abundantly, in fact, In some cases it is so scarce as to be very hard to find, and may even disappear entirely for a time. All discharges containing the gonococcus are capable of causing gonorrhoea. The slight urethral discharge from a chronic deep urethritis or from a stricture, pei-sisting months or years after an attack of gonorrhoea in the male, is very liable to cause gonorrhoea when brought in contact with virgin soil. A sad exemplification of this fact is seen in the many instances in which a bride is infected by her husband, who had gonorrhoea years before but supposed himself well. The consequence of such infection is that, instead of a healthy, happy woman with sons and daughters, the wife becomes a confirmed invalid in a childless home. This danger is not sufficiently appreciated by men generally — in fact, the man usually does not know the danger until too late. The responsibiUty of physicians in this matter is gi-eat, for the physician must decide when a man who has had gonorrhoea may safely marry. The report of the special committee appointed by the American Medical Associ- ation to consider this question, is worthy of study (Journal A. M. A., March 30, 1901). The committee was appointed to determine whether a man who has had gonorrhoea may ever safely marry, and, if so, when? Careful inquiries were made and replies were received from the leading teachers of genito-urinary surgery in this country and in Europe. Among the questions asked were the follovsdng, concerning of course gonorrhoea in the male: 1. Is gonorrhoea curable — so curable that the physician can confidently say to his patient, "You may marry now. You run no risk of infecting your wife"? 2. Upon what tests do you rely in order to determine positively whether the patient is wholly free from the gonococcus and is not infectious? 3. What period of time should elapse after the disappearance of the last evi- dence of the gonococcus before the patient should be permitted to marry? The following, I think, fairly represents the concensus of opinion of the author- ities quoted in that report: 1. Curability. Gonorrhoea is curable with the following exceptions: a. Gonorrhoea is not curable in the sense that the physician can guarantee that no infection will result therefrom, but so that in good conscience he can give an assurance that, in all human probability, no infection will result. b. There are a few cases (estimated by one authority as about 3%) which, on account of an especially deep-seated lesion or serious complications, are incurable. These patients can never safely marry. 2. Determination of Cure. All agree that the examinations must be thorough and repeated, and that only on the basis of repeated negative examina- tions, conducted over a considerable period of time, should the conclusion be reached that the patient is no longer infectious. The following points are insisted on; a. Absence of the gonococcus. b. Absence of pus germs. c. Absence of pus cells. 386 DISEASES OF EXTERNAL GE.VITALS AND VAGINA It is pointed out that the ordinary pus germs may cause trouble, and that eases have occurred in which the husband carried to the wife a pj'ogenic infection caus- ing serious pelvic disease, though the gonococcus had entirely disappeared and did not reappear in either husband or wife. 3. Time Limit. The period of time which should elapse after the disappear- ance of the last evidence of the gonococcus before the patient should be permitted to marry, is given by several authorities as one year. Others state three months to a year, depending on the circumstances of the case. Though the usual cause of gonorrhoea is sexual contact with an infected per- son, it maj^ exceptionally be caused by other means, as by contact with an infected towel or douche-nozzle or chamber utensil or closet-seat. PATHOLOGY. There is acute inflammation of the vulva and usually of the vagina and of the urethral mucous membrane near the meatus. There are present the cardinal signs of inflammation — heat, pain, redness and swelling. There is at first abnormal dryness of the parts, then a slight secretion, which rapidly increases in a day or two, and when the inflammation is well established it becomes a free yellow discharge, causing much irritation of the adjacent surfaces. There is the ordinary serous and cellular infiltration into the involved areas. The most superficial layers of epithelium are thrown off and the gonococci penetrate the underl}dng tissues to a gi-eater or less extent, depending on the severity and duration of the inflammation. There may be, later, a mixed infection, one or more of the ordinary pus germs being found with the gonococcus. The process may affect only the vulva or the upper part of the vagina. Some authorities state that this is the rule, but in my experience such limitation is exceptional in adults Tvdth primary infection, the first examination usually show- ing involvement of practically all of the vaginal wall. The gonorrhoeal inflammation is very liable to extend into one or both of the vulvo-vaginal glands or into the cervix uteri, and to remain active there after all other symptoms have disappeared. In the gonorrhoea of children the process is usually limited to the vulva and urethra, for the reason that penetration of the vagina by the infection carrier rarely takes place. In reinfection in adults, the process is comparatively mild and is usually limited to certain areas, for example the vulva or urethra or upper part of the vagina. The gonococcus seems to thrive best in the urethral m.ucous membrane, and it may penetrate into Skene's glands and remain there indefinitely. SYMPTOMS. Within a few days after suspicious coitus the patient complains of slight irrita- tion about the genitals. The parts feel dry and uncomfortable, and there may be a slight burning seasation. The feeling of discomfort increases and a discharge appears. About the same time or a little later, there is noticed a smarting or burning on urination and increased frequency of urination. Within two or three DIAGNOSIS (.!• liONORRHOKA 3g7 days of the beginning of the troiil^le the discharge is profuse and the signs of irri- tation (burning and itching and frequent painful urination) are marked. On inspection, the structures immediately surrounding the vaginal orifice are found reddened and painful on pressure. There is a yellow discharge from the vagina and frequently some discharge from the urethra. Acute gonorrhoeal discharge leaves a yellow stain where it dries on the clothing. On digital examination, the vaginal walls are found rough and hot and tender. Pressure on the anterior vaginal wall directed from the upper end of the urethra to the meatus, will bring to view one or more drops of urethral pus (Figs. 46, 47) . If the case has passed beyond the acute stage, the pain and discomfort are not so marked, but the discharge, more or less profuse, is still present, DIAGNOSIS. Gonorrhoea must be distinguished from vulvitis and vaginitis due to various other causes. The distinguishing characteristics of gonorrhoea are as follows: 1. Rapidity of development and severity of symptoms. The inflammation with its accompanying symptoms usually reaches its height within the first week and then begins to subside. As a rule with but few exceptioas, other infiammations of the vagina are not so severe nor the discharge so profuse. Occasionally there occur instances of very mild gonorrhoeal infection. This mild reaction to the the gonococcus is found almost exclusively in tissues that have suffered previous gonorrlioeal infection or that have become somewhat hardened by frequent child- bearing. 2. Involvment of the urethra and vulvo=vaginal glands or ducts. These exten- sions of the inflammatory process are rare in ordinary pus infections. In fact the involvement of the meatus and of the openings of the ducts of the vulvo-vaginal glands is so constant in gonorrhoea and so infrequent in other forms of inflamma- tion, that some authors hold that it can be determined whether or not a patient has ever had gonorrhoea by determining the presence or absence of evidences of previous inflammation of the structures just mentioned. Such evidences are a reddish margin around the meatus, with rolling outward and chronic congestion of the urethral mucous membrane, and a bright red spot marking the orifice of the vulvo-vaginal gland of each side (so called "gonorrhoeal maculae"), and some- times pressure on the gland will cause pus to appear at the opening of the duct (Fig. 50) Though such inflammation is usually caused by gonorrhoea, it occasionally occur from other causes, and consequently is not an absolute in^ dication of previous gonorrhoea. 3. No other apparent cause for the inflammation. Vaginitis other than gonor- rhoeal presents some cause for its existence, for example, pus infection following labor or abortion, the use of an infected douche-nozzle or the development of that local nutritive change which causes senile vaginitis. 4. Development within a few days after sexual intercourse. Considerable pain from slight traumatism and some bladder disturbance may follow coitus, particu- larly in the newly married, but such cases do not present the profuse yellow dis- 388 DISEASES OF EXTERNAL GENITALS AND VAGINA charge of gonon-hoea. In the case of a married woman, be careful not to question her in such a waj^ as to associate the trouble with coitus, as it may arouse her suspicion and cause trouble in the family. 5. Presence of the gonococcus. The presence of the gonococcus is determined by microscopic examination of the pus from the infected areas. With the tip of the applicator take a small amount of the urethral discharge and spread it in a thin film on two glass slides, or on cover-glasses if preferred. If using cover- glasses, spread four or five with the urethral pus, for some may get broken. If desired, specimens of pus may be taken from other locaUties also, for example, from the ducts of the vulvo- vaginal glands or from the upper or lower part of the vagina or from the cer^'ix, the specimens from the different localities being desig- nated a.s described on page 35. Staining the Gonococcus. One of the spread preparations, on a cover-glass or a glass slide, is stained by a methylene-blue solution. If the microscopic findings, taken in connection with the history of the case and the physical signs, make the diagnosis clear, no further etaining is necessary. If it is doubtful, then another prepared cover-glass or shde is subjected to Gram's decolorization method. The details of staining are practically the same whether the preparation be on a glass shde or on a cover-glass. The cover-glass is held in a forceps, while the slide is held in the fingers. We will suppose the preparations are on cover-gla.sses and were made some minut-es ago and laid aside, while the other steps in the diagnosis and treatment were carried out and the patient dismissed. The cover-glasses are now dry and ready to be stained. 1. Staining with methylene=blue solution. The steps in this process are as fol- lows: a. With the cover-glass forceps pick up one of the prepared cover-glasses, charged side up, and pass it, rather slowly, three or four times through the flame of the Bunsen burner or alcohol lamp. This "fixes" the specimen to the glass, so it is not washed off in the subsequent manipulations. b. Flood the prepared surface of the cover-glass, held in the forceps, with a few drops of Loffler's alkaline methylene-blue solution or 1% aqueous solution (fresh) of methjdene-blue. Hold the cover-glass high above the flame, so that it steams some but does not boil, for about half a minute. This stains the specimen. c. Then wash off the excess of stain with clear water. d. Then lay the cover-glass, charged surface down, on a clean glass slide and remove the excess- of water and dry the upper surface of the cover-glass with blot- ting paper. e. Put on a drop of cedar oil and examine with the oil-immersion leiLS. The microscope for this work should be provided with a 1-12 inch oil-immersion lens and an Abbe condenser. The cover-glasses should be very thin (No. 1). The No. 2 cover-gla.sses do not break so easily, but every once in a while there is one that is too thick for the use of the oil-immersion lens. The cover-glasses may be STAINING THE GONOCOCCUS 389 kept in alcohol in a flat wide-mouthed bottle, from which they are removed and dried (cleaned) as needed. In the methylene-blue specimen, the nucleus of each pus cell is stained a light blue. These nuclei are very irregular in shape and some of them are broken into two or more parts. They form the prominent light blue masses which largely occupy the field. The protoplasm, or body, or each cell is stained only very faintly, so faintly that it is ill-defined and hardly noticeable. All bacteria taking the stain, including the gonococci, are stained a very dark blue (almost black) and contrast well with the light blue nuclear masses. In vaginal specimens, the field is so filled with bacteria of various shapes and sizes, that the gonococci are more or less obscured. In urethral specimens, how- ever, there are as a rule but few other bacteria and consequently the gonococci are more easily found. Fig. 479. Specimen of pus from a case of Gonorrhoea, stained with Methylene-blue. This field contains two gonococcus-colonies, each within a pus cell. Only the nuclei of the pus cells are seen. The lower colony has the circular outline of the cell containing it. (Kolle and Was- sermsLQu—Handbuch der Pathogenen MiJcroorganismen) . si Fig. 480. Indicating the Shape of the diplococcus of gonorrhoea (Gono- coccus). (Byford — Manual of Gynec- ology.) In acute gonorrhoea the gonococci are seen lying in colonies in the pus cells (Fig. 479) with a few scattered between the cells. They occur as diplococci, the two together having about the shape of two coffee grains with their flat surfaces turned toward each other and slightly separated (Fig. 480). They are spoken of as "biscuit-shaped" or "roll-shaped." The occurrence of the gonococci in small detached groups (Fig. 479), is a striking feature in a good specimen. The little colonies occur inside the pus cells, the pus cell being recognized by the well-marked blue nucleus of irregular shape. The proto- plasm is hardly visible, but it is known that the gonococci must be within the cell be- cause they are gi-ouped so closely about the nucleus. In some cases the cell has broken down and the colony has outgi'own its dimensions. But the colony is still 390 DISEASES OF EXTERNAL GENITALS AND VAGINA close to the disintegrating nucleus, and the outlines of the colony have the general cir- cular shape of the cell which recently housed it. At some other point a cell has ad- vanced still further in the process of disintegration and has largely disappeared and the colony of gonococci has broken up, the individual gonococci being scattered through the space between the other cells. Only comparatively few of the pus cells show a gonococcus colony. In some cases several microscopic fields, filled with pus cells, may be looked over without seeing a gonococcus, and then a pus cell with a fine colony is encountered. The distinguishing characteristics of the gonococci are: a. Roll-shaped diplococci, occurring in detached groups or colonies. b. Presence within the pus cells. c. Decolorization by Gram's method of staining. Fig. 481. Specimen of pus from a case of Gonorrhoea, stained by Grain's Decolorization method. As explained on the next page, the gonococcus is a "Gram-negative" bacte- rium, and hence is decolorized by this method and does not appear in a specimen thus prepared. {Photomicrograph by Dr. C. Fisch.) In acute cases it is rarely necessary to stain by Gram's method. If the patient gives the clinical history and evidences of acute or subacute gonorrhoea, and the microscopic examination of the discharge shows a diplococcus within the pus cells, presenting the form of the gonococcus and occurring in large numl^ers and arranged in groups and without other bacteria to account for the discharge, that patient has gonorrhoea beyond- a reasonable doubt. If the patient presents the clinical evidences of acute gonorrhoea and micro- scopic examination of the discharge shows the a])scncc of a diplococcus, such as above described, the strong probability is that the trouble is not gonorrhoeal, tiiough it is well to make more than one examination ((lifr(M(uit d;iys) l)efore decid- ing adversely to the ordinary clinical evidences. In the acute inflammations that arc not gonorrhoeal, there is usually found some DECOLORIZATION BY GUAM'S METHOD 391 other germ, of sufficient virulence and in sufficient numbers, to account for the discharge. If there is any question as to the identity of the supposed gcjuoccn-ci, preparations should he subjected to drain's stain. 2. Decolorization by Gram's method. The feature of Gram's staining method is that certain bacteria arc stained by it (Gram-positive bacteria) while others are decolorized and hence do not appear in the specimen (Gram-negative bacteria) The gonococcus is " Gram-negative," hence it is not seen in a specimen so prepared. The value of this lies in the fact that certain other bacteria resembling the gono- coccus closely as to form, are Gram-positive and hence appear deeply-stained in a Gram preparation. Consequently in an acute case, if, after examining a specimen of pus stained with the methylene-blue solution, and finding bacteria of the form and distribu- tion of the gonococcus (Fig. 479), another specimen of the same pus is stained by Gram's method and these bacteria do not appear (Fig. 481), the bacteiia in question are certainly gonococci. The regular Gram method is quite long and troublesome. Dr. E. F. Tiede- mann, Professor of Pathology in Washington University, has devised a convenient modification of it. I quote the details from his published report. "Gram's discovery of his differential stain was a great achievement; but it is not used by the general practitioner as much as it should be, for it is complicated and time-consuming. In order that a method may be generally used, it must em- ploy simple and stable solutions and must be reliable and quick. I have there- fore endeavored to simplify and shorten Gram's method, and my experiments have resulted in the method described below: "1. Make a thin smear on a cover-glass. 2. Dry in the air. 3. Without fixation, flood the cover-glass, held by forceps, with a 2 per cent solution of crystal violet (Hochst, pure) in methyl alcohol. Allow the stain to act for 15 seconds; wash off the stain slowly with distilled water, by letting it fail on drop by drop from a pipette; this takes about 10 seconds; then wash both sur- faces of the cover-glass briskly with distilled water. 4. Flood the cover-glass with the following solution: Iodine, 1 gram. Potassium iodide. 2 grams. Distilled water. 100 cc. Allow this to act for 15 seconds. 5. Pour off the iodine solution and pour on 95 per cent alcohol, at first quickly, then slowly until no more color is given off. This takes about 10 seconds. 6. Wash thoroughly with distilled water and mount in water, or — after dry- ing — in balsam. The Gram-positive bacteria appear bluish-black. "The advantages are: Absence of fixation, the use of a simple methyl-alcohol solution of the dye which keeps indefinitely instead of the usual aniline-water gentian-violet solution, which is troublesome to prepare and keeps only for a few weeks, the use of ordinary 95 per cent alcohol in place of the absolute alcohol usu- 392 DISEASES OF EXTERNAL GENITALS AND VAGINA ally advised, and finally the shortening of the various steps; the entire process is? completed within one minute after the violet stain is applied. "Gentian violet or methyl violet may be used in the same manner and strength in the place of crystal violet, but the last named gives the best results. 'Method alcohol cannot be substituted for ethyl alcohol for decolorizing, be- cause it dissolves out all the stain from the Gram-positive bacteria. " It is possible to combine the violet stain with iodine in one solution and to stain with this mixture and then apply alcohol, which will remove the color only from the Gram-negative bacteria. But the results are not so good, and the method above given is already so simple that I do not advise the combination of the violet stain with iodine in one mixture. " Experience has shown that the alcohol removes the stain completely from the Gram-tiegative bacteria in a few seconds, but will take it from the Gram-positive bacteria only after the lapse of some minutes." Significance of the Microscopic Findings. In a few cases, diplococci showing the staining qualities of gonococci have been found in patients where apparently there has never been gonorrhoea. But such cases are exceptional and only serve to show that the positive diagnosis of gonor- rhoea must rest on the clinical symptoms and microscopic findings together, and not on the microscopic findings alone. As already stated, in acute and subacute cases there is rarely any difficulty in determining certainly whether the trouble is or is not gonorrhoeal. In chronic cases, on the other hand, there is often great difficulty. If a few ap- parent gonococci (shape, groupings, situated in pus cells, decolorized by Gram's method) are found, the diagnosis is not positive (may be "pseudo-gonococci"), though the strong probability is that the lesion is gonorrhoeal, if the history and ordinary examination findings point that way. The employment of culture meth- ods by a skilled pathologist may aid some in deciding the question in a doubtful case. If no apparent gonococci are found in a chronic discharge, that is not proof that the lesion is not gonorrhoeal. In many cases of chronic discharge from lesions that are undoubtedly gonorrhoeal, no gonococci are found, because they have temporarily disappeared from the secretion. But they lie hidden in the tissues from which the discharge comes and are still capable of causing infection, and they are likely to be excited to activity by anything that causes pelvic congestion, as, for example, sexual intercourse or an attack of pelvic inflammation. Thus it is seen that the presence or absence of apparent gonococci falls short of decisive import in a considerable proportion of cases of chronic discharge. Diagnosis in Doubtful Chronic Cases. In the doubtful chronic cases, just referred to, an approximately correct diag- nosis may be made by giving attention to the following points: 1. Careful consideration of the clinical history as pointing to previous gonor- rhoea or excluding the same. In this connection, it must be borne in mind that DIAGNOSIS OF GONORRHOEA IN CHRONIC CASES 393 in the adult married woman, particularly after the vagina has been toughened Ijy child-bearing, gonorrhoea may produce but slight inflammation of the vagina, and hence might be missed entirely in the history. A point against gonorrhoea is that the inflammatory trouble was apparently caused by infection following labor or abortion or by instrumentation or by some other sufficient cause aside from coitus. Remember, however, that an old gonorrhoea may be stirred up by labor or abortion. From a chronically inflamed vulvo- vaginal gland or cervix uteri, the infection may spread upward into the body of the uterus and there set up a puerperal gonorrhoeal endometritis. This may be the first decided intimatiou the patient has of her gonorrhoeal infection. The discharge from such a fresh focus usually shows undoubted gonococci in abundance, if the patient happens to be seen at that time. 2. Evidence of inflammation of the urethra or of the duct of one or both vulvo- vaginal glands. 3. The presence in the discharge of a germ presenting the characteristics of the gonococcus. In a patient who has once had gonorrhoea, the presence in the dis- charge of such a germ is strong presumptive evidence that the gonorrhoeal pro- cess is still active. 4. Effect of treatment. A chronic inflammatory trouble due to the gonococcus is usually more resistent to treatment than when due to other causes. 5. Tubal complications. Chronic salpingitis, is much more frequent and per- sistent in gonorrhoeal than in other forms of endometritis. Also, it is more fre- quently bilateral. 6. Sterility. Persistent steriUty is one of the marked characteristics of gonor- rhoeal inflammation, much more so than of the ordinary pyogenic infection. 7. History of gonorrhoea in the husband. This fact, if established, would of course help much in the diagnosis in a doubtful case. In such a case the husband should be seen and questioned. As a rule no question on this point should be asked the wife, as it might arouse suspicion in her mind, and cause domestic trouble that would bring more unhappiness than the pelvic disease. TREATMENT. The treatment of acute gonorrhoea in women, like the treatment of the same disease in men, has been the subject of much experimentation and of many differ- ent conclusions. The treatment employed by different authorities varies all the way from the most active and radical interference to practically no treatment beyond some external cleansing. Before stating in detail the methods, I would like you to get clearly in mind the principal purposes of the treatment. They are as follows: a. To prevent extension upward of the disease to the endometrium and Fal- lopian tubes. The extension to the Fallopian tubes is the most serious result of gonorrhoeal infection and condemns a large proportion of the victims to chronic invalidism or to a serious operation. In either case, there will probably be sterility. b. To completely eradicate the infection from the lower genital tract so that no infective discharge will remain. As long as one spot of gonorrhoeal inflammation remains in the vagina or in the vulvo-vaginal glands or in the urethra or in the 394 DISEASES OF EXTERNAL GENITALS AND VAGINA uterus, the discharge is infective and is a source of danger to the patient and to those around her. At any time, there may be an extension upward to the tubes or there may be infection of the eyes of the patient or of some one else in the house- hold. It is probable that a considerable number of the cases of gonorrhoeal vul- vitis in children come from accidental infection from a contaminated towel or closet- seat, in the home or elsewhere. c. To relieve the discomfort attendant on the inflammation and to prevent con- tamination of the patient's clothing and surrounding objects with the discharge. It must be recognized at the start that the principal influences preventing ex- tension upward of gonorrhoea, are the resistance of the tissues and the barriers (constrictions, cervical mucus) placed in the canal by nature for the purpose of protecting the deeper organs. The strength of this natural resistance to the spread of the disease varies much in different persons. In some cases the gonorrhoea is well limited, extending up- ward not at all or only by short steps at long intervals. In other cases it runs a rapid course from the external genitals to the inmost recesses of the genital canal. This marked variability in the course of the disease is easily demonstrated by closely questioning patients who give a history of gonorrhoea some months or years before. The favorite time for extension to the endometrium and Fallopian tubes, is dur- ing the last day or two of menstruation and the first few days following menstrua- tion. No measure of treatment should be employed that interferes with the natural protective influences. One point of particular importance, is to be very careful not to carry the infec- tion any further than it has already extended. For example, the examination and treatment should be confined to the inflamed vulvar surfaces alone, unless there is positive evidence (such as a profuse discharge) that the trouble has extended past the vaginal entrance. Likewise in vaginal gonorrhoea, no treatment or ex- amination should extend past the external os of the cervix uteri, unless there is unmistakable evidence that the gonorrhoea has extended into the cervical canal. A second important point is to use no application or instrumentation that will injuriously irritate the surfaces. Though such a strong irritating antiseptic ap- plication may kill most of the gonococci on the surface, it causes so much desqua- mation and irritation of the surface that it favors multiplication and penetration by the remaining gonococci and tends to cause, rather than prevent, extension of the process, both into the tissues and upward along the surface. On the other hand, when no treatment is employed, the accumulating irritating discharge and vast colonies of bacteria in the affected canal, caused marked irrita- tion, and favor extension deeper into the tissues and upward along the canal. I think the best results are achieved in most acute and subacute cases by a pro- gram about as follows: 1. Office applications. If inspection shows that the process is apparently con- fined to the vulva (including meatus urinarious and ducts of the vulvo-vaginal glands) be very careful not to carry the examining finger or the applicator pv TREATMENT OF ACUTE GONORRHOEA 395 other instrument past the hymen or hymen-remnants. Having secured tiie required specimen for microscopic examination, the parts are cleansed and the affected surfaces painted over with a 25% solution of argyrol or a 2% to 5% solu- tion of protargol. The application is made with a small cotton-ball (the size of a bean) caught in the end of the dressing forceps and dipped int(j a small amount of the solution poured out into a medicine glass. Or a cotton-wrapped ap- plicator may be used. Silver nitrate solution (1% to 5%) does very well, but is rather painful, and the discoloration it causes on the clothing and fingers is not removed by washing. After a free application of the medicine has been made, the surfaces are dried and some drying antiseptic powder dusted in. I use xeroform and boric acid (1 to 3) and find it very satisfactory, and without the odor that attaches to iodo- form. Most any non-irritating antiseptic powder will answer the purpose. If it is found that the patient experiences more smarting and burning after this drying of the surafce, the powder may be left off the next time. A large piece of absorbent cotton is applied to cover the vulva, the inner portion being so disposed as to lie between the inflamed surfaces, to keep them apart and absorb the discharge. The cotton is held in place by a T-bandage. If the examination shows that the process has extended up into the vagina and the tenderness has subsided so that the speculum may be used without pain, the speculum is introduced and the affected areas (usually, in the primary acute at- tack, the entire vaginal wall and vaginal surface of cervix) are painted with the 25% arg}'rol or one of the other solutions above mentioned. The vagina is then dried and the non-irritating antiseptic powder dusted in. The vulva is treated in the same way and covered with absorbent cotton, as above described. 2. Prescriptions. Give the patient a prescription for a concentrated antiseptic solution for making up an antiseptic wash or douche solution as required. I usually give the regular bichloride douche solution (see Formulse) . The bichloride tablets are cheaper, but they are dangerous to have about a house where children live or may come visiting. If the patient is nervous and sleepless and upset by the trouble, give a prescrip- tion for some sedative solution, such as the sodium bromid solution (see Formulse), with instructions to take at 8 and 10 p. m. and 8 a. m., and repeat after three hours, when very restless. If the patient is not very nervous, but complains of marked bladder irritability (frequent painful urination) give the hyoscyamus and potassium citrate mixture (see Formula) instead of the bromide. If there is neither marked bladder irritability nor decided nervous disturbance requiring a prescription, it is well to give the patient some one of the internal urinary antiseptics, which tend to prevent extension of the trouble along the ure- thra and tend also to allay discomfort there, such as urotropin or cystogen. Tell her to get also a pound of surgical absorbent cotton. 3. Instructions. Give the patient the following instructions: a. When you reach home, lie down and stay in bed practically all the time, as long as there are any acute symptoms (pain, burning, bladder irritability). It is 396 DISEASES OF EXTERNAL GENITALS AND VAGINA especially important to be quiet in bed during menstruation and for some days afterward. b. Keep the bowels well open every day, as that tends to diminish the pelvic congestion. Free bowel movements should be secured by internal laxatives. No enema is permissible, ordinarily, because of the danger of carrying the infection into the rectum. For the same reason, rectal suppositories should not be used. c. Keep the parts covered with a large piece of absorbent cotton, held in place by a bandage or napkin such as is used during menstruation. As often as the in- ner surface of the cotton is soiled it should be removed and a fresh piece applied. This removes the discharge from the inflamed surfaces and prevents the irritation that would result from its accumulation there. More important still, it prevents general contamination of the clothing and hands and other surfaces by the infective discharge. Each time, after the patient changes the dressing, she should immedi- ately cleanse her hands with soap and water and then in the antiseptic solution which she uses for a douche. In explaining to the patient the necessity of keeping the infected surfaces cov- ered with cotton, and of changing the cotton often and of washing the hands well afterward each time, take particular care to arouse no suspicion that might lead to domestic infelicity. Your work is to lessen suffering, not to cause it. If the patient should become apprised of the fact that her husband has been untrue to her and in addition has brought to her a loathsome disease, her suffering would be far greater than any physical distress that might result from the disease, even though it goes on to pelvic suppuration requiring operation. I have no sympathy for the man who commits adultery and brings a disease of the women of the streets to the pure woman whom he has promised to love, cherish and protect. He reaps his reward in due time. It is not to protect him that I mention the need of caution, but to protect the woman herself from unnecessary suffering. This can usually be accomplished by the exercise of a little tact. To the patient's question, "What is the trouble?" a good answer is " Inflammation. "- Then pass quickly to the directions concerning treatment. At a convenient time mention that the discharge is irritating and that she must be careful that none be carried to the eyes on contaminated fingers or serious inflammation of the eyes may result. The patient usually becomes so interested in the treatment that she forgets to inquire as to the cause of inflammation. However, if she asks, as they sometimes do even when having no suspicion, "Doctor, what is the cause of inflammation?" I usually reply that "Inflammation is due to various causes," in a tone that shows that I have neither the time nor the inclination to give the pa- tient a course in medicine in order that she may understand all the details about inflammation. This rarely fails to stop troublesome questions. Of course, some patients are so suspicious that they will not stop questioning until they have got- ten all the information they can possibly secure, while others are well aware of the nature of the trouble and question the physician out of curiosity or to see if he has a grasp of the situation. With such I do not waste much time. I will not tell them the exact nature of the trouble, when I do not think best to do so, neither will I tell them an untruth. When pressed too closely, I simply remind them that their TREATMENT OF ACUTE GONORRHOEA 397 principal desire is to get well, that they have come to me for treatment, that I am giving tlieni the treatment, and have given them all the information necessary to treatment. If not satisfied with that they may go elsewhere. Of course, some patients know or will probably find out in a short time the nature of the trouble. But I prefer that they find out from some other source, if at all. My imparting the information, or confirming that imparted by some of their anxious friends, will do no good and may do much harm. d. Use the weak antiseptic wash every 3 to 6 hours, depending on the amount of discharge. If the vagina also is involved, have the patient, in addition to the external .washing, take a douche of the weak bichloride solution about every eight hours. The internal remedies mentioned are to be used as indicated by the special symptoms in the case. e. The patient should be directed to return for local treatment every second or third day, provided she can do so without aggravating the inflammation. If there is much discomfort in walking or if the patient must come a long way to reach the office, she will experience more benefit from remaining quiet at home and following the directions already given for the treatment there. 4. When the patient can come to the office without detrimen', treat the affected surface just as described for the first visit. Such treatment, so applied as to cause no irritation, seems to me to aid materially in diminishing the patient's discomfort and in hastening the subsidence of the inflammation. The treatment is repeated every second or third day until all inflammation has disappeared from the affected surfaces, the intervals being gradually lengthened as improvement takes place. I do not think it advisable during this first part of the attack, that is, in the first two or three weeks, to swab out the lower part of the urethra or of the cervical canal, or to inject medicine into Skene's glands or into the ducts of the vulvo- vaginal glands. Such treatment is likely to carry the inflammation further in than it might otherwise go, and may make permanent an infection which nature would throw off if given a little time. If inflammation in any of these situations persists into the chronic stage, then they require particular treatment. In those very severe acute cases where the patient suffers a great deal from the burning, itching, smarting and throbbing pain, and the trouble is increased when the patient stands, she should be put to bed and kept there until the most acute symptoms have disappeared. In the meantime, she should follow the directions given for the treatment at home. If the weak bichloride solution seems to cause any irritation (it does with some patients), use a weak |% lysol solution or some other antiseptic in weak solution. The potassium permanganate douche (see Formulae) is effective. The principal effect of the wash and douche is to remove mechanically the irri- tating secretion. It may be used warm or tepid or cool, as found most agreeable. In cases where the smarting and itching are marked, the 25% argyrol may be applied with the patient in bed, by bringing the patient around in the bed, with each foot on a chair, as for a vaginal examination (Fig. 116). If neither the cleansing nor the argyrol applications relieve the smarting about the external genitals, give the patient a prescription for the "lead and opium wash" (see 398 DISEASES OP EXTERNAL GENITALS AND VAGINA Formulse) and direct her to use it freely, dabbing it on uith cotton balls fre- quently enough to keep the surfaces moist with it. In some of these severe cases, a hot sitz-bath every 4 to 6 hours gives consider- able reUef, Treatment of Chronic Gonorrhoea. A chronic gonorrhoea! discharge is due to persistence of the specific inflammation in one or more isolated areas. When such a discharge persists after the inflamed surfaces generally have returned to normal (i. e, after 3 to 6 weeks, depending on the severity of the inflammation), make careful search for its exact source. The situations in which the inflammation is likely to persist are the: Vulvo-vaginal glands or ducts. Skene's glands, in the urethra. Upper end of vagina. Cervix uteri. Corpus uteri. In Vulvo=vaginal Glands or Ducts. Persistence of the gonorrhoeal inflammation in the duct of a vulvo-vaginal gland, is indicated by reddening about the mouth of the duct and by a discharge from it, a drop of which may usually be pressed out. Microscopic examination of this discharge usually shows gonococci in abundance, though in some old cases they may disappear temporarily. The treatment for this condition is to make an application of 25% arg}a-ol or 5% to 109o protargol about eveiy other day. The acute and subacute symptoms have all disappeared, and the patient may now come to the office as often as necessary, -udthout any probability of disturb- ance from the exercise. The application of arg}^rol or protargol to the interior of the duct is made by a fine applicator with a thin cotton ^\Tapping. The mouth of the duct should be opened so it will easily admit the applicator carrying the medicine. Occasionally the necessary widening may be effected by simple dilatation. Usually, however, it T^ill be necessary to incise the opening so as to give a wide entrance. A small piece of cotton soaked in 20% cocaine solution is laid over the area, a small amount being pushed into the opening a short distance. Leave this in place 5 minutes. Then introduce into the duct the sharp point of a slender bistoury and make a cut outward or downward from an eighth to a quarter of an inch. If the external application of cocaine does not obtund the sensibility, as tested by the bistoury point before cutting, inject some ^-% cocaine solution or some of the Schleich solution No. 2 (see Formula?) into the area to be incised. When the duct is thus made accessible, make a thorough applicati^m to its in- terior, taking care, however, not to carry the infection into the gland if it has not already gotten there. The other duct if involved is treated the same way. TREATMENT OF CHRONIC GONORRHOEA 399 If the inflammation subsides the appHcations are kept up until all discharge ceases, lengthening the intervals as improvement takes place. There are usually other points, as in Skene's glands, or in the cervix, that require treatment at the same time. If no decided improvement appears after a few applications, the affected duct with its gland needs to be extirpated. Also, if the gland shows evidence of chronic involvement (firm nodule in that situation) it requires extirpation, for as long as it remains, it prevents complete cure and the discharge from it is a source of danger. If an abscess forms in the gland, it is allowed to develop until the gland is proba- bly destroyed and the collection is near the surface, covered only by a thin wall of tissue. It is then opened freely. If the abscess is well developed so that all septa are destroyed and the recesses form part of the main cavity, there may be complete healing afterward and an end of the trouble. If a second abscess forms later, however, that means that portions of the infected gland remain, and in such a case, all the involved indurated tissue should be extirpated, after the abscess has been drained and all acute symptoms are gone. When it is necessary to wait a few days for an abscess to get in good condition for opening, the patient is directed to stay in bed and make hot applica- tions of absorbent cotton wrung out of very hot water or weak antiseptic solution, and covered with oil silk. As a rule the pain is not severe until the abscess is ready to open or about ready to break. Then the patient may come to the office, or, if movement is very painful, it may be opened at her home. In Skene's Glands. When the gonorrhoeal inflammation invades these peri- urethral ducts it may remain there indefinitely, causing symptoms of chronic ure- theritis or chronic cystitis and a persistent infective discharge. There is redness about the urethra and pouting outward of the swollen urethral mucosa. If the patient has passed through parturition, the opening of the duct on each side may usually be seen by rolling out the urethral mucosa (Fig. 48) . If the duct is open a drop of pus may be pressed from it. If the duct is closed, a small abscess forms in it. To treat these conditions, apply a pledget of cotton soaked in a 20% solution of cocaine, pushing a part of it a short distance into the urethra. Leave this in place five minutes and then proceed as follows: If the duct is open, inject a 25% solution of argyrol into it with a hypodermic syringe. Use a needle the point of which has been filed round and smooth, so it will easily pass into the duct without penetrating the wall. Fill the duct with the solution so that it comes in contact with all the recesses. This is simply a small duct. There is no gland back of it, into which infection may be carried, so the medicine may be injected freely. This injection is repeated every few days, at the same time that other infected structures are treated. If the inflammation persists in spite of this, then dilate the urethra and slit open the ducts and treat their interior directly with the solutions already mentioned. Some prefer to make very strong applications to the ducts after they are slit open, for example, carbolic acid and tincture of iodine, half and half.. The slitting open and treatment of Skene's ducts may be done under cocaine anesthesia. In some 400 DISEASES OF EXTERNAL GENITALS AND VAGINA cases there are other chronically infected areas that need painful treatment re- quiring a general anesthetic (extirpation of a vulvo-gland or dilatation and curet- ment of the uterus or excision of infected cervical tissue) , and the urethral ducts may be taken care of at the same time. In Vaginal Vault. Persistent inflammation at the vaginal vault is due usually to an irritating and infective discharge from the cervical canal. The chronic uterine infection, may be located in the cervix or in the body of the uterus. The treatment of these conditions will be found under inflammatory diseases of the uterus (see chapter vi.). Occasionally there will be persisting inflammation of the vaginal vault without involvement of the cervical canal, the cervical discharge being practically clear mucus, though considerably increased in amount by the hyperemia. Whether the inflammation at the vaginal vault exists alone or is secondary to chronic gonorrhoeal endocervicitis or endometritis, it requires treatment. There are two methods of treatment — the glycerine-tampon treatment and the dry treatment. 1. Glycerine-tampon Treatment. Introduce the speculum, expose the cer- vix and vaginal vault, cleanse the surfaces with an antiseptic solution, and tieat the interior of the cervix if it requires treatment. Cleanse the surfaces again and dry them and then apply a 25% argyrol or 10% protargol or 10% silver nitrate solution to the vaginal vault and vaginal surface of the cervix. Wipe out the excess of fluid and then apply an absorbent-cotton tampon with the inner end soaked in 10% ichthyol-glycerine or 10% protargol-glycerine. It is supposed that the glycerine, by its hygroscopic action, helps to work the deeper gonococci towards the surface, where they may be acted on by the antiseptic. The tampon should be packed in rather firmly, so as to stretch the vaginal wall. This firm packing of the vaginal vault, smooths out the wrinkles and brings the gonococci nearer the surface. It has much the same effect that the passage of a large-sized sound has in chronic gonorrhoeal urethritis in the male. This firm tamponade of the upper part of the vagina is best applied with the pa- tient in Sims' posture or in the knee-chest posture. If there is much uterine discharge, this tampon must be removed by the patient in 8 to 12 hours, and the antiseptic douches continued until she returns in two or three days for the next treatment. If the uterine discharge is slight, the tampon may be left in 24 hours, and then removed and the douches continued until the next treatment. If there is decided infiltration and thickening of the vaginal wall, it may be ad- vantageous to use 25% ichthyol-glycerine on the tampon, for a few times. This causes desquamation of the superficial layers of the vaginal mucosa, thus bringing the medicine closer to the bacteria, and permitting better penetration of the affected tissues by the medicine. 2. Dry Treatment. Expose the vaginal vault with the speculum, cleanse the surfaces, treat the interior of the cervix, if it needs treatment, and cleanse the sur- faces again. Dry the vault well and apply the 25% argyrol, or 10% protargol or 10% silver nitrate to the affected surfaces. Apply this thoroughly and let it soak into all the fine depressions. Then dry GONORRHOEA IxN CHILDREN 4()1 the wall again and dust in a lai-ge amount of some astringent-antiseptic drying powder. I use a powder composed of tannic acid (1 part), xeroform (1 part) and boric acid (3 parts). This is put in freely with the powder-blower. For throwing powders in large quantity into the upper part of the vagina, I find the ordinary 8-ounce Politzer-bag very convenient. The tip is unscrewed, the bag filled about one-third full of the powder and the tip screwed on again. Now, by tipping the bag, the powder runs into the tube, and little or much, as desired, may be thrown to the top of the vagina. If the tube clogs with powder, turn the tube end up and tap the bottom of the bag on some solid surface. This jars the powder out of the tube and clears it for use. Of course, if the powder gets damp, then the tube must be cleansed with an applicator, and possibly the bag emptied and fresh powder put in. After the powTler has been dusted into the vagina, then a good-sized cotton or wool tampon is spread at its upper end and a quantity of the same powder placed in the depression, and the tampon carried to the vaginal vault. One or two smaller ones may be packed below it to hold it well in place. This constitutes a "dry treatment." If there is but little discharge from the cervix, this tampon may be left in place for two days, the patient returning then to have it renewed. In such a case the powder should be dusted in freely between the tampons, in order to have a strong antiseptic effect and prevent decomposition during the two days that the tampon- ade is in place. When the patient returns the tamponade is removed, the vagina thoroughly cleansed and another dry treatment given. These are continued until the vaginal wall has apparently returned to a normal condition, then the treatment is stopped and the case watched. Examinations, to determine the amount of discharge and the condition of the vaginal vault, are made at intervals of a week or so, and also microscopic tests of any discharge that appears. In a case where there is much uterine discharge, the tamponade must be re- moved in 24 hours and antiseptic douches continued until the patient returns for the next treatment. In such a case the tampons must be arranged with strings so that the patient may remove them easily. This modified dry treatment is very useful in cases where an endocervicitis is being treated at the same time. However, in the cases of persistent uterine discharge, it is useless to continue this treatment except as a palliative measure. As long as the infective uterine discharge continues, there will necessarily be irritation of the vaginal vault. In such a case, effective treatment for the chronic uterine inflammation is the import- ant matter. In Cervix and Corpus Uteri. Gonorrhoeal inflammation of the uterus is consid- ered in chapter vi. Gonorrhoea in Children. Gonorrhoeal inflammation in female infants and children is more frequent than is generally supposed. In any case of severe or persisting discharge from the vulva, microscopic examination should be made in order to establish the presence or absence of gonorrhoea. 402 DISEASES OF EXTERNAL GENITALS AND VAGINA In infants and children the process is more likely to be confined to the external genitals, for usually there has been no penetration into the vagina by the infecting a^ent. Some of these cases are due to rape, but probably the most of them are due to accidental contamination from soiled clothing or closet-seat or from the nngers of the mother or attendant. The principles of treatment are the same as for the adult — namely, frequent cleansing, the use of a reliable gonocide preparation and the exercise of care not to carry the infection higher than the surfaces already involved. Particular care should be taken to instruct the mother as to frequent cleansing of the parts with warm water or with a mild antiseptic wash and as to keeping the parts covered to pervent contamination of the clothing by the discharge. Argyrol is an excellent gonocide for use in these cases, as it causes little or no pain. Start with a weak solution (5%) and advance to the stronger (25%) as the patient be- comes accustomed to it. If the vagina is involved, the washing out, and also the application of the gonocide, may be carried out through a small soft-rubber catheter, SIMPLE VULVITIS. Simple vulvitis is superficial inflammation of the external genitals due to irri- tation or to infection with ordinary pus germs. Sometimes it takes the form of scalding or chafing. Etiology. The predisposing causes of simple vulvitis are poor general health, and local con- ditions which cause pelvic congestion, for example, pregnancy and pelvic tumors. The exciting causes are as follows: 1. An irritating vaginal discharge. In the various forms of acute vaginitis and acute endometritis, the discharge alone may be sufficiently irritating to cause pro- nounced vulvitis. In chronic vaginal discharge there may be considerable itching, and the conse- quent scratching and friction is principally responsible for the inflammation. In children this is a very frequent cause of troublesome and persistent vulvitis. 2. Irritating urine. Dia" ;uic urine may cause vulvar irritation with resulting chronic inflammation and thickening of the tissues. In this condition there is a brawny induration with sometimes considerable enlargement. Other substances in the urine, such as pus, or high concentration of the urine, may cause irritation leading to scratching and consequent vulvitis. 3. Parasitic affections. In pediculosis pubis, the pediculi are located about the pubic hairs, where they cause much itching and irritation and may lead to vulvitis. Ascarides (the thread-worm from the rectum) may cause severe scratching and vulvitis. In persistent vulvitis in children without apparent cause, the stools should be examined for the presence of the thread- worm or "seat- worm" as it is sometimes called. 4. Masturbation. Friction from masturbation may lead to inflammation of the external genitals. There is usually some irritant that first causes scratching and the masturbation is an after-development. In children this may lead to se- TREATMENT OV SIMl'I.K VULVITIS 4(J3 vere vulvitis. In older persons it more frequently causes simply hypertrophy of the labia minora. 5. Lack of cleanliness. In exceptional cases, this alone may act as a cause, but usually it serves only to aggravate the irritation due to some of the other causes mentioned. 6. Acute exanthemata. In eruptive diseases, the same process that affects the skin elsewhere may effect the vulva where, on account of the local heat and moist- ure, there may result much irritation and inflammation. Pathology. In acute vulvitis there are the usual signs of inflammation, the intensity of the signs depending on the severity of the process. If very severe or if there has been much scratching, there may be denuded areas discharging serum or pus. If the inflammation has been present a long time and is consequently in the chronic stage, there is cellular infiltration of the tissues, with induration and discoloration and frequently considerable hypertrophy. Symptoms and Diagnosis. The symptoms are itching and burning and heat about the genitals, ^\dth red- ness, swelling and discharge. There may be many abrasions due to scratching, and also small ulcers from the same cause. Often there is burning on urination and increased frequency of urination. In the chronic stage, the secondary condi- tions just mentioned under pathology are noticeable. Gonorrhoeal vulvitis is distinguished by the characteristics mentioned under gonorrhoea. In this connection it must be kept in mind that simple vulvitis may, in exceptional cases, lead to simple urethritis in the patient and even in her hus- band. Treatment. After determining certainly that gonorrhoea is not present (for it requires more active measures) proceed with the treatment of the simple vulvitis as follows: 1. Secure cleanliness. The parts should be washed several times daily with a carbolic solution or other mild antiseptic solution. I^ Acid Carbolici Glycerini, aa 90 c.c. Sig. Teaspoonful to a pint of water. Use as a wash several times daily. Small balls of absorbent cotton are very convenient for applying the wash to the surface and for removing the discharge. This keeps the parts clean and to some extent relieves the itching. After each washing, the parts should be thoroughly dried and then kept dry by being dusted freely with some drying powder, for example, stearate of zinc or bismuth subgallate or bismuth subnitrate or boric acid or equal parts of bismuth subcarbonate and prepared chalk or one of the numerous preparations of "talcum powder" prepared for toilet use. The in- 404 DISEASES OF EXTERNAL GENITALS AND VAGINA flamed surfaces should be kept separated by a pledget of cotton placed between them and renewed as soon as it becomes wet with the discharge. 2. Remove the cause. If the vulvitis is due to a discharge from vaginal or uterine disease, the nature of the disease must be determined and appropriate treatment, as described elsewhere, employed. In the case of uterine disease, if the discharge can not be checked at once it may be kept from irritating the vulva by tampons placed against the cervix and renewed often enough to absorb the dis- charge. In children there is often what seems to be simply loss of tone with excessive secretion, giving a vaginal discharge. If this condition does not yield to tonic treatment and external cleansing measures, the treatment described for vaginitis in children should be employed (see page 415). If diabetes or other marked urinary disturbance is present, it ^dll be discovered in the urine analysis, and must be given suitable treatment. In pediculosis pubis, a few inunctions of oleate of mercury will kill the parasites. If ascarides cause the trouble, give the following enema every other day until the worms disappear. ^ Infus. Quassiae, 120 cc. Sig. Four tablespoonfuls to a pint of warm water. To be used as a rectal injection, as directed. In masturbation, remove all local irritation, keep the genitals cleansed, give bromides to diminish the irritability of the sexual center and, if necessary, appea' to the reason and pride and fear of the child or adult, as the case may be, to pre- vent the continuance of the habit. 3. Make sedative or astringent applications. If the inflammation is acute and accompanied by burning and itching, not relieved b}' the cleansing measures, the lead and opium wash (see Formulae) may be used. A thick layer of absorbent cotton, or a soft cloth, should be soaked in this solution and applied to the geni- tals after the cleansing w^th the carbolic wash. The lead and opium mixture may be kept applied to the genitals as long as the severe burning and smarting are present. It usually gives the desired relief. The borax and opium wash (see Formulae) is another sedative application w^hich is used in the same way. In some cases it may be necessary to apply cocaine solution (4%) occasionally, when the irritation is most marked. A small piece of absorbent cotton wet in the solu- tion may be rubbed over the inflamed areas or applied to them for several minutes. Continuous applications of cocaine solution for any considerable length of time is not advisable on account of the danger of absorption. In some cases in which an irritating discharge from the vagina or urethra can not be stopped, the surfaces coming in contact with it may be somewhat protected by covering them with zinc oxide ointment. The ointment should be applied each time after the gentials have been cleansed with the carbolic wash and wiped dr}-. The addition of carbolic acid (2% to 5%) makes the ointment more effective in relieving pruritis. If this does not give relief, cocaine (2% to 10%) may be ad I led. Astringent and antiseptic applications have a direct effect toward diminishing the disease, and in most cases they can ])e used from the first. If the inflammation ERYSIPELAS OF VULVA 405 is acute and is accompanied by much discharge, the 25% argyrol solution is bene- ficial. It should be applied carefully over all the inflamed surface every second or third or fourth day. The zinc sulphate and hydrastis wash (see Formula;) is a good astringent application which may be applied by the patient. 4. Internal Treatment. Administer tonics or sedatives or other internal reme- dies as indicated by the conditions present. Patients in poor general health should have appropriate tonic treatment. If there is chronic constipation, laxatives should be given. If there is much urethral irritation, as indicated by frequent or ])ainful urination, give the hyo8C}'amos and potassium citrate mixture (see Formu- hc). If the urine is concentrated, direct the patient to drink an abundance of water. Lemonade, not too sweet, is pleasant for a change and helps to make the urine less irritating; If the patient loses sleep or is made nervous by the vulvar irritation, it is well to administer a mild sedative, such as sodium or strontium bromide. FOLLICULAR VULVITIS. Follicular vulvitis occurs in adults. It is characterized by the inflamma- tion being confined principally to the hair follicles and sebaceous glands, the in- flamed structures being represented by small red papules scattered over the labia (Fig. 216). The causes, symptoms and treatment are the same as described under simple vulvitis. This form of vulvitis is prone to become chronic and resist treatment, consequently it should be treated vigorously. The measures mentioned under simple vulvitis (acute and chronic) should be used. Also the following sometimes gives relief. i^ Liq. Ferri Subsulphatis, 4. Glycerini, qs. ad., 30. Sig. Apply two or three times daily with a camels-hair brush. If pus forms in the follicles, they should be evacuated and then washed out with Iwdrogen peroxide. If there is much local inflammation, hot compresses wrung out of weak carbolic solution may give much relief. Follicular vulvitis sometimes appears during pregnancy and disappears spon- taneously afterward. In rare cases the irritation has become so severe that it caused abortion. ERYSIPELAS OF VULVA. Erysipelas of the vulva, like erysipelas elsewhere, is a rapidly spreading inflam- mation produced by the streptococcus pyogenes. Etiology and Pathology. The streptococcus pyogenes, or "streptococcus ery- sipelatis," as it is sometimes called, enters through a crack or scratch or abrasion or other open place in the protecting epithelium. Once within the subepithelial tissue it multiplies rapidly, causing marked inflammation with a superficial parch- ment-like induration of the involved surface. There is also inflammatory edema 406 DISEASES OF EXTERNAL GENITALS AND VAGINA of the deeper tissues, causing marked swelling of the vulva. The infk,mmatory process spreads rapidh' by a well defined margin which is red and slightly raised. If the inflammation is intense, small vesicles may appear at various places on the surface and rupture, discharging serum. The process may extend up onto the abdominal wall or out onto the thighs or into the vagina. Symptoms and Diagnosis. In tire beginning there is usually a chill, followed by considerable fever and the general disturbance usually associated with fever. The patient complains of heat and throbbing in the external genitals. The fever continues and swelling of the vulva is noticed. The patient then comes for exam- ination, wliich reveals the condition described under pathology. Later, pus may form. In the diagnosis, differentiate from scarlatinal rash on vulva, from inter- trigo, from bichloride rash, from cellulitis of vulva and from hematoma. Treatment. Considerable relief will be afforded by applying pieces of absorl^ent cotton, or gauze, soaked in carbolized olive oil (1 to 2%). The exclusion of air seems to diminish the burning. The application of an ice-bag outside the oil dress- ing, tends to check the pruritis and the swelling. The bowels should be moved well. If the fever is high, it may be reduced by cool sponge-baths or by some of the reliable antipyretics. Quinine in moderate doses and tincture of tlie chloride of iron in large doses are time-honored remedies for infective processes. An abund- ance of water should be given to lielp the skin and kidneys in elimination. If the patient is weak, strychnia and other stimulants and tonics are indicated. In serious cases, some reliable antistreptococcus-serum should be used freely. I have much confidence in Steam's streptolytic serum, which I have used with satisfactory results several times. In a recent puerperal case of rapidly spreading erysipelas of the brea.st, with a temperature of 106°, the piocess was promptly cliecked by tlie free administi ation of this serum. On the other hand, in some cases, the serum has no apparent effect. The ''opsonin" treatment elaborated by Wright, promises to be of benefit in all infective processes, but it is still in the experimental stage. Unguentum Crede is an excellent local application for the inflamed area. Other local applications, found by experience to be more or less effective, are the bichloride ointment (see Formula^), carbolized licjuid vaseline (o'^i painted over the surface with a camels-hair brush, ichthyol and glycerine equal parts or ichthyol and vase- line equal parts. Subcutaneous injection of various antiseptic solutions at the spreading margin, has been recommended. But this gives the patient considerable pain, and the results are uncertain and not encouraging. If collections of pus form, they should be incised and the cavities washed out with hydrogen peroxide and drained. PHLEGMONOUS VULVITIS. Phlegmonous vulvitis is that form in which the bacteria (u.'^ually the staphylo- coccus pyogenes aureus or alijus) penetrate to the subcutaneous connective tissue and cause inflammation there. It is known also as "cellulitis" of vulva and as GANGRENOUS VULVITIS 407 "lymphangitis" of vulva. It lacks tlio superficial parclunont-liko imluration of erysipelas. Etiology and Pathology. Anything that causes an abrasion about the vulva, through which bacteria may reach the connective tissue, may lead to phlegmonous \ulvitis. Any of the previously mentioned forms of vulvitis may be followed by this form. Injuries to the vulva or furunculosis, may lead to the same. The ]iathologioal changes are the same as in phlegmons elsewhere. There is marked inflammation of the connective tissue and of the lymph channels. Resolution may take place or the process may go on to suppuration. Occasionally suppuration of the inguinal lymphatic glands occurs. Symptoms and Diagnosis. The symptoms are those of simple vulvitis with the addition of pain and swelling, indicating deeper inflammation. Sometimes there is considerable fever, but not always. The swelling may be very marked, the inflammatory exudate sometimes distending certain structures almost beyond recognition. It may be confoimded with hematoma of vulva. Tli-e latter is distinguished by the sudden onset following some injury or slight surgical procedure, for example, the introduction of a hypodermic needle for the purpose of drawing off fluid from a cyst. The hematoma begins within a few hours after the injury and increases I'apidly in size, with pain l3ut no fever. The distinctive signs of acute inflammation are absent. Hematoma sometimes occurs in pregnancy without injury, being due to subcutaneous rupture of a varicose vein. When a phlegmonous vulvitis is confined to one side, it may resemble pudendal hernia or pudendal hydrocele. In each of these affections, acute inflammation is absent at first and, also, there are special characteristics that indicate the nature of the swelling. Treatment. The treatment is the same as for celluUtis or lymphangitis else- where. The patient should stay in bed, and hot compresses, made by wringing absorbent cotton out of hot water or weak carbolic solution, may be applied to relieve the pain and limit the inflammation. If there is much superficial irrita- tion it may be diminished by the measures given under simple vulvitis. Pelvic congestion should, as far as possible, be overcome by laxatives and other measures as indicated. Hot sitz-baths sometimes give decided relief. If the inflammation is severe and spreading rapidly, it may be advisable to make several incisions through the involved area, such as are made for severe spreading sub- cutaneous inflammation in other localities. If an abscess forms, it must be opened and drained. GANGRENOUS VULVITIS. This is known also as noma. It is inflammation of the vulva of such severity that the nutrition of the structures is cut off and they become gangrenous. Ex- tensive sloughing may take place. Gangrenous vulvitis occurs almost exclusively in patients in whom the normal tissue resistance has been destroyed by exhausting general or local diseases. Local conditions interfering with the pelvic circulation, such as pregnancy and pelvic tumors, predispose to this affection. 408 ■ DISEASES OF EXTERNAL GENITALS AND VAGINA Its most frequent victims; however, are children who are poorly nourished and poorly cared for. In such it is often fatal. The exanthemata, particularly when occurring in sickly children, may cause gangrenous vulvitis. The treatment is the same as for phlegmonous vulvitis, with the addition of tonics and stimulants, as indicated by the patients general condition. In some cases it may be advisable to excise the gangrenous tissue and cauterize the remaining wound. The ulcerated surfaces remaining after the sloughs separate, require the regular treatment for ulcers of the vulva. DIPHTHERITIC VULVITIS. Diphtheritic vulvitis, like diphtheritic vaginitis, is simply diphtheria with anomalous location of the membrane, and requires the regular treatment for diphtheria, namely, antitoxin, stimulants, nourishment, and local measures to keep the infected surfaces clean and hasten removal of the membrane. It is rare, and is due to the same cause as diphtheritic vaginitis. ECZEMA OF VULVA. jVesicular eczema of the vulva is most frequently located on the labia majora. The vesicles break and form crusts, and an itching, inflamed discharging surface persists. Chronic erythematous and squamous eczema also may occur, in which case the skin is infiltrated and may become nodular. The eczema may be limited to the vulva or it may extend to the adjacent cutaneous surfaces or into the va- gina. Causes and Symptoms. The predisposing causes are the same as predispose to eczema elsewhere, namely, general nutritive disturbances characterized by gastro- intestinal disorders or rheumatism or gout. The local nutritive disturbances ac- companying the menopause seem to predispose to eczema of the vulva. The excit- ing cause is usually some local irritation, such as vaginal discharge, diabetic urine and other causes of irritation mentioned under the etiology of simple vulvitis. The symptoms of eczema of the vulva are practically the same as of eczema elsewhere, i. e., burning, itching, infiltration and induration, with some thickening of the parts and frequently a discharge. Treatment. The indications for treatment are to allay the local irritation and correct as far as possible the general nutritive disturbances, as in the treatment of eczema in other localities. Alcoholics, spices and highly seasoned foods must be forbidden. In acute eczema of the vulva, the measures recommended under acute vulvitis may be employed. The lead and opium wash gives much relief, or the calamine and zinc lotion (see Formulae) may be used. A soft cloth may be wet in this lotion and applied to the parts, being held in place by a T-bandage. If the irritation is marked,' keep the cloth constantly wet with the lotion. Another way of applying the lotion, where the irritation is not so great, is to mop it over the parts and allow it to dry and form a protective coating. As a cleansing agent, hydrogen peroxide is exceedingly useful and may be ap- plied in all stages of the disease, either diluted with one or two times its volume of water or used full strength. Another excellent application in acute eczema of ECZEMA OF vriAA 409 this region is the "black wash" (see Formula?). This is mopped freely on. the parts for several minutes and then allowed to dry. It forms a protective sediment, over which may bo applied a sedative ointment. This application may be re- peated every few houi-s. During the acute stage, a soothing ointment such as the zinc oxide and carl^olic ointment (see Formuhe) is useful, particularly if the pa- tient has to be up and about, This may be applied each time after the application of one of the lotions above mentioned. Another useful application in the acute form is the oxi('e of zinc emulsion in almond oil (see Formula). In the subacute and chronic cases, and these are the most frequent, the diachylon ointment (equal parts of emplasti-imi plumbi and vaseline melted together) may be used with much benefit. In the more sluggish cases, emplastnun i)lumlji un- diluted ma}' be used. Cleanse the affected surface thoroughly with green soap and cotton lialls, dry it and then apply diachylon ointment spread on gauze or better still, small strips of bandage muslin. This dressing should be held firmly against the surface by a T-bandage. The ointment should be kept applied con- tinuously for several days, no water being used locally except what is absolutely necessary for cleanliness. In four or five days the cleansing with gi-een soap may be repeated to be followed by the application of the ointment. If the eczematous process is sluggish and more stimulation is required the diachylon plaster (em- plastrum plumbi) may be used full strength, applied on muslin the same as the ointment. Tar ointment is still more stimulating to the skin and sometimes gives better results than the diachylon treatment. It is indicated in the dry scaly forms and should be applied tentatively as, in some persons, it produces too much irritation. Begin with a preparation containing a small amount of tar (see Formulae). If this produces no irritation and a stronger stimulant is needed, the quantity of tar may be doubled and later quadrupled. The tar ointment may be applied on strips of muslin or the patient may rub it into the surface with the fingers. Some think the rubbing in of the ointment makes it more effective. Tar ointment is not indicated when there is deep infiltration. It is most useful in the superficial chronic scaly form. When pruritis is marked, the application of hot water for a short time, followed by the application of an ointment, sometimes gives much relief. The ointment to be used should be at hand ready for application. Then a cloth wet in very hot water is applied to the involved area and held there for a few minutes until it liegins to cool. The surface is then dried with a soft cloth or cotton and the ointment applied at once. An occasional application of silver nitrate solution (4% to 10%) is of decided benefit in some cases. In the very chronic cases, one plan of treatment is to go over the surface with the sharp curet and, following the curetment, to rub into the surface a 3% solution of salycilic acid in alcohol. and then apply the diachylon ointment spread on muslin. In place of the curet the affected area may be scarified with a knife, the scarifica- tions being made deep enough to cause considerable exudate and l^leeding, which may be further promoted by the application of hot water for a short time. Then 410 DISEASES OF EXTERNAL GENITALS AND VAGINA the parts are dried and the salycilic acid in alcohol applied, followed by the diachy- on ointment. INTERTRIGO. Intertrigo is a hyperemic condition of the skin, with slight maceration and con- sequent irritation. The patients usually refer to it as "chafing" or "heat." It is due to prolonged contact and friction of opposed surfaces. The normal skin secretions are retained between the approximated surfaces and become decomposed and irritating. It occurs most frequently in stout women and in infants, because in them the skin surfaces are in contact more constantly and over a wider area. It is usually worse in hot weather because the skin secretions are increased then, and also because the additional heat hastens decomposition. Intertrigo in this region may be caused or, if present, may be made worse, by anything that acts as an irritant to the skin, for example, vaginal discharge, uncleanUness and the vari- ous etiological factors mentioned under Acute Vulvitis. The process may affect any surfaces kept in apposition. It is usually located in the genito-crural creases, but may spread inward over the labia or outward over the thighs and upward on the abdominal wall. At first, intertrigo consists simply of hyperemia and slight irritation of the skin, but after a time there is considerable serous and cellular infiltration, with thickening and fissures and pigmentation. Infection may take place through some of the fissures or abrasions, and the result is an acute inflammation of the skin. Intertrigo gives rise to a great deal of burning and itching and discomfort, frequently to such an extent that walking causes much distress. When the irri- tation is marked, there is a serous secretion from the surface, which adds to the patient's discomfort and to the local irritation by soiling the adjacent portions of the clothing. Clinically the dividing line between intertrigo and eczema is not distinct. Treatment. Secure cleanliness by the frequent application of the carbolic v.^ash or a strong solution of baking soda (tablespoonful to a pint of water) . After each washing, the parts should be carefully dried and then dusted freely with some dry- ing and antiseptic powder, for example, the zinc oxide and magnesium carbonate powder (see Formulae). Other drying powders are mentioned under Acute ^'ulvitis and also under Pruritis Vulvae. After the application of the powder, a piece of cotton or gauze should be placed so as to keep the affected surfaces from coming in contact. The cleansing and dusting must be done from three to six times daily, i. e., frequently enough to keep the surfaces clean and dry. If the patient can rest in bed for a few days, the surfaces may be covered and kept separated by pieces of gauze wet in the calamine lotion (see Formula). The treatment is much more effective when the patient can be kept quiet and in bed. If she is obliged to work during the day, frequent washings, of course, can not be employed, and it is then advisable to prescribe a sedative ointment such as the zinc oxide and carbolic ointment (see Formula^) to be applied between the applications of the lotion. The surfaces must be kept separated by a soft cloth or cotton. HERPES OF VULVA 411 In chronic cases, some of the stimulating ointments mentioned under Eczema are beneficial, lu-zema may develop over an area of intertrigo, and in that case the treatment given under Eczema is required. Ravogli recommends the following measures for intertrigo. When the surface is excoriated and there is considera])le secretion, keep the patient in bed and ap- ply Burow's solution (see Formula") in strength of 3%, on strips of Unt, which serve to keep the sui-faces apart. This usually causes the intertrigo to disappear after a few applications. If the patient must work, then the bathing with the above solution may take place morning and evening, while during the day some sedative ointment may l)e applied to the surfaces, which should be kept separated with soft lint. In chronic intertrigo with papillary hypertrophy, make two or three applicatioas of Wilkin- son's ointment (see Formula) which causes desquamation of the old epidermis, with consequent development of new soft epidermis. The resorcin and salicylic acid ointment (see Formula?) has been found effective in some Ccoses. To prevent relapses, it is well to wash the creases in the genito-crural region \ er}^ frequently and keep them dusted with starch powder containing 2% of boric acid or salicylic acid, or with some other suitable dusting powder. HERPES OF VULVA. Herpes may occur on the vulva, where it is known also as " herpes progenitalis." I'he vesicles of the herpetic eruption are usually of larger size than those of vesic- ular eczema. Furthermore, they occur in gi'oups and do not rupture easily, whereas the vesicles of eczema rupture spontaneously, causing a sticky discharge. Herpes is seldom accompanied by the intense burning and itching which character- ize eczema. Herpes occurs especially in nervous women, particularly when there is marked pelvic congestion from any cause. With some women it occurs at nearly every menstrual period. The discomfort from uncomplicated herpes is so slight that not much treatment is required. The parts should be kept clean and dry and may be dusted frequently with some drying powder, for example, equal parts of zinc oxide and prepared chalk. All irritation should be avoided. If there is troublesome pruritis or burn- ing or smarting, a sedative lotion or ointment may be used. The erosions left by rupture of the vesicles should not be cauterized, as it is not necessary and may cause deep ulcers. PRURIGO OF VULVA. This is a rare disease of the skin, beginning usually in early childhood and re- appearing in later life at irregular intervals and sometimes continuing for long periods. It is characterized by a papular eruption and very troublesome itching. The papules are at first of the color of the skin and are more readily felt than seen, giving, on palpation, a rough "goose-skin" sensation. Later there are various secondary changes (abrasions, pigmentation, desquamation and decided infiltra- tion and thickening) due to the scratching excited by the severe pruritis. The pathology of the disease is somewhat in doubt, some authorities holding that it is a neurosis and others holding that it is dilatation of the lymphatics, causing irri- 412 DISEASES OF EXTERNAL GENITALS AND VAGINA tation of the nerve filaments of the skin. The disease is usually limited to the ex- tensor surfaces of the arms and legs, the genitals being rarely affected. When it does affect the genitals, it causes troublesome and persistent pruritis, helping to swell the Ust of cases of "pruritis vulvae." In the treatment, the patient's general health should be put in the best condi- tion. The irritability of the nervous system should be reduced by the adminis- tration of sedatives, such as bromides or cannabis Indica. The pruritis is dimin- ished in some cases by tincture of cannabis Indica by the mouth and also by pilocarpine hypodermatically. Locally, an ointment containing menthol or both menthol and chloroform, may give much relief (see Formula). Also the salicylic acid and creosote ointment (see Formulae) has proven useful. If the itching is severe and persistent in spite of the ointments mentioned, cocaine suppositories may be used for temporary relief. The cocaine suppository is to be introduced into the vagina when the itching is severe, and as the suppository melts the medicine becomes distributed over the affected surfaces. Other remedies for the itching may be found under Pruritis Vulvae. Ether and alcohol (1 to 4) and also chloro- form and alcohol (1 to 4) have been recommended for the purpose of dissolving out the tenaceous masses at the bottom of the papillae. PARASITIC DISEASES OF VULVA. The parasitic diseases, pediculosis and scabies, occur here as elsewhere on the body surfaces. They give rise to much irritation and, unless search is made for the parasites, the patient may be treated ineffectually for a long time for the resulting pruritis and irritation. Pediculosis Pubis. This is the most common parasitic disease of the vulva. The pediculus pubis or "crab louss" (Fig. 482) differs from the pediculi found on other parts of the body. It inhabits the pubic hairy region and may give rise to much irritation. It is conve3^ed from one person to another by contact, usually in sexual intercourse. There is itching and consequent scratching, with resulting abrasions and vulvitis. The diagnosis is made by finding the parasites (Fig. 482), which are attached to the hairs near the skin. At first they may not be noticed, but on close inspection they are seen as small Fig. 482. Tiie Pediculus Pubis, brownish particles attached to the hairs very close to magnified. {Stelwagon— Essentials , , . 0/ Skin Diseases.) ' tne SKm. The treatment is to apply oleate of mercury (10%) once daily, rubbing it well into the hairy region. After the remedy has been applied for four or five days it may l)e washed off, and need not be apjilied again unless there develop evidence that some of the parasites escaped destruction. At the end of the treatment, a soap and water bath and complete change of under- clothing must take place. An elegant and effective preparation used in the same SIMPLE VAGINITIS 413 way is Kapozi's petroleum salve (see Formulic). Some recommend to shave the pul)i.s or to clip the hair there, but that is usually not necessary. If there is much local in-itation remaining after the parasites are killed, the measures given under Simple ^'ulvitis may be employed. Scabies. Scabies may appear about the external genitals as part of an exteasive develop- ment of scabies, the infection usually appearing first on the fingers. There are the usual symptoms — severe itching, worse when the body is warm, and the abrasions and irritation resulting from scratching. The diagnosis is made by find- ing the burrows of the itch-mite on other portions of the body, usually on the fingers. The treatment consists of a warm soap-water batli followed by the free use of a sulphur ointment (see Formulae). Immediately after the bath, the patient should rub the ointment thoroughly into all the infected areas, and put on clean under- clothing. The inunction should be repeated night and morning for three days, the same underclothing and same bed linen being used during the course. On the fourth day a warm soap bath should be taken and clean underclothing put on. If some irritation of the skin remains, a mild ointment, such as zinc oxide ointment or carbolized vaseline, may be used for a few days. If any of the burrows, con- taining the ascarus scabiei, escape the first unction course, another similar course must be carried out. SIMPLE VAGINITIS. Simple vaginitis is inflammation of the vagina due to irritation or to the ordi- nary pus germs. It is known also as "catarrhal vaginitis." Etiology. The normal vaginal secretion is destructive to the ordinary pus germs and tends to protect the vaginal wall, as well as the cervix uteri, from in- fection. Anything that lowers the nutrition of the vaginal wall interferes also with the protective action of the vaginal contents and hence predisposes to in- flammation. Wasting diseases of every kind have that effect to some extent, but it is especially noticeable in those conditions causing congestion of the vagina, such as pelvic tumors, pelvic inflammatory affections, pregnancy and heart dis- ease. In the presence of any of the predisposing causes, and sometimes without them, vaginitis may be produced by the following causes: 1. Use of an infected syringe-nozzle or syringe, carrying staphylococci or strep- tococci into the vagina. Ordinarily these germs are killed by the vaginal con- tents, but in cases in which the nutrition of the vaginal wall is disturbed and the resistance consequently lowered, these germs may multiply rapidly and cause severe vaginitis. 2. An infective uterine discharge, for example, in acute septic endometritis. 3. Decomposition of a chronic uterine discharge. Ordinarily a chronic dis- charge from the uterus passes out of the vagina, causing only slight irritation, but if it is retained long in the vagina, decomposition takes place, causing marked irritation and vaginitis. 4. Use of strongly irritating substances in the vagina, for example, where a too 414 DISEASES OF EXTERNAL GENITALS AND VAGINA concentrated douche solution is used by mistake, or where some irritating sub- stances are introduced into the vagina for the purpose of causing an al^ortion. 5. Foreign bod}^ in the vagina. A pessar}^ worn too long or without proper pre- caution may cause severe local vaginitis, extending even to ulceration. In some cases of this character it has happened that the ulceration has extended deeply into the vaginal wall. Kelly illustrates a case in which ulceration took place with so much resulting cicatricial contraction below the pessary, that the vagina was occluded and a collection of pus formed above the point of occlusion. Foreign bodies introduced for the purpose of masturbation are liable to cause vaginitis. 6. In sexual intercourse, germs, other than the gonococcus, may be carried into the vagina, and, if the soil is favorable, simple vaginitis will result. Again*, slight traumatisms in difficult coitus furnish an entrance for germs, with resulting vagin- itis. 7. In the exanthemata — measles, scarlet fever and the other eruptive diseases — the eruptive disturbance may extend to the vagina, causing much irritation and, as a consequence, vaginitis. Pathology and Symptoms. The inflammatory phenomena are the same as in gonorrhoeal vaginitis, except not so marked. The vaginal walls present active congestion. They are red and hot, and manipulations cause pain. At first the secretion is slight, but very soon it is increased and becomes purulent. There is a serous and cellular exudate into the vaginal wall and the superficial layers of epithelium are thrown off and form part of the discharge. In chronic cases the acute symptoms have disappeared but the cellular infiltra- tion and epithelial exfoliation persist. The papillae may become especially swol- len, giving the sensation of a rough granular surface. The lor.ger the process con- tinues, the deeper the infiltration extends. In acute vaginitis usually the first symptoms are dryness, heat and itching in the vagina and about the vulva. Later, a discharge appears with consequent ii-ri- tation about the vaginal orifice and the meatus. The valvar irritation and the urinary disturbance are usually not nearly so marked as in gonorrhoea. General disturbances are slight. The patient feels somewhat feverish, but decided rise of temperature is rare, and when present should arouse suspicion of complications. Diagnosis. The fact that the vagina is inflamed can be directly demonstrated m the examination, so it remains onl}^ to distinguish simple vaginitis from the other forms of vaginal inflammation.. Gonorrhoeal Vaginitis is distinguished by the following: a. Inflammation is rapid in development and severe. b. Involvement of urethra and vulvo-vaginal glands. c. No other apparent cause. d. Gonococci in the discharge. e. History of suspicious coitus within a few days before the beginning of the trouble. In exceptional cases a simple vaginitis may give rise to a simple ure- thritis in the husband. But simple vaginitis never gives rise to a gonorrhoeal ure- thritis, as some husbands endeavor to make out. Diphtheritic Vaginitis is distinguished by: a. Development of a false membrane on the vaginal wall. SIMPLE VAGINITIS IN CHILDREN 415 b. Marked systemic effects. c. Presence of diphtheria bacilli, as demonstrated by bacteriological examina- tion. Adhesive Vaginitis presents the following characteristics: a. Inflammation is only chronic or subacute. b. Occurs in patches, resembling abraded areas. c. Walls of vagina adhere, and separation of the adhesions causes a bloody dis- charge. d. Patient is usually past the menopause. Treatment. In the severe cases the same treatment is indicated as in gonor- rhoeal vaginitis. Usually, however, the inflammation is comparatively mild, and an antiseptic douche, such as bichloride 1-5000, two or three times daily, is all that is required. The cause must be sought and removed, for example, if it is due to an irritating discharge from the uterus, the uterine lesion must receive appropriate treatment. If the vaginitis becomes chronic, the treatment described under Chronic Gonorrhoeal Vaginitis should be employed. Simple Vaginitis in Children. In children a troublesome discharge sometimes appears and gives rise to much vulvar irritation. The trouble is frequently not severe enough to be called inflam- mation of the vagina — there seems to be simply an excess of secretion, causing a vaginal discharge. But the vulvar irritation, which is the most marked symptom, often necessitates measures to stop the excessive secretion. The treatment of this affection consists in keeping the external genitals clean and dry by washing frequently with a weak carbolic solution, then drying with absorbent cotton and then dusting with a drying powder, such as boric acid powder. Bismuth subnitrate and prepared chalk, equal parts, is also a good dusting powder. Keep the vulva covered with a pad of absorbent cotton. The child should be put in first-class general health. Often the patient presents lowered vitality and anemia and a general relaxation or want of tone in the tissues — the so-called strumous diathesis. In such a case, a course of tonic treatment, restoring the patient's vitality, will often cause the discharge to cease. If the dis- charge persists, a mildly astringent vaginal suppository may be introduced into the vagina once daily (see Formulae). Of course, in severe vaginitis in children, the vagina should be irrigated, muck the same as in adults, but in the mild disturbance here described vaginal irrigation is rarely necessary. When it is necessary, the vagina may be carefully washed out once or twice daily with the carbolic or other douche solution, using a small soit- rubber catheter instead of the ordinary douche-nozzle. PARASITIC VAGINITIS. Parasitic vaginitis is the term applied to inflammation of the vagina due to the same fungus which causes thrush in the mouth. It is known also as "mj'cotic vaginitis" and as "aphthous vaginitis." The cause is invasion of the vagina by parasites of the order of oidium albicans, 41(3 DISEASES OF EXTERNAL GENITALS AND VAGINA or, perhaps more correcth', saccharomyces albicans. The infection is carried to the genitals usually by the fingers of the patient, who has been handling some or- ganic substance on which the fungus was gi-owing. A mother whose baby is suft'er- ing with thrush may infect herself. It usually occurs in nursing women or in preg- nant women or in cases of prolapsus uteri. • It is said to occur sometimes as the result of sexual intercourse with a diabetic husband. The pathological changes are practically the same as in thrush in the mouth. There are white patches, representing the growing fungus, and accompanying in- flammation of the adjacent tissues. The patient complains of burning, itching or smarting, but there is not much discharge. In the examination through the specu- lum, the vaginal wall presents thei©rdinary e\adences of inflammation and in ad- dition it is studded "^dth small white patches about the size of a pin-head. In some cases small ulcers may form. A scraping from one of the white patches, examined with a microscope, will show the fungus (Fig. 483). Treatment. Douches will give some relief, but must be supplemented by application through the speculum of a more concentrated antiseptic, such as argja-ol 25% or protargol 10% or silver nitrate 5% or bichloride solution (1-500). After the appHcation, du.st powdered borax into the vagina and then introduce a tampon wet in 50% boroglyceride. Such treatment, given every day or every other day for several days, usually stops the disease promptly. After the fungus has been de-- stroj'^ed, mild antiseptic douches are required for a time for the accompanying simple vaginitis. Fig. 483. The Thnisli Fungus, under the micro- scope. (Holt — Diseases of Children.) DIPHTHERITIC VAGINITIS. This form of vaginitis is due to infection of the vaginal wall by diphtheria bacilli. It is rare. It is liable to occur when there is diphtheria in the house, if there are nbrasions of the vagina, particularly after labor. Diphtheritic vaginitis is characterized by the development of a false membrane over the abraded areas and by the marked systemic effects of diphtheria, in ad- dition to the usual signs. of vaginitis. Streptococci sometimes cause a membrane. The differential diagnosis is made by the surrounding inflammation and the sys- temic disturbances in the two diseases, and especially by a bacteriological examin- ation when that is available. The treatment should include the measures recommended for simple vaginitis, and, in addition, antitoxin and other remedies indicated in diphtheria. ADHESIVE VAGINITIS 417 EMPHYSEMATOUS VAGINITIS. In emphysematous vaginitis, small collections of gas appear under the epithe- lium or in the meshes of the connective tissues. It is a rare form of vaginal in- flammation and occurs almost exclusively in pregnant women. Its seat is the up- per part of the vagina and the vaginal portion of the cervix. The little air vesicle? are close set and vary from the size of a pin head to several times as large. They are frequently surrounded by an area of hyperemia, but the inflammatory reaction is slight. When punctured the air escapes and the vesicle collapses. There is rarely any secretion from them. The gas contained in them is, in part at least, trimethylamine. The vesicles show little tendency to reform after puncture. The affection is du€ to a mild gas-producing bacillus. But it apparently bears no relation to infection with the gas-forming bacillus known as the bacillus aerogenes capsulatus, for this deadly germ gives rise to a severe and rapidly spreading phlegmonous inflammation. As to the treatment of emphysematous vaginitis, nothing more is usually required than puncturing the air vesicles and washing of the vicinity with an antiseptic so- lution. If there is an irritating discharge, mild antiseptic douches may be given. If the patient is pregnant, great care must be exercised not to cause much irrita- tion, as an abortion might result. ADHESIVE VAGINITIS. Adhesive vaginitis is the term given to that form of vaginal inflammation in which there is a tendency of the opposed surfaces to become adherent. It occurs almost exclusively in women past the menopause, hence the name "senile vagin- itis" by which it is often designated. Occasionally it occurs in children. The predisposing cause in most cases is the disturbance of nutrition due to old age. The exciting cause is probably a slight uterine discharge, which macerates the vaginal epithelium and produces considerable irritation. A certain amount of Fig. 484. Indicating the condition in an area of Adhesive Vaginitis. The epithelium is thrown off. The granulating surface left may unite with a similar area on the opposite wail, causing ad- hesions as described. (Bnesky— Diseases of Vagina.) senile vaginitis is very frequent and often produces no symptoms. In fact it is probable that only a small proportion of women over sixty are entirely free from some disturbance of this kind, with slight adhesions here and there. Over irregular patches the superficial layers of epithelium are thrown off (Fig. 484) , forming erosions from which there is a scanty secretion. The eroded areas are tender and usually bleed on manipulation. 418 DISEASES OF EXTERNAL GEXITALS AND VAGINA When such areas develop on opposed surfaces of the vaginal walls, adhesions take place between them. For a long time the adhesion is weak and the surfaces may be easily separated. If the process of adhesion is allowed to go on undis- turbed, the adhesions become organized and firm, and in the course of time maj^ become so extensive and strong that the vagina is practically^ obliterated. Adhe- sive vaginitis is accompanied by a slight ''gluey" discharge, small in amount but irritating. The symptoms are, vaginal discharge, sometimes bloody, ^ith some pain in the pelvis and vaginal burning and discomfort. There may be some burning or smart- ing on urination, from irritation of the vulva by the discharge. On digital examination, the vaginal walls are felt adherent in places, especially at the upper portion of the vagina, and the separation of the walls causes some pain and bleeding. Examination of the vagina through the speculum shows hemor- rhagic areas of denudation and inflammation, principally in the upper part of the vagina. Diagnosis. The evidences of subacute vaginitis with marked tendency to ad- hesion of the walls in spots, establishes the diagnosis of adhesive vaginitis. Vagin- itis occurring after the menopause is usually of this form. Be careful to distin- guish gonorrhoeal vaginitis from the ordinary adhesive vaginitis. Serious disease of the uterus causing discharge, particularly cancer, must be excluded. Treatment. If the trouble is slight and causing no symptoms, it needs no treat- ment. The adhesions in themselves cause no trouble and consequently" need no treatment. When the disturbance gives rise to an imtating discharge or to bleeding or to pain, then the following treatment is indicated: 1. Put the patient in the best possible general health. 2. Keep the vagina free from the irritating discharge by the use of a mild antiseptic douche, such as the carbolic douche, two or three times daily. If the parts are atonic and show a marked tendency to bleed, an astringent douche, such as the alum and zinc sulphate douche (see Formulae) may be used. 3. Every second or third or fourth day, depending on the severity of the vaginitis, make a vaginal application of some astringent and antiseptic, for example, arg^-rol 25*^ or protargol 5% to 10^. This should be applied thoroughly to all parts of the vaginal wall involved in the inflammatory process. If the hemor- rhage tendency is marked, an application more strongly astringent, such as copper sulphate solution (109c) ^^Y be used. After the application, some measure should be employed to keep the vaginal walls separated, at least for a time. For this purpose we may use cotton tampons or gauze strips soaked in carbolized glycerine (2%) or covered with carbolized zinc oxide ointment (2% to 5%), or the ointment may be spread on the vaginal walls and then the tamjpons introduced. Carbolized olive oil (2% to 5%) makes a sooth- ing application to the vaginal walls and prevents adhesion of the opposed surfaces. In very sensitive cases, either almond oil or ungentum aquae rosae may give more relief than the other remedies mentioned. For use at home, between the office applications, astringent vaginal suppositories (see Formulae) are sometimes beneficial. SIMPLE ULCER 4](j 4. The exciting cause of the trou])le must be sought and, if possible, removed. Frequently it will be found to be an irritating discharge tlue to senile endome- tritis, which must, of course, receive appropriate treatment. SIMPLE ULCERS OK N'l'LVA AND \'A(II\A. Ulcers or ulceration of the vulva or vagina may indicate the following condi- tions: 1. Simple irritation or pus infection. Any of the nunicrous irritants that cause vulvitis may cause one or more ulcers, as may also infection at any point with ordinary pus germs. 2. Chancroidal infection. 3. Syphilis. 4. Tuberculosis. 5. ^Malignant disease. 6. Ulcus rodens vulvae. Those coming in the first class constitute the simple ulcers. Pathology and Symptoms. The simple ulcers are the ones considered here — the other varieties will be taken up later. The essential feature of an ulcer is that the epithelial coat is lost down to the connective tissue, the base being covered with granualtion tissue or a slough. The infecting germs lie in the tissues close to the surface of the ulcer, and outside them is a limiting zone of round-cell infiltration. There is more or less discharge from the surface of the ulcer, and it usually bleeds on slight manipulation. These characteristics pertain to all varieties of ulcer. There is some pain and tenderness about the ulcer, and the discharge may cause considerable initation. If the ulcer is situated so that the urine flows over it, the patient may experience smarting and burning on urination. Diagnosis. The diagnosis of ulcer presents no difficulties, as it is established by finding an area devoid of epithelial covering and presenting a granulating sur- face. An eroded area on the vulva or in the vagina, which is sensitive and bleeds easily, may l^e mistaken for an ulcer, but close inspection will show that the surface is still covered with a thin layer of epithelium. The diagnosis of the variety of ulcer present is very important and sometimes difficult. From simple ulcer there must be distinguished the chancroidal, the syphilitic, the tubercular and the malignant ulcer. The chancroidal ulcer presents a ragged or irregular base with punched out or undermined edges, and a tendency to spread and also to infect surfaces with which the secretion comes in contact (Fig. 218). The chancroidal ulcer appears within a few days after suspicious coitus. It is tender and sometimes quite painful, and is liable to be accompanied with painful inguinal adenitis, in which the glands become matted together and later suppurate. There is no marked induration underlying the sore — it is a "soft sore." On account of the infective character of the secretion, other ulcers appear, and fre- quently the ulcers of the vulva are complicated by ulcers about the anus. It 420 DISEASES OP EXTERNAL GENITALS AND VAGINA often happens that these lesions about the anus give rise to more troublesome symptoms than the vulvar ulcers and are really what causes the patient to seek relief. Syphilitic ulcers are of two kinds, the primary lesion, called also "chancre" or "hard sore," and the deep tertiary ulcers. The characteristic primary sore of syphilis becomes apparent two to four weeks after suspicious coitus. It is small and not particularly painful, but presents an underlying area of induration which feels to the examining fingers as though a small piece of stiff paper were lying be- neath the ulcer. The inguinal adenitis, which appears after a short time, is prac- tically painless and there is no tendency to suppuration nor to matting together of the glands. However, the primary sore is seldom so distinctly characteristic that it is justifiable to begin constitutional treatment before secondary manifest-* ations confirm the diagnosis. The superficial secondary lesions, which about the vulva appear as flat condylomata, are not really ulcers but simply erosions. The ulcers appearing in the later stages of syphilis are usually ragged, irregular, in- dolent and persistent, and there are other evidences of syphilis. In a doubtful case, a course of potassium iodide may assist in clearing up the diagnosis. By a bacteriologic examination of a piece of tissue excised from the lesion, a positive diagnosis may be made at once, in the primary or secondary or tertiary stage of the disease (see under Syphilis, page 427). In tubercular ulcer there may be other organs presenting tuberculosis. Also the nature of the ulcer is indicated by its appearance, by finding tubercle bacilli in the discharge or scrapings and, if still doubtful, by the examinations of sections of tissue from the margin of the sore. In malignant ulcer, that is, an ulcer due to the breaking down of tissue infiltrated with carcinoma or sarcoma cells, there is a surrounding area of induration, rep- resenting that portion of the malignant infiltration which has not yet broken down. A malignant ulcer is chronic and bleeds easily, and the tendency to bleed is not checked, but rather increased, by the application of 10% copper sulphate solu- tion. In the case of a chronic ulcer of doubtful character, a piece of the margin of the ulcer should be excised for microscopic examination. Carcinoma in this situation causes death in about two years. To remove the growth completely, the operation must be performed in a very early stage, hence the importance of an early diagnosis. Treatment. The first efforts in the treatment of any ulcer of the external geni- tals should be directed toward securing cleanliness and allaying irritation, liy the measures recommended under Acute Vulvitis. In simple ulcer, after cleansing with carbolic or bichloride solution and drying with absorbent cotton, the patient may apply an antiseptic ointment, such as carbolized vaseline (1%) or the chlore- tone ointment (see Formula?). This cleansing, followed by the application of the ointment, may be carried out two or three times daily by the patient at home, or more frequently if there is much discharge. A very efficient cleansing application for the patient's use is hydrogen peroxide. Every second or third day apply some astringent, such as protargol (10%) or silver nitrate solution (10%) or copper sulphate solution (10%), to all portions of the surface of the ulcer, and after that an astringent antiseptic powder. The genitals should be kept covered CHANCROID 421 with a piece of absorljcnt cotton held in place by a T-bandap;e. If there is an ac- companying vaginal discharge, the i)atient should take an antiseptic douche one to three times daily. If these cleansing and antiseptic measures do not cause the ulcer to heal promptly, it is probably not a simple ulcer but belongs to one of the special varieti-es. CHANCROID OF Vulva and A'agina. Chancroid is an infectious ulcer, entireh' local in its effects and due to inocula- tion with secretion from another chancroid. It is known also as "soft chancre" and as "soft sore." It constitute sone of the three so-called "venereal diseases" (gonorrhoea, chancroid, syphilis). It is due to a specific infectious agent which causes chancroid and nothing else. It is invariabh' due to contact with virus from another chancroid, and sexual intercourse is nearly always responsible for this contact. The infectious principle of chancroid is much more exclusively conveyed by sexual intercourse than syphilis. Converseh'', chancroidal virus is much less liable than syphilitic virus to be coveyed in an active state simply by contaminated articles. However, such method of conveyance is probably possible and must be guarded against. The chancroidal virus does not penetrate healthy epithelium but makes its entrance through a crack or abrasion. The infectious agent is a short bacillus, discovered by Ducrey and hence desig- nated as the Ducrey bacillus. It occurs in the discharge, but cannot be satis- factorily identified there because of contaminating material. For diagnostic examination a tissue=specimen should be secured. In the case of enlarged glands, the serum secured by puncture with a large hollow needle is usually satisfactory for diagnostic examination. Pathology. Within twenty-four to forty-eight hours after infection, there appears a small pustule on an inflammatory base. This point of infection may be situated at any part of the external genitals or in the vagina. This beginning lesion may not be noticed by the patient, so that according to her statement the lesion may not have appeared for several days or a week after coitus. In a short time the epithelial covering over the infected spot is lost and a small ulcer is thus formed. This ulcer has sharp, punched-out margins, a rough and sometimes necrotic base, is sun-ounded by a red inflammation zone and is accompanied by more or less inflammatory edema. In cases of long standing or of much inflammation, there may be con- siderable round-cell infiltration and induration around the ulcer and under it, but there is rarely if ever the marked parchment-like or cartilage-like induration that develops under the primary lesion of syphilis. Usually the ulcer gradually enlarges and deepens, the destruction as a rule being more rapid and extensive in the vagina than on the external surface. During this stage the base of the ulcer usually shows sloughing tissue or false membrane, and the surrounding inflammatory zone is marked. Alcoholic drinks, friction from 422 DISEASES OF EXTERNAL GENITALS AND VAGINA exercise and also uncleanliness, increase and prolong the destructive action. Ordinarily after several days, the time depending somewhat on the patient's habits and general health, the ulcer shows a tendency to heal. Under treatment, the base clears off and shows apparently healthy granulation tissue, the surround- ing inflammatory zone grows less and the secretion becomes more like ordinary pus. Gradually the gi^anulating surface is replaced by a thin layer of scar, which begins at the margin and progi-esses towards the center. The usual duration of a chancroid is two to three weeks. A relapse may occur at any stage of the healing process and even when apparently healed, the lesions are for some time infectious. Such is the regular course of a chancroidal ulcer, but several other conditions may develop, as follows: a. In chronic alcoholics and other subjects of diminished resistance, the ulcer may present ragged and undermined edges and becomes very destructive and rapid in its advancement, constituting what is known as a phagedenic chancroid. b. Any surface which lies against a chancroid is liable to develop a secondary chancroid at the point of contact, after sufficient time for the irritating discharge from the primary chancroid to cause an erosion and thus open an avenue for in- fection. Again, if pus from a chancroid comes in contact with a scratch or abra- sion in the vicinity, it causes another chancroid. This is called auto-inocculation and it is one of the marked characteristics of chancroidal lesions in contra-distinction to the syphilitic chancre. It is also one of the strong proofs of the purely local character of chancroid. On account of this property, chancroids are usually multiple. There may be two or three or there may be many (Fig. 218). Frequently the secretion runs down over the anus, where it comes in contact with abrasions and causes chancroidal ulcers that are more painful than the vulvar lesions. Sometimes the infective secretion pene- trates the hair follicles or sebaceous glands of the vulva, forming small round sores called follicular ulcers. c. Not infrequently the virus is carried by the lymphatics to the inguinal glands and there causes chancroidal bubo which usually suppurates and gives rise to a discharge, which is as infective as that from the original ulcer. Of course, ordi- nary pus germs accompany chancroidal inflammation, and the ordinary pus germs may cause a simple bubo, not containing any chancroidal virus. Such a bubo would not of course be a chancroidal bubo, but would be a simple bubo accompany- ing a chancroidal ulcer. It is not settled just what proportion of buboes are of this class. d. It sometimes happens that syphilitic infection takes place at the same time as the chancroidal infection or just before it or after it. This constitutes a mixed infection which not infrequently causes a mistake in diagnosis and much chagi-in on the part of the physician, who sees unmistakable evidences of syphilis develop from a sore which he had pronounced simply a chancroid. For the first two or three weeks there may be nothing to indicate that syphilitic infection has taken place, but after that time the ulcer, instead of cicatrizing as a chancroid should do, develops the induration and other charatceristics of a syphlitic sore. This mixed infection occurs rather frequently and its 'possibility in any particular case DIAGNOSIS OF CHANCROID 123 must be kept in mind, that due caution may be exercised in giving the diagnosis and prognosis. Symptoms. There may be few or no symptoms, except when the ulcer is touched or rubl^ed by the clothing. In some cases the patient complains only of a discharge and smarting on urination. She may be unaware that any sore is present on the jreni- tals. On the other hand, the patient may complain of much itching and of other symptoms of acute vulvitis due to the irritating discharge. If the ulcer is so situ- ated that the urine flows over it, there is usually considerable smarting and pain on urination. When situated in the vagina, the ulcer gives rise to an irritating discharge, frequently blood-streaked, and also to other symptoms of vaginitis. In multiple chancroids, the discomfort is accordingly increased, and in phage- denic chancroid the general health may be seriously impaired. In chancroids about the anus, there is much pain, particularly on defecation, and occasionally the ex- cruciating pain of anal fissure appears. If infection of the lymphatic glands takes place the patient complains of pain in the affected gi'oin, increased by walking, and of a tender lump in the gi-oin. The conditions found on examination of a chancroidal ulcer have been described under pathology. In the case of mixed infection, symptoms of secondary syphilis de- velop after sufficient time has elapsed. Diagnosis. The diagnosis of chancroid is based on the following points: 1. Development within a few days or a week after suspicious coitus. 2. Location and mode of development and appearance of the lesion. 3. Two or more lesions, indicating auto-inoculation. 4. Absence of parchment-like, or cartilage-like, induration under the ulcer. 5. Presence of a painful bubo tending to suppuration. 6. In a doubtful case, a piece of tissue may be excised from the involved area, and submitted to a bacteriologic examination, to establish the presence or ab- sence of the Ducrey bacillus. A Simple Ulcer may be due to an abrasion in the first intercourse after mar- riage, or to infection of a denuded point with ordinary pus germs. A simple ulcer is not so exclusively associated with coitus, does not give rise to so much inflam- matory reaction nor exhibit such an angry appearance, does not show such a ten- dency to spread and destroy tissue. If kept clean for a few days, it shows healthy gi-anulations and healing edges, is more liable to be single (as auto- inoculation is not so frequent and marked) and involvement of the lymphatic glands with suppuration is rare. In Herpes, the abrasion is preceded by a vesicular eruption and there are usually several lesions close together or joined. The lesion is very superficial, the red surafce being still covered with a thin layer of epithelium. The margin is small and regular and there is but little inflammatory reaction. It must not be forgotten, however, that an herpetic lesion may afford entrance to ordinary pus germs or to chancroidal virus or to syphlitic infection, in which 424 DISEASES OF EXTERNAL GENITALS AND VAGINA case characteristic signs will develop in due time. For the distinguishing char- acteristic of sj^philitic lesions and tubercular ulcer and malignant ulcer, see the succeeding pages. Treatment. The treatment for chancroid is through cauterization, to destroy the chancroidal virus. The earlier this is done the fewer ulcers there wdll be and the less chance of suppurating bubo. Carbolic acid (95%) is, I think, the preferable cauterant in the cases where the ulcer is comparatively superficial and no general anesthetic is necessary. The ulcer is cleansed and then covered %\dth a pledget of cotton soaked in 20% cocaine solution, which is left in place five minutes. Then remove the cotton and cleanse the surface of the ulcer again. Then cauterize every portion of the ulcer with the carbolic acid. For applying this, a tooth-pick with a few shreds of cot- ton wound firmly on the end of it, is very convenient, or a cotton- wrapped appli- cator may be used. If any of the carbolic acid should touch the skin, an immedi- ate application of alcohol will stop destructive action Rub the carbolic acid into every crevice and irregularity of the ulcer, removing any soft granulations and working the cauterant into the depth of the affected area. When the surface has been thoroughly cauterized then apply alcohol to stop further action. Then cleanse the ulcer and apply some soothing ointment. Vaseline or carbolized vaseline does very well. The patient should keep rather quiet (lie down most of the time if she can) for a few days. She should cleanse the parts frequently with the carbolic wash or other antiseptic wash and dry with cotton and apply the vaseline or other oint- ment. There is some reaction, but that subsides after a few days, and the ulcer begins to show healthy granulations and rapid healing. After that the treatment is the same as for a simple ulcer. In cauterizing the ulcer it is important that every particle of the infected sur- face should be thoroughly cauterized, for if active virus is left at any point, it will reinfect the enlarged ulcer left after the sloughs from cauterization separate. The advantage of carbolic acid over nitric acid or the thermo-cautery is that it is less painful. It has an anesthetic effect that lasts for sometime after the cocaine anesthesia has disappeared. If the ulcer becomes very painful from the reaction following cauterization, hot applications may give much relief. These are made by wringing a large piece of absorbent cotton out of hot water or hot antiseptic solution. The moist cotton, while still steaming, is applied to the genitals and covered with a piece of oiled-silk. These hot applications may be used frequently if required to relieve pain. If the sore is in the vagina, hot antiseptic douches should be used. At the office treatments, later, the ulcer is cleansed with hydrogen peroxide, dried with absorbent cotton and then dusted freel}' with some antiseptic powder. Iodoform is efficient, but its odor prevents its use. There are a number of good powders \vithout the odor. Among the best are xeroform and aristol. The ulcer should be protected from irritation from the clothing by a pad of ab- sorbent cotton over the genitals. The office treatment is repeated every second or third day until the ulcer is healed. For home treatment, the patient may wash TREATMENT OF CHANCROID 425 the genitals three or four times daily with a weak carbolic solution or some other mild antiseptic. If pain or restlessness is marked, a sedative may be given as required to produce rest. If the patient's general health is poor, she should of course be given tonics. The diet should be liberal and nourishing. Alcoholics are to be avoided in most cases. Constipation must be overcome. There is no specific internal treatment for chancroid. The following remedies have been thought by different observers to help in controlling the ulceration, and it is w^ell to use one of them in severe cases: Calcium Sulphide, 1-12 to 1-8 gr. every four hours. Hydrag-bichloride, 1-50 to 1-30 gr. three times daily. Potassio-tartrate of Iron, 3 to 5 gr. three times daily. In phagedenic chancroid cauterization is the most effective treatment. The cauterization must be thorough, extending into every irregularity of every chan- croidal lesion present, for if active virus is left at any point it will reinfect the enlarged ulcers left after the sloughs separate. If the chancroidal ulceration is extensive or if there are sinuses or if there are severe anal lesions, it is best to give the patient a general anesthetic, that sinuses may be laid open freely and all lesions carefully cauterized. After cauterization, there is left a simple ulcer which usually heals rapidly under the ordinary cleansing and antiseptic treat- ment previously given. If the granulations become sluggish, they may be stimu- lated by the apphcation of silver nitrate solution (5% to 10%) or copper sulphate solution (10% to 25%). The copper sulphate is especially indicated where there is any hemorrhagic tendency. If the granulations are persistently unhealthy, they may be cleared away with the sharp curet and the surface then stimulated to healthy action, as above indicated. The treatment of chancroidal adenitis, and of suppurative buboes in general, has been the subject of much thought and experimentation. Of first importance is prophylaxis. The most certain means of preventing a bubo is to secure rapid healing of the genital sore. This is one of the strong points in favor of cauterization of chancroids, for thorough cauterization, probably more than any other one measure, checks the infective process and causes rapid healing. When soreness in the groin with some enlargement of the glands is noticed, the patient should be put to bed and kept there, and compresses wet in the lead and alum lotion (see Formulae) should be applied to the affected region. A piece of absorbent cotton is moistened with this solution and then applied over the affected glands and held in place by a bandage so arranged as to make rather firm pressure on the glands. A " spica" bandage is the form usually used. The dressing should be renewed two or three times in the twenty-four hours, depending on the intensity of the inflammation. Spitschka, who originated this treatment, regards it as by far the most effective abortive treatment in the first stage of adenitis, much more so than applications of tincture of iodine or poultices or the ice-bag. Under this treatment the pain usually subsides rapidly, and frequently suppuration is pre- vented. If dermatitis results, the solution may be weakened or discontinued, a soothing ointment being then applied. Inunction of half a teaspoonful of mercurial ointment over the tender glands 426 DISEASES OF EXTERNAL GENITALS AND VAGINA once daily for a few days is another measure which seems to prevent suppuration, but mercuriahzation must be guarded against. Another method much used, is the apphcation of the mercury, belladona and iodine ointment (see Formulae) . The ointment is rubbed in over the swollen glands, then cotton is applied, and over all a firm spica bandage. The bandage should be applied firmly enough to make con- siderable pressure on the glands. The dressing may be changed once or twice daily. If after a few days trial of one of the above measures, the adenitis is still in- creasing, the time for intra-glandular injection has arrived. Many solutions for injection have been tried T\dth benefit. Probably the best injection-solution is the 1% solution of benzoate of mercury, recommended by Welander. With an ordi- nary hypodermic syringe, five to ten drops of this solution is injected into each of the enlarged glands, the skin having, of course, been thoroughly disinfected. The needle may be entered at several points, if necessary to reach the various glands. The total amount of solution injected should not exceed twenty or thirty drops. The injection causes considerable reaction, as evidenced by pain and swelling and some fever. After two or three daj^s, the irritation subsides and usually reso- lution takes place, if the buboes were not fluctuating at the time of injection. If one injection is not sufficient, another may be made after several days, even though fluctuation is present. If the evidence of fluid persists several days after all irritation from the injection has subsided, the abscess should be opened by incision and the incision kept open by a strip of antiseptic gauze, and the cavity treated in the ordinarj^ way with per- oxide and bichloride solution. Some cases presenting fluctuation have been cured by injection. Even when incision later is necessary the injection seems to be beneficial in three ways: a. The glands opened after injection rarely show chancroidal ulceration, but heal as simple abscesses. b. Complete liquifaction of all involved tissues is more frequent, so that deep curetting or extirpation of partially broken-do-^m glands is rarely necessary. c. Other glands are seldom involved after the injection of those first affeeted, consequently man}^ glands are saved and an extensive scar avoided. The most certain and rapid method of curing a chancroidal bubo in an earl}- stage is to completely excise the affected glands and close the wound immedi- ately by sutures. However, only a small proportion of patients will submit to this radical treatment, particularly in view of the fact that many buboes recover without suppuration. Then there is the danger of the general anesthetic, slight to be sure, but ever present. After the bubo has resisted abortive measures several days, suppuration is very probable and complete extirpation ma}' then l)e urged with more force. Most pa- tients, however, prefer the less radical injection method and some object even to that, insisting on simple external applications to relieve the pain and incision later when absolutely necessary. A chancroidal sinus, persisting from a bubo, may be injected with iodoform in glycerine (10%) once daily, after washing out with peroxide. If this does not cause the sinus to heal it mav be curetted with a small curet under cocaine anesthesia. SYPHILIS 427 If it still persists there are probably broken down glands that must be completely extirpated under a general anesthetic, before healing can take place. SYPHILIS OF Vulva and ^'AGINA. Syphilis is a general infectious disease, characterized by an initial sore (the point of entrance of the infecting germ) and by general secondary manifestations after several weeks and by tertiary lesions, localized in various parts of the body, after several years. The infectious agent is the spirochaete pallida, a very small microbe which is found in all lesions (primary, secondary and tertiary). The demonstration of this germ, makes possible a positive diagnosis of syphilis at once, even in the primary stage and long before the clinical evidences appear. The positive iden- tification of this infectious germ requires considerable bacteriologic experience, hence the specimens should be sent to a pathologist. The following directions for preparing specimens, are those given by Dr. Carl Fisch, of this city, who has done much work with the spirochaete paHida. In the case of a suspected primary lesion (chancre), wipe the surface of the ulcer clean, with cotton or gauze, and then scarify the surface with a needle. From the "irritation serum" which results, make a spread=preparation on a slide or cover-glass, just as in making a preparation of blood. Half a dozen speci- mens are made and dried and then packed for transmission. In SECONDARY LESIONS (mucous patchcs, moist papules , dry papules) , a spread- preparation of the "irritation serum", made as above directed, will usually suf- fice for a diagnosis. A negative finding, however, does not certainly exclude syphilis. Consequently, to make the diagnosis certain , a tissue=specimen should be examined. This is easily secured by clipping off a small papule. Preserve all tissue-specimens to be examined for the spirochaete pallida, in 10% formol solution. Specimens preserved in alcohol do not do so well. In TERTIARY LESIONS Only tissue=specimens can be used for diagnosis, and they must be taken from the capsule, or tissue about the gumma. The gummatous material, or necrotic material in the center of a "gumma", is not suitable for such diagnostic examination. Syphilis may be hereditary or r.cquired. In the hereditary form the lesions of the genitals either constitute only a small part of the general syphilitic picture, as in the severe cases leading to death of the infant, or appear as ordinary tertiary lesions later in life. Consequently hereditary syphilis requires no special consider- ation in this connection. Acquired siphilis is due to inoculation of a crack, scratch or abrasion with secretion from a syphilitic sore or with syphilitic blood. In the case of a primary sore of the vulva or vagina, there has, of course, been contact of the genitals with the syphilitic virus, either by sexual intercourse, which is the more common way, or by contact with contaminated clothing or fingers or household utensils or bath-room articles (particularly the water-closet seat in pul^lic places). In the case of tertiary or secondary lesions of the genitals. 428 DISEASES OF EXTERNAL GENITALS AND VAGINA the primary lesion may have been on the genitals or on any other part of the body. Pathology, Symptoms, Diagnosis. Syphilis of the vulva or vagina may appear in the form of primary or secondary' or tertiary lesions. Primary lesions. For a period of two to three weeks after infection with syph- ilitic virus, there is nothing to indicate that such infection has taken place. The small abrasion, through which the infection took place, heals in a few days as though nothing had happened and there is apparently no morbid process going on there. This is known as the "first incubation period." In exceptional cases it may be less than two weeks or more than three weeks, sometimes extending to six or even eight weeks. At the end of the incubation period a papule appears at the point of infection. If the ^irus entered at two or three points, there may be a like number of lesions, but this is exceptional. The small red papule is the usual form which the initial lesion takes. The papule may be decidedly elevated and pointed, or it may be fiat and scarcely raised above the surface, but in either case some induration, slight at first, may be felt. If this papule is situated on the external surface and is kept dry,it remains simply as a dr}' papule -^ith some scaling but no ulceration. This form of primary lesion is kno-^m as the dr}' scaling papule. It enlarges peripherally and may var^- in size from a pea to a dime. Exceptionally, the fiat papule may grow to the size of a silver quarter. The induration also increases, and at the end of a week or ten days is character- istic. The best way to feel this induration is to grasp the lesion between the thumb and finger and gently squeeze it or, more accurately, squeeze the tissues beneath it. The induration assumes two forms. It may be present as a thin dense layer under the papule or ulcer. When grasped as just indicated, such form of indura- tion gives the sensation of a small piece of thick T\Titing-paper or stiff blotting- paper lying horizontally under the lesion. The margins are quite distinct and, when pressed, the plate of induration can be felt to bend much as a piece of blot- ting paper would. This is called "parchment induration." On the other hand, the induration may be present as a thick rounded mass, occupying the base of the papule or ulcer and extending a considerable distance below it. This area of in- duration is in the form of a nodule which is dense and firm and presents distinct outlines. When examined by grasping, as before described, it gives the impres- sion of a piece of cartilage beneath the sore and is kno\^TL as " cartilaginous indura- tion," called also "nodular induration." The induration of a- syphilitic chancre disappears very slowly. When well marked it persists through the second incubation period, i. e., until the develop- ment of secondary symptoms, and then gradually undergoes involution. As a rule, the primar}' lesion with its accompanying induration, disappears completely within six to eight weeks after the beginning of the secondaries. Frequently some induration or a pigmented spot marks the cite for several months longer, and oc- casionally the indurated tissue becomes somewhat organized and persists indefi- nitely as a small hard nodule of scar tissue. VARIOUS FORMS OF PRIMARY SYPHILITIC LESION 429 Another form of primary lesion is the superficial erosion. This is noticed as a small round or oval red spot which may or may not be slightly raised. The center is often slightly depressed. The top layers of epithelium over this spot have been thrown off, forming a superficial abrasion, or raw place, called an erosion. A thin gray film usually occupies the center of the lesion and in many cases covers all of it. The characteristic induration is present. A third form of initial lesion is the indurated ulcer. If either the dry papule or the superficial erosion lose all their epithelium, so that granulation tissue forms, there is an ulcer with an indurated base. This transformation is especially liable to take place when the lesion is kept moist, hence it is most frequently met with in the vagina or on the inner surfaces of the labia. It may, however, occur in any situ- ation, and in many cases the ulcer is apparently present almost from the begin- ning. This indurated ulcer was the first form of primary lesion recognized as in- dicating infection from syphilis, and to it were given the names "hard chancre" and "hard sore" and "Hunterian chancre." Any of the three forms of primary lesion may be small or large. Unless accom- panied with pus infection, they give rise to very little pain or disturbance, and if small may be overlooked entirely by the patient. Many women presenting un- mistakable evidences of syphilis can give no history of a primary sore because it escaped their notice. This is especially liable to occur if the lesion is situated in the vagina. Furthermore, a small primary lesion in the vagina may, after a short time, disappear so completely that even the physician can find no trace of it. There is a fourth form of primary lesion, and that is the mixed sore. By a "mixed sore" is meant a sore with a double infection — both chancroidal and syphilitic, the former disease being manifest first, and the latter, two to four weeks later. At first the sore is apparently an ordinary chancroid, but after two or three weeks the sore loses its chancroidal characteristics, induration appears under it and an ordinary hard chancre develops, to be followed by other eviderres of sjqjhilis. In other cases, the chancroidal ulceration heals during the incubation of the syphilitic germ, but at the end of that period the scar becomes indurated, perhaps ulcerated, and a primary syphilitic lesion appears. A primary syphilitic ulcer does not present the angry appearance and destructive characteristics of the chancroidal sore. It is apparently a much less virulent affair. The edges are not undermined but slope inward, there is not such a marked zone of inflammatory reaction and the ulcer does not spread so rapidly nor so persist- ently. It is more indolent and frequently is nearly painless. In fact, the absence of pain, such as would ordinarily be expected from the size and location of the sore, is one of the striking characteristics of syphilis. But any syphilitic lesion may become infected with ordinary pus germs, in which case it usually becomes painful. The primary sore may heal within a week or two after its appearance, or it may persist all through the second period oi incubation. The primary syphilitic lesion of the external genitals is accompanied by enlarge^ ment and induration of the inguinal glands on the same side as the lesion. This enlargement may be marked or it may be slight, but it is always present. It be- gins in a week after the appearance of the primary lesion. It is due to an indolent inflammation or induration of the glands. Several glands are affecteci 430 DISEASES OF EXTERNAL GENITALS AND VAGINA and they may be felt as distinct painless nodules, entirely separate and freely movable. Unless there is a mixed infection, with chancroidal virus or with ordi- nary pus germs, the glands do not present any evidence of acute inflammation and there is no suppuration. Secondary Lesions. On the vulva, secondary syphilis usually manifests itself by the development of moist papules, called also "condylomata lata" (Figs. 261, 262). These may appear any time during the first twelve months of the sec- ondary period. The syphilitic condyloma consists of a slightly elevated, flattened area from which part of the epithelial covering has been thrown off. It may be any size from the head of a pin to as large as the thumb-nail. There are usually several lesions and in some cases dozens of them. The individual lesions have a fairly regular circular or elliptical outline. Several of them may coalesce, forming large ir- regular infiltrated patches (Fig. 261). In some cases there is a slight secretion, and all of them are kept moist a portion of the time l^y the secretion from the vagina. They are not painful and cause very little disturbance, except when irritated. When the vaginal discharge is very irritating, some of the lesions may becomes in flamed, in which case they are reddened and angry-looking and painful. When inflamed, the thin epithelium may be lost, giving rise to an ulcer which may in- volve a part or all of the lesions. Sometimes abrasions on the lesions are caused by scratching. The favorite locations for the moist papules or flat condylomata, are the labia minora and the inner surfaces of the labia majora. In some cases, however, they cover all the external genitals and extend even on the adjacent surfaces of the thighs (Fig. 262). Associated with them are other evidences of secondary syphilis, such as a gen- eral eruption, enlargement of the inguinal and epitrochlear and post-cervical glands, persistent sore throat, sores in the mouth and loosening of the hair. Tertiary Lesions. Tertiary syphilis of the vulva and vagina usually presents itself in the form of persistent and destructive ulceration. When occuiring in the vicinity of the vestibule, it not infrequently leads to destruction of the urethra. Its victims are usually in a state of poor health and lowered vitality. They have little tissue resistance, hence the destructive action of the ulcer. Coincident ulcera- tion of the rectum, with stricture formation, is frequent. When syphilitic ulcera- tion affects the upper part of the vagina or the cervix uteri it may be mistaken for cancer. A tertiary syphilitic ulcer is usually indolent, comparatively painless and persist- ent in spite of local treatment. There are usually other evidences of tertiary syphilis or a history of previous secondary or tertiary symptoms. The ulceration heals under anti-syphilitic treatment, provided the patient's vitality is not so lowered that the normal tissue resistance is destroyed. The diagnosis of tertiary syphilitic ulcer is made principally by the presence of other evidences of syphilis, l)y the exclusion of other forms of chronic ulceration (chancroid, tuberculosis, cancer) and by the effect of treatment, local and consti- tutional. In the case of persistent ulcer, of doubtful character, a piece. of the margin of the ulcer should be excised for microscopic examination. TUBERCULOSIS OF VULVA 4;-{l Treatment. A patient should not be given coiLstitutional treatment for syphilis until the diagnosis is positive. As a rule a positive diagnosis before the appearance of the "secondaries" is not possible by the ordinary clinical evidences. By Imcterio- logic examination, however, a positive diagnosis may be made at once, even in the very earliest stage of the primary lesion. When the diagnosis is thus made early, it is recommended by some author- ities that the primary lesion be at once completely exci.sed — not with the idea of preventing general syphilis, but to modify it and lessen the effect of the succeeding stages. This excision treatment of the primary lesion is still experimental. Otherwise the only treatment that the primary lesion requires is local cleansing and antiseptic measures, such as are recommended under Simple Ulcer. The sec- ondary and tertiary lesions require regular constitutional treatment for syphilis, i. e., mercury in the secondary stage, iodides and tonics in the tertiary stage and a combination of the two in the intermediate stage (late secondary and early ter- tiary). For the details of the internal treatment of syphilis the reader is referred to works treating of that subject. The local treatment for the secondary and tertiary lesions of the vulva and va- gina, is simply cleansing and antiseptic and astringent, i. e., the same as for Simple Ulcers. Arg3Tol (25%), protargol (10%), silver nitrate (2% to 10%) are excellent applications for mucous patches. Bichloride solution (1-2000) is a good wash for the same. Calomel as a dusting powder is also useful in relieving the irritation. These applications are likewise beneficial in tertiary ulcers. For cleansing all the irregularities of a deep ulcer, hydrogen peroxide is effective. When there is a tendency to bleed, copper sulphate solution (10%) may be used. Ravogli highly recommends emplastrum hydrargyri as an application in tertiary S3''philitic ulcerations. Wash the ulcer with bichloride solution (1-2000) and then apply the emplastrum hydrargyri. This causes temporary increase in the dis- charge due to the breaking down and discharge of the unhealthy gi-anulations and detritus at the bottom of the ulcer. After a few applications healthy granu- lations appear and healing begins. After that the ulcer is given ordinary anti- septic treatment, i. e., it is washed with bichloride solution or hydrogen peroxide, or both, and then dusted with an antiseptic powder. TUBERCULOSIS OF VULVA. Tuberculosis of the vulva is the term applied to those lesions of the external genitals produced by tubercle bacilli. Tuberculosis of this region and other forms of persistent vulvar ulceration were formerly described together under the terms "lupus vulvae," "lupus hypertropicus," "lupus perforans," "ulcus rodens," "de- structive ulcer of vulva" and "perforating ulcer of vulva." As the pathology of the various forms of ulceration was gradually worked out, it was found that in many of the cases of destructive ulceration, tubercle bacilli were present. The tuber- cular lesion^, were then formed into a class by themselves and this class includes a 432 DISEASES OF EXTERNAL CENITALS AND VAGINA large number of the cases of persistent ulceration formerly described under the titles above mentioned. Tuberculosis of the vulva is due to local infection -^ith the tubercle bacillus. The infection may take place through an abrasion, in which case the infecting germ may be brought to the abrasion by a tubercular discharge from the uterus or vagina, or possibly by coitus with a husband having a tubercular lesion of the genito-urinary tract or by fingers or clothing infected with tubercular discharge either from the patient or from some other person. On the other hand, tissues may, in rare cases, be infected without any break in the epithelial covering. In such a case the tubercle bacilli may come by way of the blood or lymph. Tuberculosis of the vulva begins as a small nodule, usually situated near the meatus or the clitoris or at the posterior commissure. It may be of a dusky red or bluish color. Microscopic examination of such a nodule shows the usual round- cell infiltration, the necrotic areas, the giant cells and the tubercle baciUi, found in tubercular lesions elsewhere. There may be only a single nodule or there may be many. After a time the nodules break down and form small ulcers. The ulcers have hard margins and an irregular base and are very hable to have an area of irregular infiltration about them. The ulcers discharge some, and this dis- charge may or may not show tubercle bacilli. As the ulcers enlarge they coalesce, forming extensive areas of ulceration of very irregular outline (Fig. 219). As the ulcer extends at one part it may heal at another, giving rise to much scar tissue. By gradual contraction the scar tissue interferes with the local circulation of the blood and lymph and may lead to marked stasis hypertrophy and induration of the labia and clitoris. Tubercular ulcers are chronic and persistent and may extend deeper and deeper until fistulous openings are formed into the rectum or bladder or urethra, hence the name perforating ulcer. Even when adjacent cavities are not opened, the ulcers, in conjunction with the contracting scar tissue, may form sinuses and dis- charging surfaces extending deeply in various directions, and sometimes causing- perforations through the labia. A positive diagnosis requires a microscopic examination. In a doubtful case the crucial test of the character of the ulceration consists in finding tubercle bacilli in the secretion or in demonstrating the characteristic pathological changes in a specimen of tissue removed from the margin of the ulcer. Treatment. If there are no marked tubercular lesions elsewhere, the whole in- filtrated area should be excised and the wound closed by sutures. If the infiltra- tion can not be excised, the ulcer should be thoroughly curetted and then deeply cauterized with carbolic acid or the thermo-cautery. If the patient does not wish these severe measures, the surfaces may be touched frequently with tincture of iodine or with lactic acid and then powdered with iodoform. In some cases the use of these substances causes healing. At the same time the patient should re- ceive constitutional treatment for tuberculosis. If any new areas of the tuber- cular process crop out they should be given the treatment found effective Avith the first lesion. When the disease is still in the stage represented by small nodules, the following treatment is recommended by Unna. A number of the nodules are TUBERCULOSIS OF VAGINA 43^} punctured with an acne-lance. Tlien a small shred of absorbent cotton is moist- ened in a mixture of mercury (one part), carbolic acid (four parts) and alcohol (twenty parts), and pushed into the lance opening with a sharp-pointed instru- ment and turned about and left there ten or fifteen minutes. In three to five days the irritation has subsided and other nodules may be treated in the same way, and thus the process is continued until all traces of the tubercular infiltration has disappeared. For tuberculosis of the vulva and for rodent ulcer, there is a treatment which promises to be superior to any other yet devised, not excepting the knife. I refer to treatment by the X-Ray and by the Finsen light. In superficial tuber- culosis, a cure is almost certain and" with comparatively little disturbance of health}/ tissue. In ]3oth of these affections this treatment is as a rule preferable to the knife. The treatment is long but it gives better results, i. e., there is as large a percentage of cures, with less disfigurement and with practically no pain. TUBERCULOSIS OF VAGINA. Tuberculosis of the vagina is usually secondary to tuberculosis of the uterus and tubes, the vaginal surface being infected from the tubercular discharge from above. Some cases occur, however, in which there is no tubercular trouble higher in the genital tract. In such a case the vaginal tuberculosis may be due to sexual intercourse with a husband having tubercular lesion of the genital tract, or to the use of an infected douche-nozzle or to the extension inward from tuberculosis of the vulva. The most common site for vaginal tuberculosis is the posterior vaginal fornix, which region comes most in contact with the uterine discharges. It is supposed that the resistance of the vaginal epithelium must be lowered by an irritating dis- charge or otherwise, before invasion by the tubercle bacillus can take place. The first manifestation of tuberculosis of the vaginal wall is the development of a num- ber of miliary tubercles. These may be confined to a small area, for example, to the posterior fornix, or may appear over a large part of the surface at once. Each miliary tubercle is a small, raised, grayish or yellowish dot, the size of a millet seed or smaller. As the lesions develop they break down and form small ulcers, which may coalesce and form ulcers of various sizes. The tubercular ulcer has a punched out appearance, the edges being perpendicular, and the base is yellowish gi-ay and may show many miliary tubercles. The miliary tubercles frequently occur in large numbers in the hyperemic zone about the ulcer. Symptoms and Diagnosis. The stage of ulceration is usually the time at which the patient consults the physician, complaining of discharge and discomfort. Examination reveals the suspicious ulcer or ulcers and further investigation wil' usually show tubercular disease of the uterus or tubes. The discharge from a tubercular ulcer contains tubercle bacilli, but sometimes in such small numbers that they are not found when the discharge is stained and examined. In a doubtful case, some tissue from the margin of the suspected ulcer may be sent to a pathologist for examination. In such a specimen, in ad- dition to the tubercle bacilli, there are found the characteristic giant cells and necrotic areas. Another way of testing for tuberculosis in the laboratory, is by 434 DISEASES OF EXTERNAL GENITALS AND VAGINA injecting some of the secretion into the peritoneal cavity of a guinea pig, where it causes tubercular peritonitis with characteristic lesions. Treatment. The treatment is the same as that described under tuberculosis of vulva. MALIGNANT DISEASE OF THE VULVA. Carcinoma and sarcoma may affect the external genitals, In this situation they are distinguished by the same signs that characterize them elsewhere, namely, progressive induration, ulceration and involvement of the neighboring lymph glands. Malignant disease of the external genitals is rather rare. Epithelioma is the most frequent form. This begins usually on the lower por- tion of the labium majus as a small hard nodule with a bluish tinge especially about the edge. The nodule grows slowly and at first may produce no symptoms. In some cases, however, even from the first there is severe pruritis. After a time, part of the nodule breaks down, forming a small ulcer which is surrounded by an area of induration. There is a watery discharge sometimes mixed with blood. When occurring about the meatus it sometimes causes the urethra to appear as a firm indurated cylinder. The progress of the disease is now more rapid, the ex- tension-being usually in the long axis of the labium. Later, the adjacent surfaces and structures become involved. A fungus or protruding gi'owth may appear. Figs. 220, 221, 222, 270, 271 and 272, show various cases of epithelioma of vulva. The inguinal glands become enlarged early, at first simply from the lymphatic en- largement that always takes place when there is inflammation or persistent irritation of the genital region. Later the glands become infiltrated with cancer cells and often gi-eatly enlarged. In the latter stage the carcinomatous glands break down and ulcerate externally. Experience has shown that, unless recognized and extirpated very early, the dis- ease is usually incurable. Its duration from the beginning is usually about two years. The patient may suffer from burning and superficial pain in the early stages and later there may be severe pain from involvement of the deeper structures. Car- cinoma of the clitoris (Fig. 222) has been observed a number of times. Frequently it is melanotic. A more rare location for cancer is the vulvo- vaginal gland, the particular form of growth originating here being the adeno-carcinoma (Fig. 273). In all of these forms of growth, extirpation in a very early stage gives the only probability of cure. Consequently, in the case of a suspicious ulcer or nodule in which the diagnosis remains doubtful after careful treatment for a short time, a \jiece of the margin of the area should be excised for microscopic examination. Treatment. Ea-rly and wide excising is the treatment to employ when the dis- ease is operable. No time should be wasted with X-ray or other uncertain methods. After extirpation, X-ray treatment may be used to prevent recurrence. If the malignant infiltration has gone too far for complete removal, palliative measures must be employed. These consist of general sedatives and local appli- cations to relieve pain, curetment and cauterization of the ulcer. X-ray treatment and the employment of the various measures mentioned under simple ulcer. In advanced cases there is so much destruction of tissue by ulceration that it is difficult MALIGNANT DISEASE OF VAGINA 435 to keep the ulcerating surface clean and free from odor. Iodoform and charcoal, half and half, sprinkled freely over the surface and covered with gauze, aids in this. The salicylic acid and iodoform powder (see Formulae) has much the same effect. In the inoperal:)le cases, opium will be required sooner or later to diminish suffer- ing, and, when needed, it should l^e given freely and gradually increased as re- quired to give relief. In the inoperable cases, particularly the cases of sarcoma, the mixed toxins of the streptococcus and bacillus prodigiosis (Coley's toxins) may be found beneficial. If these fail, the growth may be somewhat retarded by repeated injection of a few drops of alcohol in various parts of the growth. These injections may be repeated every two or three days or at longer intervals, according to the disturbance they cause. MALIGNANT DISEASE OF THE VAGINA. Carcinoma of the vagina is usually secondary to carcinoma of the uterus or rec- tum or bladder or external genitals, and the treatment depends on the situation and extent of the principal lesion. Primary carcinoma of the vagina is rare. It is of the squamous-cell variety (epithelioma) and, according to Pozzi, it occurs in two forms. 1. As a papillary gi'owth. This form usually attacks the posterior wall of the vagina, making its appearance as a broad-based excresence, which first invades the fornix and then extends downward toward the vulva. It appears, in some cases, to have its origin in the neighborhood of plaques of chronic vaginitis. 2. Nodular or infiltrated form. This 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 known as "periurethral cancer." Ulceration here advances rapidly. In primary cancer of the vagina, as in cancer elsewhere, a positive diagnosis in the early stage must rest upon the microscopic findings in an excised piece. The treatment is complete extirpation, if seen early enough. The results thus far have been unsatisfactory. There is usually recurrence. However, it is probable that the adoption of recent radical operations looking to the extirpation, not only of the infiltrated area but of all surrounding tissues likely to be involved, will give much better results, at least in the early cases. Also by special apparatus X-ray treat- ment and Actinic-ray treatment may aid some in preventing recurrence. Chorio-Epithelioma. This variety of carcinoma sometimes occurs in the vagina. This curious form of tumor will be considered in greater detail under Malignant Disease of the Uterus. It arises from chorionic villi and may develop after normal parturition or after abortion or after mole-pregnancy. It usually develops in the uterus, but occasionally one of the chorionic villi transported to the vagina (pieces of chorionic villi are normally transported to various parts of the body in probably all pregnancies) takes on the peculiar change and forms a malignant growth. As it grows, it breaks into the veins, causing miniature hema- tomata in the vicinity. As this kind of tumor usually causes metastases through the body, with rapid death, it is important to recognize and remove it at the earliest possible moment. Such a growth in the vagina or in the vulva is usually 436 DISEASES OF EXTERNAL GENITALS AND VAGINA metastatic from a similar growth in tlie uterus, hence the condition of the uterus should be investigated. Sarcoma. One form in which sarcoma of the vagina occurs, is as a diffuse infil- tration and degeneration of the lining membrane. This is the form sometimes found in young children. It occurs most frequently in the posterior vaginal wall. It begins as a small indurated area which slowly increases in size. After a time the epithelium covering the area is lost and an ulcer forms. The ulcer bleeds easily and is surrounded by an area of induration. A large part of, or even the entire circumference of the vagina may become involved in the sarcomatous infiltration, which may be mistaken for carcinoma or tuberculosis. The symptoms of sarcoma of the vagina are leucorrhoea, hemorrhage, pain and obstruction of the vagina by the infiltration. Slight hemorrhage may appear in the early stages, particularly after coitus or exertion. In the late stages, profuse hemorrhages occur and there is also a muco-purulent or watery discharge that may cause much pruritis. The pain is slight at first but gradually increases in severity. It is usually worse at night. Examination reveals a nodular tumor or an area of induration or ulceration and more or less narrowing or obstruction of the vagina. For a positive diagnosis of the nature of the growth a microscopic examination of a section of tissue is necessary. The treatment is the same as for carcinoma. ULCUS RODENS VULVAE. From the large group of affections formerly classified roughly undef the terms "rodent ulcer," "lupus," "esthiomene," "perforating ulcer" and similar names, there have been cut out distinct classes, until now these cases are pretty well di- vided up as syphilis, tuberculosis (to which the term lupus is now restricted) and malignant disease, with special characteristics for each. There still remain, how- ever, certain persistent destructive ulcers whose etiology is not definitely known, and consequently whose etiological classification can not yet be positively made. They are not syphilitic nor tubercular nor malignant. They constitute a class by themselves and, in the absence of more definite infor- mation, are very appropriately designated by the non-committal term "ulcus rodens"* (gnawing ulcer). Rodent ulcer of the vulva may be defined as a destructive chronic ulcer that is not syphylitic nor tubercular nor malignant. The affection occurs almost exclusively in prostitutes and is apparently due to the combination of depressed general health and the chronic irritation of frequent coitus (traumatism) and varied and repeated infections and uncleanliness. The post-syphilitic state is undoubtedly an important etiological factor in many cases, the effect being due prolmbly to the deteriorated general health and lowered tissue resistance. Real .syphilitic lesions, i. e. those yielding to antisyphilitic treatment, are excluded by the terms of the definition of rodent ulcer, the clinical differentia- tion being aided by the therapeutic test. The cicatricial tissue which forms around and under the ulcerated area tends further to interfere locally with nutrition, * This must not be confounded with the "ulcus rodens" of the face, which is a definite and peculiar variety of epithelial cancer. ULCER RODEN VULVAE 437 The pathological changes are those found in chronic ulceration with cicatrical change, but without any of the special characteristics found in syphilitic, tuber- cular or malignant ulcers. There is the granulating surface, the round-cell infil- tration and the connective tissue hyperplasia. The ulceration often extends deeply into the structures in various directions and causes perforations and fistulae. As it spreads at one part it heals at another, thus forming scar-tissue. The contrac- tion of this scar-tissue and of the inflammatory infiltration under the ulcer causes more or less interference with the lymph circulation. If the trouble persists for years, as it sometimes does, there is very likely to be stasis hypertrophy. Symptoms and Diagnosis. The patient complains usually of leucorrhoea and of burning on urination and of pain on coitus. There are frequently evidences ot irritation of the bladder or of the rectum. If the ulcer has penetrated deeply enough there may be incontinence of urine or feces. In some cases there is pain on walking or sitting, while in other cases, even with extensive ulceration, the patient has but little pain. In many cases the ulceration is accompanied with stasis hypertroph}'-, and in such cases there is nearly always considerable skin irritation. This is increased by uncleanliness and by the decomposition of the discharge in the folds and depressions of the hypertrophied structures. Examination shows the ulceration, with or without stasis hypertrophy. A com mon site for the ulceration is about the vestibule and extending up into the vagina In some cases it extends deeply into the urethra, separating the lower urethral wall so that it is simply a flap, which falls away from the upper wall. This destructive ulceration may extend to the neck of the bladder and cause incontinence of urine. If the ulceration appears at the posterior part of the vulva it may penetrate into the rectum and cause a recto-vaginal fistula. In the examination, it is important to separate the swollen structures and trace the ulcer in all its ramifications. Sometimes there are two or more ulcerated areas, and also spots of dermatitis due to the irritation of the discharge. If the manipu- lations cause too much pain to permit of a thorough examination, apply some 20% cocaine solution to the painful areas. Rodent ulcers usually bleed but little from the ordinary manipulations — not nearly so frequently nor so freely as malig- nant ulcerations. From rodent ulcer we must distinguish the simple, chancroidal, syphilitic, tubercular and malignant ulcers. In simple ulceration, there is usually some cause apparent, and the ulcer heals promptly on removal of the cause and the maintenance of cleanliness and the use of some mild antiseptic or astringent. In chancroid, the ulcer is acute and presents the characteristics previously described for chancroid, and there may be a history of suspicious coitus followed in a few days by the painful ulcer which rapidly enlarges. Cauterization and the other treatment recommended for chancroid leads to prompt healing. Tertiary syphilis often leads to destructive ulceration which very much reseml)les rodent ulcer. But there are usually other evidences of active syphilis, and the lesion is much benefitted by antisyphilitic treatment. Tuberculosis of the vulva, in some cases, causes deep and persistent ulceration which is much Uke rodent ulcer. But the special characteristics given under 438 DISEASES OF EXTERNAL GENITALS AND VAGINA tubercular ulcer are present, also microscopic examination of excised tissue or of pus and scrapings from the ulcer will show the trouble to be tubercular. Malignant disease is characterized by the tendency to bleed on slight manipulation and by an area of induration about the ulcer. In a doubtful case a piece of the margin of the ulcer should be excised under cocaine for microscopical examination. Treatment. The measures recommended under simple ulcers should be carried out and should be supplemented by general tonic treatment to build up the tissue resistance. In addition to this, practically every case of this kind should receive a thorough course of iodides, both for diagnostic purposes and for therapeutic effect. Very few cases of rodent ulcer are much benefitted by the iodides but occasionally one is considerably benefitted. Other measures are mild cauterizations, deeper cauterization and other measures mentioned under chancroid. The X-ray treat- ment sometimes produces prompt healing. A very important point in the treat- ment is rest of the parts. To secure this there must be no sexual intercourse and no unnecessary walking or standing. URETHRITIS. Inflammation of the urethra and also of the urethral ducts (Skene's glands) have already been considered, under Gonorrhoea. PERIURETHRAL ABSCESS. This term is applied to an abscess situated outside of the urethra but due to infection from the urethra. It usually lies between the urethra and vagina. The pocket of pus may or may not communicate with the urethra. This condition is known also as "urethrocele," ''sacculation of urethra," "sinus of urethra," "urethral diverticulum" and "suburethral abscess." Etiology and Pathology. In some cases there is infection of a urethral gland which becomes somewhat obstructed and dilated with pus and is accompanied with considerable inflammation and infiltration and pus formation outside the gland. In other cases there is probably first either a congenital cyst or a cyst formed by obstruction of the duct of one of the urethral glands which becomes markedly di- lated by accumulating secretion. Later there is infection of the cyst by rupture or otherwise, and consequent abscess. It is supposed also that injuries in labor ma}" lead to localized dilation, sacculation and suppuration. In either case, as the collection of fluid increases in size a swelling appears in the anterior vaginal wall below the urethra (Fig. 285). In some cases the vaginal wall over the swelling is normal, while in other cases there is much infiltration and thickening and induration. The abscess frequently ruptures into the urethra and empties itself incompletely. It may continue for weeks or months partially filled with pus and decomposing urine, and discharging through a small opening. In other cases there seems little or no active inflammation and no discharging sinus, .simply a collection of fluid resembling a cyst. In such a case there may be simply a retention cyst without infection or there may have been an infection that died out without forming pus. Symptoms and Diagnosis. When there is an acnitc aljsccss, there are all the ordi- URETHRAL AFFECTIONS 439 nary evidences of inflammation with urethral irritation added, causing frequent painful urination. In some cases there still remain evidences of the urethritis that was responsible for the periurethral infection. There is a reddened tender indurate< I swelling of the anterior vaginal wall under the urethra. The swelling and indura- tion may be diffuse or circumscribed. If a collection of pus of any size has formed there will be fluctuation. If the abscess has opened into the urethra, pressure on the swelling will cause pus to flow into the urethra and out at the meatus. Some- times a probe may be passed from the meatus through the opening into the peri- urethral cavity (Fig. 286). When the acute inflammation has subsided, there is left simply a swelling with considerable urethral irritation. If the cavity is discharging into the urethra, the swelling may have largely disappeared. Such a pocket outside the urethra may cause urethral and l)ladder disturbance for months without the real condition Vjeing suspected, particularly if there is simply a sinus or small pocket with but little swelling. It ma}- keep up a urethritis indefinitely and, if gonorrhoeal, the patient is capable of communicating the infection as long as the sinus exists. An exac- cerbation of the inflammation with acute symptoms may come on at any time. Such a periurethral sinus may be the unsuspected cause of the persistent presence of pus in the urine. Treatment. The treatment for this condition is to drain the cavity at the most dependent part, that is, where it comes closest to the vaginal wall. At this point a large opening should be made and the incision should be kept open by gauze packing or a drainage tube until the cavity heals from the bottom. The abscess cavity should be washed out with hydrogen peroxide and given the usual treatment of a suppurating cavity. When drainage is free below, the opening into the urethra usually closes prompty. When there is only a collection of fluid without active inflammatory symptoms, the small cyst thus formed may be extirpated. In extirpation of such a mass, care should be exercised not to dissect too close to the urethra nor to the sphincter at the neck of the bladder. In either situation it is better to leave part of the cyst wall than to injure the important structures adjacent thereto. When there is simply a sinus or small pocket communicating with the urethra by a fairly large opening near the meatus, the plan may be tried of treating the cavity with various anti- septics such as hydrogen peroxide, iodoform in glycerine (10%) oi" silver nitrate solution {i% to 2%), injected into the cavity by way of the meatus through a small tube such as the Eustachian catheter. If this fails, then the external in- cision and drainage is to be employed. PROLAPSE OF URETHRAL MUCOSA. This affection is known also as "procidentia urethrae." It consists of a pro- lapse of the urethral mucous membrane, accompanied by more or less prolifera- tion of the submucous connective tissue. Symptoms and Diagnosis. The red projecting membrane sun-ounds the meatus (Fig. 283). It often bleeds easily and is somewhat sensitive to the touch, though not nearly so sensitive as a caruncle. It usually gives rise to considerable irri- tation, with frequent painful urination and some discharge. It is distinguished 440 DISEASES OF EXTERNAL GEXITALS AND VAGINA from polypus and caruncle by the fact that it surrounds, or almost surrounds, the meatus. Marked prolapse of the urethral mucosa is not a common affection, though sHghfc gaping of the urethra, through which the mucous membrane may be seen, is very common in women who have had urethritis or have passed through several labors. Treatment. If symptoms are absent or slight, no treatment is necessary. If the prolapse is marked enough to be troublesome, the part may be cocainized, or the patient anesthetized, and the redundant portion of mucous membrane excised and the wound closed by sutures. It is convenient to pass the sutures first, then excise the tissue, then tie the sutures. This prevents the inner edge from retracting out of reach. The sutures should be placed close enough together to close the wound and prevent hemorrhage. Another good method of excision is to begin at one side and divide the tissues for a short distance and immediately close the resulting wound by suture, continuous or inteiTupted as preferred. Another portion is then divided and the wound closed as before. This process is continued until the redundant tissue is removed all the way around. This prevents hemorrhage, prevents retraction and secures good approximation. Clean excision ^dth the knife or scissors followed by immediate suture of the wound is decidedly preferable to cautery amputation. Fine catgut is the preferable suture material. URETHRAL CARUNCLE. Urethral caruncle is a small papillary growth occurrmg about the meatus, most frequently near the low^er portion. It is usually very sensitive and often gives rise to excruciating pain on urination. It is known also as "irritable caruncle" and "urethral angioma." The cause of urethral caruncle is not known. Probably chronic inflammation of Skene's glands has some influence in its causation, as it usually occurs in the neighborhood of the gland openings. Inflammation of the urethra, particularly gonorrhoeal inflammation, is supposed to be a causative factor. The little tumor is essentially a vascular gi-owth. Skene, who made a special study of urethral neoplasms, applied to caruncle the term "papillary polypoid angioma" and gave the following description. "It consists of a bunch of dilated capillaries, set in a moderately dense stroma of connective tissue, covered vAth. mucous membrane which has the usual pavement epithelium. One case, however, is recorded where the pavement was replaced by columnar epithelium. The vessels are greatly dilated and in some cases very tortuous, while in others less so." The growth is seen as a deep red mass at the meatus (Fig. 284) or just within the canal. It is sensitive when touched and may bleed easily on manipulation. It may have a distinct pedicle or a broad l)ase. Usually there is but one gi-owth, but sometimes there are two or more. Symptoms and Diagnosis. The principal s3'mptom is pain on urination. It may be slight or it may be very severe. In some cases the pain is so troublesome that the patient will hold the urine as long as possible, to avoid the suffering caused by pass- ing it. Walking may cause pain as may also pressure of any kind, even contact VtTLVO-VAGINAL GLAND AFFECTIONS 441 of the clothing. Imtability of the bladder, as indicated by frequent urination, is usually present. Occasionally retention of urine is caused by reflex spasm. Pain and hemorrhage may be caused by sexual intercourse, and in some cases coitus is impossible. The patient's general health necessarily suffers from the constant irritation and she becomes nervous, irritable and despondent. Polypi of the urethral mucous membrane and prolapsed mucous membrane differ from caruncle in being less vascular and less sensitive. Also, polypi are attached higher, while in prolapse of the mucous membrane the base of the mass includes the larger part, if not all of the circumference of the meatus (Fig. 283). Treatment. The treatment for caruncle is removal. First apply a small piece of absorbent cotton soaked in cocaine solution(20%) and leave in place five minutes. Then with a hypodermic syringe inject several drops of a weaker cocaine solution {h%) under the base of the gi'owth and wait a few minutes longer. Then clip the growth off with scissors. All the abnormal tissue must be removed. Then intro- duce one or more fine catgut sutures, close the wound and stop the hemorrhage. If the base is small and the resulting wound slight and without much hemor- rhage, it may be simply touched with carbolic acid or liquor ferri subsulphatis, no sutures being needed. When the growth has a broad base and the patient is very nervous or hysterical it may be necessary to give a general anesthetic. In some cases, anesthesia is required for other reasons, for example, a thorough pelvic ex- amination or curetment or repair of pelvic floor, and in such a case the cai uncle may be taken care of at the same time. The urethral and bladder irritation usually subsides rapidly after the growth is removed. While the patient is waiting for operation, some temporary relief may be given by the frequent appHcation of cocaine solution (5% to 10%). INFLAMMATION OF VULVO=VAQINAL GLAND. Inflammation of the duct of the vulvo-vaginal gland and of the gland proper, has been considered under Gonorrhoea. Inflammation in this gland of Bartholin is sometimes referred to as "Bartholinitis." ABSCESS OF VULVO=VAQINAL GLAND. The cause is infection with the gonococcus or the ordinary pus germs. The first is by far the more frequent, and the gonorrhoeal inflammation often persists in the gland long after the vaginal inflammation has disappeared. The infection enters at the mouth of the duct and progresses along the duct to the gland proper. The secretion of the gland is increased, the duct becomes ob- structed and a collection of pus forms, distending the gland and pointing in the direction of least resistance. Sometimes the duct alone is involved, the gland proper escaping. This is indicated by the swelling being small and confined to the region of the duct. Symptoms and Diagnosis. The symptoms are a painful swelling at the side of the vaginal opening with some fever. Examination reveals a swelling the size of a small egg situated in the tissues at one side of the vaginal orifice and projecting beyond the median line (Figs. 264, 265). The swelling is tender on pressure and is 442 DISEASES OF EXTERNAL GENITALS AND VAGINA red and hot. Fluctuation is distinct and the fluid seems near the surface. The orifice of the duct may be seen, but a probe will not enter the gland because the duct is obstructed. If the obstruction is so slight that it gives way before the probe, then pus is discharged through the duct. The following conditions may be confounded with abscess of the vulvo-vaginal gland. Cyst of Vulvo- Vaginal Gland. This is a chronic affair, the patient usually giving a history of the swelling having been there for a long time and the inflam- matory signs (heat and pain and redness) are absent. Pudendal Hernia. This must always be taken into consideration in determining the character of a swelling of the vulva. Hernia presents one or more of the hernial signs, such as impulse on coughing, reducibility, intestinal obstruction, resonance on percussion. The first evidence of hernia is usually noticed at once after some straining effort or injury, much more promptly than either abscess or cyst would appear. Tumor of Labia. This differs from abscess in the al^sence of inflammation and fluctuation, in growing slowly and in presenting the signs that distinguish the var- ious kinds of vulvar tumors. Treatment. Open the abscess freely by an incision where the pus is nearest the surface, wash out the cavity with hydrogen peroxide and pack with antiseptic gauze. The wound should be dressed the next day and as frequently thereafter as is necessary to keep it clean. Care must be taken that a good sized piece of gauze projects into the cavity, that the edges of the incision may be kept separated until the cavity gi-anulates from the bottom. If the incision into the abscess is not made when the patient is first seen, but is postponed to another day, much relief in the meantime may be obtained from the application of a hot poultice. Direct the patient to take a large thick piece of absorbent cotton, wring it out of very hot water and apply it immediately to the inflamed structures and cover it with a piece of oiled-silk. This hot moist dressing may be held in place with a T-bandage. It may be renewed as soon as it begins to cool, if the pain is troublesome. SINUS OF VULVO=VAQINAL GLAND. In many cases of abscess of the gland, after the pus is discharged the cavity closes entirely and there is permanent cure. In other cases a sinus persists, giving rise to a constant slight discharge. The outer end of the sinus may close and a reaccumulation of pus take place, forming another abscess. This may be repeated several times in the course of a few years. Again, in inflammation of the vulvo- vaginal gland, the duct may remain open giving exit to the pus as it forms and constituting a sinus or discharging tract. The diagnosis of sinus of the vulvo-vaginal gland is made by the history of inflammation of the gland associated with a sinus in that locality. By palpating the gland (Fig. 51), it can often be felt as a small hard lump, indicating infiltration and enlargement. Pressure on this lump will sometimes cause pus to flow from the sinus. A small probe introduced into the sinus passes into the region of the gland. Treatment. If the sinus has a goorl-sizcd external opening and has been present only a few weeks, it may close if washed out daily with hydrogen peroxide. The CYST OF VULVO-VAGINAL GLAND 443 peroxide should be forced to the bottom of the sinus and it may be followed by iodoform in glycerine (10%) or argyrol (25%) or protargol (5% to 10%) or silver nitrate solution (2% to 5%). In most cases however the only way to effect a per- manent cure is to extirpate the sinus tract and the infiltrated gland. This is a small operation, but the patient will usually require a general anesthetic, for considerable dissection is necessary. The parts are very vascular and there is much oozing. The resulting cavity is closed with sutures. The sutures serve also to stop the bleeding and ligatures are seldom necessary. Quite a depression is left where the inflamed gland was situated. This depression is not of particular im- portance and in time becomes less pronounced. It is well, however, to mention to the patient before operation that a small depression will be left when the inflamed gland is removed. When beginning the operation, in addition to the usual antiseptic measures, the sinus should be washed out thoroughly with peroxide and then with bichloride, During the operation, care must be exercised to avoid contaminating the cut sur- faces with pus from the sinus. The object is to remove all the infected tissue and secure union of the wound by first intention. CYST OF VULVO=VAQINAL GLAND. A cyst of the vulvo-vaginal gland is due to an obstruction of the duct, with accu- mulation of secretion in the gland causing it to become dilated. In some cases of inflammation, gonorrhoeal or otherwise, cyst of the gland, instead of abscess, results. The cyst appears as a fluctuating swelling in the region of the gland (Fig. 266). The swelling is not painful and the skin may be moved freely over it. The form and location of the swelling is like that of abscess, but none of the acute inflam- matory symptoms are present. Sometimes the duct only is the seat of the cyst. In that case the swelling is small and is situated at some part of the course of the duct. The only affection that is liable to be confounded with this cyst is pudendal hernia. The distinguishing characteristics of hernia are marked increase of the trouble on straining, obstructive bowel disturbance, impulse in the mass on coughing, tympanitic percussion note over the mass (if containing bowel) and the possibility of partial or complete reduction into the peritoneal cavity. Treatment. An attempt may be made to secure obliteration of the cyst without a cutting operation. Cleanse the inner side of the cyst and introduce the needle of a small aspirator or a hypodermic syringe and draw off the contents as com- pletely as possible. The labia minora and the tissues lying to the outer and anterior part of the cyst are full of veins and must be avoided. The bulb of the vestibule also, which lies against the upper end of the cyst, should be avoided. If the needle is introduced through any of. these structures a troublesome hematoma may result. Con- quently all punctures of the cyst should be made at its inner and lower portion, just at the margin of the vaginal mucous membrane where the intervening tissues are thin and comparatively free from veins. 444 DISEASES OF EXTERNAL GENITALS AND VAGINA After the evacuation of the cyst, a pad of cotton or gauze should be appUed over it and held firmly against it by a T-bandage. As soon as the patient reaches home she should go to bed and remain there for two or three days, keeping the bandage applied firmly. If swelling or pain appears, elevate the hips on a pillow and apply an ice-bag. If the cyst refills, the contents may again be drawn off and some irritating fluid injected into the cavity as in the injection treatment for ordinary hydrocele. There are two cutting methods. One method is to open the cyst on the inner side, cut out some tissue on each side of the incision, so that it will not close so easily, curet the inner surface of the sac and pack with antiseptic gauze. The external wound is kept open until the cavity is obliterated. In this method the treatment is prolonged and a sinus may result. The other method is to extirpate the cyst. In extirpating the cyst, avoid cut- ting into it if possible, as it is much easier enucleated when distended than when collapsed. The resulting cavity is closed with sutures. This method is the on-e of choice from the very first in all cases in which there is no contra-indication to general anesthesia. When the patient is not in good condition for a general anesthetic, the cyst may in some cases be extirpated by injecting a considerable quantity of a weak cocaine solution (1% to J%) or the Schleich solution No. 2 (See Formulae) around the cyst and under it (infiltration method) . This will do away with the greater part of the pain. To facilitate the dissection in such cases, Pozzi adopted the very ingenious plan of filling the cyst with paraffin. The cyst is first punctured and the fluid drawn off. The cavity is then washed out with hot water and the melted paraffin is introduced at a low temperature. When the cavity is distended, ice is applied and in a few minutes there is formed a solid mass, which is extirpated under the anesthesia of the cold and cocaine. CONDYLOMATA OF VULVA. Condylomata are small non-malignant growths occurring about the vulva. There are three varieties. 1. The common wart, called also "verruca vulgaris." 2. The pointed condyloma, called also "condyloma acuminata," "venereal wart" and "moist wart." 3. The flat condyloma, called also " condyloma lata. " Etiology, Pathology, Symptoms. The common wart occurs rather frequently about the vulva. It is usually situated on the labia majora or mons veneris. The particular cause for it is not known. It is dr-^- and sometimes much pigmented, but rarel" causes any disturbance. T pointkd coxdvloma or moist wart ^'-cnrs on those parts of the vulva whic-h are quently moist, namely, the "^ osblbule, the vaginal entrance, the labia minora, the rineum and about the anus. In some cases they occur on the labia majora and even on the thighs. Tliey are usually associated with venereal disease but not necessarily so. They are small pointed papillary masses with a thin covering of epithelium. They occur CONDYLOMATA OF THE VULVA 445 singly or in groups or in large numbers (Figs. 257, 258). They may vary in size from the head of a pin to a large cauliflower mass covering half or more of the vulva (Figs. 259, 200). They are due to some irritating discharge, usually gonorrhoeal. Sometimes they are due to a simple discharge as, for example, the increased vaginal flow of preg- nancy. When present during pregnancy they grow very rapidly. Whenever they are found, a careful search should be made for evidences of previous gonorrhoea. Usually condylomata are not particularly painful nor tender. In some cases they become inflamed and are then painful and may bleed easily. When the condy- lomata are multiple and grouped together in large masses (Fig. 259), secretion is liable to lie in the interstices of the gi-owth and become decomposed, giving rise to an offensive odor and considerable irritation. If situated near the meatus, con- siderable liladder irritability may result. The FLAT CONDYLOMATA (Figs. 261, 262) constitute the characteristic vulvar lesions of secondary syphilis. If the overlying epithelial layers are thrown ofT, the flat condyloma becomes a superficial ulcer, as mentioned under syphilis. Treatment. The common wart needs no treatment unless large or in some way troublesome. In such a case it may be removed the same as warts elsewhere, viz. : by injecting a few drops of cocaine solution beneath it and then snipping it off with the scissors. The base should be touched with carbolic acid or other cauterant, to check the bleeding and prevent return of the wart. If the bleeding is free, it may be checked with one or two sutures. If the patient objects to this excision of the wart, the cannabis Indica and salicylic acid mixture (see Formulae) may be applied. This is to be painted over the wart with a camels-hair brush. It should be applied freely morning and evening, the hard crust over the top of the gi'owth being occasionally removed, that the medicine may penetrate deeper. This treat- ment continued for a week or two will often cause the wart to disappear, but it does not always do so. This treatment is rather tedious and uncertain, but it is not painful and patients frequently prefer it. The pointed condylomata are treated as follows: 1. Stop the irritating discharge which causes the condylomata. This requires an antiseptic vaginal douche, once, twice or thrice daily, depending on the amount of discharge. The douche removes the discharge from the vagina and prevents it irritating the structures around the vaginal entrance. In addition to the douche, the patient mil probably require special treatment as indicated by the nature of the disease giving rise to the discharge. 2. Keep the condylomata clean and dry. This is accomplished by washing several times daily mth an antiseptic solution, for example, bichloride (1 to 2000) and then drying with absorbent cotton pnd dusting freely with some drying powder such as calomel or equal parts of bismuth Sub.-itiate and prepared chalk or rqual parts of salicylic acid and calomel. T^^^ ^^wder composed of tannic acid, bori cid and xeroform (see Formulae) does well, as does v<;:so the resorcin powder (sec or- mulse). The patient is given a prescription for the required powder and dii Led to dust it on freely several times daily. In the office treatment, silver nitrate stick or a strong solution may be applied as a cauterant, or carbolic acid may be used as a cauterant, after anesthetizing the growth by the application of cocaine solution 446 DISEASES OF EXTERNAL GENITALS AND VAGINA (20%). Another excellent cauterant application is pure formol, applied after the use of a cocaine solution to prevent pain. 3. Excision. This is the best plan to adopt when there are only a few separate condylomata. The growths are snipped off with the scissors and the base of each touched with carbolic acid or liquor ferri subsulphatis to stop the bleeding. If the base is wide and considerable pain is anticipated, a few drops of cocaine solution (y %) may be injected under the growths before excision. If there is free bleeding the little wound may be closed with a suture. When a large mass has formed (Fig. 259) with a broad and vascular base, perhaps extending into the vagina, it is better to give the patient a general anesthetic and remove the growth thoroughly with the scissors and curet. In PREGNANCY it is Well to get along if possible with local cleanliness and drying powders and mild astringents. Any operative measure, such as excision of the condylomata or cauterizing them, may lead to miscarriage. In many cases the simple measures above mentioned will effect a cure. But when the condylomata are not cured by the simple means, particularly if the growth is extensive, the patient should be anesthetized and the mass entirely removed. Though miscar- rige or premature labor may result from such treatment, it is not probable and with such a case some risk must be taken. If large condylomata, that retain secretion in the crevices, are allowed to remain until labor, they become a source of great danger to the mother on account of the liability to puerperal sepsis. There is danger to the child also, particularly in gonorrhoeal cases, because of the liability to eye-infec- tion and destructive ophthalmia. The flat condylomata require the regular constitutional treatment for secondary syphilis. Locally, cleanliness should be secured by frequent washing with a car- bolic or other antiseptic solution. If there is much vaginal discharge, antiseptic vaginal douches should be given. Each time the parts are washed, Jthey should be dried thoroughly with absorbent cotton and dusted freely with some drying powder. Calomel makes an effective drying powder in these cases. If there is troublesome itching or smarting, the lesions may be touched occa- sionally with silver nitrate solution (10%). If an ulcer forms it requires the treat- ment for ulcer, given elsewhere. CYSTS OF VULVA. Occasionally sebaceous cysts occur on the labia majora or the mons veneris. They present the same characteristics and require the same treatment as sebaceous cysts elsewhere. Figs. 278 and 279 show large labial cysts. Cysts of the vulvo- vaginal gland have already ])een considered. Several cysts of the la])ia minora have been reported (Fig. 277). It is generallly supposed that they arise from embryologically misplaced glandular rests. If large enough to be troublesome they are to be excised. Fig. 280 shows a cyst of the clitoris. CYSTS OF VAGINA. Vaginal cysts are 7-are and their origin is not certain. Some are supposed to arise from the remains of the duct of Gartner, but others are found in other situa- CYSTS OF THE VAGINAL WALL 447 tions. Vaginal cysts vary in size from the end of the finger to as large as the fist and even larger (Figs. 305, 306). In some cases the vaginal wall is separate from the cyst and moves freely over it, while in other cases the vaginal wall is closely adherent to the cyst, apparently forming part of it. The contents of the cyst may be lii<:e serum or may he milky or may be dark and thick, the color and consistency depending on the amount of hemorrhage into the cyst cavity. Diagnosis. The cyst differs from vaginal hernia in that it is of gradual development and without apparent cause, gives, on coughing, no impulse separate from the adjacent vaginal wall, can not be reduced and is not associated with intestinal disturbance. The cyst differs from vaginal abscess in that inflamma- tory symptoms are absent. In some cases, infection of the cyst contents takes place and the cyst becomes an abscess. In such cases it is distinguished from a simple abscess b}^ the presence of a swelling long before the inflammatory S3^mp- toms developed. In some cases a swelling that appears to be a vaginal cyst is simply a pocket from the urethra (suburethral abscess). Before subjecting a patient to operation, it is well in a doubtful case, to draw off a small quantity of fluid from the supposed cyst with an aspirator that the diagnosis may be confirmed. Two other conditions that should receive attention in the differential diagnosis of vaginal cyst are, double vagina and double ureter. In a case of double vagina the second vagina may be completely shut off and filled with old menstrual blood. It would usually be somewhat larger and less tense than the ordinary vaginal cyst, though the latter are frequently of considerable size. There would be double uterus and the relation of the mass to the uterus would point to one-sided hemato-colpos. From HYDRO-URETER Or a supernumerary ureter, the differentiation would also be rather difficult and depend principally on the shape and tension of the swelling. In a case of double ureter, if one ended blindly along side the vagina and became distended with urine it would form a mass which would be more sausage-shaped and have less tension than a vaginal cyst. A puncture of the mass with an aspira- ting needle, of course, aids greatly in differentiating between these conditions — the presence of blood speaking for hemato-colpos, and of urine for hydro-ureter. Hernia must be carefully excluded before aspirating, or fatal peritonitis may result. If it is intended to remove the cyst by operation, only a small amount of fluid should be removed for diagnostic purposes, for the extirpation is more easily carried out when the cyst is distended than when collapsed. Treatment. If the cyst is large and troublesome, the most satisfactory way of dealing with it is by extirpation, provided it is situated in the lower part of the vagina where complete extirpation is practicable. If it is so situated that it can not be completely extirpated, remove a large part of the wall, curet the remaining portion and pack with gauze, and treat as an abscess cavity. If the patient is averse to operation, the cyst may be simply emptied by aspiration. There is a possibility that it will remain collapsed for sometime or even permanently. How- ever, the probability is that it will refill in a short time and that extirpation will be necessary. If the cyst is first discovered during pregnancy, do not disturb it until labor begins. When labor comes on and the child's head is beginning to press into the pelvis, 448 DISEASES OF EXTERNAL GENITALS A\D VAGI.N'A smpty the cyst with an aspirator, to give room for the passage of the child. Do not attempt extirpation of the cyst nor incision and drainage, until the patient has recovered from parturition. NON=MALIQNANT TUMORS OF VULVA. Fibrous tumors (fibromata) may occur in the connective tissue of the vulva. They are rare. When present they usually involve one of the labia majora (Figs. 275,276). In some tumors there are also bundles of muscular tissue, evidently derived from the muscle fibers of the round ligament or of the skin. Such tumors are of course fibro-myomata. Other tumors have a preponderance of fat (lipomata), the con- nective tissue simply forming trabeculae between the fat lobules. Still other tumors contain myxomatous tissue, giving the myxo-fibromat a and the nwxo-lipo- mata. A very rare form of tumor in this region is the chondroma. A few ca.ses of chondroma of the clitoris have been reported, in at least one of which considerable ossification had taken place. These non-mahgnant tumors of the vulva may vary in size from an acorn to a child's head. They present, in this locality, the same symptoms and signs that cha,racterize them elsewhere. The patient complains principally of the weight of the gi-owth and of its being in the way. When large, they become pedunculated. On account of the friction the surface may become abraided and infected and ulcerated, adding greatly to the patient's distress. The treatment for these growths is excision. NON=MALIQNANT TUMOR OF VAGINA. Solid tumors (fibrous and myomatous) occasionally develop in the vaginal wall. Such a tumor may be mistaken for a hernia or a cyst or a malignant tumor. Solid tumors in this situation are so rare as to require no detailed consideration, but this po.s.sibility of their existence must be kept in mind when endeavoring to determine the character of a swelling in this region. When large enough to cause trouble, they require the same treatment as vaginal cysts, i. e. extirpation. STASIS HYPERTROPHY OF VULVA. Stasis hypertrophy of the external genitals is a chronic enlargement of the same> due principally to interference with the lymph circulation. "Elephantiasis" is the term under which most authors describe this condition, but the inport given to this word varies so much that its use leads to confusion. It has been applied on the one hand indiscriminately to nearly all chronic enlargements of the labia and, on the other hand, as a special term for the designation of the swelling due to the local invasion of the lymph channels by a parasite (filaria sanguinis hominis). To pre- vent this confu.sion I think best to adopt another term, one about which there can be no misunderstanding and which indicates the most important factor in the evolution of the clinical picture. The essential lesion is a stasis hypertrophy, what- STASIS OF HYPERTROPHY OF VULVA 449 ever the cause of the stasis may be. As explained below under etiology, the stasis maybe due to persistent ulceration with resulting scar tissue, or to an obstructive dis- turbance in the inguinal lymph glands or to local invasion of lymphatics by a parasite (hlaria). The term "ulcus rodens" given to the condition by some writers, is very good for designating that peculiarly persistent form of ulceration which is a promi- nent feature in many of these cases, but as a term for the whole clinical picture it is not appropriate. The hypertrophy may be present without ulceration and, on tiie other hand, a rodent ulcer may be present without particular hypertrophy. Stasis hypertrophy does not include the following forms of vulvar enlargement: — a. Malformations, nor the condition known as " congenital elephantiasis," which is in reality a kind of soft fil)roma. b. The slight enlargement of one or both labia minora, without lymph obstruc- tion and which is supposed to be due to frequent irritation of the structures. c. The enormous enlargement of the labia minora seen in some barbarous tribes, particularly the Hottentots (Fig. 268). This is due not to lymph stasis but to cer- tain manipulations practised on the female children, particularly stretching of the parts manually or by weights. d. Fibroma, lipoma, hematoma, carcinoma, sarcoma, ordinary edema, acute inflammatory enlargement, hernia. e. The slighter degress of enlargement found in the various forms of vulvar ulceration, namely, in the syphilitic, tubercular, malignant and rodent ulcers. In each of these conditions, when present for some time, there is usually slight stasis hypertrophy, but the disease giving rise to the ulceration is the important feature and hence the case should be classed under syphilis or tuberculosis or ma- lignant disease or rodent ulcer. However, with syphilis or rodent ulcer, as the case continues the hypertrophy may in time become the most important feature and then the case could properly be classed as one of stasis hypertrophy. If this fact of the possible overlapping of these terms were kept in mind and yet a definite meaning were attached to each term when used, much confusion would be avoided. I think the term "elephantiasis" should be reserved for those cases of vulvar en- largement in which the enlargement becomes very gi-eat, i. e. of really elephantine proportions (Fig. 255). Etiology. There are supposed to be three causative factors: 1. Chronic ulceration about the vulva. This has long been recognized as an etiological factor in the majority of cases. In most cases, the ulceration spreads at one point and heals at another, forming scar tissue. The contraction of the scar tissue, and of the inflammatory infiltration under the ulcer, obstructs the circulation, particularly of the lymph, and causes stasis, chronic irritation, infiltration and hypertrophy of the tributary structures. This same ulceration may lead to infec- tion of the lymph glands and the obstructive condition mentioned in the next para- graph. In Fig. 254, the masses are raised to show the ulceration beneath. 2. Obstructive changes in the inguinal lymphatic glands. This factor was brought out by F. Koch, and helps to account for those cases in which there has been no extensive ulceration. The obstruction of the lymph glands by disease of these structures may be an important factor also in those cases accompanied by, and apparently due to, chronic ulceration. The closing of these lymph highways 450 DISllASES OF EXTERNAL GENITALS AND VAGINA through the glands may be brought about by extirpation of the glands or by suppuration of the same, or even by inflammatory or degenerative processes that stop short of suppuration, such, for example, as tertiary syphilis. 3. Local invasion of the vulvar lymphatics by the filaria sanguinis hominis. This is rare or unknown in this country, but it occurs as an endemic affection in some countries (India, Barbadoes and the Antilles). Mosquitoes are supposed to deposit the embryo beneath the epidermis. There the parasite multiplies to such an extent as to choke the lymph channels, the obstruction being due to both the parasites proper and the ova. Stasis hypertrophy is a rather common affection among prostitutes, in whom the constant irritation from frequent coitus and from various infections and from lack of' cleanliness, tends to keep up indefinitely the chronic ulceration, which usually precedes and accompanies the hypertrophy. In this class, chronic ulceration is favored also by the depressed general health and in many cases by tertiary syphilis or the post-syphilitic state. The post-syphilitic state probably predisposes to stasis hypertrophy by producing poor tissue resistance which favors chronic ulcera- tion, and also by producing a change in the local lymph glands which interferes more or less with the flow of lymph through them. Pathology and Symptoms. There is marked hyperplasia of the skin and sub- cutaneous tissues, and the lymph spaces are dilated. There is usually considerable round-cell infiltration and connective tissue proliferation. In some cases there is infection of the lymph spaces and the formation of pockets of pus, but this is not a part of the essential pathology of the disease. In the absence of infection, there are no evidences of acute inflammation in ordinary stasis hypertrophy. The enlarged structures have about the normal color. The skin may be smooth (glabrous variety) or rough and warty (verrucous variety) v/ith marked exaggera- tion of the normal skin folds. The process may effect the clitoris alone or one of the labia alone or it may affect all of these structures simultaneously or in succession. There is usually present more or less chronic ulceration. In that variety due to the filaria, the parasite and ova are found choking the lymph spaces and there are also evidences of acute inflammatory reaction. The enlargement in stasis hyper- may vary in size from a small thickening, hardly noticeable, to a mass so large as to prevent coitus and interfere with walking (Figs. 249 to 253) Examination reveals the enlargement and usually also the ulceration and scar tissue. In the absence of infection, there are no acute inflammatory symptoms and usually but little congestion. The patients complain of some discharge and itching about the genitalia and not infrequently symptoms of irritation on the part of the bladder and rectum. What usually brings the patient to the physician is the discharge and enlargement, with resulting discomfort and inconvenience in walking and difficulty in coitus. Diagnosis. Tertiary syphilitic lesions of the vulva not infrequently resemble the affection under consideration, there being present syphilitic ulceration and syphilitic deposit in the tissue. For this reason a thorough course of iodides is advisable in nearly all these cases as a diagnostic measure. In some supposed cases of simple stasis hypertrophy, when the patient is put on anti-syphilitic treatment the ulcers heal rapidly and the swelling rapidly disappears, showing that the trouble TREATMENT OF STASIS HYPERTROPHY 451 was syphilis and not ordinary stasis hypertrophy. However, the post-syphihtic state undoubtedly predisposes to chronic ulceration with resulting stasis hyper- trophy, and a large numl^er of the persons so afflicted are old syphilitics. That it is not syphilis in the active stage, is shown by the therapeutic test — the iodides rarely doing much good. From stasis hypertrophy we must distinguish also tuberculosis of the vulva and malignant disease, ))y the special diagnostic points given under each. To be distinguished also are fil)r<)ma, li})()ma, hernia and the enlargement of the labia minora previously mentioned. Tn that rare form of stasis hypertrophy due to the filaria, considerable acute inflammatory reaction follows the invasion of the lymph spaces by the parasite A. c. Fig. 485. Excision of External Genitals. A. Showing enlarged labia ("stasis hyper- trophy;, with the incision made on the left side. B. Showing the wound left when the diseased structures are removed. The bleeding vessels are tied and the suturing is begun. (Hirst— diseases of Women.) and at this stage it is very liable to be mistaken for erysipelas or ordinary cellu^ litis. After these acute symptoms subside the brawny induraton remains. Acute exacerbations occur at irregular intervals and with each exacerbation there is a decided increase in the hypertrophy. If pus infection of the dilated lymph spaces takes place, abscesses and sinuses form. Treatment. The treatment of stasis hypertrophy is naturally divided into two parts — that for the ulceration and skin irritation, and that for the swollen structures. The first consists in cleanliness and the employment of the measures mentioned under ulcer and under vulvitis. The second, i. e. treatment for the large masses, is excision. In some of the milder cases the removal of the irritation and dermatitis and the treatment of the ulcera- 452 DISEASES OF EXTERNAL GENITALS AND VAGINA tion, will do away with part of the swelling (the coincident edema) and relieve the patient so much that she is comfortable. In most cases, however, particularly where the enlargement is marked, the masses should be removed. In some cases the masses are so much in the way that they must be removed before the ulceration can be satisfactorily treated. But on account of the danger of infection the ulcera- tion should be healed as far as possible and all the dermatitis removed before ex- cision of the mass. Infection is particularly dangerous in these cases on account of the gi-eat dilatation of the lymph spaces, and strict antiseptic care must be em- ployed in handling them. The l^est wav to remove such a mass is by clean excision with the knife or scissors and closure of the resulting wound with sutures (Fig. 485) . Bleeding is free and many artery forceps are needed to catch the small vessels. When there is a large mass with a broad pedicle, it is best to close the wound immediately, a little at a time as the incision is extended and the mass gradually excised. In this way the sutures stop the bleeding at once, no ligatures are necessary and comparatively little blood is lost. The older method of removal with the cautery leaves a broad surface to heal by gi-anulation and there is much resulting scar tissue and distortion. Except in the cases of very small pedicle, it is inferior to excision with the knife. The knife- excision leaves the edges of the wound in condition for a?ccurate approximation and rapid union wdth a minimum amount of scar tissue. PUDENDAL HERNIA. A pudendal hernia is a protrusion of the intestine or omentum or other intra- abdominal structure into the external genitals. It may take place by way of the inguinal canal, in which case the hernia is designated as " inguino-labial " or ''su- perior labial." The protrusion may take place by way of the vagina, in which case the hernia is designated as "vaginal," " vagino-labial" or "inferior labial." Inguino=labial hernia. The round ligament ends in the tissues at the top of the labium majus. In the fetus, the ligament is accompanied along the inguinal canal by a prolongation of the peritoneum, forming a small cavity. This is usually ob- literated in the full term fetus. In some cases, however, it is not obliterated but remains open, forming a small pocket or "canal of Nuck," and along this canal an inguinal hernia may take place. The hernia may advance no further than the inguinal ring or, on the other hand, it may protrude more and more, involving the upper part of the labium majus and later the whole labium (Fig. 281). It corresponds to scrotal hernia in the male and presents practically the same path- ology and symptoms. In some cases other structures than the intestine or omentum have been found in such a hernia-sac, for example, the ovary, Fallopian tube, uterus anrl even the pregnant uterus. VaKino=labial hernia. In rare cases a hernial protrusion may take place through the pelvic outlet by way of the vagina. In such a case the hernia may descend in front of the broad ligament, between the uterus and the bladder or, more rarely, behind the broad ligament between the uterus and the rectum. In either case ' ' PUDENDAL HERNIA 453 the hernial tumor appears first in the vagina and, as it grows larger, approaches the vaginal opening anil distends the lower part of one labium (Fig. 282). In this situation it produces an appearance somewhat resembling a vulvo-vaginal cyst, for which it may l^c mistaken. Diagnosis. Hernia differs from other swellings in this region, for example, hematoma, cyst, fibroma, stasis hypertrophy, cellulitis, in the following par- ticulars: Impulse on Coughing. This sign, however, may be absent if strangulation has taken place. Resonance on Percussion. This sign is present only if the mass contains in- testine. It is not found with omentum or ovary or tube. May be reduced into abdominal cavity. This, of course, is possible onh' in reducible hernia. If the supposed hernia cannot be reduced with the patient in the dorsal position, she may be placed in the knee-chest posture and the reduction again attempted. This is especially effective in the vaginal form of hernia. Intestinal Obstruction. Usually there is not enough obstruction to produce serious symptoms nor interfere with the passage of the intestinal contents, but when evidence of such obstruction does occur it is a very important diagnostic symptom. History. Hernia usually appears in conjunction with some straining effort. Hematoma of the vulva is usually due to some external injury. Cellulitis follows a wound or ulcer. Stasis hypertrophy is preceded by chronic ulceration and scar tissue formation. The other swellings of this locality (cyst, tumor) develop gradually and without apparent cause. Treatment. The treatment for hernia in this situation is the same as for hernia elsewhere, namely, reduction and retention of the replaced viscera within the ab- dominal cavity, if that can be satisfactorily accomplished. An inguino-labial hernia can frequently be retained with the ordinary hernia truss. If the reduction can not be accomplished or if satisfactory retention can not be secured, then the operation for the radical cure of the hernia is indicated. In the form of pudendal hernia in which the protrusion takes place by way of the pelvic outlet and vagina (vagino-labial), there is seldom enough obstruction at the hernial opening to produce troublesome symptoms. When the patient is placed in the knee-chest posture, the protruding mass returns within the abdominal cavity and in some cases satisfactory retention may be secured by means of a pessary that puts the vaginal walls on the stretch or that plugs the vaginal canal, ^^arious forms of pessary may be tried until an effective one for that particular case is found. In some cases the uterine supporter, consisting of an abdominal belt and vaginal stem supporting a hard rubber cup or ball (Fig. 462), is the most satisfactory form for the vaginal hernia. Where only temporary retention is needed, as at the beginning of labor, the vagina may be packed with gauze or cotton and the patient kept in bed and if necessary in Sim's posture, or in the dorsal posture with hip elevated on pillows. If the hernia still persists in coming down, the patient may be propped up for a time in a modified knee-chest posture, care being taken that the abdomen is free from constriction or pressure, so that the intestines may fall to the upper part of the abdominal cavity A vaginal hernia associated with pregnancy and labor makes a serious complication 454 DISEASES OF EXTERNAL GENITALS AND VAGINA and requires careful handling, for there is always the danger that the hernia may be caught and held in front of the advancing head, with fatal results. A vaginal hernia causing serious symptoms, which canot be relieved by other measures, requires operation for the permanent closing of the hernial opening. In a case in which the hernial opening can be satisfactorily reached for operative closures by way of the vagina, that route for the operation should be chosen as it is less dangerous. In other cases abdominal section is indicated. PUDENDAL HYDROCELE. In some patients, a canal persists along the round ligament, the internal end of the canal being closed. If a collection of fluid takes place in the sac thus formed, the result is a pudendal hydrocele, corresponding to hydrocele of the cord in the male. It is called also "labial hydrocele" and occupies the same location as an inguinal hernia. It differs from hernia in that it is dull on percussion, can not be reduced, gives little or no impulse on coughing, is not associated with evidences of intestinal ob- struction and has developed gradually without apparent cause. Great care is neces- sary in diagnosticating this rare affection, for it would be fatal to mistake hernia for hydrocele and treat it by injection. It must be differentiated also from cystic adeno-myoma of the round ligament. Several such cases have been reported. In hydrocele, the cyst wall would be thinner than in the cystic adeno-myoma, though in some of the cases the adeno-myoma can only be distinguished micro- scopically. Pudendal hydrocele must be differentiated also from hernia of the ovary with cystic degeneration. Treatment. If the collection of fluid is small and causes no inconvenience, leave it alone or have the patient rub in some ointment, such as oleate of mercury, once daily with gentle massage. If the swelling causes trouble, the fluid may be drawn off and an irritating injection made, the same as for treatment of ordinary hydrocele in the male. Before employing this treatment it must be determined positively that the cavity of the sac is shut off from the peritoneal cavity. A safer and more certain plan of treatment is to extirpate the sac, or a large part of it, and close the wound by sutures. HEMATOMA OF VULVA. A hematoma is a collection of l)l<)od in the tissues. The genitals are very vascu- lar and also present much loose sulxnitancous tissue into which hemorrhage may take place with but little- resistance until a large mass is formed (Fig. 248). Pregnancy, pelvic tumors and otiicr conditions that increase the vascularity of the parts, predispose to hematoma. The exciting cause is an injury that starts subcutaneou.'j bleeding. A severe injury caused by a fall astride some object is very liable to cause hematoma. The bruising of the tissues by the child's head in labor or by the obstetric forceps may cause hematoma. A slight sulx-utaneous surgical proceedure about the genitals, such as puncture of a cyst with a hypodermic needle, may be followed by a hematoma. For this reason it is important in Dunc- HEMATOMA OF VULVA 455 turing a cyst of the vulvo-vaginal gland to make the puncture on the inner side where the intervening hiyer of tissue is thin and comparatively free from veins. During pregnancy the veins of the external genitals Ijecome enlarged and varicose and sometimes there is a spontaneous rupture of a vein subcutaneously, giving rise to a hematoma without external injury. Symptoms and Diagnosis. After some slight injury, a swelling is noticed, which increases rapidly in size and is accompanied by considerable pain, especially when the patient is standing. If large, the swelling distorts the parts very much, in some cases so much that the individual structures are identified with difficulty. The swelling presents induration and, if a large collection of blood has formed, there may be fluctuation. The swelling and pain and induration are much the same as in acute cellulitis and it may be mistaken for that affection, particularly if the hemorrhage is situated so deeply that the skin is not discolored. In one typical case, which I saw in consul- tation, the physician was much alarmed, fearing that he had caused a serious infection. He had punctured a small cyst with a hypodermic syringe and drawn off the fluid. Within twenty-four hours a large swelling gradually formed accom- panied with much pain and distending and distorting the genitals on that side. In the next twenty-four hours the sweUing seemed to get worse instead of better He decided it would be necessary to make deep incisions to stop the serious and spreading infection. When I saw the patient with him, the examination-findings together with the history, showed that the trouble was a hematoma following the hypodermic-needle puncture. Rest with the hips elevated and an ice-bag applied locally was the treatment adopted, with satisfactory result. The differential diagnostic points between hematoma and cellulitis are that the hematoma begins to develop, within a few hours after the injury, too soon for infection to develop, and that there is little or no fever and that the tender- ness on superficial palpation and the local heat are neither so marked as in acute inflammation. In a few days the extravasated blood finds its way to near the sur- face and colors the skin and confirms the diagnosis. Treatment. Put the patient to bed and elevate the hips by placing a pillow under them, at the same time arranging a pillow under the knees so that the patient will be comfortable, and apply an ice-bag over the swelling. The patient should be kept perfectly quiet in this position until the hemorrhage ceases — several hours if necessary. If there is much pain, sedatives should be given to keep the patient quiet. The cessation of the hemorrhage is indicated by the swelling ceasing to increase in size and by diminution in the pain. If the hematoma is very large and increasing in size, it is advisable to incise the swelling, under antiseptic precautions, turn out the clots, ligate the bleeding vessel or vessels, cleanse the cavity and obliterate it with sutures. This avoids sloughing of the skin, suppuration of the blood collection and dangerous septicemia. In the later treatment of a case in which the incision has not been necessary, the patient must be kept in bed until absorption is well under way. If suppuration takes place in the collection of blood the resulting abscess must be opened. A large hematoma, especially if occuring in labor or advanced pregnancy, is a serious affair. The swelling may burst and fatal external hemorrhage occur or the 456 DISEASES OF EXTERNAL GENITALS AND VAGINA patient may bleed to death without external opening, the blood simply burrowing in the loose subcutaneous tissues. Such a serious result is rare, but the fact that it may occur must be kept in mind and, if the hemorrhage persists in spite of the ordi- nary measures, the affection should be treated by operation before the patient is too weak. After the blood-clots are turned out, an attempt should be made to catch the bleeding vessels with forceps. If the particular vessel that is bleeding can not be made out, catch the bleeding tissues rapidly with forceps until the hemorrhage is stopped and then ligate the bleeding areas en masse or include them in sutures. It has been recommended in these cases to stop the hemorrhage by firm packing, but valuable time may be lost in placing a packing which, afte, all, may fail to stop the bleecUng. The safer plan in severe cases to is catch the bleeding vessels and Ugate them, so that there is no chance for further loss of blood. VARICOSE VEINS OF VULVA. The veins about the external genitals may become markedly varicose, the irregular dilatation being due to some obstruction to the pelvic circulation, such as preg- nancy or a pelvic tumor. The dilatation of the veins only rarely gives rise to trou- A. Fig. 486. Excision of Varicose Veins of Vulva. A. Tne veins have been exposed by incision tnrough the skin, and the ligatures are being passed. B. The Hgatures have been tied, the varicose veins excised and the pedicles brought together. The operation is completed by a continuous suture closing the skin-incision. (Ashton — Practice of Gynecology.) blesome symptoms. Sometimes the patient complain,^, of itching or of tension in the parts. Sometimes she becomes ahinned on account of the enlargement and consults the physician simply to know the cause. Occasionally, however, there may be marked enlargement (Fig. 256) with acliinfi; in the i)arts and much irritation of the skin. The dan.^ s^:^' ■'^- £L A B Fig. 498. Recent Lacerations in Labor. A. Laceration involving the perineum and extending up the riglit vaginal sulcu.s. B. More severe Laceration, involving the perineum and extending up both vaginal .sulci. (Dickinson — American Text-book of Obstetrics.) it stands today as one of the best operations for repair of laceration of the pelvic floor. It tends, more than any other, to restore exactly the relations of the vaginal wall and perineum, as shown in the following explanation. A laceration usually affects first the perineum in the median line, and as the tear extends into the vagina it passes up the sulcus of one or both sides, as shown in Fig. 498. For convenience the apex of the vaginal flap (central flap. Fig. 498-B) may be called "a." On the lateral flaps, the point made by the junction of the vaginal and perineal portion of the flap may be designated Ijy "r," for the flap on the patient's right side, and by "c" for the left side (Fig. 506). Now in the repair of the injury, these three points should be brought together, to form the lower part of the restored vagi- STEPS IN EMMET'S OPERATION 488 nal entrance. In the fresh laceration, exten(lin • • scissors. (Vryiit-dynecoiogy.) Hcgar s Operation IS morc simple STEPS IN HEGAR'S OPERATION 497 than Emmet's and can be completed more qu^(•kl)^ When the denudation is extended well out to the sides and some deep excision of tissue is made, as (lescnbed under the Emmet operation (Fig. 504), the Hegar operation gives a good result. Its principal effects are: a. It removes the excess of posterior vaginal wall which, in the form of colpocele Fig. 513. Hegar's Operation. Showing the method of bringing to- gether the tissues by Buried Sutures. (Doderleia and Kronig— Opera- fire Gynakologie.) or rectocele, projects from the orifice and when marked tends to drag down the cervix uteri. b. It brings together in the median the lateral pelvic tissues about the lower part of the vagina. These are brought together between the rectum and vagina. Now some of these tissues normally lie between the rectum and vagina, but most 498 LACERATIONS AND FISTULiE of them pass back of the rectum (Figs. 489, 493). In bringing them together between the rectum and vagina the operation does not make an anatomical restora- tion of the pelvic sling, but it does to a large extent make a physiological restora- tion of the sling, in that the sling is shortened by this approximation of its sides between the rectum and vagina, and the slack is thus taken up. The line of support Fi(?. 514. Hegar's Operation. Showing the closure of the sup- erficial i^ortion of the vaginal wound by interupted .sutures. A continuous suture maybe ti.sed if preferred. (Doderlein and Kronig — Operative Clynakologie.) in the pelvic floor then runs between the rectum and vagina instead of back of the rectum as normally. Wiien the shortening is sufhcient, good support is secured, with consequent relief of the distressing symptoms. Tills drawing together of hileral tissues between tiie rectum and vagina at the anterior part of the pelvic sling, and tluur union there by scar-tissue, takes place THK TAIT OPERATION 499 to a greater or less extent in pnictically all operations for the restoration of the pelvic floor — in Emmet's, Hegar's, Tait's and the various modifications of each— and the careful bringing together of these deep lateral tissues by buried sutures is an important step in each of the operations. Tait's Operation. This is commonly known as the "flap-splitting" operation. Siinger-Tait operation. It is called also the Fig. 515. Tait's Operation. The Line of Incision for Ordinary Laceration of the pelvic floor. (Thomas and Mnade — Diseases of Women.) An incision is made along the lower margin of the area to be denuded, as show'n in Fig. 515, and the mucous membrane is raised as a flap, as shown in Fig. 518. The area of denudation is nearly the same as in Hegar's operation l>ut it has over it a large flap. This flap is both an advantage and a disadvantage. 500 LACERATIONS AND FISTULA One advantage is that it acts as a roof to protect the repaired area from the secretions from above which, in the other forms of operation, sometimes infect the wound and cause partial or complete failure. Furthermore, the flap-method gives a large raw surface for approximation without any loss of tissue, and the amount of tissue left in the flap adds somewhat to the mass which fills the weak place in the pelvic floor. A distinct disadvantage of the flap is that it may prevent free access to the upper Fig. 516. Tail's Operation. The Line of Incision for Laceration into the Rectum. The short incision extending downward from each corner of the regular incision is for tho pur- pose of exposing the torn and retracted ends of the sphincter ani muscle. (Thomas and Kunde— Diseases of Women.) parts of the wounds. When the laceration extends very high, the deepe? parts can not be so easily denuded nor sutured to the best advantage. This operation is especially ai)plicable in those cases where it is important to avoid loss of tissue, particularly in cases of laceration into the rectum that have resisted one or two previous operations. Iji some such cases, there is so much scar- tissue and apparently so much loss of tissue that approximation over a wide area by ordinary denudation fan not be secured without injurious tension. In such a STEPS IN TAIT'S OPERATION 501 case the main object is to secure union of the sphincter muscle and the rectal wall, and this is more certain of attainment by the Tait operation, because approximation over a large area is secured without loss of tissue and without injurious tension and also because the united surfaces are better protected from vaginal and rectal fluids. The special steps in the operation are as follows: 1. Making the Incision, from which the flap may be raised. For the ordinary Fig. 517. Tait's Operation. Making the Incision with » Scissors. (Reed — Text -book of Gynecology.) laceration, the incision has the outline shown in Fig. 515. When the laceration extends through the sphincter ani, special short incisions are made on one each side, extending from the lateral part of the main incision downward over the dimples formed by the retracted ends of the torn sphincter, as shown in Fig. 516. The inci- sion for raising the flap may be conveniently made with scissors, as shown in Fig. 517. 2. Raising the Flap. After making the incision (Fig. 517), dissection is made up the recto-vaginal septum and also out into the lateral tissues, so that a flap is raised as shown in Fig. 518. When the tear extends into the rectum, the dissection is made so that the rectal portion of the wound also forms a flap that may be turned down and folded somewhat and sutured, uniting the torn ends of the sphincter and closing the tear in the rectal wall. 502 LACERATIONS AND FISTULA 3. Suturing. This does not differ essentially from the suturing in the other operations. It was formerly the custom to suture only from the perineal surface, the silkwoim-gut sutures being passed deeply as in closing the perineal portion of I'i)?. 518. Tail'.- Oj^eiation. Bringing tno deeip tis?ue> together by Buried Sutures. The flap i.s raised out of the way. (DOderiein and ' Kronif; — Operative dlinakologie.) Fig. 519. Tait's Operation. The deep tissue.-^ lia\e been approximated by Buried Sutures. The Redun- dant portions of the Flap are being cut away. (Doder- lein and Kromg— Operative Gynakologie.) the wound in i^mmet's and Hegar's operations. Tlie operation is much ■ more effective, however, when the deep lateral ti.^.sues :ire fir.st l)rought together by buried sutures, us showii iu Fig. 518. The perineal portion is tiicn closed in the usual way STEPS IN TAIT'S OPERATION 503 by interrupted silkworm-gut sutures, passed well out to the sides and very deeply, so as to bring the lateral tissues from each side firmly together in the median below the restored vagina. Fig. 520. Tait's Operation. Showing the deej and superficial sutures. The redundant portions of the flap have been removed. Continuous sutures may be used if preferred. (Doderlein and Kronig —Operative Gynakologie.) Fig. 521. Tait's Operation. Showing the line of ap- proximation on the perineum and in the vagina. All vaginal sutures and all buried sutures are of catgut. The perineal sutures are preferably of silkworm-gut. (Doderlein and Kronig— Operaiire Gynakologie.) There is usually more or less excess of flap— consequently it is removed, as shown in Fig. 519, and the anterior edges of the flap are united by catgut, as indicated in Figs. 520 and 521. 504 LACERATIONS AND FISTULA Other Operations. There are several other operations for the repair of the pelvic floor, most of them being modifications of Emmet's or Hegar's or Tait's operation, the lines of denu- dation and of suturing varying in each case to suit the operator. There is one operation, however, essentially different from those previously described, and that is the operation carried out by Harris. In this, the levator ani muscle itself is exposed by dissection and the torn ends and the scar-tissue hdng be ween them, are excised. The separated ends of the muscle are then brought together by sutures and the vaginal mucosa is closed over them. On paper this operation is the ideal one, but in the actual application to the conditions found in the pelvis in these cases, its adA'antages are not so apparent. In the severe cases there is scar-tissue extending all through the damaged area about the torn ends of the muscle, and this interferes with their smooth dissection and clean exposure. Under these circumstances the accurate isolation of the levator ani muscles, as contemplated, requires so much dissection and handling of the deep tissues that it adds considerably to the severity of the operation and the length of anesthesia required. I think the "deep excision of tissue" from the sides of the pelvis, as explained in Fig. 504, is decidedly preferable. By it, a sufficient amount of tissue may be quickly excised from the damaged areas in the pelvic sling to give the required shortening and support when the sutures are tied. COLPOCELE, RECTOCELE, CYSTOCELE. In man}" cases of laceration of the pelvic floor, there is considerable protrusion of the vaginal walls, constituting colpocele. It may be the posterior vaginal wall (posterior colpocele — Figs. 239) or it may be the anterior vaginal (anterior colpocele). If the rectal wall follows the prolapsing posterior vaginal wall, the condition is called rectocele (Figs. 240, 241, 244, 245, 246). Rectocele is, of course, corrected' by the regular repair of the pelvic floor. If the bladder follows the prolapsing anterior vaginal wall, the condition is called cystocele (Figs. 240, 241, 242, 243). Cystocele, when present, requires a special operative measure for its cure, hence it is necessary to give it some particular con- sideration. Operation for Cystocele. When decided prolapse of the anterior vaginal wall and base of the bladder is present, that should ordinarily be taken care of at the same time that the posterior portion of the pelvic floor is repaired. The operative measure for the correction of this condition is designated as "anterior colporrhaphy " and also as "cystocele operation." It is carried out just previous to the denudation for the regular re- pair of the pelvic floor. Hegar's operation for cystocele. The redundant vaginal wall is removed o^'er a large elliptir-al area. This denudation may bo made by clipping off strips with the scissors as ex])laine(l when speaking of denudation of the posterior wall (Figs. 502, 503, 512) or the muco.sa of each side may be raised as a flap and then cut off as HEGAR'S OPERATION FOR CYSTOCELE 505 indicated in Fig. 522. The denudation should be wide, so that when the sides of the elUpse are brought together there will be some tension laterally, that a firm support from side to side may be formed under the base of the bladder. The deeper portions of the area are closed by buried sutures and then the nuicosa by superficial sutures, as indicated in Fig. 523. The sutures are all of catgut and Fig. 522. Hegar's Operation for Cystocele. The va- ginal mucosa raised and the redundant portions being excised. This shows also the area of Denudation. (Doder- lein and Kronig — Operative Gynakologie.) Fi^. 523. Hegar's Operation for Cystocele. Showing the method of closing by deep and superficial sutures. Continuous sutures may be used for both deep and superficial if preferred. (Doderlein and Kronig— 0;;era- tive Gynakologie.) may be made interrupted or continuous. The latter are preferable, as they save time. In the Hegar operation the lines of tension extend exclusively from side to side. There is no downward pull on the cervix, which is a serious disadvan- tage of the Stoltz operation ("purse-string' ' operation.) 506 LACERATIONS AND FISTULA RECTO=VAQINAL FISTULA. From injuries in labor or from destructive ulceration or from other causes, fis- tulous openings may form, extending in various directions. The different varieties of genital fistulae, with the name given to each, are shown in Fig. 524. A recto=yaginal fistula is an opening from the rectum into the vagina. The size of the fistula may vary from a small tortuous tract, admitting only a small probe and permitting only gas or fluid to escape, to a large opening, involving a large part of the recto-vaginal septum, and through which passes practically all the rectal contents. Fig. 524. Fistulae of tlie Genital Tract. 1. Urethro-vaginal fistula. 2. Vesico- vaginal fistula. 3. Recto-vaginal fistula. 4. Vesico-uterine fistula. 5. Uretero-vaginal fistula. 6. Intestino-vaginal fistula. (.G'lWiam— Practical G)jnecolo«jy.) Etiology and Pathology. The following are the causes of recto-vaginal fistulae. 1. Injuries in labor, in rare cases a hole may be torn through the recto-vaginal septum, resulting dii-cctly in a fistula. Usually, however, a fistula resulting from labor, is due to a complete laceration of the perineum, which is repaired at once or RECTO- VAGINAL FISTULA 507 later, but fails to heal entirely. The lower part of the approximated surfaces unite, but a small part of the upper angle fails to heal, and the result is a fistula extending from the rectum into the vagina. 2. Chronic ulceration of the posterior vaginal wall, which may be chancroidal or syphilitic or tubercular. It usually affects the lower part of the vagina. 3. Stricture of the rectum, with dilatation and ulceration of the rectal wall above it. 4. Malignant disease of the recto-vaginal septum. This is usually secondary to cancer of the cervix uteri or cancer of the rectum. 5. Operation. A pelvic abscess which has ruptured into the rectum, will, if opened into from the vagina, give a rerto-vaginal fistula. Again, in stricture of the rectum, there niay be dilatation anrl ulceration of the rectal wall above the stricture with peri-rectal inflammation and an abscess. 8uch an abscess, if opened into from the vagina, will give a recto-vaginal fistula. Again, the rectal wall may be injured directly in various operations. Diagnosis. The diagnostic symptoms of recto-vaginal fistula, are the escape of some of the rectal contents into the vagina and the vaginal irritation caused by the same. The amount and character of the leakage from the rectum varies much in different cases. In the smallest fistulae, only gas with occasionally some liquid, passes. With the opening a little larger, there may be free leakage only when the bowels are loose and the contents fluid. In still other cases, nearly all the rectal contents, whether fluid or solid, pass through the fistulous opening. Digital examination reveals a rough place in the posterior vaginal wall. If the opening is small, only a small elevation or depression or a rough place, is felt. On inspection, if the opening is large it may be seen, but if small only a rough place with a small slit is visible. Very often a reel papule marks the vaginal open- ing of the fistula. Exploration of the opening with a probe, with a finger of the other hand in the rectum, shows that the sinus communicates with the rectum. In a doubtful case in which the opening cannot be found or in which a probe cannot l3e introduced, the fact that there is a recto-vaginal fistula may be established and its location determined by injecting colored water (methylene blue, ^% solution") into the rectum and watching for its appearance on the posterior vaginal wall. If there is syphilitic or chancroidal or tubercular ulceration, or if there is a stricture of the rectum or malignant disease, the evidences of the complicating disease will be present, in addition to the evidences of fistula. Treatment. In the recto-vaginal fistula following labor, that is, where part of the repaired recto-vaginal septum failed to heal, no secondary operation should be undertaken for the closure of the fistula for six or eight weeks after labor. The fistula may close spontaneously within a few weeks. Again, an operation in the genital tract in the puerperium increases the chance of puerperal sepsis. Also, the patient is later in much better condi-tio-n generally for the operation, as she has recovered from the 508 LACERATIONS AND FISTULA debilitating effects of parturition. Locally, also, the tissues have returned to their normal condition, and complete primary union is much more certain to follow the operation. For sometime following labor the uterine discharge would tend to interfere with healing and the tissues are so friable that the sutures are much more liable to cut through. Palliative treatment. In the meantime, the vagina must be kept clean by anti- septic vaginal douches, once, twice or three times daily, as indicated by the amount of leakage through the opening. If the opening is very small, stimulation by touch- ing it occationally with silver nitrate stick or with carbolic acid, will sometimes cause the fistula to close. If the fistula persists after thorough recovery from the parturition, it may be closed by operation. Operation. In the simple form of fistula, without complicating ulceration or infiltration, the operation for closure may be undertaken without special local preparatory treat- ment. The preparation of the patient, operator, instruments and dressings are the same as for repair of complete laceration of the pelvic floor. Steps. The patient is placed in the dorsal posture and the fistula exposed by retractors or by the fingers of an assistant as is found most convenient. The sphinc- ter ani muscle should be temporarily paralyzed by stretching before beginning the operation proper. The vicinity of the fistula is then denuded as shown in Fig. 526. The denu- dation may be made with scissors or knife, as found most convenient. This removes all scar tissue along the fistulous tract and gives healthy denuded tissue for approximation. A large area should be denuded on the vaginal surface, and this as it goes deeper should slant gradually toward the point at which the fistula enters the rectum. The opening in the rectum should not be made larger than is absolutely necessary to remove the hard scar-tissue from the opening and to denude the edges of the rectal mucosa, so that when these edges are brought together union will take place. The sutures are passed as in Fig. 525. The needle enters the vaginal mucosa a short distance outside the area of denudation, passes to the bottom of the wound, is brought out in the denuded edge of the rectal mucous membrane, enters at a corresponding point on the opposite side and emerges from the vaginal mucosa. When this suture is tied it approximates the denuded area in the entire thickness of the vaginal wall and also the denuded edge of the rectal mucosa, but the suture does not touch the free surfa(!e of the rectal mucosa. It is important that the suture should not penertate to the interior of the rectimi as the rectal contents might cause inflammation along its tract. The sutures are placed about one-fourth of an inch apart, and in such a way that when tied, the line of approxi- mation lies in the long axis of the vagina. If desired, the deeper portions of the wound may be closed with buried catgut sutures, as explained under vesico-vaginal fistula (Fig. 526). A wider surface for approximation may be secured, without loss of tissue, by splitting the edges of the opening and approximating the raw surface of the rectal flaps by buried catgut, and approximating the raw surface of TREATMENT OF RECTO-VAGINAL FISTULA 509 the vaginal flaps by catgut or silkworm-gut. In the fistula with a small rectal opening the above is the method of suturing to be employed. When there is a large opening into the rectum, it may be necessary to close the opening in the rectal mucosa with a separate row of sutures passed from the recta! surface and tied in the rectum. In order to do this, it is necessary to dilate the sphincter ani widely so that the rectal end of the fistula may be reached for suturing. The denudation is made the same as previously described. The rectal sutures include only the rectal mucosa and a small amount of submucous tissue. After the opening in the rectal mucosa has been closed the remainder of the wound is closed by sutures from the vaginal surface as already described. In a case of large fistulous opening near the anus, better approximation can be secured by dividing the tissues between the fistula and the anus, thus convert- ing the fistula into a complete laceration of the perineum, which is then repaired in the ordinary way. The after=treatment. The after-treatment of a case of recto-vaginal fistula is the same as after repair of complete laceration of the pelvic floor. Special measures. In some cases there has been so much loss of tissue that the sides of the opening cannot be satisfactorily approximated. This marked loss of tissue may be due to extensive ulceration at the time the fistula was formed, or to repeated attempts at repair. In either case the vicinity of the opening is occupied by scar-tissue, extending in various directions and making the parts so rigid that the opening cannot be satisfactorily closed except by the employment of one of the following special measures. 1. Incisions of the vaginal mucous membrane some distance from the opening, to permit the mucosa being drawn over the opening without injurious tension. Each of these incisions, if made short, may be closed immediately by passing a suture in the long axis of the incision. 2. Transplantation of a flap of vaginal mucous membrane, the flap to receive its nourishment through an unsevered portion at one or both ends. 3. Detachment of the rectum from the fixed vagina, by incision in the perineum, and closure of the rectal wall independently of the vaginal wall. In certain cases of large recto-vaginal opening, the vaginal wall is bound immovably by scar- tissue and the sides of the rectal opening, are likewise held apart by their attach- ment to the vaginal wall. If a transverse incision be made in the perineum and the rectal wall dissected from the vaginal to a considerable distance above the fistula, it then becomes freely movable and the sides of the opening may be approx- imated. They should be united by one or two rows of sutures. The sutures may be passed from the opening in the vaginal wall or from the perineal wound, as found most convenient. If the fistula is complicated by ulceration, the ulceration, of whatever character, should be healed as far as possible before the attempt is made to close the fistula. In some of these cases, the patient has tertiary syhpilis and needs a prolonged course of treatment for the ulceration and for the syphilitic deposit, and also for the marked anemia and generally lowered vitality that accompanies that disease. In the syphilitic cases, if closure is attempted while the ulceration is still present or while the patient is anemic and weak from ulceration elsewhere, the operation 510 LACERATIONS AND FISTULA is very liable to result in failure and the last opening may be larger than the first. In a tubercular fistula and in a malignant fistula, it is useless to attempt closure of the fistula unless the infiltrated area can be excised and healthy tissue approx- imated hj the sutures. Other Fecal Fistulae. Occasionally there occur other varieties of fecal fistula, opening into the genital tract. There may be an opening into the vagina from the sigmoid flexure or from the colon or from the small intestine. There may be an opening into the uterus from the sigmoid or from the colon or from the small intestine. The most common form is that following some operation at the vaginal vault, particularly vaginal hysterectomy. It appears in the form of a small opening in the scar at the vaginal vault, from which intestinal gas or fluid escapes. It is caused by injury of the intestine during operation or by ulceration of the intestinal wall before or after operation. The injury may be caused by a bite of the bowel by the tip of the pressure-forceps,by a puncture of the bowel by a needle or ligature- carrier, by inclusion of a small portion of the bowel in a ligature as it is being tied or by partial or complete rupture of the bowel in breaking up adhesions. Some- times a tubal abscess is discharging into the large or small intestine and, when such an abscess cavity is opened by vaginal incision, a fecal fistula results. Fecal fistulae involving the vault of the vagina often close spontaneously after a few weeks, the vagina in the meantime being kept clean by antiseptic douches. If the fistula persists after several weeks with no apparent prospect of closing it will be necessary to close it by an operation involving abdominal section or vaginal section. The character of the operation required will depend on the character of the fistula. It should be undertaken only by one skilled in pelvic surgery, for conditions very difficult to handle may be encountered. The other forms of genito-intestinal fistula are rare, so rare that they are curi- osities. They are due to special causes and require special treatment, usually involving abdominal section. VESICO=VAGINAL FISTULA. There may bo an opening between the genital tract and the urinary tract at one of several situations (Fig. 524). The location is indicated by the name as follows: Urethro-\-aginal fistula — between urethra and vagina. A'esico-vaginal fistula — between bladder and vagina. Uretero-vaginal fistula — between ureter and vagina. Vesico-uterine fistula — -between bladder and uterus. Uretero-uterine fistula — between ureter and uterus. All of these fistulae are rare, the most common being the vesico- vaginal. A vesico=vaginal fistula is an opening from the bladder into the vagina. The size of the fistula may vary from a small opening, permitting only slight leakage, to a large opening through which all the urine passes. VESICO- VAGINAL FISTULA 511 Etiology. The following are the causes of the vosico- vaginal fistula: 1. Injuries in labor. In prolonged labor where the lower portion of the bladder is caught and held for several hours between the head and the pubic bone, sloughing may follow. Part of the base of the bladder and the anterior vaginal wall are bruised, the circulation is more or less cut off, the parts become gangrenous and after a few days the slough separates, lea\'ing a vesico-vaginal opening through which the urine passes. Such injuries are rare in recent years on account of the gTeat improvement in obstetric teaching and practice. Now, the head is not permitted to remain for several hours in such a position that it makes serious pres- sure on the bladder. If the head does not advance satisfactorily within a reason- able time after the rupture of the membranes, the child is delivered by forceps or otherwise. A still rarer form of damage to the bladder in labor is that in which the bladder is torn directly, either by the manipulations incident to a version or by the forceps. In that case the dribbling of urine is noticed immediately, or within a few hours after labor, whereas if the fistula is due to sloughing, there is no escape of urine until the separation of the slough, which requires several days. 2. Chronic ulceration of the anterior vaginal wall or the base of the bladder. The ulceration may be chancroidal, syphilitic or tubercular. 3. Malignant disease of the vesico-vaginal septum. This is usualy secondary to cancer of the cervix uteri. 4. Operations. One of the methods of treating severe chronic cystitis is to make an opening from the vagina into the base of the bladder, so as to give constant drainage of the latter. Such an opening usualy closes spontaneously a short time after the drainage tube is removed. It may, however, fail to close promptly after its usefulness is ended, and in that case becomes a vesico-vaginal fistula, reqmring operation. Diagnosis. The patient complains of urine coming from the vagina and of much vaginal irritation. In some cases the patient complains simply that she cannot control the urine. Digital examination reveals a rough place on the anterior vaginal wall. If the opening is large it may be distinctly made out with the finger. If the opening is small, only a slight elevation or depression or rough place may be felt. Upon in- spection, if the opening is large, it may be seen, but if it is small, only a rough place with a small slit is visible. Very often a red papule marks the vagnial opening of the fistula. Exploration of the opening with a probe, with a sound in the bladder, shows that the sinus communicates with the bladder. If the opening be watched a few minutes, urine may be seen escaping from it. If the diagnosis is doubtful sterile methylene-blue solution may be injected into the bladder and its appearance watched for at the supposed vaginal opening of the fistula. There is a rare con- dition which must be carefully differentiated from vesico-vaginal fistula, namely, uretero-vaginal fistula. When the vesico-vaginal opening is large, the fact that it communicates with the 512 LACERATIONS AND FISTULA bladder is apparent, and frequently the margins of the opening and the adjacent surfaces of the vaginal mucosa and vesical mucosa are encrusted with the phos- phates from the decomposed urine. In one of my cases there was a large phos- phate stone nearly filling the contracted bladder and projecting through the large vesico-vaginal opening into the vagina. The irritation caused by the decomposition of urine in the vagina is very gi-eat, and the constant odor of decomposing urine combined with the constant leakage of fluid, soaking pads and clothing, makes the patient's very existence a burden to her. Treatment. If the fistula is due to malignant disease, no attempt should be made to close it unless the malignant infiltration is so situated that it can be completely extirpated. In the inoperable cases, local cleanliness and local sedatives are indicated. If the fistula has resulted from sloughing after labor, it is best to postpone the operation for repair for at least eight weeks, until the patient has fully recovered from parturition and the tissues have become strong enough to hold the sutures well. During the time the patient is waiting, palliative treatment will be necessary. Palliative Treatment., This consists in keeping the parts clean and in receiving and disposing of the urine, so that it does not come in contact with the clothing. To accomplish the first object, a urinarj^ antiseptic such as urotropin should be given internally. Also a vaginal douche of borax (a tablespoonful to a quart of water) or a weak carbolic douche ( |%) should be given two or three times daily and the external genitals should be washed frequently with a carbolic wash. If there is much vulvar irritation, the measures mentioned under acute vulvitis may be em- ployed. For catching the urine and protecting the clothing, one of the urinals found in the instrument-stores may be used. If no satisfactory urinal can be obtained, an absorbent cotton pad covered with a large piece of rubber-sheeting may be used. The piece of rubber-sheeting is held in place by a suitable bandage and the pad is changed as frequently as it becomes wet, so that no leakage into the clothing takes place. All the surfaces with which the urine comes in contact may be coated twice daily with benzoated zinc-oxide ointment. If the fistula is very small, cauterization may aid spontaneous closure. The vaginal portion of the fistulous tract may be cocainized and then touched with car- bolic acid or nitric acid. An occasional stimulation with the silver nitrate stick is sometimes u.seful. If after the patient has recovered from parturition, the fistula shows no evidence of early closing, au operation is indicated, Operation. In an operative case of vesico-vaginal fistula the preparatory measures are important. The object is to secure a healthy condition of the edges of the fistulous opening. These edges are often inflamed and covered with phosphatic deposits. These deposits should be removed with cotton and the raw surfaces brushed with silver nitrate solution (2% to 4%) or some of the other silver preparations. If the deposits adhere to the mucous membrane and are difficult to remove, they may be dissolved by the application of a weak nitric acid solution (one or two drops to TREATMENT OF VESICO- VAGINAL FISTULA 51J the ounce). Frequent hot vaginal douches of plain water or borax solution or weak carbolic solution, are beneficial, as are also frequent warm sitz-baths. After the douches and sitz-baths the patient should dry the parts as best she can and then apply the zinc oxide ointment over all the surfaces, to prevent contact with the urine. Every second or third day the physician may introduce the Sims speculum, cleanse the parts thoroughly, apply the silver preparation and then coat the vaginal walls and adjacent surfaces with benzoated zinc-oxide ointment or other suitable protective. The urine may be made more acid and the tendency to phosphatic deposits thus diminished, by giving the benzoic acid mixture recommended by Emmet (see For- mulae). After a few days, when the uiine is strongly acid and shows but little ten- dency to decomposition, the dose of the benzoic acid mixture may be reduced from a tablespoonful to a teaspoonful, as the larger dose may produce gastric irritability. This urinary antiseptic or some similar one should be continued after operation to prevent phosphatic deposit about the bladder wound. Also, a large amount of pure water should be given to keep the urine will diluted. The same general preparation of the patient for operation should be carried out as for repair of laceration of the pelvic floor. Special attention must be given the urine. For several days before operation the patient should be given some urinary antiseptic every six or eight hours, such as the benzoic acid mixture, just mentioned, or cystogen or urotropin or salol and boric acid. A specimen of urine for analysis may be obtained by cleansing the vagina and then placing a bed-pan under the patient long enough to collect a sufficient quantity. Before operation it must be determined that the urethra is not closed by shrink- age from non-use and inflammatory adhesions. In some cases no urine has passed through the urethra for months or years. If the urethra is not of proper calibre it should be dilated during the preparatory treatment. The technique of the operation for vesico-vaginal fistulae is indissolubly con- nected with the name of J. Marion Sims. The rise of Sims to great prominence was due largely to his admirable work in these cases. Up to his time the severer gi'ades of vesico-vaginal fistula weve considered incurable, and eveiy such patient was consigned to life-long misery a burden to herself and to her associates. Ex- tensive vesico-vaginal fistula following labor was much more common then than it is now, for obstetric teaching had not then advanced to its present state. Con- sequently there were many patients in the various countries of the world suffering from the severer forms of this trouble, and all were practically without hope of relief. Sims took hold of the subject and perfected the means for exposing the fistula — Sim's speculum and Sim's posture — and also the instruments and technique for suturing with silver wire. He also provided for constant drainage of the bladder during healing, by the use of a retention catheter. These improvements together with his tactile skill, his painstaking care and his courageous perseverance, enabled him to obtain results that were before considered impossible. Apparently hopeless cases were made well, patients were restored from a miserable existence to a happy life and eventually the fame of Sims spread 514 LACERATIONS AND FISTULA everywhere in the civilized world — and history justly records him as one of the great leaders in medical progress and one of the great benefactors of mankind. He made many other advances in the treatment of diseases of women, but none so striking and complete as in vesico-vaginal fistula. The silver wire sutures and the instruments used by Sims in their application, still hold their place with some operators, though most operators now prefer the silkworm-gut sutures or buried cat-gut sutures. In some cases the Sims posture and the Sims speculum give the best exposure of the field for operation, but in most cases the operation can be more quickly and satisfactorily carried out with the patient in the exag- gerated lithotomy posture, otherwise known as the Simon posture. Steps. After satisfactory exposure of the fistulous opening, the edges are pared as shown in Fig. 526. A small sharp knife or curved scissors may be used, as found most convenient. A very good plan is to outline the area to be denuded with a knife, so as to give it an even margin, and then excise the tissue with the scissors. The denudation is made extensive on the vaginal surface and slopes inward toward the bladder opening. The denudation must be carried into sound tissue so that primary union may take place. When possible the denudation should be made in such a way that the line of union can be made to lie somewhat in the long axis of the vagina. That is prefei- able for the reason that it causes less disturbance of the pelvic relations. When the line of union extends crosswise of the vagina, the antero-posterior tension tends to drag the cervix downward and cause retroversion. The fistula should be closed, however, in the way that will permit accurate approximation without injurious tension. In case the opening is round, a V-shaped denudation may be made at each end to permit accurate approximation in a straight line without too much tension. If necessary the edges may be brought together in the shape of an X or a Y. The oozing of blood may be largely checked by the appUcation of a small cotton or gauze sponge wrung out of very hot water, or by irrigating with hot water. The denudation should not extend into the vesicle mucosa as it may start bleeding, that may continue to prove troublesome even after the suture are passed and tied. In some cases, after such operation, blood clots have formed in the bladder to such an extent that the wound had to be reopened. The sutures are passed as shown in Fig. 525. They enter the vaginal mucosa -4 to -t an inch from the margin of the denuded area, pass into the bladder sub-mucosa, emerge near the bottom of the denuded area and then pass through corresponding tissues on the opposite side of the wound. They do not appear on the vesical surface. The sutures are passed at intervals of about Fig. 52.5. The Course of the Needle ouc-fourth of an inch. They may consist of in suturing a vesico-vaginal fistula, v. . i- r>rv i , , k a i\ Vaginal surface. b. Bladder surface. SllkWOrm-gUt OT Ot 20-day CatgUt. After the The needle passes to, but does not in- suturcs are passed the bladder should be washed elude, the bladder mucosa. (Skene — ,ir- .1 ,• ^ j ^ ,1111 1 Diseaseii of Women.-) out bciorc they are tied, to wash out all blood TREATMENT OF VESICO-VAOINAL 515 from it. The sutures are then tied and cut, and, if desired, the bladder may be filled with boric acid solution (3%) to see if there is any leakage. It is preferable in most cases to first close the deeper portions of the wound with buried sutures, as shown in Fig. 526. A very useful expedient, especially when there is much loss of tissue and decided tension in bringing the sides together, is to incise the vaginal surface around the fistula, as shown in Fig. 527, and then turn in the edges without cutting any off. The raw surfaces of the turned-in flaps are sutured together by buried sutures (Fig. 528) and then the vaginal mucosa is closed over by continuous or interrupted suture as desired (Fig. 528). After the fistula is sutured, a light packing of antiseptic gauze is placed in the vagina, the soft-rubber retention catheter is introduced, if it is to be used, a dressing is applied over the vulva and the patient is put to bed. The after=treatment is the same as after repair of laceration of the pelvic floor, with the addition of frequent catheterization or constant bladder drain- age by means of the retention catheter. When the retention catheter is used, it is left in from three to eight days, depending on the case, and after that the patient urinates or is catheterized every six hours until the wound is firmly healed. If preferred, the bladder may be emp- tied by catheter every three to six hours for the first two or three days, the reten- tion catheter being thus entirely dis- pensed with. With a reliable trained nurse in attendance, the frequent cathet- erization is fairly safe, but without such an attendant, the retention catheter is safer. When it is used it should be removed and sterilized each day and the bladder washed out with boric acid solution (3%). It is well to leave the catheter out for an hour or two for a change. As long as catheterization is necessary, the bladder should be washed out with boric acid solution (3%) either once of twice daily or after each catheterization. When the retention catheter is in place, the patient may lie in the prone or semi-prone posture to favor drainage. In severe cases it may be advisable to keep her in this posture most of the time, until the opening is healed. In mild cases, no special care is necessary except to administer the urinary anti- Fig. 526. The Regular Operation for Vesico- vaginal Fistula. Showing the area of Denuda- tion and also the Deep Sutures. (Montgomery— Practical Gynecology.) 516 LACERATIONS AND FISTULA septic and to see that the bladder is emptied every four to six hours, either spon- taneously or by catheter. The sutures are removed in twelve to fifteen days. Special measures. There are various special measures required by special con- ditions. In cases in which there are bands of scar-tissue in the vagina, which hold the edges of the fistula apart, it is sometimes advantageous to divide these bands in the pre- liminary treatment, and separate the divided bands widely by a glass plug. Fig. 527. The Flap Operation for Vesiro-vagina! Fistula. Making the Incision for turning in the flap. The "flap operation" is especially useful where there has been loss of tissue. (Montgomery — Practical Gynecology.) Fig. 528. The Flap Operation for Vesico-vaginal Fistula. The flap has been turned in and the Deep Sutures passed and tied. The Superficial Su- tures also are in place. If preferred, continuous sutures may be used throughout. (Montgomery — Practical Gynecology.) In severe cases, there is danger of occlusion of a ureter, by a ligature or by an opposing surface. This accident is indicated by increasing pain in the region of one kidney and along the ureter, accompanied by a decided diminution in the amount of urine secreted. It recjuiros the removal of one or more sutures. To prevent occlusion of the ureter a cystoscopic examination- should be made ^vhenever the position of the fistula is such as to make it probable that one of the ureters enters it or lies close to it. By cystoscopic examination, the ureteral opening may be TREATMENT OF VESICO-VAGINAL FISTULA 517 located and, if it is dangerously near the fistula, a ureteral catheter may be intro- duced, that the ureter may be better located during the operation and avoided. In the severer cases, where there is much loss of tissue and scar contraction, it may be necessary to employ one or more of the special measures mentioned under recto-vaginal fistula, such as remote incisions of the vaginal mucous membrane or transplantation of flajw of the mucosa. There are other special measures that are useful in certain cases, such as the following: a. Separation of the bladder wall from the uterus and upper part of the vagina, sufficiently to permit its being pulled down and sutured to the lower edge of the opening without much tension. b. Drainage of the bladder by suprapubic cystotomy. Satisfactory drainage can usually be secured with a retention catheter in the urethra. In certain cases however the neck of the Ijladder, and consequently part of the urethra, is in the damaged area and is necessarily involved in the operative work. In such a case, if a catheter be left in the urethra, the tissues in the neck of the l^ladder immediately about the catheter, fail to heal, resulting in incontinence of urine. In such a case, the bladder may be drained and kept at rest by suprapubic cystotomy and constant drainage. Another method of dealing with these cases is to make the operation in two stages — repairing first the urethral injury and draining the bladder by the fistula, and latei closing the fistula and using the urethra for drainage. The difficulties of . operation vary much in different cases. A small vesico- vaginal fistula is easily repaired and usually heals without trouble. In the case of a large fistula in which the edges can be easily brought together with tenacula, or can be brought so near together that lateral incisions will permit perfect approxi- mation, there is but little difficulty for an experienced operator. It requires con- siderable experience in plastic surgery to be able to judge in some cases before an operation whether or not such approximation can be secured. If it cannot be secured some other measure must be adopted and planned for in detail, before the day of operation. In some cases, with the best of care, two or three operations may be required to effect a cure, the fistulous opening being decidedly reduced in size with each oper- ation. But the operator must have a clear understanding of what is to be accom- plished in that particular case by each operation. As Kelly remarks in his ad- mirable work: "It is worse than useless to denude the edges of a large fistula, without having any definite idea of what can be accomplished until the stitches are put in and pulled upon. It would be far better to let the patient entirely alone, and confess honestly an inability to relieve her, than to go on cutting away valuable tissue and increasing the size of the fistula every time, with a vague idea that by some chance the operation may succeed." There are cases of vesico-vaginal fistula presenting a contracted bladder and with scar-tissue extending in various directions binding the edges of the fistula to ad- jacent bones, that tax to the utmost the skill and ingenuity of the operator, who must devise some way of bringing the urinary stream within control of the sphincter vesicae and of providing a bladder-cavity large enough to hold a few hours urine. 518 LACERATIONS AND FISTULA Other Urinary Fistulae. Occasionally there occur other varieties of urinary fistulse, opening into the genital tract. There may be an opening into the vagina from the ureter of one or both sides, or there may be an opening into the cervix uteri from the bladder or from the ureter. The usual causes of these fistulse are severe laceration of the cervix in labor or some operation at the vaginal vault. The fistula appears as a small opening in the scar-tissue, from which urine escapes. If due to injury during operation, the injury may have been caused by a tear of the bladder wall while separating it from the uterus, by a bite of a ureter or the bladder by the tip of a pressure-forceps, by a puncture of a ureter or the bladder by a ligature-carrier, or by inclusion of a ureter in a ligature. When due to an injury during labor, the vesico-uterine fistula is caused by a severe laceration of the cervix extending up into the vaginal vault and through the bladder wall. The lower portion of the cervical wound heals, but the upper part communicating with the bladder fails to heal, and there is left an opening from the bladder into the cervical canal. In the ureteral fistulse, if one ureter only is involved, there will be leaking of urine into the vagina and at the same time urine from the other ureter will be received and contained in the bladder and passed normally. If both ureters are involved, all the urine will pass into the vagina and none into the bladder. In either case, if methylene-blue solution be injected into the bladder, none of it will pass through into the vagina. When the fistula is connected wth a ureter, the urine comes in little gushes at intervals of several seconds. The vesico-uterine and uretero-uterine fistulse are indicated by the escape of urine from the cervical canal. Colored water injected into the bladder comes out of the cervical canal if the fistula is connected with the bladder, but not if it is connected with the ureter. These fistulse at the vault of the vagina often close spontaneously after a few weeks, the vagina in the meantime being kept clean by frequent antiseptic douches. If a fistula persists after several weeks with no apparent prospect of closing, it will be necessary to close it by operation. Occasionally the fistula may be closed by a small operation, for example, in the vesico-uterine fistula if the fistula is near the free margin of the cervix, the cervix may be split up to the fistula, the infil- trated margins of the fistula excised, and the whole area closed, much the same as an ordinary cervical laceration, with the addition of a few extra sutures for the bladder wall. If the fistulous tract is situated high in the cervix the operation will involve separation of the bladder from the uterus and separate closure of the two wounds. This may be Carried out through vaginal dissection or by abdominal section, as found most convenient. The majority of fistulse at the vaginal vault require rather extensive operative procedures, vaginal or abdominal (depending upon the character and location of the fistula), and in most cases the procedures can be carried out satisfactorily only ])y one familiar with pelvic and abdominal operative work. Occasionally nephrectomy is advisable, to stop the continuous leakage of urine from a ureteral fistula that cannot be repaired. OTHER URINARY FISTUL^E 519 DESTRUCTION OF URETHRA. The condition to which I refer here is destruction of the urethra by nictation beginning in the vestibule and extending upward to the bladder. The urethra is destroyed as far as fiuiction is concerned and there remains simply an opening from the bladder to the external genitals, through which the urine constantly dribbles. The destructive ulceration is usually syphilitic. The treatment is to restore the urethra by a plastic operation. The cases often prove very rebeUious to operative treatment, it being particularly difficult to secure restoration of the sphincter function. The cause, course and effective treatment of this troublesome affection are given in detail in a paper* which I read before the St. Louis Obstetrical and Gynecological Society, * A Vesico-vaginal Opening as a means of Bladder Drainage in Extensive Plastic Work on the Urethra, by H. S, Crossen, M. D. American Journal of Obstetrics, 1899. 520 CHAPTER yi. DISEASES OF THE UTERUS. POINTS IN ANATOMY. The uterus is situated about the center of the pelvic cavity, between the bladder and the rectum (Figs. 1, 3, 593). It projects upward into the lower part of the peritoneal cavity, and its convex surface, except the lower portion, is enveloped by peritoneum. The upper end of the uterus is directed forward. The lower end is directed backward and downward and projects into the upper end of the vagina. The uterus is freely movable, especially the upper portion, and may be pushed backward by a full bladder or forward by a full rectum. The uterus is shaped somewhat like an inverted pear (Figs. 529, 530, 531), Its Reflection of peritoneum. Fig. 529. Anterior View of the Uterus. (Dickinson — American Textbook of Obste- trics.) Fig. 530. Antero-posterior Section of Uterus showing walls and cavity. (Dickinson— Ameri- can Textbook of Obstetrics.) lower constricted portion is called the cervix uteri (neck of the uterus) and to this the vagina is attached. The remainrler of the organ is called the corpus uteri (body of the uterus). It is from the upper portion of the uterus, the widest portion, that the Fallopian tubes arise. That portion of the uterus lying above the Fallopian tubes is known as the fundus uteri (Fig. 531). The uterus has a small central cavity (Figs. 531,532) which is lined with mucous membrane and which communicates through the vagina with the outside world and througn the Fallopian tubes with tlie peritoneal cavity (Fig. 628). This is the only continuous opening from the outside of the body into the peritoneal POINTS IN ANATOMY 521 sac, and it is because of this direct opening into the peritonael cavity that peritonitis is so much more frequent in women than in men. The size of the uterus is of course different in the different periods of life (Figs. - ., ,. k -r— J - , lininvene ducts loiigUudmal Miict of epoophpron \ o/ tpocpiwron -.. ^-^—k- J ampullQ qjiuba u/crina 'mesosalpinx ,- "' ' fundus of uterus uterine orifice of tubc\ ,-- serous ,j- cont body 0} utenisi^ musculai coat f mucous coat supravaginal ' portion of cenn vaginal poitton^ 7- of cervix appendix, vesiculosa cavity of uterus niesov'arian folliculi vesiculasi border of ovary canal of cervix plica palmata \ infundibuluin fimbria avarica vagina - external os uteri \aginal rugae - posterior column of rugae body of uteius supravaginal poit on/i of cervix \\ fundus of utenis cavity of uterus canal of cervix anterior iij}^ , -^^w , ^^ posterior fornix of vagina ]iiml iiortion of cervix. Kg. 531. The Uterus and the Right Fallopian Tube and the Right Ovary, laid open. View from behind. In the right lower comer, an Antero-posterior Section of the Uterus is shown. (Sobotta and McMurrich— fl^umaw Anatomy.) 533, 534, 535). At birth it is a trifle over one inch long and the cervix comprises two-thirds of the organ (Fig. 536). It is important to keep in mind the pecul- iarities of the infantile uterus, for occasionalUy an adult presents a uterus some- 522 DISEASES OF THE UTERUS what infantile and accompanied with troublesome symptoms due to lack of de- velopment. A rather common condition and a very troublesome one (see dysmen- orrhoea) is a sharp anteflexion of the cervix — the corpus uteri being in practically normal position, but the cervix being flexed sharply forward and directed along the vaginal canal toward the opening. In the fetus, the uterus lies very high and Fig. 532. Reconstruction of the uterus, showing the shape of the ca\'ity. (yii\lia,ms— Obstetrics.) Fig. 533. Uterus and Appendages of a Young Child. (WilUams — Obstetrics.) Fig J 1 1 I and Tube and Ovary of a Fourteen- year-old Gill i\\ i\ha,ms— Obstetrics.) Fig. ')'■',.'}. Uterus and Tube and Ovary of a Twenty-year- old Mutipara. (Williams— O^^.s^firJcs.) the cervix is very large. At first the axis of the cervix lies almost In the axis of the vagina, as shown in Fig. 536. Normally, as development progi"es.ses, the corpus uteri gradually comes forward and the cervix becomes directed somewhat backward, across the vaginal axis, as shown in Fig. 537. In the ca.ses of imperfect development above refei-red to, the corpus uteri comes forward normally Init the POINTS IN ANATOMY 523 Fig. 536. Vertical mesial section of the pelvis of a large fetus at time of birth. (Webster— Diseases of Women.) Fig. 537. Antero-posterior section of the pehis of an infanc. (Tait— Gynecology and Abdominal Surgery.) 524 DISEASES OF THE UTERUS cervix fails to assume its backward direction — remaining in practically the fetal position (directed along the axis of the vagina) and causing a sharp " anteflexion of the cervix" (Fig. 330). The adult virgin uterus is three inches long (cavity 2^ inches) and the cervix forms one-third of the organ. The transverse measurement at the widest part is one and a half to two inches, and the average thickness is one inch. It weighs an ounce to an ounce and a half. After childbirth the uterus is always a little larger than the virgin uterus (Fig. 538) . This is the kind most frequently requir- ing examination. The cavity measures two and one-half to three inches. After the menopause there is marked atrophy of all the genital organs, including the Fig. 538. Obstetric*.) Fallopian tube Round Li^ajnent Body ofUtei-LLs Isthmus Extra Vaqinal portion of Cervix. Zxterncd os Paste rLor Wall of A Comparison of the Nulli parous Uterus with the Multiparous Uterus. (Edgar— Practice of uterus. The extent of the atrophy of the uterus is variable. In the very aged it may be reduced to a nodule the size of the end of the thumb, and the cervix then no longer projects into the vaginal cavity, but is felt simply as an indurated area, with a small central opening, situated in the upper part of the anterior vaginal wall. Structure of the Uterus. The uterus is a hollow muscle. The central cavity is lined with mucous mem- brane wiiile the external surface of the muscle is covered with peritoneum. The wall of the uterus is therefore composed of three layers — peritoneal muscular, and mucous (Figs. 530, 531). 1. Peritoneal layer. This forms a delicate serous covering to the uterus. It does not differ materially from peritoneum elsewhere. There are certain portions of the uterus which are not covererl liy peritoneum, namely, the lateral portions of the body and the front and sides of the cervix (Fig. 539). POINTS IN ANATOMY 525 2. Muscular layer. This is the real wall of the uterus. It is h to f of an inch thick and is composed of involuntary muscular tissue. Under the micro- scope, the principal elements are seen to be the long muscle cells. They are fusi- form in shaj^e and are arranged in parallel rows. These rows of muscle cells are arranged in bundles that extend in various directions. Fig. 539. Showing the Relations of the Uterus to the Vagina and Bladder and Peritoneum. (Dickinson —American Text-book of Obstetrics.) The muscular wall of the uterus is divided somewhat into strata. In the unim- pregnated uterus the different strata are not clearly defined, but, speaking in a general way, it may be said that the muscular bundles are arranged in three strata — a thin outer longitudinal stratum, a thick middle stratum of interlocking bundles extending in various directions, and a thin inner longitudinal stratum. muoosa. muscLa Fig. 540. Endometrium of an infant, just born. (Williams— 06s/«^feK.,j^ Fig. 544. The Menstruating Endometrium. The dark areas are formed by extravasated blood. The wavy canals are the gland- cavities. (A. Martin — Atlas of Gynecology.) Peculiarities 6? the Cervix Uteri. The structure of the cervix differs from that of the body of the uterus in several particulars, as follows: a. The greater part of the cervix has no peritoneal covering (Fig. 539). b. The muscular layer of the cervix has a much larger proportion of connective and hence is much firmer. c. There are no large venous sinuses in the cervix and the blood-vessels have thicker walls and smaller lumina than those of the body of the uterus. d. The mucous membrane lining the cervix (cervical mucosa) is disposed in prominent folds (Fig. 531). These folds extend more or less obliquely outward from two ridges, one situated near the center of the posterior lip and the other near the center of the anterior lip. e. The glands of the cervix approach the racemose variety. They consist of branching ducts with dilated ends (Fig. 545). The glands are lined with columnar epithelial cells which are even taller than those on the surface. The nucleus of each cell lies at the base. These cells secrete mucus which does not stain appreci- ably in ordinary preparations (haematoxylin and eosin), consequently that portion nf the cell lying next to the lumen, which part of the cell is usually filled with mucus, appears clear (Fig. 545). The glands of the cervix secrete a clear viscid tenacious mucus that fills the cervical canal and serves to close it and prevent invasion of the uterine cavity. The ducts of these glands sometimes become obstructed causing retention cysts (Fig. 337). These are sometimes called ''ovulae Nabothi." There may be many 530 DISEASES OF THE UTERUS of them, in which case the cervix is said to be in a state of "cystic degeneration" (Figs. 559, 560). f. The layer of cytogenic tissue with characteristic stroma cells, is compara- tively thin in the cervix. g. The cervical mucosa does not take part in the changes of menstruation or Fig. 545. Longitudinal section of a Gland of the Cervix. Tliis is evidently taken from near the ex- ternal OS, as the squamous epithelium extends up to it. A cross-section of part of a gland is shown at the lower margin. (Cullen— Cancer of the Uterus.) pregnancy, except in rare cases. It does, however, undergo the atrophy of seniKt}', but here the change is not so marked as in the endometrium for the cytogenic tissue is not so abundant. Vessels and Nerves of the Uterus. The blood supply of the uterus comes from the uterine and ovarian arteries. The uterine artery of each sitJe arises from the anterior trunk of the internal iliac POINTS IN ANATOMY. 531 (Fig. 546) and passes inward and downward ))etween the layers of the broad liu;auicnt to just above the Uiteral vaginal fornix. It then turns upward und runs in a very tortuous course along the side of the uterus. Near the top 7S DISEASES OF THE UTERUS Fig. 580. Introducing the Curet. This shows the form of the curet and also tlie manner of steadying the cervix with a tenaculum-forceps. Fig. 581. Metliod of Holding tlie Curet. It should be held like a pen, so that every gradation of force may be appreciated and regulated. The cutting edge of the curet is to be turned in every direction and the shank bent .tvifficiently to systematically curet all pait.s of the cavity CU RET. ME. N'T 679 Fig. 582. lletuniing tlie Uterus tu it.'^ Xoriual Pi^i.-^ition, after cuietment, and making the Bimanual Examination under An^thesia. The Ex- amination under Anesthesia may be made immediately before the curet- ment if preferred. which are best made out by examination under anesthesia. Again, a frequent compUcation of chronic endometritis is adher- ent retroversion, and it is im- portant to determine exactly the environment of the u t e r u s — whether it can be brought for- ward without danger, how firm and extensive the adhesions are and whether there is any collec- tion of pus in the mass of adhe- sions or in the tubes. 6. When the uterus is in normal position, remove the tenaculum-forceps from the cer- vix, spread the vagina open with the examining fingers and pack the vagina lightly with gauze (Fig. 583). When this vag- Fig. 583. Putting in the Vaginal Packing. 580 DISEASES OF THE UTERUS Fig. 584. The Vaginal Packing in Place, and the Fig. 585. The Sterile Sheet Removed, and the parts parts cleansed. ready for the dressing. Fig. 586. The Vulvar Dressing. The Gauze Applied. Fig. 587. The Vulvar Dressing. The Absorbent Cotton applied over the gauze. CURETMENT 581 inal packing is finished (Fig. 584), remove the sterile sheet (Fig. 585) and put on the dressing — fir.st, a piece of gauze (Fig. 586), then a large piece of absorbent cotton (Fig. 587) and then the T-bandage (Fig. 588). After the curetment, in chronic endometritis without active germs, the interior of the uterus is again covered with epi- thelium in two weeks (Fig. 589), and at the end of two or three months the whole endometrium is restored (Figs. 590 and 591). This new endome- trial covering is supposed to come from the mul- tipUcation of the epi- thelial cells lining the deeper portions of the a— Fig. 588. The Vulvar Dressing. The T-bandage applied. Notice in Figs. 587 and 588 that the dressing covers the entire vicinitj- of the operative field, including the pubes. C ; ^^rS^^ p- (B. -^■ Fig. 589. Perpendicular Section of the Uterine Mucous Membrane, Thirteen Days After Curetment : a, b, epithelium, newly-formed. (Baldy — American Text -book of Gynecology.) Fig. 590. Vertical Section of the Uterine Mucous Membrane, Thirty-one Days After Curetment: a, a, a, cylindrical epithelium; b. d, proliferating cells in the deeper part of the epithelium; c, newly- formed stroma. (Baldy— American Textbook of Gynecology.) 5S2 DISEASES OF THE UTERUS Fig. 591. Vertical Section of Uterine Mucous Membrane, Three Months After Curetment : a epithe- lium; b. newly-formed glands; c, stroma tissue; d, muscular tissue of the uterine wall. (Baldy — American Text-hook of Gynecology .) ^^^ ^^"M i ^ P"ig. 592. Vertical Section of the Uterine Mucous Membrane. Fifly- three Days After the Application of a Caustic: a, epithelium; b, con- nective tissue; c. c. sections of glands wliich have undergone cystic degeneration; d, tubular gland.s enormously dilated; in, muscular ti.ssue of the uterine wall. (Baldy— .•Imerionn 7'e.rt-book of Gynecology.) glands Avhich are not removed in the curet- ment. This rapid gi'owth of a new (and presum- ably more healthy) en- dometrium after cu- retment, contrasts markedly with the re- sults following cauter- ization of the endome- trium with strong cau- terants, such as nitric acid or chloride of zinc, which were form- erly much employed. Fig. 592 shows the re- sult of such destructive caustic action, and should serve as a suffi- cient warning against the use of destructive cauterants within the uterus before the meno- pause. After=care. The an- tiseptic care of a pa- tient after curetmeni is practically the same as after repair of cervix. CHRONIC SIMPLE ENDOMETRITIS 583 The vaginal and uterine packing is removed in about forty-eight hours, and an antiseptic vaginal douche (e. g., 1-5000 bichloride) is given once daily. The vulvar dressing is continued for ten days. The patient may ordinarily get up in three or four days after curetnient, except when there is some associated disease that would be benefited by longer rest in bed — for example, in chronic salpingitis associated with chronic endometritis, the patient may be kept in bed ten days to two weeks with decided benefit. Some hold that inflammation in the tubes or other tissues about the uterus is a contra-indication to curetment, but I hold just the opposite, i. e., that chronic pelvic inflammation associated with chronic endo- metritis is in most cases benefited by the curetment. Curetment is only one step in the treatment of chronic endometritis. The other measures, previously mentioned, should be carried out as before, until the symp- toms subside. Additional intra-uterine applications of astringents, the same as used before curetment, . may be necessary in exceptional cases. More benefit may be expected from these after the removal of the bulk of the diseased tissue b}' curetment than before. It is well, however, not to disturb the endometrium for at least one month after the curetment. Associated pathological conditions, such as malposition of uterus, laceration of cervix, laceration of pelvic floor and pelvic inflammation, must also be corrected, as far as possible, for if allowed to continue the uterine congestion resulting there- from will tend to prolong the endometritis and will result in the reformation of a thickened bleeding endometrium. CHRONIC SIMPLE ENDOMETRITIS. Simple endometritis is endometritis without infection. It is a nutritive change and is nearly always chronic. It is known also as hyperplasia of the endometrium. In its various forms it is sometimes designated as catarrhal endometritis, hyper- trophic endometritis, fungous endometritis, polypoid endometritis, hemorrhagic endometritis, atrophic endometritis, chronic endometritis, pseudo-metritis. Some of these terms are used to express particular forms of chronic simple endometritis and some are used to cover all forms of chronic endometritis, both simple and infected. It is a decided advantage to designate a disease or condition b}^ some name which mil, as far as practicable, express the distinctive characteristics of that disease. An investigation will, I think, demonstrate to the reader that the names I have selected out of the mass of names applied to the inflammatory and nutritive disease of the uterus, express clear-cut clinical entities — designated by their distinguishing characteristics and covering the field under consideration without troublesome over-lapping. Etiology. The cause of simple endometritis is a disturbance of the nutrition of the endo- metrium without the intervention of bacteria. This nutritive disturbance is due to a deficiency in the quantity or quality of the blood supplied to the endometrium or to special cell-conditions. The particular conditions that tend to affect the endometrium in one or more of the three ways mentioned are as follows: 1, General diseases or extra-pelvic local diseases that produce marked anemia, 584 DISEASES OF THE UTERUS for example, chlorosis, phthisis, nephritis, leukemia, gastro-intestinal affections and all wasting diseases. 2. General diseases or extra-pelvic local diseases that cause metabolic by-prod- ucts and other abnormal substances that circulate in the blood, for example, hthiasis, diabetes and all chronic septic processes. 3. Extra-pelvic diseases or conditions causing chronic pelvic congestion, for example, heart disease with failing competency, occupations that necessitate long standing or excessive walking or much lifting. 4. Pelvic diseases outside the uterus causing chronic pelvic congestion, for example, chronic pelvic inflammation, pelvic tumors and chronic disease of the rectum or bladder. 5. Malpositions of the uterus that interfere with the circulation of blood in the endometrium — anteflexion, retroflexion, retroversion and prolapse. 6. Tumors of the uterus that interfere with the blood-circulation of the endo- metrium — fibromyomata, carcinomata and sarcomata. 7. Foreign bodies in the uterine cavity, that keep up chronic congestion and irritation of the endometrium, for example, placental remnants left after an abor- tion, or uterine secretions retained by stenosis. 8. Acute simple endometritis, with the persistence of some source of intra- uterine irritation. 9. When the uterine wall is physiologically hypertrophied and fails to return to its normal condition — subinvolution. 10. Retrograde cell-changes as seen during and following the menopause, or abnormal cell-changes as in a poorly-developed uterus. Cases of uterine inflam- mation after the climacteric originate in this may, and later, on account of the discharge, infection may take place and acute infected endometritis appear. Pathology. There is chronic congestion of the endometrium and of the adjacent muscular tissue, engorgment, serous and cellular infiltration into the tissues, and hyper- plasia of the tissue elements in varying proportion. This is the usual change. In some cases, however, there is atrophy and shrinking of the endometrium, instead of increase in thickness. Either form, after continuing many years, tends to cin-hosis of the uterus, though not so markedly as infected endometritis. As indicated under etiology, simple endometritis is nearly always symptomatic of some other affection. It is associated with and dependent upon some other dis- ease, and yet in the course of time that causative disease, for example retroflexion, may be so far surpassed by the symptoms of endometritis as to be of secondary importance. In the hypertrophic form, the glands increase in number and length and there may be hyperplasia of the stroma cells. The endometrium becomes much thick- ened and in spots the surface is imeven and nodular (fungous endometritis). Small areas of this cushion of hypertrophied tissue project from the general surface into the cavity. One of these projections may increase until it becomes peduncu- lated, thus forming a polypus. There may V)e many of these polypi, forming polypoid endometritis (Fig. 569, 570). This presents the same hemorrhagic ten- CHRONIC SIMPLE ENDOMETRITIS 585 dency as the infected hypertrophic endometritis. There is increased secretion from the glands, causing discharge. The gland-ducts become obstructed, causing cysts. When the endometritis follows abortion or labor, islands of decidual tissue may persist for a long time and act as a source of irritation. In the atrophic form, the change presented is that of atrophy of the essential tissue-elements, leaving the connective tissue to largely occupy the field. The uuml)er of glands is diminished by pressure atrophy, the ducts of some of them becoming obstructed to such an extent that cysts form. The cytogenic tissue also is diminished, and the endometrium becomes unable to perform its function of menstruation or of nourishment of the fertilized ovum. Of course, in either form, infection may take place, and then the symptoms of infected endometritis are added to those of simple endometritis. Symptoms and Diagnosis. The symptoms of chronic simple endometritis are about the same as of chronic infected endometritis, namely, vaginal discharge, menstrual disturbances, hemor- rhagic tendency, backache, dragging weight in pelvis, tired feeling, sterility, reflex disturbances, enlargement of uterus and increased sensitiveness. The number and extent of the symptoms will depend, of course, upon the extent of the patho- logical process and the reaction of the patient's nervous system. Chronic simple endometritis differs from chronic infected endometritis in the following particulars: a. There is no history of infection, i. e., of acute endometritis, either septic or gonorrhoeal. This simple endometritis is the form of endometritis found in girls and unmarried women with menstrual disturbances and in married women who have never had any infection. It is freqeuntly found in the uninfected uterus which is the seat of subinvolution or fibroids or malignant disease or post climac- teric inflammation. b. The discharge is usually not so profuse nor so irritating and, when taken from the uterus, it contains no pathogenic bacteria. c. There is no evidence about the urethra or vulvo-vaginal glands of previous infection. d. Tubal complications are very rare. e. There is nearly always some associated disease, of which the simple endo- metritis is symptomatic and which must be cured before the endometritis vidll subside. Treatment. The treatment of chronic simple endometritis is about the same as of chronic infected endometritis. The following points should be kept in mind: 1. The general condition, especially the quality and quantity of the blood supplied to the endometrium, is of more importance and consequently the general treatment must be carefully considered. 2. The endometritis is dependent, usually, upon some other disease which must be corrected before the endometritis can be cured. 3. When it is found in virgins, or suspected from the symptoms, attempt ameli- oration by general treatment (blood, bowels, kidneys, muscular system, skin, 580 DISEASES OF THE UTERUS gastro-intestinal tract) and avoid local examination or treatment, except in those cases where the urgency of the symptoms or the persistence of the affection makes local treatment necessary. General measures in the virgin are to be tried first. If they fail, then local measures such as vaginal douches may be added. If they fail, then the question of intra-uterine treatment is to be considered. 4. In virgins, intra-uterine applications are not, as a rule, advisable. The vaginal orifice is small, the cervical canal is small and the applications are painful and unsatisfactory. Beside that, the nervous shock incident to the necessary exposure is much greater in the virgin. For these reasons and the additional one that in those cases in which intra-uterine treatment is required applications alone usually fail, my rule is to begin the local treatment in virgins by giving an anes- thetic and clearing out the diseased endometrium with the curet, that a new and healthy endometrium may develop under better conditions. Frequently all local applications will thus be avoided. If further intra-uterine treatment is required, applications may be made afterward more staisfactorily and with less pain to the patient. If applications are needed, the ones mentioned on page 351 may be used. In the hemorrhagic form, copper sulphate solution (10%), tincture of iodine and iodo- phenol are applicable. In the atrophic form (the most stubborn and painful variety), ichthyol 10% to 50% in glycerine has produced beneficial results. Pure ichthyol is sometimes used. It is well in the atrophic form to combine the appli- cations with drainage by antiseptic gauze. In patients who object to curetment or in the cases in which the endometritis is so mild or of such short duration that it will probably yield to applications, the following course of treatment may be employed: A few days after menstru- ation, under proper antiseptic precautions, introduce a narrow strip of iodoform gauze into the uterus. If necessary, dilate the cervix slightly. Then pack the upper part of the vagina lightly with gauze. At the end of two days remove the gauze and cleanse the parts carefully. Then make an intra-uterine application and introduce another narrow strip of gauze into the uterus and another light gauze packing into the upper vagina. At the end of two days the same process is repeated. This may be kept up until two or three days before the next menstrual flow is expected. In cases where the uterine discharge is free, it is desirable to have the gauze all in one strip with the end near the vulva, and direct the patient to remove the gauze the next day after it is introduced and then take a hot antiseptic douche every 6 to 12 hours until the next intra-uterine application, which is made every two or three days. During the course of treatment the patient should lie down a large portion of the time and should do but little walking and no work. If decided improvement follows this course of treatment it may, if necessary, be carried out in one or two succeeding intermenstrual periods. If there is no decided improve- ment from the first course of two or three weeks, it is a waste of time to try it longer. Curetment is then necessary. During curetment, if the uterus is in backward displacement it should bo brought forward into normal position, if practicable. In anteflexion, which in virgins is very frequently associated with simple endometritis, the dilatation incident to curetment and the subsequent SUBINVOLUTION OF THE UTERUS 5g7 intra-uterine gauze-packing, tends to some extent to overcome the flexion and the resulting stenosis. The removal of the causative disease in every case is very important, for unless it is removed there is strong probability of recurrence. 5. The prognosis is better, provided the causative disease can l^e removed, for there are no bacteria to keep uo chronic irritation and congestion in the uterus. SUBINVOLUTION OF UTERUS. Subinvolution is the term applied to that condition of the uterus found in cases in which, after labor or abortion, it fails to return to its normal size. It remains large and heavy, and its walls have not the usual tone and firmness. Etiology. Subinvolution is due to some interference with the retrograde changes that normally follow labor. These retrogi-ade changes that normally take place, con- sist of atrophy of the muscular and connective tissue. Fatty degeneration, which was formerly supposed to occupy such a prominent place in the process, has been found to be a subordinate feature. The retrograde changes may be interfered with iDy anything that prevents proper contraction and retraction of the uterus or that causes chronic congestion. A uterus which becomes infected after labor does not return to its normal size unless the infection is overcome. Retained membranes or placental remnants also interfere with the process of involution, even without infection. General diseases producing an impoverished condition of the blood may, follow- ing labor, so interfere with the nutrition of the uterus as to cause subinvolution. Retrodisplacement of the uterus after labor or abortion, is another cause of subinvolution. Pathology. The uterus is much thickened, both the muscular wall and the mucous lining being involved. Usually both the body and the cervix are affected, though either may be affected alone. The muscular fibers remain enlarged and show some fatty degeneration. There is a glandular hypertrophy in the mucous membrane and the lymph-spaces remain enlarged. The enlarged uterus often tends to sink low in the pelvis and to fall into retrodisplacement. When subinvolution has been present for a long time, more or less connective-tissue hyperplasia takes place and the change becomes, to some extent, a permanent one. There is usually emplanted on the condition, a simple endometritis of the hypertrophic variety. Symptoms and Diagnosis. The symptoms of subinvolution are simply a sense of weight and pressure and weakness in the pelvis, with menstrual disturbances (usually increased flow). As a rule the most prominent symptoms are those due to complications, such as simple endometritis, infected endometritis or retrodisplacement. 588 DISEASES OF THE UTERUS In practically all cases of infection following labor or abortion, there is subin- volution, but as the endometritis is the more important lesion, these cases are classed as endometritis The term subinvolution is left for those cases in which the enlargement and softening of the uterus is the principal lesion. The enlarged uterus is found low in the pelvis and not particularly tender, unless there is a complicating endometritis. The uterus may be retro verted and there is often laceration of the pelvic floor. The history connects the trouble with a previous labor or miscarriage, Treatment. The principal disturbances accompanying subinvolution come from the associ- ated diseases, consequently the treatment is directed largely to the associated conditions. The following measures tend to tone up and improve the condition of the uterine wall and tend also to benefit the accompanying endometritis. 1. Give general tonics as indicated by the patient's general condition, and uterine astringents (ergotin, hydrastis, stypticin) to tone up the uterine wall. 2. Give laxatives as indicated by the condition of the intestinal tract. 3. Give hot vaginal douches (antiseptic and astringent), for example, the bichloride douche or the alum and zinc sulphate douche (see Formulae). 4. Make intra-uterine applications, if indicated by the existing endometritis. Also, employs scarification or ichthyol-glycerine tampons or vaginal suppositories when indicated. 5. Electricity is sometimes of benefit — vagino-abdominal and utero-abdominal applications of either the galvanic current or faradic current. 6. Curetment is the most effective measure for checking the endometritis and reducing the size of the uterus. Curetment should be followed by the other reme- dial measures, such as hot douches, laxative, uterine astringents internally and, if necessary, intra-uterine applications. 7. Repair of cervix and restoration of pelvic floor may be indicated. Where the cervix has been severely torn or there is severe laceration of the pelvic floor, these lesions must of course be repaired. 8. Excision of cervix. If the cervix is much elongated, the regular wedge- shaped amputation may be carried out (Figs. 564, 566). If the cervix is not large enough to necessitate that and yet is enlarged and heavy, partial excision (Fig. 561) may be carried out. Prophylaxis of Subinvolution. Subinvolution is one of those diseases which may in a measure be anticipated and often prevented.- The measures to be employed in the puerperium to avoitl subinvolution are as follows: 1 . Prevent infection following labor or abortion by careful attention to asepsis. 2. See that the uterus is emptied of placental remnants and membranes. 3. Repair all lacerations of the pelvic floor. 4. Keep the uterus well contracted. If it shows a tendency to remain relaxed during the puerperum, give strychnine or ergotin or both. Hydrastis tends to SCLEROSIS OF THE UTERUS 5g9 tone up the uterus and keep it contracted. Also keep the bowels open well, to relieve pelvic congestion, and nuiintaiu the patient in good general condition by attention to the general health. 5. Pre^•ent retroversion by keeping the patient on the side after the first day or two, and not much on the back. Before discharging the patient, make an examination and determine certainly that there is no displacement. 6. If there is a generally relaxed condition of the tissues (uterus, vaginal walls, etc.), give a hot vaginal douche (bichloride 1-5000) twice daily after the first week or ten days. If the tissues still remain relaxed, then change to the astringent douche of alum and zinc sulphate (see Formulae). HYPERINVOLUTION OF UTERUS. Hyperinvolution is a very rare condition in which the process of involution following labor does not stop at the normal limit, but continues until the uterus is much reduced in size. The uterus sometimes becomes so small as to measure only an inch in depth. The cause of this trouble is not known. The principal symptom is painful and scanty menstruation. The treatment is not satisfac- tory. The same treatment is employed as for the dysmenoiThoea and scanty menstruation of simple atrophic endometritis. In the early part of this year I had a most interesting case of hyperinvolution of the uterus and adnexa. The patient was thirty years of age. Three years previously she had had a severe infection following the birth of her child, and there had been no menstruation since. Pelvic examination showed the uterus to be very small. On account of other trouble it was necessary to open the abdomen, and I had the opportunity of inspecting the internal genital organs. Every- thing was atrophic — the uterus, ovaries, tubes and round ligaments. The uterus was about half the normal size. SCLEROSIS OF THE UTERUS. Sclerosis of the uterus is connective-tissue hyperplasia of the deeper portions of the uterine wall, resulting from irritation and disturbance of nutrition as mani- fested in the various forms of endometritis. It is the final stage to which all forms of uterine infiammation tend and which they finally reach unless checked. It is eventually the substitution of scar-tissue (new connective tissue) for the par- enchymatous tissue-elements (epithelial cells and muscular fibers). It affects the entire thickness of the wall, producing a striking effect both in the mucous membrane and in the muscular tissue. It is known also as chronic interstitial metritis, areolar hyperplasia, cirrhosis of uterus and "irritable uterus." When located principally in the cervix, the seat of laceration and chronic inflammation, it is known as inflammatory hypertrophy. Etiology. It is due to persistent chronic inflammation or nutritive disturbance within the uterus. 590 DISEASES OF THE UTERUS It is favored by chronic inflammation around the uterus or by pelvic tumors that cause persistent uterine congestion. It is predisposed to by diseases that depress the general health and nutrition, especially by the blood conditions associated with cirrhosis of the kidney and arterio-sclerosis. It is usually due to one of the following chronic affections : Laceration of cervix, with resulting chronic inflammation. Ulcer of cervix, with deep inflammation. Chronic endocervicitis, with cystic degeneration. Chronic infected endometritis. Chronic simple endometritis. Subinvolution. It may follow destructive cauterization of the endometrium, for example, with zinc chloride or with steam. Pathology. The essential changes are hyperplasia of the connective tissue and loss of the par- enclwmatous elements (epithelial cells and muscle fibers). Following the inflam- matorj^ affections, the connective tissue hyperplasia is more active, crowding the special cells and causilig them to atrophy and finally disappear. Following the purely nutritive disturbances (subinvolution, simple endometritis) the paren- chymatous atrophy rather precedes the connective tissue proliferation, the latter being secondary and to some extent reparative. The process of sclerosis effects not only the endometrium but also the myometrium, so that practically the whole wall of the uterus is involved. When the process follows subinvolution, the uterus remains much enlarged for a long time. At this stage the tissues are rather soft and the whole uterus may feel flabby and atonic. Later, however, the new connective tissue shrinks and the uterus becomes firm and rigid and smaller. If the uterus was much en- larged as from subinvolution, it would hardly be reduced to normal size by this shrinking. But in a uterus only slightl}^ enlarged, as from chronic inflammation, it may be reduced to normal size or even smaller. In certain cases, this hyper- plasia may progi-ess to considerable extent in the myometrium before involving the endometrium, for example, following subinvolution. Here the whole muscular wall may show marked sclerosis (connective tissue hyperplasia and muscular atrophy) while the endometrium shows only simple hypertrophic endometritis (hypertrophy of stroma cells and glands). Later the endometrium also under- goes the sclerotic changes. Symptoms and Diagnosis. The symptoms and signs of sclerosis or chronic interstitial metritis are those of chronic endometritis, with the following exceptions: 1. In those cases in which the sclerosis has progressed so far tiiat the endonu^- trium is involved, the menstrual flow is scanty instead of profuse, and in some cases it is absent. 2. The discharge is not so profuse as is usually present in endonictvitis that produfos n'^ much distress. TREATMENT OF IITEHINE SCLEROSIS 591 3. The general disturbance and reflex symptoms and local distress are usually more marked and more rebellious to treatment than is endometritis. The fact that there is more general (listiu'l)ancc with this affection may be due partly to the debilitating disease that preceded and led up to the sclerosis. 4. When the process is well marked, the enlarged uterus is firmer in consistency than the normal uterus or than a uterus which is the seat of endometritis only. 5. Usually in sclerosis, the uterus is more sensitive than in chronic endome- tritis. Bimanual examination and sounding cause more pain. 6. Ill the cervix the enlargement may be directly seen. Treatment. Sclerosis is little amenable to treatment when it is well established, but it may to a large extent be prevented, and consequently preventative treatment is very important. This consists in checking, as far as possible, all chronic inflammatory and nutritive disturbances in the uterus, correcting displacements and restoring the normal condition. No treatment can remove the excess of connective tissue and restore the normal fibers. Treatment, however, may do good in two ways — (1) by removing endometritis and displacement and laceration, and thus removing many of the troublesome associated symptoms, and (2) by checking the further progTess of the sclerosis or at least diminishing the rapidity of such pro- gi'ess. 1. Endometritis, displacements, lacerations and other affections present, should be treated as described elsewhere. In sclerosis of the cervix (inflammatory hyper- trophy) a considerable portion of the redundant tissue may be removed in denuda- tion for repair, and the chronic irritation which is augmenting the sclerosis is at the same time removed. When sclerosis takes place without laceration (simply from endocervicitis or a nutritive disturbance) a portion of the cervix may be removed by excision of a wedge of tissue on each side, making a wound resembling a deep bilateral tear. In some cases, Ijoth lacerated and non-lacerated, it is advisable to do a regular amputation of the cervix, though such excessive enlargement in sclerosis is rare. 2. Removal of the accompanying disturbance has much to do with checking the spread of the disease. An additional step in this direction is the building up of the patient's general health in every possible way and the removal of all causes of pelvic congestion. With a view to causing absorption of the redundant tissue, various alteratives have been administered, particularly mercury and iodine in different forms, but without any decided effect. As local measures, the following may be used: hot douches, glycerine tampons, and ichthyol to cervix and as an intra-uterine applica- tion. Skene considered electricity more useful than any other remedy in this affection. It may be tried by the various methods mentioned in chapter iii. After the menopause, the symptoms may disappear, though this is by no mean> certain to occur. 592 DISEASES OF THE UTERUS TUBERCULOSIS OF THE UTERUS. This term is applied to tubercular disease of the uterine mucosa and myome- trium. When the tuberculosis affects only the peritoneal coat of the uterus it is classed as peritoneal tuberculosis. Etiology. Tuberculosis of the uterus usually comes from tuberculosis of the tubes. Oc- casionally it is due to infection from without, in which case it may come from tuberculosis of the external genitals. It may be produced by coitus with a tubercular husband, the tuberculosis in the husband being located in the genito-urinary tract. It is possible for the infection to be carried in this way when the husband has only pulmonary tuber- culosis, for tubercular bacilli have been demonstrated in the comparatively healthy testes and semen of phthisical patients. Infection conveyed by coitus may be first manifested in the cervix or in the body of the uterus. It is held by some that such infection may be first found in the Fallopian tubes. Tuberculosis of the uterus sometimes occurs as a part of a general infection, secondary to pulmonary tuberculosis, Pathology. Tuberculosis of the corpus uteri is usually associated with tuberculosis of the Fallopian tubes. Like other forms of genital tuberculosis, it occurs almost ex- clusively in patients with pulmonary or intestinal tuberculosis. It affects principally the endometrium and usually does not extend to the muscular portion of the wall until late. It may appear as (a) miliary tubercu- losis, (b) diffuse ulcerating tuberculosis (caseous form) or (c) fibroid tuberculosis — each form presenting practically the same distinguishing characteristics here as elsewhere. Tuberculosis of the cervix is very rare and is usually associated with tuberculosis of the vagina. It appears in the form of a chronic ulcer, which resists treatment. Symptoms and Diagnosis. The symptoms of tuberculosis of the endometrium are principally those of a severe chronic infected endometritis. There is nothing particularly distinctive in the clinical evidences of tubercular endometritis. A severe endometritis occurring in a virgin should arouse suspicion of tuberculosis. A persistent and severe chronic endometritis in the presence of peritoneal or tubal tuberculosis or occurring in a patient with phthisis, is possibly tubercular. The diagnosis is made by finding tubercle bacilli in the pus or finding characteristic changes in the scrapings from the uterus. Treatment. In all cases, give general anti-tubercular treatment. Tuberculosis of the lower part of the cervix alone, calls for amputation of the cervix or hysterectomy. ECIIINOCOCCUS DISEASE (.)!' THE UTERUS 593 Tuberculosis of the body of the uterus indicates hysterectomy (usually vaginal), provided there is no other involvement, e. g., advanced phthisis or very extensive peritoneal involvement. A moderate involvement of tubes and pelvic peritoneum is not a contra-indication to operation, provided the patient is in a fair general condi- tion. In cases in which the patient is not in fit condition for radical operation, or refuses the same, the case is treated on the same general principles as chronic infected endometritis, that is, by curetment followed, if necessary, by antiseptic and astringent applications. Iodoform should be used freely, in powder or emulsion or as soluble bougies. While a cure may, in some cases, follow this mild treat- ment, its attainment is very uncertain, and owing to the impossibility of deter- mining the limit of • the uterine infiltration and owing also to the fact that the infiltration is very likely to spread in spite of all treatment, hyster- ectomy is the safer plan and the one to be advised. SYPHILIS OF THE UTERUS. Primary syphilis (chancre) and secondary syphilis (mucous patches) may be found on the cervix uteri. In secondary syphilis there is probably in the endo- metrium the same hyperemia and tendency to exfoliation that is so common in other mucous membranes. But this is usually overshadowed by the other mani- festations of the disease. The intra-uterine condition may causes the symptoms of mild acute or chronic endometritis. There may be menstrual disturbances and some pain and discharge. If there is recent pregnancy, abortion may result. It is, however, in the later secondary and in the tertiary stage that the marked changes in the uterus become apparent. The exact pathological changes have not been entirely worked out, but they are supposed to consist in syphilitic infil- tration (small gummata and diffuse cellular infiltration) of the endometrium and probably, to some extent, of the myometrium — -producing a symptom-com- plex somewhat resembUng chronic simple endometritis of the hypertrophic type. The most striking clinical manifestation is repeated abortion. The frequent abortions in syphilis are, of course, dependent to a large extent on disease of the spermatozoa or of the ovum and on maternal blood deterioration, but some of them are no doubt due to, and many more are partially due to, the diseased con- dition of the endometrium. The diagnosis is made from the history of syphilis, from the effect of treatment and from microscopic examination of tissues from the interior of the uterus. The treatment is the same as for chronic endometritis, with the addition of thor- ough constitutional treatment for syphihs. ECHINOCOCCUS DISEASE OF UTERUS. This disease affecting the uterus is a curiosity, and yet it is not so rare that it can be ignored in diagnosis. Undoubted cases have been reported in early hfe and in middle life and later. The liver is the organ usually affected in echinococcus disease. Many other organs, however, have been affected, with or without co- incident affection of the Uver, and among the organs occasionally affected is the uterus. 594 DISEASES OF THE UTERUS When echinococcus disease attacks the uterus, there is nothing especially characteristic. The disease, at first, may resemble chronic endometritis with hemorrhagic tendency. As the cysts becomes larger, a tumor or several tumors become palpable, and the case may be considered one of uterine fibroids. When the masses become still larger, fluctuation may be detected or rupture into the uterine cavity may take place with the discharge of clear fluid and hooklets, and daughter cysts. If rupture takes place into the peritoneal cavity, fatal peritonitis is probable. The process may stop at any stage and the lesion undergo partial absorption. Suppuration may take place in the lesion, forming abscesses. In some cases the symptoms resemble pregnancy, as mentioned by Reed, as follows: "In cases of echinococcus infection of the uterine cavity, the symptoms may be essentially those of pregnancy. The uterus becomes enlarged and softened, the cervix presenting a bluish aspect. The womb enlarges, progressively and symmetrically, the breasts enlarge and may contain milk, while there is not in- frequently reflex disturbances of the stomach. It is the occurrence of these symp- toms which has generally caused infections of the uterine cavity by echinococcus to be looked upon as pregnancy, and the resulting cysts to be designated as de- generated ova. In practically all these cases, however, the usual amenorrhoea of pregnancy is absent, while the patient complains of more or less constant drib- bling of blood from the uterus. While this is true, the fact must be recognized that infection of the uterine cavity may coexist with pregnancy, as was true in MacNeven's case, in which a large echinococcus cyst was expelled intact, during a true labor and immediately preceding the rupture of the amniotic sac. The exact diagnosis can not be made without the demonstration of the hooklets." Echinococcus disease of the uterus must not be confounded with the more com- mon "hydatid mole," in which small cysts of varying size are found, and may be expelled in a large mass. The two affections are entirely distinct. The first (echinococcus disease) is due only to the echinococcus parasite in the uterus, while the second (hydatid mole) is due to degenerative changes in fetal membranes— the chorionic villi proliferating and becoming distended with fluid so as to form a mass of little cysts. This affection (hydatid mole) is rather frequent and is described in obstetric works. Occasionally the degenerating chorionic villi take on malignant characteristics and give rise to that form of uterine tumor known as chorio-epithelioma. The differential diagnosis between echinococcus disease and hydatid mole is made by microscopic examination of the pathological structures — hooklets being found in the first and chorionic villi in the second. The treatment of echinococcus disease of the uterus consists in the rupture and continual drainage of all cyst cavities, combined with the use of the antiseptics and astringents recommended for endometritis. If the disease persists and is not associated with some contra-indicating lesion, hysterectomy is indicated. 595 CHAPTER YII. DISPLACEMENTS OF THE UTERUS POINTS IN ANATOMY. The uterus is situated at about the center of the pelvic cavity (Figs. 593, 594) with the body of the organ incUned forward, the long axis of the organ being directed to a point above the symphysis pubis, the direction varying in different individuals and in the same individual at different times. The uterus is not fixed in one position, but can be moved easily in all directions — upward, downward, Fig. 593. Section of a Frozen Body, showing the usual Position of the Uterus. {SeWheim—WeibUchen Becl-en.) forward, or laterally. It is pressed somewhat backward in the pelvis when the bladder is distended (Fig. 344) and somewhat forward wl^on the upper part of the rectum is distended. It is seen, therefore, that the uterus possesses normally a (•f)nsideral)le range of mol^ility, and it is only when it is found beyond the normal range that it can be said to be displaced. 596 DISPLACEMENTS OP THE UTERUS What holds the uterus in normal position? As just stated, there is nothing that holds the uterus immovably in any one position. By a combination of several factors it is prevented, ordinarily, from going beyond certain limits, and is per- mitted free mobiUty within those limits. idanlitme^. !•;/ I'.v,™ pr.^n Fig. 594. A View from in front, showing the usual Position of the Uterus. This is the same frozen body shown in Fig. 59.3. (Sellheini— /re(7v?(c/(e» liecLen.) The factors that thus assist in maintaining the uterus within normal limits, or rather assist in preventing its remaining permanently beyond the normal limits, are the following: The Pelvic Floor (see chapter v). The Sacro-uterine Ligaments (see chapter vi). The Broad Ligaments (see chapter vi). The Round Ligaments (see chapter vi). The Normal Weight and Size of the Uterus. The Normal Tone and Fiilness of the Pelvic Tissues. A large heavy uterus tends to downward displacement and ])ackwar(l displace- ment more than one of normal size. After the menopause the atrophy of mus- cular tissue and absorption of fat nuiy so interfere with the normal tone and RETRODISPLACEMENT OF THE UTERUS 597 fullness of the tissues as to be a factor in prolapse of the uterus. The previous laceration of the pelvic floor in these cases was not sufficient in itseif to cause the prolapse. BACKWARD DISPLACEMENT OF THE UTERUS. Backward displacement of the uterus occurs in two forms — retroversion and retroflexion. In retroversion, the uterus as a whole is turned backward, the re- lation between the cervix and the body remaining the same. In retroflexion, the upper part of the uterus is bent backward, the point of bending lacing about at the internal os. The cervix may retain its normal position in the pelvis but its relation to the fundus uteri is, of course, much changed. In nearly all cases of backward displacement of the uterus, there is both a retroversion and a retroflexion. The causes of these two displacements are about the same, the symptoms are much the same, the treatment is practically the same and, as the two conditions are nearly always associated, they should be considered together. " Retrodisplacement " is the term I shall generally use in referring to a backward displacement of the uterus. It includes retroversion and retroflexion and the combination of the two. ETIOLOGY. A consideration of the factors concerned in maintaining the uterus within the limits of normal position, will indicate in a measure the causes of displacement. It is seldom, however, that one factor alone is affected, but usually several. There are various ways of classifying the causes of retrodisplacement of the uterus. The following classification I find satisfactory and convenient in actual work: A. Causes connected with labor or miscarriage. 1. Injury of the pelvic floor and accompanying relaxation of other support- ing structures. a. Pelvic floor — laceration unrepaired, overstretching or sub- sequent subinvolution. b. Sacro-uterine ligaments — overstretching or subinvolution. c. Broad ligaments, round ligaments and other pelvic tissues-^ overstretching or subinvolution. d. Vaginal wall — overstretching or subinvolution, producing sub- sequent dragging on cervix. 2. Subinvolution of uterus following labor or miscarriage— a. Of corpus, due to infection or to placental remnants or blood- clots retained, or to an atonic condition of uterus from other cause (anemia, poor pelvic circulation). b. Of cervix, due to laceration with infection of cervical tissue, or to persistent relaxation or atonic condition from other cause. 3. Scars in upper part of vagina, drawing cervix forward. 4. Getting up too soon after labor or at work too soon (displacement is favored by the heavy uterus arid the relaxed vaginal wall and pelvic floor). 5. Constant dorsal position after labor or miscarriage. 598 DISPLACEMENTS OF TUE UTERUS B. Non=puerperal changes in uterus. 1. In the cervix uteri. a. Inflammatory hypertrophy. b. Idiopathic hypertrophy. c. Tumors. d. Undue dragging down, in examinations and operations. 2. In the corpus uteri. a. Inflammation — increasing tlie weight of the uterus so that it drags on its supports. Also, in some cases, by causing soften- ing and lacl^: of tone in the waUs so tliat the organ bends backward more easily on occasion, and does not possess the tonic elasticity to return to its former shape. b. Tumors in the anterior wall or the posterior wall or in the in- terior of the uterus. And also projecting polypi. c. Senile atrophy. d. Displacement and failure to replace, in examination or operation. C. Non=puerperal changes in the supporting structures. 1. Relaxation and stretching from certain kinds of work. 2. Relaxation and stretching from faulty dress. 3. Relaxation and stretching from full bladder (pushing fundus back) or full rectum (pushing cervix forward) . 4. Stretching by conditions that increase the intra=abdominal pressure (persistent cough, straining efforts from stricture of rectum or from chronic bladder disease, etc.). 5. Relaxation from general atonic conditions (anemia, etc.). This is often accompanied by general poor support of the abdominal organs (splanchnotosis or enteroptosis) , due to repeated pregnancies with poor recuperation afterward or to other cause. 6. Stretching in examinations and operations. 7. Absorption of muscle and fat in pelvis, due to wasting disease or to sen- ility. This is one of the important factors in prolapse and retrodis- placements that come ou after the menopause, D. Pelvic Tumors. 1. Ovarian and broad ligament tumors. 2. Other tumors arising in the pelvis or extending into the pelvis. E. Pelvic Inflammation. 1. Cellulitis in front of uterus with the formation of contracting tissue, drawing {.'crvix forward. 2. Peritonitis, principally peri-saJpiugitis and ixM^i-oojilioritis forming ad- hesions with the intestines and the pelvic wall, which adhesions contract later and tend to drag the fundus uteri backward. CAUSES OF RETRODISPLACEMENT 5P9 3. Chronic oophoritis (follicular), increasing the weight of the ovary, and prolapse of ovary, tending to drag the uterus backward. Also chronic salpingitis may cause thickening of the tubes and prolapse back- ward and dragging on fundus uteri. F. Developmental Defects (congenital causes). 1. Short vagina, holding cervix too far forward. 2. Long cervix held forward by the pelvic floor, so that the body of uterus must be either in backward displacement or be sharply flexed forward on the cervix. 3. Imperfect descent of ovary, causing the upper posterior i:)art of the broad ligament to draw backward. Q. Falls. PATHOLOGY. The essential pathological change is indicated in the name and in the definition. The amount of backward displacement may be very conveniently expressed as first or second or third degree. In retrodisplacement of the first degree, the fundus lies just a])out at the promontory of the sacrum, in the second degree the fundus lies in the hollow of the sacrum, while in the third degree it lies well down in the cul-de-sac below the level of the internal os (Fig. 343). Of course in practice all gradations are found, from the normal position to the most marked backward dis- placement. The exact dividing line between the cUfferent degrees is not distinct and the division into first and second and third degi-ees is an artificial one but very convenient, and usually cases on examination may be easily placed in one class or the other and so recorded. The association of version and flexion is almost constant, a pure retroversion or a pure retroflexion being rare. The most common lesion is that shown in Fig. 71 — the uterus is turned backward far enough for the cervix to point forward and then it is flexed still further. The cervix is found pointing more or le.ss towards the vaginal orifice, the body of the uterus is absent in front and is found posteriorly, at the promontory or in the hollow of the sacrum or low in the cul-de-sac, as in Fig. 71. The broad ligaments are twisted more or less and the return circulation through them is impeded. This causes chronic congestion of the uterus, engorgement, cellular infiltration, simple endometritis and hypertrophy. If the displacement follows labor or abortion, it interferes with the normal pro- cess of involution and causes subinvolution. If it is accompanied with infection, it aggi'avates the resulting inflammation. If it occurs with laceration of the pelvic floor (and the association is very com- mon) it increases the distress of that condition and tends to cause prolapse, by increase in the weight of the uterus and also by bringing the point of the uterine wedge (instead of a broad surface) to press against the weak place in the pelvic floor (Fig. 287). 600 DISPLACEMENTS OF THE UTERUS The fundus as it goes back in the pelvis frequently takes the tube and ovary of one or both sides with it to some extent. The ovaries are the structures the more frequently displaced, and one or both of them may be found in the hollow of the sacrum close to the displaced fundus, or even below it in the cul-de-sac. In many cases there has been inflammation in the Fallopian tubes, resulting in peritoneal exudate and adhesions. These adhesions fasten the uterus more or less firmly in its abnormal position. They may hold the uterus almost immovable, or they may be so long as to permit the uterus much latitude in movement, but will not permit it to come entirely forward. Again, if the adhesion is to a mov- able structure, such as an intestinal coil or the sigmoid, the uterus may be brought forward temporarily but is soon drawn back into the abnormal position. There is a rare condition known as " retrodisplacement with anteflexion," in which an anteflexed uterus, while maintaining its anteflexion, becomes turned backward so that the fundus lies in the posterior part of the pelvis. SYMPTOMS. The symptoms accompanying retrodisplacement of the uterus are due princi- pally to the complications. There has been some question as to whether uncom- plicated retrodisplacement causes any symptoms. It may be said that retrodis- placement, as met with in actual work, is rarely without symptoms. Occasionall}^ a uterus is found in backward displacement without any symptoms referable directly or indirectly to it. But as a rule, retrodisplacement causes symptoms or aggravates symptoms due to some other disturbance. The principal symptoms are backache, a sense of weight in the pelvis, and MENORRHAGIA. Sometimes only one and sometimes only two of these symptoms are present, but most frequently all of them are complained of. In the menorrhagia, the increase in the menstrual flow is usually moderate only, and more marked in the amount than in the duration. It is not always present. In a certain proportion of the patients, the menstrual flow remains unchanged, and in some it is diminished. Sometimes in young women, the menorrhagia is the only symptom. This menorrhagia from retrodisplacement may be the cause of delayed menopause. When the menorrhagia is pronounced and long continued, it leads to severe anemia and marked deterioration of the. general health. The backache is usually located low over the sacrum and occasionally there is also much pain in the region of the coccyx (coccygodynia). Occasionally the backache extends higher along the spine. It is more commonly found in long- standing retrodisplacement and in the complicated cases — particularly those complicated with pelvic inflammation. Painful menstruation present is not so evidently due to the displacement, as is the menorrhagia. Leucorrhoea is usually present, but is due to the displacement only secondarily, being caused by the chronic conf!;estion of the cndometriiun and resulting excessive glandular secretion and enflometrial hyperplasia. Bladder and rectal disturbances are sometimes present, especially when the uterus is large and the fundus is dis- placed far down in the cul-de-sac, compressing tlu^ rectum or pressing the cervix far forward against the bladdei'. DIAGNOSIS OF RETRODISPLACEMENT 601 Sterility is, in some cases, apparently due to retrodisplacement, though not as frequently as to anteflexion of the cervix and the associated conditions. Not infrequently in a married woman who has been long sterile, pregnancy follows correction of the displacement. Occasionally the pregnancy follows so promptly as to leave little doubt that the sterility was occasioned by the displacement itself and not by any associated inflammatory trouble in the cervix or body of the uterus. Repeated abortion without apparent cause is another condition that should arouse suspicion of uterine retrodisplacement. Reflex symptoms, headache of \'arious kinds and stomach disturbance or functional nervous disturbance, are occasionally apparently due to a retrodisplacement, but on the whole the fre- quency of reflex symptoms is probably exaggerated. DIAGNOSIS. The symptoms mentioned are common to many diseases and hence are not at all distinctive of retrodisplacement. The diagnosis of retrodisplacement must rest upon the physical examination. In examining the patient it is found usually that the cervix is lower and farther forward than is normal, and that it also points forward. When making the bimanual examination search is made for the body of the uterus in its normal location, by placing the ends of the fingers in the vagina in the front of the cervix and pushing the cervix upward and backward and at the same time pressing the fingers of the other hand into the pelvis from above. In retrodis- placement it is not there (Fig. 69) . Then placing the vaginal fingers back of the cer- vix and making bimanual examination (Figs. 70, 71), a mass is found back of the cer- vix, which is about the size and shape of the body of the uterus and apparently con- tinuous with the cervix. This is the body of the uterus in its backward position. If the uterus is in only the first degree of retrodisplacement (Fig. 34.3), the fundus may be so high as to be out of reach of the vaginal fingers, and yet far enough back to be out of reach of the fingers above. The difficulty is much in- creased if the patient holds the abdominal muscles rather tense. In these cases the body of the uterus may sometimes be raised so it can be felt by the abdominal hand by pushing up the cervix with the fingers in the vagina. This lifts the whole uterus — body and all. If the displacement is marked (that is, second or third degree) the fundus can usually be felt by the vaginal fingers, back of the cervix. When a mass is felt in front or behind the cervix, it must then be determined whether or not it is the corpus uteri. The following conditions may cause an error in diagnosis. A tumor in the anterior wall of the uterus (Fig. 84). A tumor in the posterior wall of the uterus (Fig. 392). A mass in the cul-de-sac, due to prolapsed ovary or tube (Fig. 391) or to an inflammatoiy exudate (Fig. 401) or to a tumor. The differential diagnosis is made by making out the position, size, shape, consistency, tenderness, mobility and attachments of the mass, as explained under Gynecologic Examination (page 68). Determine Mobility. After having determined that the body of the uterus is backward, and al^out how far backward, the next point to determine is whether or not it is freely movable. The vaginal fingers are pressed avcII in imder the 602 DISPLACEMENTS OF THE UTERUS Fig. 595. Attempting to Raise the Fundus Uteri, to deter- mine whether or not it is fixed. This is also the first step in Bimanual Replacement of the uterus. (Prj-or — Gynecologij.) ing the uterus in that position, the fundus may be hf ted past the promontory (Fig. 597), provided it is not otherwise held. If still the uterus can not l^e raised, it is probably adherent — i. e., fixed in its false position by adhesions, the result of inflammation. This probability is increased if there is evidence of inflam- mation about the tube on either side. There is one other condition that may cause the uterus to be held in its backward posi- fundus and an attempt is made to lift it (Fig. 595). If it can not be raised from its position, it is fixed. The fixa- tion may be due to adhesions or to the fundus being caught under the promontory of the sacrum. To determine which condition is present, catch the cervix with the tenaculum- forceps and pull it doAvn- ward and forward (Fig. 596). This maneuver pulls the ute- rus forward and away from the promontory. Then, while hold- Fig. 596. Bimanual Replacement. Catching the Cervix and Pulling Forward the Uterus, so the fundus will be clear of the sacral promontory. (Kelly — Operative Gynecology.) Fig. 597. Bimanu.'il Po] Uteri past tlic sacral prnmriii oniciit. Raising I lie I'utidiis y. ( I'r.Nor — (I'l/iicrolor/i/. ) tion. Sometimes when the fundus lies low in the cul-de- sac, the sacro-uterine liga- ments produce some con- striction above it and prevent its return. This action of of the sacro-uterine ligaments is increased if the cervix be strongly pulled upon. This is a rare condition and is pos- sible only when the uterus is in the third degi-ee of retro- displacement. Complications. There arc TREATMENT OF RETRODISPLACEMENT 603 several conditions that frequently accoi^-^pany retrodisplacement and that must be taken into consideration. 1. Laceration of pelvic nv, 2. Laceration of cervix. v 3. Endometritis. '■' 4. Salpingitis, with or without exudate and adhesions*:^. "* 5. Tumors, uterine and ovarian. The last two men+ioned may cause trouble in determining the exact location of the body of the uterus. In examining a patient, do not stop when you find one lesion but make a thorough examination and find all the lesions present. . TREATMENT. If there are no symptoms, no treatment is needed. But the patient should be kept under observation so that if symptoms do develop, effective treatment may at once be instituted before the case has run along and developed complications. The treatment to be adopted depends on whether the uterus is movable or ad- herent. When the Uterus is Movable. In a case of retrodisplacement with movable uterus,the first step in the treat- ment is to replace the uterus to its proper position. There are two ways of do- ing this — by bimanual manipulation or by employment of the knee-chest posture. Bimanual manipulation. By the manipulation employed in the bimanual ex- amination, the uterus is often replaced. If it cannot be replaced by the ordinary bimanual examination methods, then catch and d r aw down the cervix -with a tenaculum-for- ceps (Fig. 596), and raise the fundus as high as possible with the fingers in the vagina. Then press the abdominal nand deeply into the back part of the pelvis, locate the promon- tory and then work along it into the pelvis back of the uterus (Figs. 597, 598). The fundus uteri is then brought forward and at the same time the cervix is carried backward, as shown in Fig. 599. After bringing the fundus forward, bend it well down over the vaginal fingers as shown in Fig. 600, in order to take out pjg 595 g^,^ ^ual Replacement. Working the Ab- any backward fiexion that dominal Fingers down over the sacral promontory, so as 1 , to get behind the fundus uteri and bring it forward. may be present. iFryov-dfuccoior,,.) 604 DISPLACEMENTS OF THE UTERUS To carry out these manipulations successfully, the abdominal walls must be relaxed and the uterus not very tender. If the patient has a thick layer of adipose tissue, the examining fingers some- times can not get near enough to the uterine body to manipulate it satis- factorily. If the patient holds the abdominal walls tense, on account of pain or nervousness, the abdominal fingers cannot reach the uterus. If the uterus is inflamed and tender, the pressure necessary to these manipula- tions causes too much pain. Knee=chest posture. When the ute- rus, though movable, cannot be re- placed b y t h e bimanual manipula- tions, the knee-chest posture may be used (Fig. 469). After the patient has been placed in this position (with the clothing about waist thoroughly loos- ened) the Sims speculum is introduced (Fig. 470). The cervix is then caught with the tenaculum-forceps and pulled Fig. 599. Bringing the Fundus Uteri forward and pushing the Cer^'ix backward and upward. (Kelly — Operative Gynecology.) forward. This brings the fundus uteri out from the promontory and permits it to fall forward into its proper position. The cervix is then pushed well backward into the hol- low of the sacrum, and a pessary or packing is put in to hold it there. The method of replacement by sound or repositor I mention only to condemn. The sound or intra- uterine repositor used in this way is dangerous. A uterus that is not adherent can usually be brought for- ward by one of the two methods already mentioned. A uterus that is adherent could not be brought forward by the sound or repositor, and its use in such a case is liable to lead to inflammation or perforation of the uterus. In some cases the uterus and ad- jacent tissues are too tender to per- mit the manipulations neces.sary for replacement. In such a case, hot Fig. 600. Tlie Uterus broiiglil fniward into position. This .shows also the method of taking the backward flexion out of the uterus, by bending it firmly forward over llir \rigiTial finders. (KcWy— Operative Cynccolof/y.) THE PESSARY IN RETRODISPI,ACEMENT 605 vaginal douches, purgatives and the knee-chest posture morning and evening for a few days, may diminish the tenderness very much. In such a case, after the knee-chest posture has been taken morning and evening for a few days, the uterus may be found forward at the next examination. Vaginal tamponade with the patient in the knee-chest posture or in the Sims posture, with gauze or cotton, every second or third day, helps to restore the uterus to its normal position. Also, in cases where no pessary is at hand, the uterus, after replacement, may be held in place temporarily by packing the vagina with gauze or cotton in such a way that the cervix is held well back in the pelvis. Again, when a pessary has to be removed temporarily for any cause, the method of holding the uterus by packing may be employed. This method does very well for holding the uterus in position for a short time, but the packing must be changed every few days, hence the method is not suitable for long-continued use. The Pessary. After the uterus has been replaced, then comes the problem of holding it there. The most convenient and efficient device for this purpose is the pessary. In uncomplicated cases this is often all that is needed. The vari- eties of pessaries, their mode of action, the manner of their introduction and their after-care are given in detail in chapter iii (see Pessaries). The Thomas, the Smith and the Hodge pessaries (Fig. 452) are the ones to be used for retrodisplacement, according to the particular indications given for each. In some cases the patient is made fairly comfortable by simple support of the uterus without replacement, such as is given by tampons or by the inflated ring pessary (Fig. 460). Patients sometimes secure these inflated-ring pessaries them- selves, from friends or from agents or through advertisements, and experience so much relief that they believe themselves cured. And in some cases there is con- siderable benefit persisting for some time after the support is removed, because the stretched pelvic tissues have gained in tone while the uterus was supported. The relief in these cases comes from the relief of the downward dragging of the uterus as a whole, for there is ordinarily no correction of the retrodisplacement (unless the patient happens to employ the knee-chest posture at the same time). It is far preferable in such a case to use the form of pessary that will hold the uterus in normal position and thus tend to permanent relief. The effect just noted of the simple support of the uterus, serves to show the im- portance of the shght prolapse in these cases and serves to show also that the retrodisplacement, as a factor in the causation of the_ symptoms and as a factor to be considered in the treatment, is not of such exclusive importance as one would infer from the usual teachings on this subject. The relief that follows operative replacement and permanent correction of the retrodisplacement, is due to a large extent to the simultaneous elevation of the uterus and adnexa. In some cases the pessary may be removed in a few weeks and the uterus will stay in position without further attention. In other cases the pessary must be worn for several months, being removed at intervals, as explained in chapter iii. In a considerable proportion of cases in which the uterus is movable, the pes- sary is not satisfactory, for one of the following reasons: Laceration of the pelvic floor. Prolapsed and tender ovary or tube. Nervousness. 606 DISPLACEMENTS OF THE UTERUS In the first class of cases, the pessary fails to keep the uterus in position. The weakening of the pelvic floor permits the anterior end of the pessary to sink below its point of support. It sinks down to a wider part of the pubic arch and then slips out of the vaginal opening. The cervix uteri then sinks forward and the fundus goes backward, as explained on page 330. When an ovary has prolapsed into the posterior cul-de-sac the pessary presses on it and causes pain. The same thing happens if an enlarged and tender tube drops into this situation, or if there is an inflammatory exudate there. In either case, the pessary causes so much pain that it cannot be worn. There is occasionally a case in which, though the pessary holds the uterus in position and causes no particular pain, it makes the patient uncomfortable and nervous to such an extent that its use is not satisfactory. In all such cases other measures for holding the uterus in position must be em- ployed. Operative treatment. When there are troublesome symptoms that are not re- he ved by the measures previously mentioned, operative treatment is required. The various classes of operative measures are mentioned further along (page 609). In order that the operative treatment may prove satisfactory, the patient should be put through a most careful and thorough pelvic examination, that the exact cause of the persistence of the displacement may be accurately determined, and the form of operative treatment selected accordingly. In a large proportion of the patients who have borne children, there will be found a relaxed conditionof the pelvic floor and of the broad ligaments and sacro- uteiine ligaments. It is evident that in such a case, the simple bringing of the fundus uteri forward and fastening it there is only a small part of the necessary work. The pelvic floor must be- strengthened, and some means must be used also to lift up the uterus and thus overcome the prolapse due to the relaxation of all the supports of the organ. In many of these cases the uterus is large and heavy from subinvolution and is the seat of chronic endometritis. ""Wh&n th6 Uterus is Adherent. When the fundus uteri cannot be brought forward by the methods previously described and no tumor that i^ responsible for the fixation can be felt, it is assumed that the uterus is "adherent,',' i. e., held in its abnormal position by the products of pelvic inflammation, affecting ,the tube or the peritoneum or the connective tissue. The fixation may be so close that the fundus cannot be moved appreci- ably, or it may, on the other hand, permit considerable movement in various directions, but not enough to allp-w the fundus uteri to be brought entirely forward. For the purposes of treatment it, is convenient to divide these cases of adherent retrodisplacement into two classes — :(!) those in which the inflammation is acute or subacute, and (2) those in which it is chronic or has practically disappeared, leaving only the sequelae. Inflammation Acute. Tliose oases present, in addition to the retrodisplacement of the uterus, the usual symptoms and signs of acute or subacute pelvic inflam- mation. The symptoms presented by the patient are due principally to the in- flammation, and the treatment is at first directed wholly to that. The g eral ADHERENT RETRODISI'LACEMENT 607 and special measures for acute pelvic inflammation (sec chapter x) are used and continued for several weeks, until all acute symptoms have disappeared. No operation or other direct disturbance of the tissues for the purpose of bring- ing the uterus forwai'd is indicated in this acute stage. All operative measures are to be postponed, except so far as such measures may be indicated directly by the inflammation. The patient is treated for the pelvic inflammation the same as though she had no retrodisplacement. When the inflammation subsides, the troublesome symptoms may disappear to such an extent that no treatment for the retrodisplacement is required. It is the relief of pain and discomfort that the patient seeks and when this can be secured simply by the relief of the inflammatory trouble, it is not necessary to disturb the uterus. In fact, as a rule, anything in that direction short of removal of the inflammatory focus, will tend to stir up again the troublesome symptoms. Most of these patients require operative treatment later, but occasionally there is a patient who continues to feel perfectly well after she recovers from the attack of pelvic inflammation — she can work hard, goes as much as she pleases, and she is symptomatically a well woman. It has been my experience that this permanent or long-continued freedom from troublesome symptoms without satis- factoiy replacement of the uterus, occurs more frequently in the cases of retro- displacement with a fixed uterus than in those with a movable uterus, though it is not very frequent in either. The fixation prevents the constant downward dragging (beginning prolapse) which produces a large part of the distress in the ordinary cases of large heavy retrodisplaced mobile uteri. Operation is required however in a majority of these cases sooner or later, either because of a persisting focus of inflammation, with chronic invalidism, or because of the sinking and dragging of the heavy retrodisplaced uterus on the damaged and sensitive adnexa or adjacent structures. In the cases of a partially movable uterus, the wearing of a pessary (for example, the inflated-ring pessary) that holds the heavy uterus up some, will sometimes give considerable relief. Such a pessary prevents the constant dragging of the uterus on its supports and on the sensitive adnexa, and in that way gives relief, though there is no correction of the retrodisplacement. Inflammation Chronic. In the chronic cases, fixation of the retrodisplaced uterus is usually due to inflammation beginning in a Fallopian tube, consequently it is frequently accompanied by salpingitis and an inflammatory exudate involving one or both tubal regions. There may be a collection of pus in a tube or in the mass of exudate about the tube, or there may be only a mass of inflammatory exudate without pus, or there may be only adhesions. If the previous inflammation was in the connective tissue, there will be infiltration remaining from the pelvic cellulitis (parametritis). In either case, the uterus is found in an abnormal po- sition and cannot be replaced by the methods previously described. In these cases, considerable relief may be given by measures that tend to allay the accompanying pelvic inflammation and that stretch the adhesions and that support the uterus to some extent. The palliative measures mentioned under chronic pelvic inflammation (see chapter x) may be employed. For support, the inflated-ring pessary is useful (Fig. 460). 608 DISPLACEMENTS OF THE UTERUS For stretching the adhesions and infiltrated tissues, in an endeavor to restore the uterus to its normal position, pelvic massage and pressure treatment are use- ful (pages 359, 364). Cases with sUght adhesions, and especially cases in which the uterus is held in its abnormal position by the sequelae of a pelvic celluUtis only, may be benefited thereby, and in such cases these measures may be given a thorough trial. But in the majority of cases of fixed retrodisplacement, the inflammatory lesions are of such character that this attempted stretching can do no good and may do much harm. The proportion of cases in which permanent relief of the pelvic distress can be secured, in this way, is very small. At least, such has been my observation, as I have studied this class of cases month after month and year after year. And I have endeavored to find for each variety, the treatment that would give the required relief with the least danger to the patient and the least sacrifice of tissue. In the SEQUELAE OF CELLULITIS, without associated peritoneal involvement, I expect softening and stretching of infiltrated tissue, increased mobility of the uterus, improvement of the intra-pelvic circulation (lymph and blood), relief of distressing symptoms, and in some cases a complete restoration of the uterus to its normal position. When there is a peritoneal or tubal involvement, as evidenced by a history of attacks of pelvic peritonitis and by induration in one or both tubal regions, little can be expected from stretching or kneading of the affected tissues. Even though all acute inflammation has apparently long since disappeared, these tubal anc peri-tubal and peri-ovarian lesions are usually aggravated rather than improved by massage or pressure treatment. As previously explained, there is present in nearly all these cases a focus of active irritation in the tubes. Nature may take care of this and, if assisted by rest and general measures, may limit it so that it causes little trouble or may eradicate it entirely, but pelvic massage and pressure treatment are likely to interfere with this natural cure instead of aiding it, ex- cept as to hastening the absorption of outlying masses of exudate. Operative treatment is indicated in practically all cases of fixed retrodisplacement, except in those in which the fixation is due wholly to the sequelae of pelvic cellu- litis or scar-tissue about the vaginal vault. I refer, of course, to those cases in which troublesome symptoms persist in spite of treatment for the pelvic inflam- mation. The objects of the operative treatment are two, first the removal of products of inflammation and of damaged organs as far as necessary and, second, the lifting and bringing forward of the body of the uterus and fastening it. These objects may be accomplished by either vaginal section or abdominal section. There are certain cases in which vaginal section is the preferable method of approach and there are other cases in which abdominal section is clearly indi- cated. Between these special cases at each extreme there is a large middle class of the chronic cases in which the work may be satisfactorily accomplished by either route. Some operators prefer one and some the other route. For my- self, I think that in the majority of these cases abdominal section is preferable. It gives a much better chance for an accurate determination of what structures should be removed and what should be left. It gives a better chance also for OPERATIONS KOU RRTRODISPT.ACEMENT 609 complete and aceuvate removal of diseased structures without injury to tissues that are left. Furthermore, it permits the fastening of the uterus well forward in such a way that it and its adncxa are satisfactorily elevated as well as brought forward. The portion of the operative work dealing with the inflammatory trouble will be mentioned under chronic pelvic inflammation (chapter x). The operative measures for the correction of the displacement, after the inflammatory trouble has been taken care of, are mentioned below: Operative Measures. The operative measures required in patients with rctrodisplacement of the uterus may be divided into three gToups — (a) measures for reducing the inflammation and enlargement of the uterus and for restoring the pelvic floor, (h) measures for relieving or removing the pelvic inflammation, and (c) measures for bringing the Litems and adnexa forward and upward and fastening them there. The measures of the first and second classes are given elsewhere, under the respective diseases. The operative measures for holding the uterus forward are verv numerous, the number running well above a hundred. There are, however, certain repre- sentative operations that may be mentioned in order to give an idea of the various methods of approach and the various structures utilized. The methods of ap- ■roach are (A) through the inguinal canals, (B) through a median abdominal cision, and (C) through the vagina. A. Through the Inguinal Canals. 1. Extra-peritoneal Shortening of the Round Ligaments (Alexander- Adams Operation). An incision is made over tiie 2. '^^nal canal on each side and the round hgament is isolated and drawn ouu t,ur?^iently to take up the slack and bring the uterus forward. The ligamenLs are then fastened in the canals by sutures. The peritoneal cavity is not opened. a. Operation is entirely extra-peritoneal. b. Utilizes the strong proximal portion of the round ligaments for supporting the uterus. c. Does not permit the breaking up of adhesions. d. Does not permit direct exploration of the pelvis, to ascertain ab- normal conditions or to make certain that the uterus comes satisfactorily forward without comphcations. e. Ligaments pull laterally instead of forward and hence permit return of displacement when there is much backward tendency. 2. Inguinal Coeliotomy with Shortening of Round Ligaments (Gold- spon Operation) . This is practically the same as the Alexander opera- tion, except that the peritoneal cavity is opened on one or both "jides. a. Utilizes the strong proximal portion of the ligaments for sup- porting the uterus. b. Permits partial exploration of the pelvic cavity and the breaking of light adhesions. . — ^. -v -r^is*r~^ / J r 610 DISPLACEMENTS OF THE UTERUS c. Ligaments pull laterally instead of forward. d. Has the disadvantage of median abdominal section (peritoneal cavity opened) without the advantages (through exploration, safe removal of diseased structures, forward pull of new liga- ments) . B. Through Median Abdominal Section. Pertaining to all the operations in this class are the advantages of thorough exploration of the pelvis and lower ab- domen and the safe removal of diseased structures, including the appendix when necessary. The special advantages and disadvantages of each sub- method are indicated below. 1. Fastening the Fundus Uteri directly to the Abdominal Wall. I. Ventro-fixation. The fundus uteri is scarified and sutured di- rectly (without intervening peritoneum) to the subperitoneal aponeurotic structure of the abdominal wall. a. The uterus is fastened very firmly forward, so that there is hardly a possibility of return of the displacement. b. Causes serious interference with the development of the uterus in pregnancy, hence is not permissible ordinarily in the child-bearing period. II. Ventro-suspension. The fundus uteri is fastened by small silk sutures to the peritoneum of the abdominal wall. The idea is to secure the formation of a band of tissue which will hold the fundus forward (suspend it from the wall) but will not inter- fere with the development of the uterus in* pregnancy. (Some prefer to pass the suspension sutures through the utero-ovarian ligaments rather than directly through the uterine tissue). a. Direct forward pull, holding the uterus well forward. b. Does not interfere with the development of uterus in preg- nancy. c. Uncertainty of ultimate result. The suspending band may become so stretched that it permits return of the displacement or, on the other hand, an unusual amount of scar-tissue may form causing a firm fixation of the uterus to the abdominal wall, which would seriously interfere with the pregnancy. d. There is a free band in the abdominal cavity, occasionally \ , leading to intestinal obstruction. \ 2. Intra-abdominal Shortening of Round Ligaments. I. Folding of the round ligaments in various ways. a. No interference with pregnancy, as the round ligaments enlarge with pregnancy and undergo involution after- ward. b. No free band in abdominal cavity. OPERATION'S FOR RETRODISPI,ACEMENT 611 c. The strain comes on the weak part of the ligament near the inguinal ring. This is Ukely to stretcii Snd permit return of the displacement. n. Drawing the round ligaments through a hole in the bi-oad liga- ment of each side and fastening them together back of the uterus, a. Secures excellent elevation of the uterus and adnexa. I). The strain falls on the weak portion (distal poi-tion) of the round ligaments. III. Suturing middle of round ligaments to tlie peritoneum of the anterior abdominal wall. ■ a. Peritoneal adhesions stretch in time and are likely to per- mit return of the displacement. 3. Transplantation of Round Ligaments into the Abdominal Wall. The intra-alDdominal portion of each ligament is drawn into the musculo-aponeurotic layer of the al^dominal wall and fastened in the median incision (the median incision may be longitudinal or trans- verse). The shortened ligament leaves the abdominal cavity at different points in the different classes of operations, as follows: I. Out through the aponeurotic wall at the internal inguinal ring, and then to the median incision (Sandberg, Peterson, Mont- gomery, Barrett and others). a. Utilizes the strong portion (proximal portion) of ligaments for supporting the uterus. b. No free band in peritoneal cavity. c. Direction of pull on uterus is lateral instead of forward, hence the displacement is likely to return if there is much backward tendency. II. Out directly through the rectus muscle (Gilliam Operation). a. UtiUzes the strong proximal portion of the Ugaments. b. Direction of pull is directly forward, hence holds uterus and adnexa well forward and upward, against even strong backward tendency. c. Can be used even when the round ligaments are fixed by inflammatory infiltration or are too weak to be used for extensive implantation. d. Gives two free bands in the peritoneal cavity, which may cause intestinal obstruction. III. Out directly through the rectus muscle, with the addition of a suture in each side to unite the distal portion of the round liga- ment to the anterior abdominal wall and thus close the open- ing through which an intestinal coil might slip (Gilliam-Fergu- son Operation). a. Utilizes the strong portion of the ligaments. b. Direction of pull is directly forward. 612 DISPLACEMENTS OF THE UTERUS c. Can be used even with fixation of the round hgaments or serious attenuation of the same. d. No free band in peritoneal cavity. e. Operative manipulations more complicated and time-con- suming than necessary, where the round ligaments are in good condition. IV. Out through the peritoneum near the internal inguinal J'ing, then along in the subperitoneal tissue and out through the rectus muscle (Gilliam-Crossen Operation). The details of this are explained later (Figs. 601, 602, 603). a. Utilizes tlie strong portion of the ligaments. b. Direction of pull is forward. It is not so directly forward as in the regular Gilliam operation, but sufficiently so to answer the purpose in practically all cases. c. No free band in peritoneal cavity. d. Operative manipulations are few and quickly executed. e. Not applicable in cases of fixation of round ligaments nor when the ligaments are seriously attenuated. 4. Reefing the Broad Ligaments. a. This lifts the uterus and adnexa. b. Does not hold fundus uteri well forward. 5. Shortening of Sacro-uterine Ligaments (through the abdominal incision) . a. Draws the cervix uteri well back and upward in the pelvis, which is an important consideration in cases in which the cervix comes far forward. b. When used alone it does not satisfactorily elevate and hold for- ward the fundus uteri and adnexa. It is used when necessary in combination with some anterior operation for holding the fundus forward. C. Through the Vagina. The vaginal operations in general have the advantage that they are easily combined with the vaginal work previously mentioned as necessary in a considerable proportion of the cases of retrodisplacement. Again, there is less handling of peritoneal surfaces and, consequently, less shock and less danger of peritonitis. On the other hand, they have the disadvantage that they do not provide for satisfactory elevation of the fundus uteri and adnexa nor for the decided pull forward and upward that is necessary when there is a strong backward tendency. Again, pathological conditions in the pelvis or lower abdomen can not be so Well determined nor so safely and accurately treated. 1. Vagino-fixation. The peritoneal cavity is opened by antoiior vaginal section and the fundus uteri fastened forward by sutm-es passing through the vaginal wall and the anterior surface of the uterus, a. Fixes the fundus uteri well forward and throws the cervix back- ward. Ol'KRA'riOXS I"(il< KI'.TKdDlSI'LACK.MIiNT 613 D. Does not provide for satisfactory elevation of the uterus and adncxa. c. I'ncertainty of ultimate result. As formerly carried out it caused serious trouble in pregnancy. Improvements in the technique have lessened this danger, but have not eliminated it entirely. When the uterus is fastened forwartl securely enough to in- sure its staying there, an excessive amount of scar may forr: and cause trouble in pregnancy. On the other hand, when the operation is so conducted as to practically eliminate this danger, the fixation is likely to be insecure and there may be return of the displacement. 2. "S'esico-fixatiox. The peritoneal cavity is opened by anterior vaginal section and the fundus uteri is brought forward and sutured to the vesical peritoneum. a. Fundus brought well forward. b. Does not provide for satisfactor}' elevation of the uterus and adnexa. c. The peritoneal adhesions are likely to stretch and permit return of the displacement. 3. Shortening the Round Ligaments through Vaginal Incision, by folding them in various ways. a. Brings fundus uteri forward. b. Does not provide for satisfactory elevation of uterus and adnexa. c. Uterus is suspended by the weak portion (distal portion) of the ligaments. d. Direction of pull is lateral instead of forAvard. 4. Anterior Coaptation of the Broad Ligaments. The bladder is sepa- rated from the uterus, as in anterior vaginal section, and then the strong tissues in the lower part of each broad ligament are brought together in the median line in front of the cervix and sutured there. This operation. promises much, both in cases of retrodisplacement and in prolapse of the uterus. It is a comparatively new operation, but there are already several modifications. Its effects are as follows: a. Cervix is elevated and held well back in the pelvis. This is sufficient in some cases to keep the fundus uteri forward and to lessen the dragging sufficiently to relieve the symptoms. b. It does not strongly elevate the fundus and adnexa. c. Like the other vaginal operations, it fails to provide for the thorough exploration and operative treatment of pathological conditions in the pelvis and lower abdomen. 5. Shortening of Sacro-uterine Ligaments through a Posterior Vaginal Incision. a. Draws cervix well back and upward and throws fundus forward. b. Does not satisfactorily elevate the fundus uteri and the adnexa. c. Tubal and appendiceal complications cannot be so satisfactorily determined nor so accurately treated. 614 displacements of the uterus 6. Posterior Vaginal Section, with packing of cervix back to form ADHESIONS (PrYOr). a. Cervix is fastened well backward and upward and the fundus pushed forward. b. Very uncertain as to whether satisfactory posterior fixation of the cervix will be secured. It may be tried when the cul-de- sac is opened for other cause. The packing may be used ad- vantageously when the sacro-uterine ligaments are shortened by vaginal section. c. Does not provide for satisfactory elevation of the fundus uteri and adnexa. Choice of Operation. As to what operation is preferable in a particular case, that depends on the conditions present in that case. When the uterus is freely movable and stays forward well with a pessary, but the wearing of the pessary is not satisfactory because of tenderness or nervousness or other discomfort, the uterus may be held forward by the extra-peritoneal shortening of the round ligaments (Alexander-Adams Operation) or by vesico- •ixation. I think the former is preferable usually because it gives better elevation of the uterus and adnexa and also gives a more permanent forward fastening. The field of either of these operations is very limited, for most of the cases in which they are efficient may be satisfactorily treated with pessaries. When there is so much disturbance that a pessary is not satisfactory, there is usually some intra-ab- dominal condition that can be more satisfactorily handled by abdominal section which permits thorough exploration and direct treatment. In those cases in which al:)dominal section is required, there conies the question as to "Which is the preferable method of fastening the uterus forward after the abdomen is open? " The answer to this depends on the conditions within the pelvis. These conditions vary widely in different cases of retrodisplacement, and in order to handle the cases intelligently they must be grouped into classes representing the principal pathological conditions. Then, for each class, that operation should be selected which best meets the requirements of that class. This definite classification of the cases of retrodisplacement, with a clear compre- hension of the obstacle to be overcome in each class, I consider a very important matter and one that must receive much additional study before the subject is thoroughly understood. The matter of classification and the adaptation of the operative measures to the special conditions present in these different classes, is presented at some length in a recent article of mine.* In respect to the conditions present in the ])el\-is, tlu> cases niay be divided into four classes, as follows: * The Preferable Metliod of yVntcrior Fixation of tlic Uterus When the Abdomen is Open. The President's Address, St. Louis Oljstetrical and Gynecologi(vil Society. H, S, Crossen, M, D, Journal of American Medical Association, May 4, H)07. CHOICE OF OPERATION FOR RETRODISPLACEMENT 615 1. Those in which the round ligaments and adjacent tissues are freely movable. 2. Those in which the round ligaments and adjacent tissues are fixed by inflam- matory infiltration or other condition. 3. Those in which the cervix Ues so far forward that the axis of t)ie uterus still lacks the normal anterior direction even when the fundus is brought into the front part of the pelvis. 4. Those in which there is so much inflammatory infiltration and contraction of the posterior part of the broad ligaments, that the uterus can not be brought entirely forward, without danger of serious injury to important structures. In each class the particular operative measure best suited to that class must be chosen. The preferable operative measures for each of the various classes is dis- cussed in the article previously mentioned. From this same article I quote the follo\ving description of the operation which I find most useful in the cases of the first class. It is the Gilliam-Crossen Operation mentioned in the preceding clas- sification of operative measures. "1. The special work for which the abdominal cavity was opened having been completed, the left rovmd ligament is grasped with an ordinary tenaculum-forceps, about 1-2 inches from the uterus. The right ligament is caught in a similar man- ner with another forceps, and then any retractors that are in the way are removed from the abdominal wall. The giasping of the ligament of each side with the tenaculum-forceps facilitates the subsequent manipulation of the ligaments, after the removal of the retractors which expose the pelvic cavity. "2. The point of the puncturing tenaculum-forceps (Fig. 601) is entered in the left side of the wound, just beneath the upper sheath of the rectus muscle and about one inch above the pubic bone. It is passed outwarrl just beneath the sheath for an inch and then the point is directed downward and made to punc- ture the rectus muscle and posterior sheath, but not the peritoneum. Guided by the fingers in the ab- domen, it is then passed outwaid between the pe- litoneum and the apo- neurosis to a point about one inch from the in- ternal inguinal ring, where it is made to pen- etrate the peritoneum. The handle of the in- strument is then raised so as to direct the point toward the round liga- ment, and it is made to grasp the ligament and overlying peritoneum about 1-2 inches from the Uterus (Fig. 602). Fig. 601. The Puncturing Tenaculum-Forceps. The instrument is strongly made and slender, and is designed to pass easily through the tissues of the abdominal wall, to penetrate the aponeurosis and peri- toneum at any desired point, to grasp the round ligament firmly with- out bruising it, and to return through the wall, bringing the ligament along the new canal. (Crossen— Journal of American Medical Associa- tion.) 616 DISPLACEMENTS OF THE UTERUS " In the class of cases under consideration, the ligament and peritoneum are usually so stretched and lax that they are easily drawn into the new canal as a small cord. If the ligament is unusually thick or if the peritoneum is so thickened that it probably will not pass easily into the forceps canal, a window may be snipped in the peritoneum in front of the ligament and the ligament alone grasped and brought into the canal. "3. The forceps is then withdrawn, bringing the ligament with it into the forceps- Fig. 602. The Puncturing tenaeulum-forceps Introduced Through the Wall, as de- scribed, and grasping the round ligament. In introducing the forceps through the wall, the point is carried along the course indicated by tlie dotted line a to b in the small sketch in the corner. Notice that the puncture through the strong musculo-aponeurotic wall is made at the rectus muscle, while the puncture through the peritoneum is made at b, which is near the internal inguinal ring. The distance from b to the internal ring is so short (about one inch) that no puckering suture is necessary. This point is further explained in Fig. 603. (Crossen — Journal of American Medical Association.) track and out at the al:)dominal wound (Fig, 603). The loop of ligament brought out is now caught and held by an ordinary tenaeulum-forceps, while the right liga- ment is brought out in a similar manner with the puncturing tenaeulum-forceps. After the ligaments are brought into position the tension is adjusted. It may be necessary to bring out a little more of the proximal portion or a little more of the distal portion, the former to bring . the fundus well CHOICE OF OPERATION FOR RETRODISPLACEMENT 617 forward and the latter to close effectively any space that may exist be- tween the distal portion and the parietal peritoneum. By paying attention to this latter point the peritoneal puncture may be made a considerable distance from ■■■;he internal inguinal ring without leaving any opening through which an intestinal Fig. 60-3. The Left Round Ligament Drawn into Place. Notice that the direction of the pull on the uteru.s is changed from lateral to anterior. At the same time there is no large opening between the distal portion of the round ligament and the anterior ab- dominal wall requiring a suture, as in the regular Gilliam-Ferguson operation. The distance from the peritoneal exit of the new ligament to the lateral edge of the peri- toneal cavity at thi.s level i.s so small (represented in the corner sketch in Fig. 602 by the distance from b to the internal inguinal ring) that it is closed by moderate traction on the distal portion of the round ligament loop appearing in the wound. If it is desired to bring the uterus farther forward the pro.ximal portion of the ligament is pulled on. If the peritoneum becomes tense before there is sufficient tension on the round ligament to bring the uterus well forward, the peritoneum over the ligament loop may be incised and the ligament itself grasped and drawn out as desired. (Crossen — Journal of American Medi- cal Association.) coil might slip. If doubtful on this point, the forceps may be carried to within half an inch of the ring or even practically to the ring before puncturing. The peri- toneum, being freely movable on account of the loose subperitoneal tissue, is drawn inward and puckered when the proximal portion of the ligament is drawn tense to 618 DISPLACEMENTS OF THE UTERUS bring the uterus forward. This brings the peritoneal exit near the aponeurotic exit of the new ligament, beneath the rectus muscle. The direction of the new ligament therefore is forward, practically the same as in the Gilliam operation. "4. The ligaments are then fastened in their new position. If long enough, the loops are overlapped in the median line and fastened to each other and to the upper Fig. 604. The Use of the Puncturing Tenaculum-forceps in the regular Gilliam-Fergu- son Operation. The puncture is made directly through the upper sheath, the rectus muscle, the lower sheath and the peritoneum, and the ligament is grasped and brought out —the puckering suture having been previously passed, .\fter the ligament is brought out as desired, the puckering suture is tied, thus closing the opening at the side between the distal portion of the round ligament and the anterior abdominal wall. (Crossen — Journal of American Medical Association.) sheath of the rectus. If not long enough to reach to the median line, thej- are fastened securely in the forceps-track by catgut sutures passed through the upper sheath and the ligaments beneath. The abdominal incision is then closed in the usual way. By the method just detailed, the ligaments may be transplanted into the ab- dominal wall very quickly — giving a strong reliable forward and upward traction to the \iterus and adnexa and without any free bands or dangerous adventitious PROLAPSE OF THE UTERUS 619 openings. The advantages of this particular technique in suitable cases over the usual technique of the Gilliam-Ferguson operation is that it simplifies and expe- dites the work by doing away with the temporary ligation of the ligaments and also with the lateral puckering suture. The puncturing tenaculum-forceps here mentioned may be used also with ad- vantage in the regular Gilliam-Ferguson operation (Fig. 604). It may be used also in those operations in which the puncture of the aponeurotic wall is made practically at the internal inguinal ring, though care must be exercised that the deep epigastric vessels be not injured." " I designed this puncturing tenaculum-forceps some time ago and after con- siderable experimenting arrived at the present form. I have been using it now for a year and have found it so convenient and satisfactory that I thought it worthy of presentation as a useful addition to our armamentarium. " I have used it both with the ordinary longitudinal incision and with the transverse incision. It is strong and slender and is designed to pass easily through the tissues of the abdominal wall, to penetrate the aponeurosis and peritoneum at any desired point, to grasp the round ligament firmly without bruising it and to return through the wall, bringing the ligament along the new- canal. Possibly some one has already described such a forceps ; if so, it has escaped my notice. Both the Gilliam forceps and the Barrett forceps are radically different." PROLAPSE OF THE UTERUS. Prolapse of the uterus is that condition in which the uterus sinks decidedly below its normal level in the pelvis. It is known also as "procidentia uteri" and is fre- quently referred to by the patient as "falling of the womb." ETIOLOGY AND PATHOLOGY. The causes of proJapse are practically the same as those of retrodisplacement (see page 597) . In fact, a slight prolapse is usually the first step in retrodisplace- ment. The uterus normally has considerable up and down movement. Respiration causes movement of the uterus, which is noticeable during the speculum examina- tion, especially with the patient in the Sims posture. There may be considerable exaggeration of the usual downward displacement without any symptoms, and that could hardly be called pathological. The con- dition is not called prolapse unless there is marked downward displacement, and this is almost always accompanied with backward displacement of the uterus. If the cervix is still well within the vagina, the condition is designated as pro- lapse of the FIRST DEGREE. If the cervix protrudes from the vaginal orifice it is called the second degree. If the uterus lies outside the pelvis it is called the THIRD degree, or Complete prolapse. See Figs. 287, 288, 289, 290, 291, 292, 293, 294, 295, 296. In the usual case of prolapse, the uterus is found retrodisplaced and low in the pelvis, the pelvic floor is found lacerated and there is present more or less endo- 620 DISPLACEMENTS OF THE UTERUS metritis with discharge. The vaginal walls also are relaxed and thrown into folds by the position of the uterus, and may be found projecting outward at the vaginal opening, forming an anterior or posterior colpocele. The projecting vaginal wall precedes the cervix on its downward journey. If the bladder follows the projecting vaginal wall, as it frequently does in severe prolapse, the concUtion is known as cystocele (Figs. 292, 293). In some cases of severe prolapse, the anterior rectal wall follows the projecting posterior vaginal wall, forming rectocele. The cervix in many cases has been severely lacerated and is chronically in- flamed and is the seat of cystic disease and of an irritating discharge. In severe prolapse, ulcers often appear on the cervix or vaginal walls, being due to irritation of the clothing and to interference with the circulation of the prolapsed portion. The interference with the circulation may be due to two factors — constriction of the prolapsed portion by the vaginal opening and stretching of the uterine blood vessels with consequent diminution in their calibre. All the ligaments of the uterus are stretched until they give practically no support, and the lower pelvis is occupied by the intestines instead of by the pelvic organs. Sometimes coils of intestine may lie in the cul-de-sac back of the uterus, outside the vaginal opening. SYMPTOMS. The symptoms of prolapse of the uterus are dragging pains in the back and pelvis, worse when walking, some protrusion at the vulva and sometimes diffi- culty in urinating. In some cases the protruding bladder must be pushed back into the pelvis before the patient can urinate. Even then there is more or less residual urine which is likely to lead to cystitis. Some patients complain of partial incontinence of urine when coughing or laughing. In exceptional cases, it is this partial incontinence that brings the patient to a physician, and he must recognize the cause or he will fail in the treatment. Examination reveals as follows in the different degi*ees of prolapse: First degree. The pelvic floor is relaxed and there is more or less protrusion of the vaginal walls. The uterus is usually retro verted and the cervix is low in the pelvis and far forward, near the vaginal opening. Coughing or straining cause the cervix to sink lower and the vaginal walls to protrude more. If there is still doubt as to whether the uterus sinks low enough to be called pro- lapse or to cause symptoms, the patient may be examined in the standing posture (see page 50), but this is rarely necessary. Second degree. The cervix is found presenting at the vulva (Fig. 288) and may be made to protrude by bearing down (Fig. 289). There is also protrusion of the vaginal walls and sometimes of the bladder. The cervix and vaginal walls may return into the pelvis when the patient is lying down. There is more or less erosion about the cervix and sometimes ulcera- tion. Third degree. There is a mass nearly as large as the fist protruding from the vulva and lying between the thighs (Fig. 290). It is covered by the turned out vaginal wall which, from friction of the clothing, has liecome dry and hard re- sembling ordinary epidermis. At the lower part of the mass is the cervix, which DIAGNOSIS OF PROLAPSE 621 is represented by a hard nodule with an opening in the center and more or less erosion or ulceration about it. The appearance of the cervix depends upon how much laceration of the cervix there has been. Grasping the mass and palpating it to determine its contents, there is found a hard elongated mass— extending upward from the cervix. Usually the size and shape of the uterus can be accurately made out. From the cervix there is more or less discharge which may be clear and glairy, resembling the white of an egg, or it may he muco-purulent. If the l;)lad(ler has prolapsed also, it is felt as a thick cushion of soft tissue in front of the hard uterus (Fig. 292). To determine just how much the bladder is displaced, a sound may be introduced into it and the outline of the cavity thus determined (Fig. 293). The vaginal wall often presents spots of ulceration, especially about the cervix (Fig. 290), and there is often much irritation over the whole prolapsed mass and about the external genitals. DIAGNOSIS. The diseases from which prolapse must be differentiated are as follows: 1 . Hypertrophy of cervix. In this condition, the body of the uterus is felt nearly at its normal height in the pelvis. Also the depth of the uterus is increased, the amount of increase depending on the length of the hypertrophied cervix. Further- more, the posterior vaginal wall is usually not pushed down, as it would be by a prolapse of the uterus, and the bladder is usually not involved in the projecting mass. See Figs. 298, 299, 300, 301, 302. 2. Tumor or Cyst of Vagina. Anything that causes the vaginal walls to swell over a limited area and protrude, may be mistaken for prolapse of the uterus, for example, vaginal cyst, vaginal hernia, or tumor of vaginal wall. In all these conditions, by careful digital examination, the cervix may be felt above the pro- jecting mass and near its normal position. See Figs. 305, 306, 326, 327. 3. Tumors of uterus, projecting from cervix. Such tumors are, of course, more or less pediculated and almost invariably they are fibroids. In such cases, there is felt near the vaginal entrance, a mass, which maybe hard or soft. If the mass is sloughing, part of it will be soft. No cervical opening can be felt in the mass and, by exploring higher around the mass, the cervical ring can be felt at the upper part of the vagina. If the tumor is sloughing, there is usually bleeding and a very offensive discharge. Furthermore, by bimanual examination, the body of the uterus may be felt near its normal position. See Figs. 303, 307, 308, 309, 310, 311, 325. 4. Inversion of uterus. In a case of inversion, a large mass, apparently a tumor, is felt in the vagina. The vaginal walls can be felt extending up past the mass. If it is sloughing, there will be bleeding and a foul discharge. Furthermore, the body of the uterus is not felt where it ought to be (Fig. 322). It is apparently nowhere in the pelvis, and by deep bimanual examination a depression may be felt with the abdominal hand at the upper end of the vagina — a cup-shaped de- pression with a hard margin, where the body of the uterus should be (Fig. 323). Inversion differs from a tumor, in that a sound can not be introduced far into the 622 DISPLACEMENTS OF THE UTERUS Uterus, for the cavity is more or less obilterated (Fig. 324). See also Figs. 304, 312, 313 to 321, 325. TREATMENT. The means of treatment may be divided into two classes — palliative and cura- tive. Palliative Measures. The palliative measures make the patient more comfortable, by relieving the irritation which cases the ulceration and bj^ diminishing the dragging on the uterine supports. 1. Treatment of the ulceration and erosion, and reduction of the mass. All se- cretion should be cleansed from the extruded mass and from the adjacent sur- faces. Areas of ulceration or erosion should be touched "uith some astringent silver preparation or with 10% copper sulphate solution, and dusted with an antiseptic-astringent powder. The mass should then be anointed with an antiseptic ointment and reduced within the pelvis. By bimanual manipulation, the backward displacement should be corrected as far as possible, the fundus being brought forward and the cervix pushed far back in the pelvis. 2. Pessaries and Tampons. The next step is to hold the uterus in the pelvis, as near its normal position as possible. If there is enough left of the pelvic floor to retain a pessary, that should be tried. The style of pessary preferred in suitable cases is that used for retrodisplace- ment (Fig. 452') . for the object is to keep the fundus uteri in the forward position. A long as the fundus is forward and the cervix well back in the pelvis, the organ can hardly prolapse, at least not to the extent of coming outside. This form of pessary is effective only in cases of slight prolapse. In cases of marked prolapse, the above-mentioned pessary fails, because the pelvic floor has been too much stretched to hold the pessary in place. The anterior end of the pessary slips down to the vride part of the pubic arch and slips out of the dilated vaginal opening. In such a case, the inflated ring pessary (Fig. 460) will sometimes hold the uterus within the pelvis. The Menge pessary (Fig. 461) is sometimes effective where other forms of pessary fail. Where no form of intra-vaginal pessary will hold the structures back, a firm vaginal packing of gauze or cotton tampons may be placed, preferably with the patient in the knee-chest posture or in Sims' posture. This packing will hold the uterus up temporarily and, by placing a pad over the vulva and liolding it firmly in place by a strong T-bandage, the packing may be kept in place two days. This method is very useful when treating the ulceration often found about the cerv-ix, and also to give temporary relief while preparing the patient for operation. 3. Cup and Belt Pessary. When the ordinary pessaries fail to keep the uterus within the pelvis and the patient refuses curative operative measures, the cups pessary with the abdominal belt may be used (Fig. 462). In many cases this make the patient fairly comfortable, and with proper care it can bo worn indefinitely. In other cases, it causes so much distre.ss, by pressure on the vaginal walls or OPERATIONS FOR PROLAPSE 623 cervix or other pelvic strnetures or In* the abdominal or perineal bands, that the patient abandons it after a trial. 4. Rest in bed and astringent douches. If the patient can spare the time to go to bed and remain there a week or two and take an astringent douche two or three times daily, she will experience considerable relief from pain and discomfort. This is especially important when there is ulceration of the cervix or vagina requiring treatment. Curative Measures. These are all operative and may de divided into two classes — (a,) those that preserve all the genital functions and (b) those that do not. A. Genital Functions Preserved. The uterus and adjacent structures are re- stored to approximately normal position and a'll the genital functions are pre- served. 1. Fastening of Fundus Uteri Forward and Upwaiu), and Repair of Pelvic Floor. The body of the uterus is brought forward and elevated and the fundus is fastened in the desired position by one of the methods detailed under retrodis- placements. The pelvic floor is thoroughly repaired by one of the methods de- tailed in chapter v. A curetment is usually combined with the above measures to reduce the weight of the uterus, and if the cervix is sufficiently enlarged or elongated, a part of it is amputated (see chapter vi). All this may be done at one anesthesia or it may be divided into two operations some weeks apart, as tliought best in the particular case. These measures are carried out in such a way tliat the function of pregnancy and parturition is not interfered ^^'ith. In fact, the chance of pregnancy is increased by the restoration of the uterus to its normal position. Practically all cases of prolapse in the child-bearing period can be treated satisfactorily in this way, where the form of operation best adapted to the par- ticular case is selected and the proper technique employed. There are exceptional cases, but they are very rare. 2. Bringing a Strong Portion of the Lower Part of Each Broad Lie- ment in Front of the Cervix Uteri and Fastening it There. Tliis is accor plished through an incision in the anterior vaginal vault. It promises much in these cases, especially when combined A^-ith shortening of the sacro-uterine liga- ments and operation for cystocele and repair of the pelvic floor. It has not yet been long enough in use to demonstrate certainly how well the shortened broad- ligaments will stand the strain. B. Genital Functions Sacrificed. The uterus is removed or partly removed or so placed that pregnancy would be dangerous. These measures are, of '-ourse, applicable only to patients past the menopause or in the menopause, or in whom for some reason pregnancy can not again occur. 1. Utilization of the Uterus to Overcome Prolapse of Bladder and Vaginal Walls (Freund, Fritsch, Wertheim, Landau). Through an incision in the anterior vaginal wall, the bladder is separated from the vagina and uterus, and pushed up. Then the fundus uteri is brought forward beneath the bladder and fastened securely to the anterior vaginal wall. The redundant portion of 624 DISPLACEMENTS OF THE UTERUS the anterior vaginal wall is cnt away. The sutures extend deeply at the sides sg as to unite the firm lateral tissues to the uterus and thus gives good support to the bladder and other structures above. This, at the same time, turns the cervix into the posterior part of the pelvis and puts the vaginal walls on the stretch and prevents their prolapse. This is combined with a strong repair of the pelvic floor. The special steps and the various modifications, it will not be necessary to detail here. This operation has several advantages over hysterectomy and, if the results eventually prove lasting and satisfactory, will probably largely replace it as a cure for prolapse. 2. Hysterectomy, Either A^\c4inal or Abdotminal, with High Fixation OF the Vaginal Stump, and followed by repair of the pelvic floor either at the same sitting or later. I would call particular attention to the fact that hysterectomy fails in many cases to cure the prolapse of pelvic structures unless particular care is taken to fasten the vaginal stump very high. Without this precaution, the vagina is hable to prolapse again. The intestines and bladder also come down and the last state of the patient is worse than the first. This defect of the old vaginal hysterectomy for prolapse, I pointed out, and illustrated by cases that came to me from other operators, some years ago, when that operation was at its height as a cure for this affection.* Hysterectomy as mentioned above, however, with high fixation of the vaginal stump (to the broad ligament stumps or to the anterior abdominal wall), is a differ- ent proposition and is effective in relieving the distressing symptoms. OTHER DISPLACEMENTS OF UTERUS. Anteflexion of the Cervix Uteri. In this affection the cervix uteri is bent for- ward so that the axis of the cervix is directed along the vaginal canal instead of across it The axis of the cervix forms a sharp angle with that of the corpus uteri, the point of bending being at about the internal os. Anteflexion of the cervix uteri is nearly always a developmental defect, due to the persistence of the fetal position of the cervix uteri, as explained when considei'- ing the anatomy of the uterus at different periods of life (see chapter vi). Almost the only symptom of anteflexion of the cervix is dysmenorrhoea, and therefore I have thought best to consider the subject in detail in chapter xiv, imder the ''neuro-trophic" form of dysmenorrhoea. Anteflexion of the Corpus Uteri, Anteversion of the Corpus Uteri and Lateral Dis= placements of the Uterus can hardly be classed as diseases. They occur only as symptomatic disturbances in the course of other diseases, and of themselves do not give . ' ^e to symptoms nor require treatment. Inversion of the Uterus. Tiiis serious and rare displacement is an obstetrical affection. It practically always occurs in the puerperal state, except when due to the dragging weight of a tvnnor. When due to a tumor, it simply constitutes one of the pathological conditions incident to the tumor (Fig. 310, 325) and does not require separate consideration. * Vaginal HystTectomy for I^olapsus, by H. S. Crcssen, M.D. Western Medical and Surgical Gazette, 1898. 625 CHAPTER Viri. NON-MALIGNANT TUMORS OF UTERUS. FIBROMYOMA OF THE UTERUS. Fibromyoma of the uterus is a tumor composed of fibrous and muscular tissue. It is called also uterine "fibroid" and uterine " myoma." ETIOLOGY. The essential cause is not known. Some interesting theories have been ad- vanced, but they are still theories only. The tumor is analogous to those growths Avhich frequently enlarge the prostate in the male. As bearing on the etiology of uterine fibromyomata, it may be noted that they are usually multiple, there being but few exceptions to the rule that where there is one palpable fibroid there are many smaller nodules. They occur most frequently in middle life (period of sexual activity), though they may occur at any age. Again, child-bearing apparently has no influence in causing them. This is in marked contrast to carci- noma, particularly carcinoma of the cervix, which occurs almost exclusively in ■women who have borne children or who have had some injury to the cervix. PATHOLOGY. 1. Composition. A fibromyoma is composed principally of connective tissue and involuntary muscular tissue — the same tissues that compose the uterine wall. In a small proportion of fibroids there are found small irregular cavities resembling glands and lined with epithelium. Such tumors are designated by the term ''adenomyoma." 2. Relation to uterine wall. The fibroid starts as a small nodule in the muscular layer of the uterine wall. As it enlarges there usually develops a distinct capsule, or layer of condensed tissue, which separates the tumor proper from the normal uterine wall surrounding it (Figs. 605, 606, 607). From this capsule it may be easily shelled out, except when there has been inflammatory infiltration of the ■ capsule and tumor. As long as the tumor is surrounded l:)y the muscular tissue of the wall, it is known as an intramural or interstitial fibroid (Figs. 605, 606, 607.) They comprise 60 to 70 per cent of the cases. As the ordinary encapsulated tumor gi'ows, it pushes in the direction of least resistence, stretching the muscular tissue around it and tending to push the mus- cular tissue aside. When it pushes aside the muscular tissue to the outer side of it and comes to lie just beneath the peritoneum, it is known as a subserous or subperitoneal fibroid (Fig. 375). They comprise 20 to 30 per cent of the cases. 626 FIBROMYOMA OF THE UTERUS This process of escape from the gi-asp of the muscular tissue may progress, the tumor projecting farther and farther beyond the outUne of the uterus but still covered b}" the peritoneum, until it is attached to the uterus only by a compara- tively narrow band of tissue, or pedicle, carrying the blood vessels and covered by peritoneum. It is then a pediculated subperitoneal fibroid (Fig. 375). V Fig. 605. Multiple Fibromyomata of the uteras. A. The divided uterine cavity. (Bishop — Uterine Fihromyomntn.) Fig. 606. Multiple lilirornjoinata of the Uterus, sertioned .so a.^ to .show the relation of the tumor- ma.«sesto the uterine wall. Tlie enoap.«ulation of the fibroid nodules i.s well .^hown. To the extreme left is a subperitoneal fibroid (not .sectioned). The top of the uterine cavity is seen near the center of the left half of the sectioned ma.ss. ]'t)I\TS I\ l'Aril()I-0(JY 62< In some cases adhesions to adjufcnt structures are formed, and through these adliesions the tumor may receive part of its blood supply. Occasionally the pedicle of such a tumor is severed by torsion or otherwise and the tumor is thus entirely separated from the uterus and receives its blood supply through the vas- cular adhesions. Such a tumor is known as a detached or "parasitic" or wander= ing fibroid, and constitutes one of the curiosities of pathology. If a tumor which is escaping outward from the gi-asp of the muscular wall is so situated that it projects into the broad ligament, it is known as an intra= ligamentary fibroid. If it projects in such a situation that it raises the peritoneum behind the uterus and passes back of the peritoneum, it is then called a retroperitoneal fibroid. On the other hand, the fibroid, as it develops, may push its way inward instead Fig. 6^7. A Single Encapsulated Fibromyoma of the uterus. (Bishop — Uterine Fihro- myomata.) of outward, and may come in time to lie beneath the endometrium, where it is known as a submucous fibroid (Figs. 605, 357). Submucous fibroids comprise about 10 to 15 per cent of the cases. The submucous fibroid may project farther and farther into the uterine cavity, until it is attached to the uterine wall only by a naiTOw pedicle (pediculated sub= mucous fibroid — Figs. 309, 325). A pediculated submucous fibroid may be forced out into the vagina while still attached to the uterine wall (Figs. 308, 309) and may in this way cause partial or complete inversion of the uterus (Figs. 315, 325), a fact that must be kept in mind when removing such a gi-owth l)y operation. Some fibroids, especially the adenomata, are withf)ut a distinct limiting cap- sule. The tumor tissue blends directly with the uterine wall (Fig. 608). Such a tumor is called a diffuse fibroid. It may occupy only a small area or may extend all the wav around the uterine cavity. 628 FIBROMYOMA OF THE UTERUS Fig. 608. A Diffuse Adeno-myoma of the Uterus. (Bla.nd-iiutton—/Ii/sterec(07ny.] Most fibroids are found in the body of the uterus, as indicated in the various illustrations. In a certain proportion of cases, the fibroid is situated in the cervix. Bland-Sutton found in a series of 500 cases, that 5% were cervix fib- roids. These are more often single, and rarely project into the cavity, as the cervical cavity is small. They ai'e usually comparatively small, but sometimes reach a size of 8 lbs. 4. Secondary Changes. Under composition is given the primary structure of the various forms of fibromyoma. In many cases there are found secondary changes in the tumor structure. These changes are edema, myxomatous degeneration, necrobiosis, necrosis, suppuration, cystic degeneration, calcification, malignant degeneration and other rarer changes (atrophy, fatty degeneration, amyloid degeneration). The relative frequency with which the more important of these secondary changes has been noted in operated cases, is shown in the table on page 655. Necrosis and suppuration are shown in Figs. 609, 610 and 611. Cystic change is shown in Figs. 426 and 612. Sarcomatous development is shown in Figs. 613 and 614. 5. Complications and Associated Diseases. These are very numerous and very important, for a large proportion of the deaths and of the suffer- ing in fibroid cases, comes from them. Some of these conditions are due directly to the fibroid, some are due indirectly to it and some have no etiological c o nn e c t i o n with the fibroid, ])ut are only associated affec- tions. Some of them can not be assigned exclu- . . , I'lg. fiOD. .Necrosis of ati IiilraliKaiiu'ntary Fibromvonia. (llirst- sively to one group or the mseases of women.) POINTS IN PATHOLOGY 629 other, so I think best to consider them all together. For convenience they are divided into three classes according to locality — (a) in the uterus, (b) in adja- cent structures and (c) in distant organs. Fig. 610. Section of a Necrotic Fibroid. I saw the patient in consultation with Dr. C. O. C. Max. There was a large fibroid extending nearly to the umbilicus, which had become necrotic from infection due to the introduction of a uterine sound by a midwife. The patient was in a desperate condition. The clinical features are mentioned briefly on page 660. .\t the operation we found that the necrotic fibroid had perforated the uterine wall and was in contact with the omentum. This Antero- posterior Section of the removed Uterus and Tumor shows accurately the relation of the necrotic mass to the uterine wall. It was almost free in its suppurating bed. Fig. 61 1 shows the ijcrforation through the uterine wall. 630 FIBROMYOMA OF THE UTERUS a. In this class come thickening of the endometrium, distortion of the uterine cavity and displacement of the uterus. b. Here are found salpingitis, Iwdrosalpinx and pyosalpinx. Also, compression of the ovaries, with inflammation and sometimes hematoma. There may be Fig. 611. A Necrotic Filiroid I'erforatiiig the Uterine Wall. Same specimen as shown in Fig. 610. The specimen consists of the uterus and tumor removed by total hysterectomy. The patient recovered. The Perforation here shown was covered by adherent omentum. .\3 soon as the omental adhesions wcro separated, pus from the suppurating bed in which the necrotic mass lay poured into the peritoneal cavity. Tlic tumor was large and the perforation was at (lie top of tiic mass, near the umbilicus. SYMPTOMS 631 troublesome pressure on the l^laddor or rectum or pelvic blood vessels. In some cases there is marked displacement of the bladder (Fig. 615). c. The changes in distant oi-gans concern principally the heart and the kidneys. These changes are often serious. They are mentioned at some length below, in considering the dangers from long-standing fibroids (sec page 650). Fig. 612. A Large Cystic Fibroiiiyouia. (KeUy— Operative Gynecology,) SYMPTOMS AND SIGNS, Symptoms. The symptoms given by the patient are, in the usual order of their appearance, (1) menorrhagia, (2) leucorrhoea, (3) pressure symptoms, (4) pain and (5) a lump in the lower abdomen. 1. Menorrhagia, This is usually the first disturbance noticed, particularly in 632 FIBROMYOMA OF THE UTERUS submucous and interstitial growths. There is much variation in the menstrual disturbance. Usually the flow is increased, but sometimes it is diminished. Emmet, in a series of 216 cases, found the menstrual flow decidedly increased in 50%, unchanged in 20%, lessened in 16% and irregular in 13%. Fig. 613. A Sarcoma Developing in a Cervical Stump. The pelvis is viewed from above. Rising from the pelvis between the bladder and the rectum is a smooth lobulated growth. To the left is the intact and normal left ovary. The right appendages were removed at the first operation. The first operation was supravaginal hysterectomy for Fibromyoma. The original tumor is shown in Fig. 614. (Cullen — Journal of American Medical Association.) 2. Leucorrhoea is usually present after a time, especially in the submucous and interstitial grov/ths. This is due to the accompanying chronic simple endome- tritis. 3. Pressure symptoms. These are indefinite, simply an indication that there is SYM1TOM8 633 some slight disturbing element in the pelvis. The patient has some bladder irritability and a feeling of weight in the pelvis. There is usually constipation. After the tumor becomes large, marked pressure symptoms occur. 4. Pain. This appears later. It is usually present as a backache (lumbar or e /^ ^^-^, mil , 'slid -Ifl'iiJ mrm Fig. 614. The Fibromyoma removed in the Supravaginal Hysterectomy mentioned under Fig. 613. After the development of the sarcoma in the cer\-ical stump, the original tumor (supposedly a simple .^ibroid) was sec- tioned as here shown. Several large areas of sacromatous degeneration were found, the most marked of which are indicated by the letter d. (Cullen — Journal of American Medical Association.) sacral) or as pain in the lower abdomen or as thigh-pain on one or both sides. The pains usually come and go at first, and are worse when the patient is on her feet and also at the menstrual periods. 5. Lump. In a large proportion of the cases, after .some months or years, a 634 FIBROMYOMA OF THE UTERUS lump is noticed in the lower abdomen. If the mass is smooth, however, it is surprising how large it will sometimes get before the patient notices it. Of course a mass with nodular projec- tions is usually noticed as soon as it b e g i n s to distend the lower abdomen. In a certain proportion of cases, the mass even when large is still too deeply placed in the pelvis to be appreciable to the patient, and in some cases (small sub- mucous fibroid) the mass is not appreciable to the physi- cian, even on careful bimanual , , , examination, though there Fig. 615. A Large Fibromyoma of the Uterus, which has drawn u i i j' i the Bladder far up into the abdomen. Notice the immense veins may be .mUCh bleeding and on the peritoneal surface of the bladder. (Kelly — Operative HistrPSS Gynecology.) Examination Signs. The diagnosis of uterine fibroid must rest on the examination findings, for the symptoms are not distinctive. Taking up the Points as given in the Diagnostic Table (pages 287, 288), we find as follows in the case of a fibromyoma: 1 . Position of mass. In the central part of the pelvis and extending from there toward one side. 2. Size of mass. May be any size, from one barely palpable in the wall of the uterus to a large tumor filling the abdomen. 3. Shape. Individual tumors are apparently spherical, but as they project from the uterus or grow beside each other, they form a mass of very irregular contour, usually presenting several distinct bosses or rounded projections outside the general outline of the mass. 4. Consistency. Firm, usually much harder than the adjacent uterine wall. Occasionally, part of a tumor will undergo cystic change — but even then the greater part of the mass is usually solid. 5. Tenderness. Not tender, unless incarcerated in pelvis or pressing on nerves or accompanied with inflammation. 6. Mobility. The tumor and uterus are movable together up and down in the pelvis, but they are not movable separately unless the fibroid is pediculated. 7. Attachment. Attached in the uterine region and free elsewhere, unless complicated. A subperitoneal fibroid with a long pedicle may be mistaken for a growth from some of the abdominal organs. The pedicle connecting the mass with the uterus, can usually be felt on deep bimanual palpation. In a difficult case, a useful expedient is to have an assistant grasp the tumor and draw it up into the abdomen while the examiner makes deep bimanual palpation in search of the pedicle, which is thus made tense and is easier felt (Fig. 103). 8. Apparent point of origin. From uterus. Occasionally a fibroid becomes DIAGNOSIS 635 detached from the uterus or has such a long pedicle that it appears free, but that is rare. 9. Relation to uterus. Intimately connected to the uterus, growing from the same. May be from any part, usually from body. 10. Position of uterus. May be displaced in any direction, may be in normal position. 11. Size of uterus. Enlarged by tumor in wall, cavity lengthened. But do not explore with sound unless necessary. 12. Shape of uterus. Usually distorted and presenting one or more distinct projections. Occasionally symmetrically enlarged. 13. Consistency of uterus. Uterine tissue proper of normal consistency, but fibroid nodules harder. Occasionally a tumor will present a softened area (ede- matous) or a fluctuating area (cystic). Occasionally the cervix is softened by edema incidental to impaction in the pelvis, but there is rarely enough softening to imitate pregnancy. 14. Tenderness of uterus. Not tender on palpation or movement, except when complicated. 15. Mobility of uterus. Movable in pelvis with tumor, unless tumor is so large as to fill pelvis or so situated as to put uterine supports on stretch, or complicated by pelvic inflammation or another tumor. Uterus and tumor movable together, but not separately unless tumor is pediculated. 16. Discharge from uterus. Usually there is a discharge, due to complicating endometritis (simple or infected). 17. Discoloration of cervix or vagina. None, except what can be accounted for by evident pressure on vessels. 18. Relation of mass to tube and ovary. No connection with tube or ovary, except possibly lying against them. Tube and ovary of each side may be felt (if abdominal wall not too tense), unless mass is so large or so situated as to obscure them. 19. Helation to pelvic wall. No connection with pelvic wall, except when large enough to extend to it or when complicated by inflammation or another tumor. 20. Relation to vaginal wall. Depends on situation of tumor, usually well above wall. When in cervix, the mass lies against vaginal wall, just beneath ex- amining finger. 21. Bladder. May be compressed by mass and distorted, or maybe pulled up into abdomen (Fig. 615). 22. Rectum. May be pressed upon to such an extent as to cause hemorrhoids. 23. INIass elsewhere. In addition to the main tumor springing from the uterus, one or more other nodules may usually be felt in some other part of the uterus. 24. Colon or small intestine in front. Not unless retroperitoneal or complicated by adhesions. 25. Outline of dullness. Dullness over mass and resonance elsewhere, unless complicated by ascites. 26. Shifting outline of dullness. No change in outline of dullness on change of position of patient, except when complicated by ascites or when tumor rolls some in the abdomen. 636 FIBROMYOMA OF THE UTERUS J 27. Hard masses within a cystic mass. Nothing hke this, simulating fetal parts in the uterus, except rarely when complicated by ascites. One case is recorded in which this condition was present and even ballotement could be secured (Fig. 429) . 28. Pulsation of mass. No pulsation felt, unless tumor lies over aorta. To differentiate between this pulsation and that of aneurysm of aorta, palpate well down to the sides of the mass to see if there is expanding or lateral pulsation. 29. Fetal movements. None felt. In a large smooth tumor, suspicious of pregnancy near term, dip the hands in cold water and then palpate the abdo- men, watching for fetal movements. 30. Vascular murmur. May or may not be murmur in region of large vessels. 31. Fetal heart sounds. None heard. Fetal heart sounds are often not heard in full-term pregnancy, consequently not much value attaches to their absence in excluding pregnancy. 32. Fever. No fever unless there are complications in the pelvis or elsewhere. 33. Emaciation or fat deposition. There may be either or neither. If much hemorrhage, usually anemia and some emaciation. 34. Breast disturbance. None ordinarily, though occasionally there is some tenderness. 35. Evidence of disease elsewhere. None, unless complicated. The usual symptoms with the history and general course have already been given. In a doubtful case it may be necessary to run over the other Points (36 to 63) in the Diagnostic Table (page 288). When making the diagnosis of fibromyoma of the uterus, the following condi- tions and questions must be considered: A. Other diseases presenting a mass or induration, which may be mis- taken for a fibroid. The more common of these diseases are salpingitis v/ith exudate, pelvic cellulitis, hydrosalpinx, pregnancy, extrauterine pregnancy, pel- vic tuberculosis, ovarian or parovarian tumor, cancer of the uterus. B. Diseases of the uterus without a mass or induration, which may be mistaken for fibroid. For example, retrodisplaced uterus with chronic endo- metritis, chronic endometritis with subinvolution, carcinoma of corpus uteri, tuberculosis of uterus, prolapse of uterus, inversion of uterus. C. Fibroid with complications. In a case presenting anomalous symptoms, . the condition may be a fibroid complicated with pregnancy or extrauterine pregnancy or salpingitis or ovarian tumor or broad-ligament tumor or malignant disease of the uterus. D. Additional questions. After it has been established that a uterine fibro- myoma is present, the following points are to be considered: 1. Does the fibroid tumor cause all the symptoms? If not, what symptoms are caused by it? What causes the other symptoms? 2. What is the relation of the tumor or tumors to the uterine wall and ca^^ity? 3. What is the relation of the tumor or tumors to the other pelvic organs and to the pelvic wall and to the peritoneum? 4. What complications are present — particularly pregnancy, malignant disease, pelvic inflammation, heart disease, kidney disease? PALLIATIVE TREATMENT 637 5. What has been the progi-ess of the disease in this case, and what will probably be the further progi-ess? TREATMENT. In regard to treatment there are three propositions to be considered: (A) no treatment, (B) palliative treatment and (C) curative treatment. A. NO TREATMENT. A certain small percentage of fibromyomata are discovered by accident, i e., during a pelvic examination for symptoms not due to the fibroid. The fibroid is small, has caused no symptoms, is not likely to cause symptoms soon, and is not likely to aggi-avate the symptoms due to the other trouble. Such a tumor requires no treatment, and it is just as well, as a rule, that the patient be not informed of its presence. She should, however, be kept under ob- servation, to see if there is any increase in the gi-owth. Explain the condition to the husband or other responsible relative, that your skill be not called in ques- tion should the patient be examined by some other physician and the presence of a tumor announced. There is one class of small fibroids, that I feel constitutes an exception to this rule of "no symptoms, no treatment," namely, cervix fibroids. When situated in the lower part of the uterus, a fibroid of any considerable size is a dangerous affair in the child-bearing period. If pregnancy should take place, the tumor will probably increase in size and may become a serious menace to labor at term. Again, a cervix fibroid is likely to cause symptoms (bladder, rectal or menstrual) at any time, even though small. Such a tumor in a married woman should be removed. If not complicated by tumors elsewhere in the uterus, it may be approached from the vagina and removed by a comparatively simple operation. B. PALLIATIVE TREATMENT. Palliative treatment is symptomatic. It is directed towards relieving the dis- turbances occasioned by the fibroid and making the patient more comfortable. The principal disturbances requiring the palliative treatment are the bleeding and the pressure symptoms. Measures for Palliative Treatment. The palliative measures are (1) tonic measures, (2) uterine astringents, (3) vaginal packings, (4) intrauterine treatment, (5) ligation of uterine arteries, and (6) removal of ovaries with ligation of ovarian arteries. 1. General tonic and hygienic measures. The better the patient's general health, the less the annoyance from the fibromyoma. Consequently there should be employed laxatives (as in pelvic inflammation), tonic medicines, avoidance of long walks, rest at the menstrual periods, douches as indicated by discharge, and a general regime to improve the general health and diminish pelvic congestion. 2. Uterine astringents. These are hemostatic remedies, administered for the 638 FIBROMYOMA OF THE UTERUS purpose of diminishing the bleeding (menorrhagia and metrorrhagia). The hem- ostatic remedies thus used are ergotin, stypticin, hydrastinin, adrenalin (prefer- able to thyroid extract or mammary extract) and calcium chloride (see Formulae). Ergotin is the one that has been most extensively used, It is an exceedingly useful remedy for temporarily lessening the memorrhagia. Continued for several months in one grain to two grain doses it produces marked improvement in cer- tain cases. Other tonics may be combined mth the ergotin (see ergotin and nux vomica capsule — Formulae) and if there is much pain it is well to combine also a sedative such as cannabis Indica (see Formulae). Byford cites a series of 101 fibroid cases treated by ergot. Twenty were reported cured. In 39 others the tumor was reduced in size and the symptoms relieved. In 19 others the hemorrhage diminished but the tumor remained the same size. In 21 there was no effect. Nelson collected 153 cases treated by ergot, of which 11 died. Even in cases where operation is necessary, ergot (preferably in the form of ergotin) is a useful palliative measure while the patient is waiting. 3. Vaginal treatment. Antiseptic vaginal douches are required in cases present- ing leucorrhoea or bloody discharge. Vaginal packing may be needed to check bleeding temporarily or to raise an impacted tumor out of the pelvis. A firm vaginal packing of antiseptic gauze, or of cotton (made antiseptic by iodoform and tannic acid equal parts, dusted in freely) is an excellent measure for temporary control of bleeding from within the uterus. The patient is kept quiet in bed and the packing changed every two or three days as necessary to prevent decompo- sition. This may be used in conjunction with uterine astringents, to control bleed- ing temporarily, while the patient is being built up for operation or is being taken to a place for operation. When the bleeding can be thus controlled, the dangers of intra-uterine disturbance (packing, instrumentation) are thus avoided. 4. Intra=uterine measures. The intra-uterine measures for the control of the hemorrhage are (a) electricity, (b) curetment and (c) applications and packing. a. Electricity. In certain cases of small interstitial or submucous gi-owths, this is a useful palliative measure. The details of the application of electricity for uterine bleeding are given in chapter iii (page 356) . The use of heavy currents, running up to 200 and 250 m. a. (Apostoli method), with or without puncture, is not advisable. It is too hazardous for the uncertainty of result. It may cause serious necrobiotic or inflammatory changes, which add very much to the danger of the subsequent operation, and it has even caused death. It is not to be recommended except in urgent conditions where the patient can not undergo operation for the removal of the gi'owth. Some still cling to it as a cura- tive measure. Massey, of Philadelphia, in reporting 86 cases subjected to this treatment, stated that 64 resulted in " practical success " (symptomatic cure) and of these the tumor was "extruded through the cervix in whole or in part or in 4, disappeared by absorption in 12, and was reduced in size in 3%." Hirst, of Phila- delphia, who was one of a committee of three appointed by the Philadelphia County Medical Society to investigate this treatment, states that " in three years' time not a single case was presented to us of a tumor reduced in size by electrical treatment.' ' Even the \ise of the milder currents, as first mentioned above, presents the usual dangers of intra-utorine instrumentation and is, as a rule, advisable only in non- PALLIATUE TRi:Ar.Mi:NT ^39 operable cases, or in operable cases only to control otiierwise uncontroluble l^leed- ing until the patient can be gotten in condition for operation. b. CuRET.MENT. This may control bleeding temporarily in those cases in which the bleeding is due to hyperplasia of the endometrium. In many cases, however, the cavity is so distorted that the curet can only wound parts of the wall here and there without removing the entire endometrium. In addition to this uncertainty of controlling the hemorrhage, there is danger of infection of the uterine wall or infection and necrosis of the gi-owth, leading to an exceedingly dangerous con- tlition. Schroeder reports a case of necrosis of a submucous tumor, the capsule of which had been torn by the curet. In carefvdly selected cases, curetment may be advisable, partially as a diagnos- tic measure, but there must be a clear understanding of the dangers incident to it and good reason for taking the risk. In the hands of those experienced in the selection of cases and in the use of the curet, the probability of any serious com- plication from a clean curetment is not great. But there is gi-eat risk in careless intra-uterine instrumentation in these -cases, even the simple introduction of the uterine sound (see Figs. 610, 611). c. Intra-uterixe applications. These are dangerous and inefficient. In inoperalbe cases the judicious use of the curet or of electricity is preferable. Occasionally, as an emergency measure for the immediate control of alarming hemorrhage, intra-uterine packing may be used. But usually a firm vaginal pack- ing \vi\\ secure the same results without the dangers incident to intra-uterine instrumentation. 5. Ligation of the uterine arteries to diminish the blood supply to the gi^owth and check bleeding. There has been considerable dispute as to who is entitled to the claim of priority in originating vaginal ligation of the uterine arteries for this disease. My friend. Dr. W. B. Dorsett, of this city, suggested it in 1890 in an article entitled "A Case of Atrophy of the Female Genitalia Follow- ing Pregnancy, and Remarks." Gottschalk, in an article published in 1892, remarked that ligation of the uterine arteries might be a useful measure and stated that he had performed the operation in two cases. Franklin H. ^lartin suggested vaginal ligation of the base of the broad ligaments in 1893, and in 1894 reported six cases treated by this method. Several series of cases have since been reported. The operation proves disappointing in a large proportion of the cases. Since the perfection of myomectomy and hysterectomy, this uncertain method is applicable only in exceptional cases. It is useful in certain patients who are in too bad a condition for operation for removal of the tumor. Also, it may be tried in patients who refuse radical methods and prefer to submit to the smaller and less serious operation. Only interstitial growths are suitable for it, and the operation should be conducted so as to ligate practically all the main vessels sup- plying the region of the gi-owth. In cases where the vessels in the upper part of the broad ligaments can be reached from below, they also should be ligated. 6. Removal of the ovaries, with ligation of the ovarian arteries. This opera- tion cuts off the blood supply through the upper part of each broad ligament and also stops the recurring menstrual congestion. There is frequently considerable dif- 640 FIBROMYOMA OF THE UTERUS ficulty in reaching the adnexa and vessels, because the tumor-mass is in the way or because of comphcating adhesions from tubal inflammation, so there is more dan- ger attached to it than one might at first thought suppose. In a reported series of 29 cases there were three deaths. In another reported series of 262 cases the mor- tality was 1.5%. Cullingworth had 25 cases without a death. He mentions also that in three cases in which the operation was attempted, one or both appendages could not be recog- nized and their removal had to be abandoned. In Martin's 65 cases, menstruation continued indefinitely after operation in a considerable proportion of them, and in 6% subsequent hysterectomy was neces- sary. This operation, also, is limited to comparatively small interstitial tumors. In these it will diminish the hemorrhage and reduce the size of the growth in pro- ably more than half. In 10 to 15 % of the cases, continued hemorrhage or contin- ued growth of the tumor or some serious degeneration of the same, necessitates later radical operation. As an operation of choice, it is not to be compared to removal of the gi-owth, but as an operation of necessity, it may do much good. For example, when the abdomen has been opened and the tumor found of such charac- ter or with such complications that its removal is not advisable, or when the patient suddenly passes into such serious condition during operation that the contemplated radical operation cannot be proceded with, then the ovarian vessels and other vessels within easy reach may be quickly ligated and the ovaries removed and the abdomen closed. Of course, every particle of ovarian tissue must be removed if the cessation of menstruation is to be secured,though the simple ligation of the principal vessels sup- plying the tumor may make some improvement. The enlargement of the blood vessels in the vicinity of the tumor, adds materially to the danger of the opera- tion. Fatal hemorrhage has occured from the puncture of a dilated vessel by the pedicle needle. Indications for palliative treatment. Palliative treatment is required in the following classes of cases: 1. When the symptoms are slight and transitory. In some of these cases the judicious employment of pallative measures No. 1 and No. 2, will relieve the pelvic disturbance so much that the patient is symptomatically a well woman. 2. When the patient is not in condition for operation, because of some temporary trouble. In some cases the patient is so anemic that to subject her to a major oper- ation would be a most serious menace, hence the necessity of preparatory treatment. It may be necessary to employ palliative measures for several weeks before the op- eration. The percentage of hemoglobin should be brought up to at least 50% if possible, and the- red blood corpuscles to 3,000,000. 3. When the patient is deban-ed from operation by some permanent trouble. In these cases, the palliative measures must be employed indefinitely. 4. When the patient refuses operation. Some patients prefer to get along as best they can, rather than undergo a serious operation. In all of these cases, much relief can be given by palliative measures judiciously employed, and some may be kept in comparative comfort indefinitely. CURATIVE TREATMENT 641 G. CURATIVE TREATMENT. The only reliable curative treatment for uterine fibromyomata is removal by operation. Operative measures. The various operative measures looking to the removal of the growth are as fol- lows : Myomectomy — Removal of the tumor or tumors and preservation of the uterus. Abdominal Myomectomy — Enucleation from the outer surface of the uterus. Vaginal Myomectomy — Enucleation from the outer surface of the uterus (cer- vix) or from the inner surface (by splitting the uterus). Supravaginal Hysterectomy — Removal of the tumor and of the body of the uterus, leaving the cervix. This is, of course, carried out through the abdomen and is the form of operation usually referred to as "abdominal hysterectomy for fibroid" and "abdominal hystero-myomectomy." Total Hysterectomy — Removal of the tumor and of the entire uterus, including the cervix. This is carried out through the abdomen or through the vagina, as thought best in the particular case. In certain exceptional cases it is preferable to carry out the operation as a combined vaginal and abdominal hysterectomy. Each of the operative measures given above has its advantages and disadvan- tages in various classes of cases. While there is not space here for a general dis- cussion of this subject, I think it advisable to call attention to certain precautions that should be taken in order to avoid cancer of the cervical stump after supra- vaginal hysterectomy. The physiological and technical advantages of leaving the cervix are beyond question. The stubborn fact, that will not down and that stands as a spectre imper- atively demanding a close study of the question is this: that in a number of cases, treated by supravaginal hysterectomy, the patient has later died of malignant disease of the cervix. It is easy to say " for that reason we should remove the cer- vix in all cases." That would be an easy solution of the problem as far as the operator is concerned, but I do not believe it is the best from the standpoint of results to the patients. The mortality would be higher and the morbidity would be higher — all for the purpose of attaining a security which I am satisfied can be obtained in a way that is decidedly safer, though somewhat more troublesome. That way, is to observe the following precautions before and during and after operation: Before Operation. 1. Examine carefully to exclude malignant disease of the cervix or corpus uteri, in suspicious cases making a microscopic examination of clippings. If malignant (342 FIBROMYOMA OF THE UTERUS disease is found, of course, total hysterectomy with wide removal of the parame- trium is indicated. 2. Ascertain if the cervix is severely lacerated or the seat of chronic irritation from any cause. If so, employ total hysterectomy. 3. If there has been recent infection in the uterine cavity or adjacent tissues, with the development of a condition making immediate operation necessary, employ total hysterectomy. 4. In some cases total hysterectomy is required because of the situation of the tumor. In all other cases requiring removal of the uterus, supravaginal hysterectomy is the preferable operation. During Operation. 5. As soon as the tumor is removed, have a responsible assistant open it and make a rapid and critical examination of the tumor and uterus. If anything sug- gesting malignant change is found, remove the cervix. After Operation. 6. After operation submit all specimens to a microscopic examination, of suffi- cient thoroughness to determine the presence or absence of malignant infiltration. If mahgnant change is found, promptly remove the cervical stump. This can be readily removed per vaginam. By these measures, supravaginal hysterectomy is limited to cases in which the cervix is practically normal and in which the chance of development of malignant disease is so sUght as not to constitute a practical contra-indication to preserva- tion of the cervix. Indications for Operation. In what cases is removal of the growth advisable? As a general proposition it may be stated that the growth should be removed when there are troublesome symptoms which persist after the employment of palliative measures No. 1 and No. 2, or in which the conditions are such that those measures are not likely to give relief. In a considerable proportion of the cases the symptoms are so severe and threatening that there is no question as to the advisability and urgency of opera- tion for removal. In the majority of cases, however, the symptoms are not so severe nor threaten ing, and by palliative measures the patient may be made fairly comfortable for a time. In such cases should the tumor be removed or should it be left alone until serious symptoms develop? This is one of the most important problems now be- fore gynecologists for solution. The facts so far available indicate that in those cases with persistent symptoms, the interests of the patient are best conserved by the removal of the growth while the patient is still in good condition and the risk accordingly small. If further experience confirms this, it will mark one of the most important advances in surgery — ranking with the establishment of the interval- operition in appendicitis. OIIOICK OF TUKATMFA'T 043 To present this important su]:)jec-t cleaily, I give the following quotation from a paper which I read before tlie Missouri State Medical Association in May, 1906.* " In order to come quickly to the point I will eliminate at once those classes of cases about which there is practically no question. 1. Cases in which the tumor causes no symptoms. These are seen by the physi- cian only rarely and then usually by accident. 2. Cases in which the tumor is small and is causing only slight sympt()ms(moder- ate menorrhagia or dysmenorrhoea) which are relieved by general tonic treatment with the addition of uterine astringents (ergotin, stypticin, hydrastis), and tiie symptoms do not return soon after the treatment has been discontinued. 3. Cases in which the patient is past 45 years of age and the tumor is stationary in size, not large enough to cause disturbing pressure symptoms, accompanied by only moderate menorrhagia and without troublesome inter- menstrual symptoms. " It will hardly be questioned that for these three classes the expectant plan is the preferable treatment. 4. Cases presenting conditions that threaten life or cause persistent severe suf- fering. The necessity of operation in this class has long been generally recognized. " It is the cases which lie between these two extremes to which I wish to direct your attention. What is the best treatment for the patients who have no threaten- ing symptoms? They come for advice and treatment and the question is, what is best to do for them? "The tumor is of moderate size, perhaps as large as the fist or two or three times as large. The patient is fairly well nourished, probably somewhat anemic, but not seriously so. The menstrual flow is excessive but by the continuous administration of ergotin or stypticin it can be held down to very moderate menorrhagia. The backache and pelvic pressure are very troublesome at the menstrual periods but between periods the patient feels fairly well and is able to do her work and attend to her social duties. She feels dragged out a good part of the time and has back- ache and pelvic discomfort after extra exertion. The patient is a semi-invalid — • not sick enough to be called sick and not well enough to be called well. "She is between 30 and 40 years of age and has been under treatment, including a general tonic regime with the addition of uterine astringents, long enough to make it plain that the condition described is the best that can be obtained short of operation. "What advice shall we give such a patient? Should the tumor be let alone or should it be removed? "It is easy to say to the patient: 'Wait. There is no special indication for operation just now, there may be no serious increase in the symptoms at any time, and it is possible that after the menopause the troublesome symptoms will largely disappear.' " The points made in that advice are all literally true and the advice itself seems plausible. But when some complication that would have been pre- * Some Questions Concerning the Treatment of Uterine Fibromyomata, by H. S. Crosseu, M. D. Journal of Missouri State Medical Association, Vol. Ill, No. 3, 1906. 644 FIBROMYOMA OF THE UTERUS vented by early removal of the tumor, rapidly causes the death of our patient or forces her to operation with quadrupled risk, we begin to doubt the wisdom of the waiting advice. This is not a picture of fancy. Nearly all the fibromyoma cases that were operated on the world over previous to the last two or three years, and the larger part of those that are operated on today, have passed through the process just mentioned. " The patient went to a physician who treated her expectantly, according to the established usage, and congi-atulated himself that she was getting along pretty well. And she was "getting along pretty well" — "pretty well" toward a condition that greatly increased the risk of the operation which was finally necessary. "I may speak plainly for I speak from experience. The cap fits and I put it on — I trust others will do the same. "In many cases the physician who long treated the patient loses the lesson of the case through no fault of his own. Some of these patients pass through many hands in the various stages of the tumor's growth, for it extends through many years. Per- haps half a dozen physicians have, from the same case, been established in their conclusion that fibroid patients get along very well and rarely need operation, while only the last physician whom the patient consults has the true lesson of the case forced upon him in a way that cannot be misunderstood. In some cases the ser- ious condition advances so rapidly or so insidiously that the patient dies without the consideration of operative measures, or is found in such condition that opera- tion is no longer possible. "Some physicians find it hard to believe that uterine fibroids really cause death except so rarely that the cases may be classed as curiosities. A practical experi- ence with even a moderate number of advanced cases will quickly dispel this illusion, provided the physician watches the cases to their terminations. Bishop reports 27 deaths due to fibroids without operation. " On the other hand, in deciding what to do for these patients, it is easy to take the other short-cut and advise all patients with palpable fibroids to be operated on — that is, it is easy for the physician. But before advising operation in any case we must assure ourselves that the chance of death assumed is fully justified by the danger of delay in that particular case. Then, if death comes in spite of every precaution, we know at least that it was not an unwarranted sacrifice. It is easy enough to advise operation, but it is not so easy to restore life to the deceased — who, but for the operation, might have lived in comparative comfort to old age. "But what advice shall we give our patient? The symptoms at present are not such, in themselves, as to necessitate operation. They are not threatening speedy death, neither are they causing great disability. If they continue as they are, the patient, by continuing under treatment, by lying down most of the men- strual days and by being careful at other times as to extra work and walking, may live a fairly comfortable life. "Many women, probably most women in ordinary circumstances, would prefer this state rather than seek complete health through a dangerous operation, even though the operative mortality is small. And I am not going to condemn such a choice — in fact, granted the stationary character of the trouble, I would strongly advise such a course. CHOICE OF TREATMENT 645 "But have we any well-grounded assurance that the trouble will remain station- ary? There lies the gist of the matter. "The patient comes to the physician to learn, not what she already knows, viz., that with the present symptoms she can get along in comparative comfort, but she comes to learn whether or not it is safe for her to go along in that way. She wants to know whether she had better have the tumor removed now, while she is in good condition and the risk accordingly small, or whether she had better wait and see whether or not severe symptoms develop. "This brings us up squarely to the question of prognosis in this class of myoma cases. "It is interesting, and pertinent to the subject, to notice for a moment the method of development of surgical treatment in general and of abdomino-pelvic surgery in particular. "At first major surgery was invoked in only the most desperate cases, those that were passing to certain and speedy death. This was proper for, in the state of ex- perience at that time, the operation itself meant death in many cases. It was a desperate remedy for a desperate condition, and occasionally attained success. As the technique was perfected, more of the desperate cases were rescued from death. As these fatal conditions for which operation was carried out, were studied in con- junction with the experience gained in the operative work, physicians began to anticipate the desperate and terminal conditions, and to operate when the pa- tient was in a somewhat better condition — and with much better success. "'Then they began to look still further ahead and consider the possibilities of sur- gery in conditions that became inoperable many months before death. Thus was gradually worked the prognosis and required treatment for ovarian tumors, for uterine cancer and for other pelvic and abdominal diseases that were found to prove invariably fatal within a few years. The necessity of early operation in these conditions that proved fatal in a comparatively short time, was soon estab- lished, and gained general acceptance long ago. The course of such diseases was quickly run. Within the short period of a few years, the physician saw the pa- tient a well woman, then the disease beginning, then its full development and then the invariable death, this series of events taking place so quickly that it was all under the one physician and within his recent recollection. The lesson was obvious — delay meant death. "That field conquered, surgical attention was directed to the question of early operation in those diseases which, though not invariably causing death, never- theless frequently caused death and in another large proportion of the cases caused persistent suffering and invalidism. Then was worked out the advisability of operation in the quiescent period (before the onset of the threatening or terminal symptoms) in cases of persistent salpingitis, appendicitis, nephrolithiasis, chole- lithiasis, and many other abdominal and pelvic conditions that run a comparatively rapid course. In the case of a patient with one of the diseases, the prognosis is not necessarily fatal. Many such patients having persistent symptoms have lived to old age. And yet when any one of these conditions is unmistakably pres- ent, and there are persistent symptoms from it, there is little question l^ut that re- moval of the disease is the part of wisdom, not so much because the present symp- 646 FIBROMYOMA OF THE UTERUS toms are troublesome but because the symptoms indicate that the process is con- tinuing active — it having been established, and generally accepted, that when any one of these diseases is persistently active, it is liable at any time to develop a con- dition that may cause the patient's death or make more hazardous the operation then necessary to save her from death. "This is exactly the condition that is present in uterine fibromyoma with persist- ent symptoms, even though the symptoms are not for the present threatening or disabling. Yet this fact is not generally recognized, and there is good reason for its not being recognized. Physicians generally have the excellent habit of requir- ing proof before accepting a statement, and the absolute proof as to the advisa- bility of early operation in uterine fibromyoma has not been forthcoming. I say this with all due respect to the many excellent men who have expressed as many excellent variations of the opinion that early operation is advisable. Opinion is not proof. It usually precedes proof and stirs up and brings out proof. When the proof is produced, however, it is sometimes found that the opinion which pre- ceded it, proceeded in the wi-ong direction. So I am not surprised that the profes- sion waits to see the proof, before accepting the statement that early operation should be the rule in these cases. "When we come to produce the proof we find that we haven't it — at least, if any one has it I have not seen it, and I have spent a good deal of time looking for it in the last few years. "Facts are gradually being accumulated, and many bearing on various phases of the subject have already been presented to the profession, but the actual life- history of fibromyoma patients, of the class under consideration, has not been followed up and completely recorded in a sufficient number of cases to enable us to present positive proof as to what proportion of them die of the disease, what proportion suffer chronic invalidism, and what proportion experience no serious trouble. "The finding of fatal complications in a large proportion of the operated cases. is not proof positive that the less severe cases should be subjected to operation, any more than the finding of perforation or abscess formation in a large proportion of the severe operated cases of appendicitis was proof positive that it was wise to sub- ject the less severe cases to operation. "The principal question concerning these fatal complications is not 'What pro- portion of operated cases present them?' but 'What proportion of the mild cases progress to them?' "I do not minimize the importance of tlie arduous work of determining accurately the number of these complications in operated cases. That is needed and is neces- sary to the determination of the proportion of serious results in nil clincial fibroid cases. "But in our (nithusi;isni over the ;i(U',oini)lishinent of tlu^ fh'st, we must not mistake it for the second. The proportion of operated cases presenting these fatal and disabling complications is now a matter of record, and the record includes a suf- ficiently large number of cases to justify fairly definite conclusions on that point. The proportion of mild cases that progress to the serious condition is not a mat- ter of record, in fact, has not been even approxi-mately determined, and cannot be CHOICE OF TREATMENT 647 until the life-histoi'y nf n very large series of the vai-ious classes of fibromyoma cases, is available for analysis. "This can l^e secured only by following the patients of each class through many years to the end. No doubt this matter Has been taken up to some extent and will be taken up very generally and prosecuted till a sufficiently large series has been secured. I hope to accumulate some information on this point, at least for mv own satisfaction; l)ut it is uphill work. The patients move and are lost sight of. There is not the same mutual interest that attaches in operated cases, and the patients are followed with gi-eater difficulty and fewer returns. But this life- history of the less severe cases can be obtained in time and must be obtained, for it is necessary to complete knowledge of the subject. "Some of us have had an experience in these cases sufficiently large to justify us in forming and expressing an opinion to assist in the guidance of others. And though we may believe that our views are sound and founded on the facts as far as they go, and will become more generally recognized as more and more facts are established, yet we must not forget that the complete proofs, in black and white, are lacking at the present time. "Why is it so hard to establish certainly the exact proportion of fibromyoma cases that turn out badly? Because of the slow progress and long duration of the disease. In persistent salpingitis or appendicitis the cases that are going to turn out badly usually do so within one or two or three years, so by watching a large series of cases for that length of time it could be determined what proportion resulted seri- ously, and could be established by statistical proof just what proportion of cases could be saved from death or disablement by early operation. The fibromyoma cases, on the other hand, present a much more difficult problem. Here the al^sence of threatening symptoms for five or ten or twenty years, gives no assurance that serious trouble may not develop at any time. Case histories are numerous showing that patients have waited patiently and hopefully for ten or twenty years, with fibroids that produced no serious symptoms, only to come at last to the operating table because of some rapidly developing trouble dependent on the tumor. Con- sequently each patient must be followed to the end before we can say that there was no occasion for removal of the growth in that case. "But we cannot wait until all these things are determined before giving our patient advice. " What are the facts so far established, that Avill help to guide us in ach'ising this patient? "1. Some fibromyomata never give serious trouble. I refer of course to clinical fibromj'omata, i. e., tumors that were recognized during life or that could have been recognized had the patient come for examination. The small latent fibroid nodules, found in such a large proportion of sectioned uteri removed post-mortem, are not now under consideration. "A patient may go through a long and useful and happy life with a palpable fibroid, and experience no particular difficulty from the growth. This fact has been demonstrated over and over again in clinical work and in autopsies on patients who have died of independent diseases or of senility. "What proportion of cases run this course we do not know either exactly or ap- 648 FIBROMYOMA OF THE UTERUS proximately. We know only that "some" — a considerable number — have done so. This fact, however, is sufficient to overthrow the contention that "all palpable fibroids should be subjected to operation." There is a mortality due to the operation. To be sure the mortality is small, under proper technique and surroundings, and will become much smaller as the cases are subjected to opera- tion earlier and therefore under safer conditions. But even in the most favorable cases there is, and will continue to be, an occasional death from the operation. And before advising operation in any case we should, as already remarked, assure ourselves that the chance of death assumed is fully justified by the danger of delay in that particular case. "2. In a certain proportion of cases there have developed fatal complications, which were due to the tumor or would have been prevented by its early removal. "Just what proportion of all clinical fibroid cases have developed, or will develop, these fatal complications we do not know, and cannot know in the present state of knowledge. "Just what proportion of operated fibroid cases have developed these com- plications has been determined in several series of cases, through the careful ob- servation and painstaking labor of the physicians under whose care the patients came. No one can investigate this subject mthout coming to feel under personal obligation to the men who have taken the time and the labor to prosecute this work in a reliable way and to place the results before the profession. To Dr. Chas. P. Noble, of Philadelphia, belongs the credit of stirring up the profession on this subject, by presenting and keeping before it incontestible evidence, from his own work and the work of others, of the great frequency of fatal and disabling compli- cations, due directly to these tumors or associated with them. "In a series of 1,188 cases collected by Noble (Noble 278,Scharlieb 100, McDonald 280, Martin 205, Cullingworth 100, Frederick 215, Hunner 100), there were found the striking number of 795 complications. "However, in looking over this list it is seen that many of the complications are not serious and, of even the serious ones, some are in no way dependent on the presence of the tumor. "In order to determine approximately what probable fatalities, here noted, could have been prevented by early removal of the growth, I prepared the tabular anal- ysis given below. "The number of tubal and ovarian complications prevented by early removal of the growth depends, of course, on the number of tubes and ovaries removed. I made the estimate on the basis of two-thirds of the tubes removed (hysterectomy in two-thirds of the cases and myo- mectomy in one-third) and half of the ovaries removed (both ovaries removed in one-third of the cases and one ovary removed in another third). Of course, if found advisable to limit myomec- tomy to a smaller proportion of the cases, more tubes would be removed and hence more tubal complications prevented. "As to whether myomectomy is preferable to hysterectomy in a considerable proportion of the cases, that is a question concerning which there is much of interest to be said on both sides and it can not be taken up here. However, there is no question but that, as early operation is more widely adopted, a larger proportion of the cases will be found suitable for myomectomy. In fact, the more frequent saving of the uterus is one of the benefits that will follow the adop- tion of early operation in these cases. The chance of later enlargement of small " latent " fibroid CHOICE OF TREATMENT 649 nodules to the dignity of clinical fibroids, is not so great as to deter us in preserving the uterus in suitable cases. Such growth takes place occasionally. Some months ago I was obliged to remove the uterus for extensive multi-nodular intra-ligamentary fibroid development in a patient, aged 31, who eighteen months previously had undergone myomectomy in a New York hospital. In this particular case I attribute the rapid growth of the fibroids partly to the chronic congestion of a severe pelvic inflammation, resulting in pyosalpinx, the infection evidently ha^^ng been contracted some time after the first operation. Ordinarily, according to the reported cases that have so far come to my notice, this development of other tumors after operation has not taken place often enough to constitute a serious objection to myomectomy in suitable cases. Again, in certain cases, the preservation of the uterus is well worth the risk of a second or even a third operation. "In estimating the number of serious tubal and ovarian complications prevented by early removal of the tumor, the bare proportion of tubes and ovaries removed does not fully represent the proportion of complications prevented, for only apparently normal adnexa are left. Those tubes and ovaries w hich would show serious trouble later, are likely to show some abnormality at the time of operation and hence would be removed. "The table includes 1,815 cases, consisting of nine series of consecutive cases (Noble 1,118, as mentioned above, Watt-Keen (from Hofmeier's clinic) 417, Webster 210). The question is: 'What probable fatalities, from degeneration of the tumor or from local complications, would have been prevented by early removal of the tumor?,' and only the complications bearing on this question are mentioned. In the first column (A) is given the number found of the particu- lar degeneration mentioned. In the second colum (B) is given the number of these that would almost certainly have been prevented by the early removal of the tumor. And in the third column (C) is given the probable fatalities from the latter. "Number of cases, 1815. ABC Necrosis of tumor 86 Suppurating tumor 10 Oedematous tumor 11 Myxomatous degeneration of tumor 56 Cystic degeneration of tumor 53 Calcareous degeneration of tumor.. 36 Serious intra-lig. development of tumor 44 Malignant disease of tumor or of corpus uteri 65 Large hydronephrosis from tumor pressure 6 T^^^sted pedicle of tumor 33 Pyosalpinx 37 Salpingitis 127 Abscess of ovary 10 Carcinoma of ovary 3 Ovarian (cyst) including dermoids 118 Probable Fatalities 345 "This shows probable fatalities numbering 345, or 19 per cent, simply from the tumor degenerations and local complications mentioned, exclusive of other fatal and disabling effects of the fibroid. This I consider an ultra-conservative estmate. I believe that, were these cases traced to the end without operation, the number of deaths simply from the conditions specified would considerably exceed the num- ber here estimated. 86 80 10 8 11 4 56 40 53 30 36 6 44 15 65 65 6 3 3 2 24 15 84 12 5 3 2 2 75 60 650 FIBROMYOMA OF THE UTERUS ''In a recent report by Winter of 753 operated cases, malignant disease of the tumor or corpus uteri was found in 39 cases and total necrosis of the tumor in 17 cases. Thus, counting only two of the serious concUtions mentioned in the table, it is found that they include nearly 8 per cent of his cases. [In an article by Noble since published, in which he analyzed a series of 2,274 cases, it was estimated that 23 per cent of the patients would have died, from degenerations or complications existing in the uterus or in the appendages or in the abdomen. In Ms study of a series of 4,480 cases in respect to carcinoma, he found carcinoma was present in 2.8% (in corpus uteri 1.5%, in cer\ix 1.29%). In a careful examination of his own 337 consecutive cases, however, he found carcinoma in 4%. As to sarcoma, Winter, in 500 cases in which grossly suspicious areas only were examined microscopically, found sarcoma in 3.2%, but in 253 cases sectioned systematically, sarcoma was found in 4.3%. It is probable then, that if all tumors operated on late were subjected to systematic microscopic examination, malignant cUsease (sarcoma or carcinoma) would be found in 8%.] "3. In a certain proportion of cases, serious ^dsceral degenerations appear in dis- tant organs. The frequent association of heart disturbance with advanced uterine fibroid, has attracted much attention. The proportion of cases showing heart disturbance is striking. Winter had 266 consecutive cases examined for heart diseases and found heart disturbance in forty per cent. In five series carefully examined (Winter 266, Strassmann and Lehmann 71, Boldt 79, Fleck 325, Web- ster 210), the number showing heart disturbance varied from 25 to 47 per cent., averaging 38 per cent, for the whole 951 cases. Of course, a certain number of these heart disturbances would have been found in any series of patients. But making due allowance for these the number is too marked and constant to be a mere coincidence. The exact connection between the two has not been v*^orked out. But whether the heart disturbances are due principal^ to the chronic anemia from hemorrhage or to the direct action of some toxin manufactured in the fibroid, or constitute simply an associated product of the same conditions that produced the fibroid — whatever the cause — the fact remains that they are there and must be reckoned with. Some of these are minor functional disturbances but on the other hand many are of serious import. "That such is the case is sho\Mi by Baldy from the records of the Gynecian Hospital. In the series of 3,413 operations, sudden post-operative death due to circulatory disturbance occurred 16 times. Thirteen of these sudden deaths occurred in the 366 fibromyoma cases, while the 3,047 other operative cases furnished only 3 such deaths. It occurred 36 times as frequently in the fibroid ca-ses a>s in the general run of operative cases. "Other visceral degenerations, from the chronic anemia, from pressure on the ureters and from other, ejects of the fibroid, produce fatalities due really to the fibroid, but attributed to other cases. "Let us now look at some of the facts that arc put forward against tlic idea tluil myoma causes death in any considerable proportion of the cases. "1. General mortuary records show only an insignificant death rate i:om this disea-se. CHOICE OF TREATMENT 651 "The U. S. Census (1900) shows 657 deaths from fibroid tumor of the uterus in a population of about 37,000,000 females. "The Great Britain Census (1901) shows 339 deaths from fibroid tumor of the uterus in a population of about 17,000,000 females. There is a striking agi-eement here, both indicating that the death rate is about 1 in 50,000 — a very soothing proposition to one called to treat a patient so afflicted. But was this all the deaths from fibroid disease in that time? Do not the numl^ers here given represent simply the cases in which nothing else could be found to account for the death. How about the fibromyoma patients that died of kidney disease, of heart disease, of anemia, of "uterine hemorrhage," of uterine "cancer" (cancer of the endo- metrium associated with fibroid or a sloughing fibroid mistaken for cancer), of salpingitis, of peritonitis, and of other conditions due directly to the fibroid of that would have been prevented by its early removal? Until we count the deaths due to these complications, the census figures amount to very little as showing the deaths due to fibroid disease. The}^ show simply that, in the countries men- tioned, few patients die of uncomiilicated fibroids. "2. Hospital records of fibroid cases show few deaths among them. In St. Bar- tholomew's Hospital, among 547 uterine fibromyoma cases there were but 29 deaths, and 28 of these followed operation. Here is a series of 547 fibroid cases only one of which died of the fibroid while 28 died of the operation — accurate records, careful diagnosis, thoroughly reliable report. What shall be said to that? "Before deciding as to the practical significance of these figures I would seek some additional information. How many of the 28 patients who died following operation, would have died without operation? How many of the 547 patients with fibroid tumors were saved from death by operation? What was the after- history of each one of the non-operated cases? When this additional information is obtained, then we will have some idea as to how many deaths from fibroid would have occurred without operation in this series of 547 cases. "Practicall}^ the same deficiencies appear in all hospital series of fibromyoma cases, and in a measure necessarily so, for hospital records can not show the number of non-operated cases that come to death or operation after they leave the hospital. "3. Large series of cases from private records show only a small proportion of the patients in realh' serious condition. There are many such reports. A recent one is that of Dr. E. J. Ill, of Buffalo, in which he reports all fibroid cases seen by him in the preceding three years. There were 300 cases. He operated on 53 and advised operation in 6 others, making 59 cases in which operation was required according to the indications that he followed. So we have here a large series of fibromyoma cases, carefully observed and reported, and in only about 18 per cent was 'life endangered' or 'health so impaired that life was a burden.' Eighteen per cent of serious terminations is not a small per cent for what some are pleased to style a ' harmless' gi-owth. ' But is that the total number of serious terminations in the whole 300 cases? How many of the patients who v/ere in good conditions when he last saw them will pro.gress to the same stage of the disease in which he saw the 18 per cent? "Fibromvoma of the uterus is a very slow growing tumor. It may gradually 652 FIBROMYOMA OF THE UTERUS progress over a period of twenty years or more. Taking off the first five years, as ttie tumor may not come under observation then, we have fifteen j^ears of the growth's progress in which the patient is likely to consult a physician. If in a mixed series observed during a period of three years, 18 per cent are found to have reached the serious condition mentioned, what per cent will have reached the same condition when the same series has been observed six years or nine }■ ears or twelve years or fifteen j-ears? Of course, it would not be true to assume that be- cause observation of the series for three years showed serious terminations in IS per cent, observation of the same series for fifteen years would show serious terminations in 90 per cent, but it would be much nearer the truth than the assumption of 18 per cent as the total serious terminations in the 300 cases. ''Physicians see but a small number of their fibromyoma cases to the end. The patient in the earlier stages of the disease drifts from one physician to another, helping to swell the list of patients 'not requiring operation' for two or three or more physicians. Later there develop threatening symptoms demanding opera- tion, which is carried out. In the records of the last physician only does the case appear as one 'requiring operation.' So from this one case there would be statistical proof that operation is required in only 33 per cent of fibroid cases. This shows how easy it is to fall into serious eiTor. "Tn looking up the records of my own fibromyoma cases, in hospital and clinic and private work. I find that 17}4 percent were subjected to operation. Opera- tion was advised in a numl^er of other cases, but just how many I cannot state, as the recommendations were not alwav-s recorded. In about two-thirds of the total number of fibroid cases seen, there were, at the time, no urgent or threaten- ing symptoms. But I do not deceive myself with the idea that, because these patients were in fairly good condition when last seen, they should therefore be classed as fibroid cases that at no time required operation. They could not prop- erly be so classed until traced to the end. "Even in the occasional case which is seen through all stages by one phj^sician, the progress is so slow and the last stage is so far removed from the first, that the relation of cause and effect is in a measure overlooked. If the end came in two or three years, as in cancer, it would be impressive, but the first appearance of the tumor and the ultimate result being so far separated, the connection is somehow lost. The case seems an exceptional one, some new factor at work — the terminal condition can hardly be recognized as due to the 'harmless' fibroid which the patient has caiTied so many years without particular trouble. 'T mention these things because I believe that many are misled by them. The latest contribution to this part of the subject that has come to my notice, is that by Thos. Wilson, of Birmingham.. England. He assures us, on practically the same deceptive evidence, viz., the analysis of a series of cases seen for a short time, that of fibroids giving rise to symptoms, only 30 per cent require removal. The re- maining 70 per cent require merely watching and minor palliative treatment. "As to what eventually becomes of this 70 per cent he furnishes no proof. How- ever, in the recommendations for the care of them, after giving directions for the relief of various distressing .symptoms, he states, 'And, finally, operation sliould be recommended when bleeding gives rise to anemia and does not yield to ordinary CHOICE OF TREATMENT 653 treatment; when pain is severe and obstinate; when pressure symptoms, especially retention of urine, occur; wiien the tumor is rapidly increasing in size; and generally when there is evidence that the health of the patient is becoming impaired ' — and he might have added, when the kidneys are damaged; when the cardio-vascular system is seriously affected; when the patient is in bad condition for operation; and when the operative mortality is necessarily high. I fail to appreciate the advan- tages of the enumeiated conditions secured by waiting. "I am anxious to get at the real significance of the facts presented on this subject. I am not interested in supporting any particular theory. I have fibromyoma cases to treat, however, and I want to know what is best for them, and do not intend to be misled in the matter, one way or another, by taking facts to mean something that they do not mean, if I can avoid it. I am anxious to know all the facts against early operation as well as all the facts for it. I would gladly welcome any information establishing the safety of waiting in these cases, for no one feels more than I do the responsibility of advising a patient in comparatively good health to undergo the dangers of a serious operation. "As to the conclusions in this matter, I would urge that each physician form his own opinion after critical consideration of established facts— not hastily, not too much influenced by the opinions of others, but carefully and seriously, as one who is personally responsible for the welfare of the patient. "My own working rules in this matter, are as follows: " 1. A patient who has a small fibroid that is causing no symptoms, requires no treatment for the fibroid. Such tumors are rarely seen. Occasionally one is discovered in the course of an examination for symptoms plainly due to other cause. In such a case I usually do not mention to the patient that she has a fibroid, unless she asks directly concerning it, though I take pains to state the fact and its bearing to the husband or other responsible relative. " 2. A patient who has a tumor of moderate size, causing only slightly trouble- some symptoms which may yield to general tonic treatment with the addition of uterine astringents (ergotin, stypticin), is put on that treatment for one to three months — long enough to satisfy me as to whether the symptoms will subside under this treatment. If so, the treatment is continued as necessary to control the symptoms. By 'control' of the symptoms I do not mean just to the extent that the patient can manage to get along as a semi-invalid, but to such an extent that they are not noticeable to her — that she is practically a well woman. " If I find the symptoms persist after a satisfactory trial of this treatment, it means that they are due largely to the activity of the tumor, and not simply to the accompanying pelvic congestion (depending principally on some minor in- flammatory trouble or on constipation or on methods of work or on other cause independent of the tumor). The persistence of symptoms, after a satisfactory trial of the measures to eliminate symptoms due to other causes, means that the tumor itself is already an active irritant in the pelvis. Not active in the sense that it is necessarily rapidly enlarging or degenerating, but active in the sense that it has not passed into the resting, non-active, clinically-cured state, but is working the other way. It is active in the same sense that a persisting appendi- 654 FIBROMYOMA OF THE UTERUS citis is active in the quiescent periods between the acute attacks. The difference is that the activity of the fibroid is more insidious, less disturbing for the time being, slower, not published by acute exacerbations — but nevertheless persistently progressive. "However, before recommending operation in a fibromyoma case because of persistent symptoms, I take pains to make certain that the persistence of the symptoms is due to the tumor, and not to some associated condition or conditions that can be relieved by less dangerous meatsures. " Having established beyond doubt that the tumor itself is already a continual irritant in the pelvis, I say to the patient substantially as follows: " 'There is persistent trouble in spite of the treatment, and this trouble is due to the tumor. There is little chance of its getting better or of its remaining per- manently stationary. The strong probability is that it will get progressively worse. And it may at any time get rapidly worse, and develop conditions that would increase many times the danger of the operation which would then be necessary to save your life, if it could be saved. I am satisfied that the danger of operation now is much less than the danger of delay.' "3. In cases where the tumor is causing symptoms that plainly cannot be cor- rected by other measures, I at once recommend operation, without wasting time with the other measures. " What about large tumors without symptoms? I am skeptical on the subject of large tumors without symptoms. They are certainly very scarce. I do not remember having seen any case of large fibromyoma in which careful inquiry did not show some evidence of disturbance from the growth before it had attained a large size — unless the following case, seen recently in consultation with Dr. C. 0. C. Max, of St. Louis, could be classed as such. "The patient, a white woman, aged 30, unmarried, noticed in a casual way, about the middle of last February, that the lower abdomen seemed rather larger and firm. Subsequent developments indicate that the tum.or must have been of con- siderable size at that time, probably reaching half way to the umbilicus. Careful inquiry elicited no noticeable evidence of disturbance at that time, not even bladder irritation. As the patient felt well she paid no particular attention to the fullness of the abdomen. At the middle of March the menstrual flow was not so free as usual and, for reasons best known to herself, she became frightened and went to a midwife who, March 21, introduced a sound into the uterus and assured the patient there was no pregnancy. For two days she worked and felt well. The second night, however, she had a chill followed by fever and intermittent pains in the abdomen and a bloody flow with clots. The trouble increased and the patient's condition became serious and she called in Dr. Max, who very properly proceeded to empty the infected and partly emptied uterus. But there was not much material to be removed. The fever and pains kept up and the patient's condition became still more serious. It was then that I was asked to see her in consultation. Though it had been only eight days since the onset of decided symp- toms, the fibroid uterus was then as high as the umbilicus. "Thinking that possibly the acute infection was of such character that it would quickly subside, permitting a safer operation when the virulence was spent, ^\e CHOICE OF TREATMENT 655 treated the case accordingly. But the fever continued high, the abdominal pains increased, the pulse became rapid and the patient, instead of getting better, went from bad to worse. So we were obliged to operate, April 14, in the presence of tiie acute infection. The specimen furnishes a particularly clear illustration of one of the dangers of a sloughing fibroid, so I brought it for your inspection (Figs. 610, 611). The necrotic fibroid has caused a perforation through the uter- ine wall into the peritoneal cavity. '•' This was one of those mild cases that 'get along comfortably and present no justification for subjecting the patient to the risks of a serious operation.' There were no threatening symptoms, in fact, there were no S5^mptoms of any kind that the patient had noticed, except a slight fullness in the lower alxlomen. And yet within four weeks the pat rent was in a most serious condition, and had to be operated on in that condition with the greatly increased risk. ''There was a streptococcus infection, causing sloughing of the fibroid, and the large sloughing fibroid had caused perforation of the uterine wall, destroying an area as large as a silver dollar, as here shown. The omentum was adherent over this opening. When the adhesions were partially separated the bloody in- fected fluid from around the necrotic fibroid poured out into the peritoneal cavity. This gives an idea of the desperate character of the case. The oper- ation was total hysterectomy. On account of the extensive infection, involving the peritoneal cavity, we drained freely both into the vagina and through the abdominal incision. The patient recovered, but it was a close call for her. "Returning to the general subject of advice to fibromyoma patients, the three worldng rules just given very readily incUcate in most cases whether the tumor should be let alone or removed. I refer to the general run of cases — the common forms of myoma in patients under ordinary circumstances. "There are, of course, certain exceptional cases in which there must be taken into consideration special conditions — in the fibromyomatous uterus or in the age or physical condition of the patient or in her surrounding circumstances. For example, if the uterus is pregnant and the tumor is of such size and situation that it vnW probably not interfere with pregnancy and parturition, I would not interfere at that time. If the patient is in the menopause or safely through that period, I would feel justified in leaving some growths that I would not leave in a younger woman. Again, a patient may be in circumstances in which it is important that for a time she take no risk, not even a small one, unless absolutely forced into it by the most threatening conditions, as when she has small children wholl}' dependent on her for the time being. Again, the distribution of the tumor tissue has, in certain cases, a considerable influence on the decision, for example, a patient presenting several good-sized nodules in the uterine vv^all can wait with more safety than where the same amount of fibromyomatous growth is collected in one or two large tumors. There are many such special conditions that must be taken into consideration. This is true to such an extent that, in a measure, each case re- quires particular consideration and decision. This is the reason why it is impos- sible to formulate rules applicable to all cases. "However, we necessarily, even in the exceptional cases, base our advice largely on some general guiding principles. And it behooves us to be certain that those 656 FIBROMYOMA OF THE UTERUS general principles accord with the facts (the real facts and not the supposed facts; as far as the facts are known. "In closing I wish to emphasize the following points: "1. A fibroid tumor of the uterus, which has reached a size to be appreciated clinically, is a much more serious affection than is generally supposed. "A considerable proportion of the patients develop fatal local conditions, another considerable proportion develop serious distant visceral degenerations, and a large proportion of the remainder (possibly most of them) finally pass into a condition of chronic suffering and invalidism. "2. The progress of the disease is so slow as to be deceptive, many cases taking fifteen to twenty years to reach full development — hence the serious results do not appear in the observation of a series of cases for a few years, a few years constituting but a fraction of the developmental period. "Yet the wide-spread teaching that serious conditions develop in only a very small proportion of the cases, is based largely on just such limited observations, recorded and unrecorded. No large series of consecutive cases followed to the end without operation has shown a small mortality. "3. Uterine fibroid kills principally by inducing serious local and general com- plications, that go down in the mortuary records as the cause of death — hence mortuary records give no indication of the ravages of the disease. It kills secretly and indirectly, but none the less surely. "4. The proportion of the various classes that (a) go on to a fatal termination or (b) become chronic sufferers and invalids or (c) develop no serious symptoms, can be exactly determined only by securing accurate records of a large series of cases, comprising all classes, from the beginning of the trouble to the end. "5. Enough is already known to show that delay is dangerous. Many patients develop fatal conditions, many find operation necessary when in such a state as to make the operation exceedingly dangerous, and some must be refused operation because of advanced complications — nearly all of which loss of life and health could have been prevented by early operation. "6. The chance of satisfactory improvement after the menopause is, speaking generally, more than overbalanced by the frequency of serious degenerative changes and complications. "7. We assume a grave responsibility when we advise a patient to wait until serious symptoms develop before having the tumor removed. "Early operation, under proper conditions, means small risk to the patient. Late operation means great risk." PREGNANCY AND FIBROID. The association of fibromyoma with pregnancy is always a matter for serious concern, though many patients get along without trouble. Lafour, in a series of 300 cases of fibroid and pregnancy in which delivery took place by way of the birth canal, found the maternal mortality 40% and the infantile mortality 77%. In a series of 147 cases of fibroid and parturition, collected by Susserott, the maternal mortality was 53% a,nd the infantile mortaUty 66%. In 20% of these cases forceps were used, with the loss of 8 mothers and 13 children. TREATMENT WHEN COMPLICATED BY PREGNANCY 657 "Johnston estimated that thn-ing pregnancy or hibor one-third of the mothers and more than one-half of the children die, and recommends celibacy when the tumor can not be removed." Rosenwasser said in 1899 that antisepsis and im- proved technique had reduced the maternal mortality only to 37%. Methods of Treatment. 1. Non=mterference. The patient is allowed to go along until term, in the hope that there may then be a satisfactory delivery (spontaneous or operative). As mentioned later, this is the preferable plan in many cases. The results have been reported in various series of cases, as follows: Spontaneous delivery. In a series of 84 cases of labor complicated by fibroids, 64% of the patients managed to deliver themselves, while 36% required assistance by forceps or otherwise. Forceps, In Veit's series of 39 forceps cases, the maternal mortality was 33% and the infantile mortality was the same. Version. In Veit's series of 87 version cases, the maternal mortality was 64% and the infantile mortality 82%. In fibroid cases there seems to be a marked tendency to adherent placenta. In a series of 147 cases of fibroid complicating labor, manual removal of the pla- centa was necessary in 21 cases, and 13 of these women died. This serves to call attention to the difficulties of this condition, which is always a serious one in the presence of a fibroid. Caesarian section. In Sanger's series of 43 cases, the maternal mortality was 83.7% and in Pozzi's 28 cases the maternal mortaUty was 86%. In 48 Porro operations in fibroid patients, the maternal mortality was 33%. In a later series of 49 cases of the Porro operation in fibroid patients, the maternal mortality was only 12.5%, showing that immediate removal of the fibromyomatous uterus is the safer operation. 2. Myomectomy. The patient is subjected to operation for the removal of the tumor, but the pregnancy is allowed to continue — if it will. Leopold, in his myomectomies in the pregnant uterus, from 1884 to 1894, had a maternal mor- tality of 17.4% and a fetal mortality of 37.6%. Stavely had a maternal mor- tality of 24.2%. The probability of abortion is great and must never be lost sight of, though many cases of extensive myomectomy have recovered without abortion. Olshausen reported 21 myomectomies. Abortion followed in 38%. In a series of 57 myomectomies and enucleations during pregnancy, 12% of the w^omen died and 24% aborted. 3. Hysterectomy. The fibromyomatous uterus is removed in early pregnancy. In a recent series of 89 cases of supravaginal hysterectomy for fibroid complicated by pregnancy, the mortality was 11%. When the operation is canied out promptly (before serious complications intervene) the mortality is very little higher than hysterectomy in the non-pregnant. 4. Induced abortion. As the patient is in a serious condition and her life threat- ened, the plan of emptying the uterus has been suggested and carried out. Lafour collected 39 cases of fibroid and pregnancy in which this method of treatment was (358 FIBROMYO:\IA OF THE UTERUS employed. The mortality was 36%. In the case of a fibromyomatous uterus the dangers from abortion (spontaneous or induced) are great, because of the difficulty of completely emptying the uterus and the consequent frequency of hemorrhage and sepsis. Selection of treatment. The treatment to be employed depends on the size and location of the fibro- myoma and the stage of pregnancy at which the patient is seen. When the tumor is in the upper part of the uterus and is of small or medium size and not causing much trouble, it should be let alone until after parturition. When the tumor is so large or so situated (cervix fibroid) that it precludes the possibility or probability of full-term delivery per via naturalis, the treatment turns somewhat on the stage of pregnancy. ^ If the patient is seen in early preg- nancy, hysterectomy is the safest plan of treatment. In some exceptional cases the tumor may be so situated that myomectomy (abdominal or vaginal), with hope of continuing the pregnancy, is justifiable. If the patient is first seen in late pregnancy, it may be advisable to postpone operation until full term or nearly full term, with the hope of saving the child by Caesarian section. Of course, there are all gTadations in seriousness, from the cases where it is almost certain that there will be no trouble to the cases in which full-term delivery by the natural route would be absolutely impossible. It is the middle class that contains the cases that furnish the most puzzling problems. When seen in early pregnancy there is an uncertain factor, namely, the probable extent of develop- ment of the fibroid during pregnancy. This makes it difficult in some cases^ to decide just which line of treatment is preferable. In cases of doubt after giving due consideration to the various aspects of the case, the rule is to await develop- ments. . A numerous class of fibroid cases complicated by pregnancy, is that m which the patient has one or more fibroids that give no particular trouble until she be- comes pregnant. After the patient has been pregnant three or four months the symptoms become so acute and threatening that the tumor and uterus must be removed or the uterus must be emptied, with the dangers incident to miscar- riage in these cases (see above) and the probability of operative removal of the tumor and uterus later. I think immediate hysterectomy is the safest plan under these circumstances. The choice of the treatment in such cases is discussed in detail in a paper I read before the St. Louis Medical Society in 1901.* LIPOMA OF THE UTERUS. Lipoma of the uterus is rare, so rare as to constitute a curiosity. A few case« have been reported, one of which is shown in Fig. 361. A lipoma in the uten/- wall may come without particular cause, as in other situations, or it may come from fatty degeneration of a fibroid. Tiio symptoms and treatment are practically the same as for fibromyoma. The exact diagnosis is made after the mass is re- moved and laid open. * Report of Two (^usos of rrcgniincy Kequiring Operation, by H. S. Crossen, M.D. St. Louis Medical Review, Avig. 24, 1901. 659 CHAPTEK IX. MALIGNANT DISEASE OF THE UTERUS. Malignant disease of the uterus occurs in the form of carcinoma and sarcoma. Carcinoma of the cervix uteri is so different cUnically from carcinoma of the corpus uteri, that I think advisable to consider the two separately. The sub- ject of this chapter then may be divided into three parts, as follows: Carcinoma of the Cervix Uteri. Squamous-cell Carcinoma (Epithelioma). Cylindrical-cell Carcinoma (Adeno-carcinoma). Malignant Adenoma. Endothelioma. Carcinoma of the Corpus Uteri. Adeno-carcinoma. Malignant Adenoma. Endothelioma. Chorio-epithelioma. Sarcoma of the Uterus (Cervix and Corpus). CARCINOMA OF THE CERVIX UTERI. This term signifies malignant disease of epithelial origin, situated in the cervix. It may arise from the squamous epithelium covering the vaginal surface of the cervix, in which case it is a squamous-cell carcinoma and is ordinarily designated as "epithelioma." It may arise from the glandular epithelium in the interior of the cervix, in which case it is a cylindrical-cell carcinoma and is ordinarily designated as "adeno-carcinoma." ETIOLOGY. The cause of carcinoma, as of other forms of new growth, is still a mystery. As in the case of fibromyoma, there are some interesting theories but they are still theories only. P.ATHOLOGY. Cancer of the uterus is,, in the beginning, essentially a local process. The ap- parently independent gi'owths appearing later in various organs, are simply metastases from the primary tumor. This fact has been firmly established by the most thorough and painstaking investigation by many authorities. The 660 MALIGNANT DISEASE OF THE UTERUS supposition that it is simpl}- the local manifestation of some constitutional dyscrasia, has no foundation. The important bearing of this on treatment is apparent. Frequency. As far as known at present, primary carcinoma occurs more fre- quently in the uterus than in any other organ, carcinoma of the stomach coming next in frequency. Welch found in a series comprising 31,000 carcinoma cases Fig. 616. A Small Epithelioma of the Cervix Associated with Fibromyoma of the Corpus Uteri. In this case the most evident lesion was the fibroid, but further examination revealed induration and irregularity about the external os, with some bleeding on examination. A piece of tissue exci.scd from the suspicious area and submitted to microscopic examination show- ed epithelioma. The specimen is shown sectioned in Fig. 617. that the primary growth was in the uterus in approximately 29% and in the stomach in 21%. Most carcinomata of the uterus occur iu the cervix. Cullen, in a strict analysis of his 128 cases of carcinoma of the uterus, found that 74 were epitheliomata of the cervix, 19 were adeno-carcinomata of the cervix and 35 were adeno-carcino- mata of the corpus uteri. The great frequency of carcinoma in the cervix is supposed to l)e due largely to injuries there in child-bearing, with resulting PATHOT.OGY OF CARCINOMA OF CERVIX 661 scar-tissue, inflammation, cystic degeneiation and chronic irritation. It is rare in the uninjured cervix, though some cases have been reported, even in children. Varieties. Carcinoma of the cervix occurs in two principal forms — epithelioma (squamous-cell cancer) and adeno-carcinoma (cylindrical-cell cancer), the epithel- ioma being by far the more frequent (74 to 19 in Cullen's cases). Epithelioma of the cervix originates from the squamous epithelial cells cover- ing the vaginal portion. Arising from that part of the cervix known as the " portio vaginalis," it is sometimes spoken of as "cancer of the portio." The disease begins as a small area of infiltration on the vaginal surface of the cervix, supposedly at a point of persistent irritation from scar-tissue or erosion or other irritating process. If the patient happens to be examined at this stage, the infiltrated spot feels rather firm to the touch. That is all. There is no pain, there may be no bleeding or discharge, though there may be some discharge from the preceding chronic irritation. As far as the naked-eye appearance is con- cerned, it does not differ materially from a small area of chronic inflammatory infiltration or erosion. The essential pathological change is that, at the point indicated, the squamous epithelium is beginning to penetrate into the underlying connective tissue. This invasion is resisted by the leucocytes which collect in the adjacent tissue. As the process continues, the carcinomatous infiltration, with the opposing round-cell (leucocyte and lymphocyte) infiltration, penetrates deeper into the tissues and the small area of induration gradually increases in extent. A small abrasion or ulcer appears (Figs. 616, 617, 443). This usually bleeds slightly when touched. Frequently the first evidence of anything wrong that the pa- tient notices, is a slight streak of blood or spot of blood after coitus or after extra walking or other exertion. This may remain the only external evidence of the dis- ease for many months — in fact, in a considerable proportion of the cases, no other symptoms appear until the disease has penetrated deeply into the cervix and out into the parametrium. As the disease extends in the cervix, more infiltration becomes appreciable on palpation and more ulceration (which may be mistaken for laceration or erosion) may be seen through the speculum (Figs. 618, 445). Still later there may be ulceration into the rectum or bladder (Fig. 619), forming fistulae which add greatly to the patient's suffering. As the disease advances, projecting growth may occur, causing distinct papillary outgrowths on the affected portion of the cervix (Fig. 447). Still later the cervix may be replaced by a papillary fungus tumor-mass. On the other hand, particularly in the aged with very slow-growing epitheliomata, the formation of contracting scar-tissue may so draw in the affected region that it can not be seen. In such a case it can be appreciated only by palpation, which reveals induration at the vaginal vault (Fig. 446). In addition to the regular and essential elements of the diseased tissue, there may be secondary changes. Areas of softening and degeneration occur in which the cells are broken down and become simply fluid and debris. Hemorrhage into certain parts of the growth may occur and, as a result of that hemorrhage, there remain clots and discoloration and fluid. Infection may take place, leading to suppuration or sloughing. Occasionally lime salts are deposited in the cancer 662 MALIGNANT DISEASE OF THE UTERUS cells. This chalky deposit may be extensive and may even be found in the metastases. Adeno=carcinoma of the cervix arises from the cylindrical cells lining the interior of the cervix and forming the cervical glands. It may then in the beginning be located at the external os or in the cervical canal or in any part of a gland extending deeply into the cervical wall. As the cell-columns penetrate the under- lying tissues, the cells assume somewhat a gland formation owing to this deriva- tion from gland-forming epithelium. This gland formation, however, is very irregular and atypical, being represented to a large extent only by solid columns Fig. 617. An Antero-posteiior Section of the specimen sliown in Fig. 616. Microscopic examination showed that the epithelioma extended along the cervical canal practically to the internal os. of cells. "Malignant adenoma"' is a rare form of adcno-carcinoma in which the penetrating cells preserve, to a marked extent, the glandular arrangement. The infiltration in adeno-carcinoma, being situated in the interior of the cervix, is not appreciatcnl by the examining finger until a considerable mass has formed. The disease pursues much the same general course as described for epithe- lioma, the carcinoma cells penetrating deeper and deeper into the cervix and into the surrounding connective tissue (Fig. 620). I'ArilULOGV OF CARCINOMA OF CEUVIX 663 Endothelioma is a rare form of malignant disease of the cervix in which micro- scopic examination shows spaces Uned with proUferating cells resembling endo- thelium. Its exact nature and origin have not been determined — in fact, it is still uncertain whether it is an epithelial growth (carcinoma) or a connective-tissue growth (sarcoma). Modes of extension. Carcinoma of the cervix extends in four ways — by con- tinuity of tissue, by the lymphatics, by the blood-stream and by implantation. Fig. 618. An Epithelioma of the Cervix Uteri, advanced to stage of the destruction of the cenux. (Cullen — Cancer of the Uterus.) Extension by continuity of tissue is the principal method and, aside from ex- ceptional cases, the only method in the earlier stages of the growth. In tliis method of extension, the carcinoma cells grow into the tissues against which they lie. This differs markedly from the way in which a non-malignant tumor extends. A fibro myoma as it grows, pushes aside the adjacent tissues, but a malignant tumor as it grows penetrates the adjacent tissues and destroys them. It is this insidious involvement of contiguous tissues that makes many cervical carcinomata inoperable when first seen. It i.s this same gradual extension outward 664 MALIGNANT DISEASE OF THE UTERUS by continuity of tissue that later causes the patient most of her suffering and that in most cases causes her death, by involving the uterus or bladder or rectum. In extension through the lymphatics, some carcinoma cells are caught in the lymph current and canied to lymphatic glands, where they lodge and grow and destroy tissue the same as the parent growth. This invasion of the lymphatic glands by carcinoma cells does not occur usually until rather late in the disease — until it has extended by continuity of tissue through the cervix into the parametrium. Winter found cancerous glands in only 2 cases in 44 autopsies on patients where Fig. 619. An Epithelioma of the Cervi.K Uteri, still farther advanced. The growth has invaded the bladder and rectum, causing fistulae into these organs. (Cullen — Cancer of the Uterus.) the disease was confined to the uterus. Wertheim, in 60 operated cases, found involvement of removed glands in 15 percent of early cases and in 31.7 per cent of all cases. Schauta made a most thorough autopsy-study of 60 cases, in 40 of which the patients died from the natural effects of the cancer and in 9 from inter- current affections. In 43.3 per cent of the whole series, the glands were entirely free of carcinomatous metastases, The lower (removable) glands alone were PATHULUGV OK (JAHCINOMA UK CI;K\IX 665 involved in 13.3 per cent, the upper (not removable) glands alone in 8.3 per cent and both lower and upper glands in 35 per cent. Kundradt, in a study of 76 cases operated on by Wertheim, in which the para- metrium was involved on one or both sides, found the glands entirely free of metastases in 71 per cent. The glands on one side were involved in 22 per cent, and the glands on both sides were involved in 7 per cent. The glands are rarely involved until the cancer has advanced into the Fig. 620. .\dvanced Adeno-carcinoma of the Cervix Uteri. Notice the involvement of the parametrium. (Kelly — Operative Gynecology.) parametrium. Kundradt, in his analysis of 80 cases, found only four in which the glands were involved with the parametrium free. Enlargement of the regional glands is very common in the early stage of carci- noma but this enlargement is, as a rule, not due to carcinoma cells but to the in- flammatory hypertrophy that nearly always takes place in the glands draining a region that is subject to severe chronic irritation. In exceptional cases, how-. 666 MALIGNANT DISEASE OF THE UTERUS ever, the glands may become infected with carcinoma cells at an early stage of the disease. This matter of glandular involvement has a very important bearing on the question of operative treatment. In extension by the blood stream, some carcinoma cells penetrate into a blood-vessel, are caught in the current and are carried to distant organs, where they lodge and grow and form metastatic tumors. In whatever kind of tissue these metastatic growths are situated, they reproduce the structure of the parent growth. The lungs arc most frequently affected, though there are many other organs that are affected occasionally. The possibility of metastases must be kept in mind in deciding whether or not a case is operable. If metastasis to distant organs has occurred, hysterectomy would of course be useless, except as a palliative measure. However, such metastases almost never occur except in the last stage, and then not very frequently. Winter, in 202 cases, found metastases in distant organs in only 23'i2 per cent. Direct implantation of cancer cells into the healthy tissues of a raw surface takes place principally in operations for cancer — the cells being carried on the knife or scissors or other instrument, or on the fingers or sponges, from the infil- trated area to the healthy tissue which has been laid open in the operative work. Many undoubted instances of this occurrence are on record. It furnishss a strong reason for keeping entirely clear of the involved area in operations for the cure of cancer. Complications. Aside from the tumor itself, there are several conditions re- sulting from it that enter into the pathological and clinical picture. The ureters may be compressed, leading to dilatation of the ureters and also to hydronephrosis (Fig. 621). In the later stages there is compression of the pelvic nerves and ves- sels, causing pains and edema. The infiltration may penetrate the wall of the bladder or rectum, and if the infiltrated tissues break down, fistulae into these organs are formed (Fig. 619). Associated diseases also add to the pathological picture in certain cases. Fibro- myoma of the uterus is a rather frequent association (Figs. 616, 421). Various inflammatory lesions are frequent and add much to the danger and difficulties of operative treatment. Duration of the disease. . This is variable, the limits ordinarily being one to three years. The duration depends somewhat on the kind of tumor (the softer the tumor the more rapid the growth), upon the age of the patient (the younger the patient the more rapid the growth) and upon the proximity to child-birth — those carcinomata appearing within one year after parturition progressing very rapidly. These arc only general rules, to which there arc, of course, exceptions. Effect of pregnancy. Sometimes carcinoma of the cervix may appear while the patient is pregnant, or occasionally pregnancy may take place in the earl}' stage of carcinoma of the cervix. In either case the effect of pregnancy is to hasten the progress of the carcinoma. The softening of the tissues and the cojigestion associated with pregnancy, seem to favor rapid extension of the malignant dis- ease. DIl FERENTIAL DIAGNOSIS OF MALIGNANT DISEASE 667 Fig. 621. Dilatation of the Ureters and Kidneys, due to obstruction of the ureters by Cancer of the Cenis Uteri. {Kelly— Operative Gyne- cology.) SYMPTOMS AND DIAGNOSIS. The first symptom, in practically all cases of carcinoma of the cervix is a slight ieucorrhoeal discharge, with an occasional spot of blood. This shght streak of blood is seen usually after extra exertion (extra work, long walk, lifting) or after a douche or after coitus. It is especially liable to appear within 24 hours after coitus. A history of such "spotting" of the discharge or of the clothing, calls for a most careful examination, that the presence or absence of carcinoma of the vaginal surface of the cervix or of the interior of the cervix, may be certainly determined. In giving the symptoms and the diagnosis of this disease, I shall speak nearly altogether of the early stage. It is in this stage that the diagnosis is most diffi- cult and it is in this stage that the diagnosis is most important, for operation then will, in a large proportion of the cases, save the life of the patient. In this connection it \Aill be an advantage to consider the differential diagnosis between the early stage of malignant disease of the uterus in (jenerul (Ijoth carei- 668 MALIGXA.VT DISEASE OF THE UTERUS noma and sarcoma) and the conditions T^ith ^'liich it is likely to be confused. This is a very important subject, particularly to the general practitioner who usually sees the patient first and upon whom rests the responsibihty of recognizing mahgnant disease in its beginning, or of recognizing the cases in which it may be present and which require special investigation accordingly. Concerning early diagnosis of malignant disease of the uterus, I quote from a paper of mine pubhshed in 1900:* '■'How, then, are we to discharge our responsibilities in this matt-er? We can not curet even,^ woman that comes to us, nor excise and examine a piece of the cervix, simply because she might have cancer. " What is needed is the adoption of a practical mode of procedure for determin- ing certainly, in patients -v^ith uterine disease, whether or not mahgnant infiltra- tion is present. ''Malignant di.sease of the uterus means carcinoma or sarcoma. Carcinoma may start from the squamous epithehum covering the cervix or from the cyhndrical epithelium lining the canal of the cervix and body of the uterus or from the gland- cells situated deeply in the substance of the cervix and body. Sarcoma may start from any part of the organ. "]\Ialignant trouble is invariably chronic and there is always present either induration or ulceration. "In the CERVIX, if there is induration it can be felt. If there is ulceration or erosion of the outer surface of the cer\ix it can be seen. If there is ulceration within the cer^■ical canal it will cause a troublesome discharge. "In the BODY of the uterus, if there is ulceration it will cause a troublesome dis- charge. By "troublesome discharge" I mean what is ordinarily called "leucor- rhoea" — not the watery discharge of advanced cancer. Induration in the body of the uterus can not, of course, be detected until a considerable mass has formed. I am satisfied, however, that practically even,- case of malignant disease of the body of the uterus, whether carcinoma or sarcoma, presents a discharge while the infiltration is still in an early stage — that is, before it has gone beyond the reach of radical operation. "In forming a conclusion as to whether or not a lesion is malignant, we should not give too much weight to the j'outh of the patient. To be sure, in carcinoma the patient is usually past thirty-five. But carcinoma may occur before thirty. One patient for whom I did an abdominal hysterectomy for carcinoma w^as but twenty-eight and the disease had then been present long enough to form a large mass and had been gi\'ing her much trouble for several months. Several cases of this disease in patients under twenty have been reported. Sarcoma may de- velop at any age. "Called to see a patient with pelvic di.sea.se, if there is no erasion or ulceration of the cervix, no induration of the cervix or body of the uterus, and no chronic pathological discharge, we are safe in assuming that the uterus is free from malig- nant trouble. When any of these signs are present we must make a differential diagnosis. * Early Recognition of Uterine Cancer. II. S. Crossen, M. D. St. Ix)uis Courier of Medi- cine, 1900. DIFIERENTIAI. DIAGNOSIS OF MALIGNANT DISEASE 669 Induration in the Cervix. "Induration in the cervix may be due to cystic disease or to scar-tissue from laceration or to a fibroid or to malignant disease. In cystic disease, if the nodule be punctured and then pressed upon the char- acteristic clear glairy substance will be extruded anfl the induration will largely disappear. If there remains enough induration to make the diagno.sis doubtful, excise a small wedge-shaped piece and submit it to a pathologist for examination. "In scar=tissue from laceration, the induration is limited to the site of injury and the cause is plain. Also in, scar-tissue the area of induration remains practically the same, whereas if malignant the area of induration gradually increases. In this case, as in every other, if there is reasonable doubt after a short period of careful observation, excise a piece for microscopic examination. ''In fibromyoma of the cervix, fibroids elsewhere in the uterus may often be de- tected, making it probable that the nodule in the cervix is similar in nature. A well-marked tumor of the cervix, even a fibromyoma, should be removed, for almost without exception a fibroid in that situation causes very troublesome symptoms. A small mass with no fibroids elsewhere should have a piece excised to make certain the diagnosis. Ulcer or Erosion on Cervix. "An ulcer or a spot of erosion on the cervix may be due to an irritating discharge, to a pessary or other irritant, to eversion of the mucous membrane by laceration, or to tuberculosis, syphiUs, chancroid or cancer. In the first two mentioned the lesion heals promptly on removing the cause. "Where the cervix is torn so deeply that the mucous membrane is everted and gi-anulating, the cervix should be repaired, and the tissue removed in the denuda- tion for repair may be examined microscopically. If there is no malignant trouble, the cervix ^^•ill be in much better condition than before, and we will have satisfied ourselves that it ..as only simple trouble and the patient need never know that there was a suspicion of malignancy. If malignant infiltration is found in the excised tissue the uterus can be removed at once with the probability of a permanent cure. "Tubercular ulceration of the cervix is rare. The diagnosis is made from micro- scopic examination of pus and scrapings from the diseased area. "In syphilitic ulceration there are usually other lesions or a history which makes the diagnosis clear. Furthermore, a syphilitic lesion of the cervix, whether pri- mary, secondary or tertiary, should yield within a reasonable time to appropriate treatment, provided the patient's general health is not too much depressed. "Chancroidal ulceration, which is thoroughly causterized, should within a short time thereafter show healthy granulation and rapid healing. A sore on the cervix that resists appropriate treatment should have a piece removed for examination. "The following method of differential diagnosis has been proposed: Soak a pledget of cotton in 10 per cent copper sulphate solution and apply it, for a minute or two, to the suspicious surface. If the lesion is a simple erosion, a 670 MALIGNANT DISEASE OF THE UTERUS bluish-white coating will form without hemorrhage. By repeating the application at intervals of three or four days the erosion will soon be healed. If the lesion is an ectropion it will be blanched by the appUcation. If the lesion is cancer- ous ulceration, the copper sulphate application will cause bleeding. A few days later another apphcation is made, and if the bleeding is more free the diagnosis of incipient carcinoma is almost certainly correct. Heitzman, who brings for- ward this method, states that he rarely failed to find microscopic confirmation of this provisional diagnosis. In all ulcerations except malignant, the bleeding is checked by the copper sulphate of solution in a few applications, and the persist- ence of a single bleeding point after the rest of the raw surface is healed in- dicates malignancy and calls for a microscopic examination of tissue from the suspected area. Discharge From the Uterus. ''There still remain for differential diagnosis the diseases causing uterine dis- charge, and here is where the difficulties begin and where there have been so many failures. I say 'many failures, ' for of the hundreds of women who die annually of cancer of the uterus, I believe a large number go to physicians in the early stages and are treated for chronic endometritis. "Taking up the differential diagnosis, we know that malignant disease is always chronic. So we can eliminate at once all the acute diseases, leaving only the following: Chronic endocervicitis (septic, gonorrhoeal and glandular), chronic ENDOMETRITIS (simple, septic, gonorrhoeal and tubercular), Polypi and fibromy- omata. "In differentiating these affections from malignant trouble the effect of treat- ment is an important item. Inflammation of the uterus in any form is gTeatly benefited by appropriate treatment. Consequently every case of uterine dis- ease presenting induration, ulceration, or discharge, should be subjected to careful and vigorous treatment for the purpose of differential diagnosis as well as for the purpose of effecting a cure. "Chronic Endocervicitis. In suspected chronic endocervicitis, a very good plan is to give a hot antiseptic douche two or three times daily, and every second or third day apply a 4 per cent silver nitrate solution, or tincture of iodine, to the cervical canal. If there is a marked congestion of the cervix, make multiple punctures. If the external os is so small as to interfere with drainage, open it by dilatation or incision. If there are cysts, puncture and evacuate them and touch the cavities with silver nitrate or tincture of iodine or carbolic acid. If there are polypi, remove them. If the cervix is hypertrophied and riddled with cyst, excise most of the diseased area and repair the cervix or partially amputate it. • ''Any tissue removed from the cervix, either curetings or polypi or pieces removed in denudation for repair, should ])0 subjected to a microscopic examination in every case that is tlie least suspicious. The simple fact that cystic disease is present do(iS not exclude cancer. Both may be present, and if the pathological discharge persists after a course of treatment, a piece should be excised from the suspicious area. DIFFERENTIAL DIACNOSIS OF MALIGNANT DISEASE 071 "Chronic Endometritis. Simple eudonietiitis — t luit is, where there is no pus in- fection — is due usually to poor blood or a nuilposition or a stenosis or subinvolution or a tumor. Remove the cause and, if the changes in the endometrium are not marked, they will subside spontaneously or after a few astringent applications. If the pathological changes are marked, it is not sufficient to remove the cause but we must remove also the diseased endometrium, that a new and better one may develop under the bettered conditions. If the case is not perfectly plain, the scrapings should be examined microscopically that the diagnosis may be con- firmed or disproved. "In chronic septic endometritis and in chronic gonorrhoeal endometritis, the idea of effecting a cure by long-continued intra-uterine applications, repeated week after week and month after month, is a delusion and a snare. These long-con- tinued applications rarely, if ever effect a cure, they frequently cause extension of the inflammation to the tubes, and worse still, they deceive the patient and the physician with the thought that something is being done towards a cure — whereas, little or no real progress is made against inflammation, and if malignant disease be present it is allowed to develop till it is past cure. " In all these cases in which the trouble persists after a course of treatment in- cluding a few intra-uterine applications, the uterus should be carefully cleared out with a curet. Then if the trouble is only inflammation, the patient is in a fair way to get well, and if the microscopic examination of the scrapings shows malig- nant disease, the uterus can be removed in this early stage with a well-founded hope of saving the patient's Kfe. " Fibromyomata are frequently multiple, and when only a single tumor can be felt it may be of such large size or have existed so long with but little disturbance, that malignancy is excluded. But there are many cases in which the mass is small and as far as known has existed only a short time. In these cases the most important point in the differential diagnosis is the change that takes place in the endometrium in the two diseases. " A fibromyoma frequently causes a chronic hypertrophic endometritis which gives rise to discharge and hemorrhage. " A malignant tumor starting deep in the uterine wall may at first cause similar changes, but in the course of time and before it reaches a large size or passes beyond the limit of complete removal, it extends to the endometrium, and characteristic elements will be found in the uterine scrapings. Furthermore, the gi-eat majority of malignant growths of the body of the uterus begin in the endometrium and so produce characteristic changes there in the very earliest stage. " Therefore, in a case of small tumor of doubtful character, accompanied with discharge or bleeding, curetment is advisable as a means of diagnosis. If the uterine scrapings do not show malignant infiltration we are justified in assuming that the tumor is a fibroid, but if the scrapings do show malignant infiltration the radical operation is, of course, indicated at once. " Another point which should be kept in mind is that a malignant tumor which at first causes disturbance of the endometrium by pressure or proximity only, may later send its characteristic elements to the endometrium where they csm be reached with the curet. Consequently, when the first examination shows nothing 672 MALIGNANT DISEASE OF THE UTERUS malignant, if signs of marked endometrial disturbance again appear, the dis- eased tissue should again be removed for examination. " In the later stages also of uterine tumors, curetment is valuable as a diag- nostic means. For instance, a patient presents a large tumor of the uterus of doubtful character, with pain and discharge and marked disturbance of the general health. Curetment will lessen the hemon-hage and discharge temporarily and will furnish tissue for examination. If the scrapings show no malignant infiltration, the tumor is probably a fibroid and removal may be indicated. If the scrapings do show malignant trouble, only palliative measures are indicated, as the gro^^•th has advanced too far for complete removal. "There remains still unmentioned the one form of malignant disease that is most difficult of positive diagnosis. I refer to a malignant tumor growing in a fibroid or resulting from the degeneration of the same. In a number of well-authenti- cated cases, malignant tissue has been found in tumors that were undoubtedly for several years simple fibroids. Fibrocystic tumors seem more dangerous in this respect than the solid tumors. The cases are not very frequent but they do occur, and a fibroid that takes on rapid growth at any time near the meno- pause is open to this suspicion. As the malignant infiltration is for a long time confined within the fibroid, it does not reach the uterine canal, and a positive diag- nosis can be made only by removal of the tumor." In the later stages of carcinoma the pressure symptoms and other complications mentioned under pathology, develop and cause the patient much suffering. Can- cerous CACHENiA (a yellowish anemic color with emaciation, due to deterioration of the blood) appears, and also a foul discharge and persistent bleeding. If the cervix is involved, a fungating mass may be felt in the vagina. In the differential diagnosis of cancer, I have purposely avoided giving promi- nence to these symptoms, for they represent a late stage of the disease. The diagnosis should be made before such symptoms develop, if the patient conies under observation in time. In working for general early diagnosis of cancer of the uterus, we meet with one very serious difficulty which, probably more than any other, is responsible for the many deaths from this disease. I refer to the want of knowledge on the part of the public generally, as to the serious import of irregular blood-tinged vaginal discharges in women approaching the menopause. A very large proportion of patients with cancer of the uterus do not consult a phj^sician until the malignant infiltration has advanced bej'ond cure. The disturbance in the early stage is so slight (just a slight leucorrhoea streaked with blood occasionally) that the patient thinks it of no particular significance and neglects to have any investigation until too late. Whenever an occasional streak of blood or spot of blood appears in a leucorrhoeal discharge, particularly in a woman approaching forty or older, an examination is urgently required, in order to determine certainly whether or not there is beginning cancer in the cervix or body of the uterus. Such women should seek medical advice at once, that the cause of the blood-streak may be determined without delay. Education of the public in this matter is urgently needed and if carried on patiently and persistently and judiciously, will save thousands of women from TREATMENT OF CARCINOMA OF CERVIX 673 death by uterine cancer. However, as I remarked when speaking on this subject two years ago,* "The education of the pubUc in this matter is an exceedingly luird task. Of course physicians, as individuals, can help by giving information to their patients. But there is a larger medium of publicity that should certainly be utilized in some way in a matter of such great importance to the public. I refer to the public press and periodicals. This, however, is a delicate matter and one for concerted action only on the part of the profession as a body, and not for individual action. This phase of the subject is being already considered in a practical way and it is hoped that at the next meeting of the American Medical Association the matter will be thoroughly discussed and some definite and effective steps taken for the general dissemination of this much-needed information." The Reportf of the special committee appointed by the American Medical Association to consider this matter should be read by every physician, and the information contained therein should be disseminated in every practicable way. That much good can be accomplished by a systematic and sustained fight in this direction is shown by the results in East Prussia. Winter, aided by the professional, sociologic and governmental conditions there existing, carried on a most successful campaign against this disease. The report of the first year's work showed, among other things: (a) that the proportion of carcinoma patients who consulted a physician within three months after the ap- pearance of symptoms, was raised from 32 per cent to 57 per cent; (b) that the proportion of patients operated on within two weeks after the first consultation, increased from 78 per cent to 90 per cent; and (c) that the operabihty in patients seeking treatment was raised from 62 per cent to 74 per cent. TREATMENT For purposes of treatment, the cases of carcinoma of the cervix are divided into two classes — operable and inoperable. OPERABLE CASES. This class comprises, theoretically, those cases in which the mahgnant disease is still limited to tissues that admit of complete removal. Practically, it comprises those cases in which there is a chance, even a small chance, that the carcinoma is limited to the tissues mentioned and in which the patient is in condition, or can be put in condition, to stand the radical operation with reasonable safety. By "radical operation" I do not refer to any particular form of operation, but to any operation that removes all the tissues likely to be involved in that partic- ular case. As to what tissues may be removed, by those skilled in pelvic work, that is well known. The removal of the uterus is the least that is to be done. In selected cases, the lower part of one or both ureters may be removed, or a part or the whole of the bladder, or a part or the whole of the rectum. Also, the pelvic con- * The Promotion of Early Diagnosis in Malignant Disease of the Uterus, by H. S. Croseen, M.D. Medical Bulletin of Washington University, 1905. t Journal of the American Medical Association, Dec. 8, 1906. 674 Malignant disease of the uterus nective tissue generally with its contained lymphatic vessels and glands, may be cleared out to the soft structures of the pelvic wall, and the enlarged lymphatic glands about the illiac vessels may be extirpated. I am not stating that any of these extreme measures should be employed in any case. I am only pointing out what may be done and the patient still survive, in selected cases. The question as to the advisability of such extensive operative work does not turn upon any question as to the possibility of removal of these structures, but upon the probability that carcinoma cells have simultaneously extended to other and inaccessible regions. Careful investigations in this direction have been made and many extensive operations have been carried out, but the question is not yet settled. However, results so far have not been such as to encourage operation in these extensive cases. I feel that the lesson to be drawn from the work up to the present time, is that ordinarily recurrence is practically certain when the carcinomatous infiltration has extended so that it involves the bladder or the rectum or the outlaying lymph- atic glands or the connective tissue around the ureters. When any of these struc- tures are evidently involved, it is almost certain that there are scattered carcinoma cells in adjacent deeper and inaccessible tissues, hence these cases lie outside the operable class. There are exceptional cases, for example, of distinctly localized involvement in a slow-growing tumor, where it may be advisable to excise a portion of the bladder or ureter. But for the present, I feel that, ordinarily, to subject such a patient to an attempted radical operation is to cause her to pass through the dangers and the suffering of one of the most serious operations in surgery, without any reasonable hope of cure. If hysterectomy as a palliative measure, is desired, that is an entirely different proposition, and is carried out in a less extensive and less dangerous way. In order to get a clear understanding as to the limit of the operable class, it is well to divide the course of carcinoma of the cervix into three stages. In the first stage the disease is confined entirely to the uterus. Removal of the uterus will remove the entire process and effect a permanent cure. In the second stage the carcinoma cells have gotten outside the uterus into the parametrium for a short distance — but still not beyond the reach of operation, provided the opera- tion includes a wide removal of the connective tissue beside the uterus. In the THIRD stage there is evident involvement of the ureters or of the outlying con- nective tissue or of the bladder or of the rectum (with less evident involvement of deeper and inaccessible tissues), making complete removal of all involved tissue impossible. The cases belonging to the first and second stages are operable as a general proposition. The. cases in the third stage are inoperable. How to Determine Operability. How extensive is the carcinomatous infiltration — has it reached the third stage? That is the important question, for the answer determines whether or not the patient is to be subjected to radical operation. TREATMENT OF (;Anf'[.VOMA OF CERVIX 675 To determine this absolutel}- in any case is impossible. It may, however, be determined approximately. The signs upon which we must depend largely for determining it are the in- duration (occasioned by the infiltration of the tissues with carcinoma cells and opposing round cells) and the fixation of the uterus, which is present when the infiltration extends out to the pelvic wall. Uterus Movable. If the uterus is freely movable operation is indicated. Uterus Fixed. When the uterus is not movable, it is then necessary to deter- mine whether the fixation of the organ is due to malignant infiltration or to inflammatory infiltration. If the fixation is due to malignant infiltration, opera- tion is not indicated — the case has already passed into the third stage and pallia- tive measures only are permissible. If the fixation is due to inflammatory infiltration, it is not a bar to operation. The infiltration is probably carcinomatous if it is in the lower part of the broad ligament and directly continuous with the carcinomatous area of the cervix, if it is not tender and if there is no history of recent inflammatory trouble and no evidence of the same in the pelvis. The inflammation is probably only inflammatory if there is a mass about one or both tubes (salpingitis), if the infiltration of the broad ligament is mostly in the upper part, if the bladder and rectal walls are not involved and if the patient gives a long history of inflammatory trouble and short history of cancer. In such a case, radical operation is indicated. In order to determine approximately the amount of fixation and its probable character, it is often necessary in a doubtful case to employ examination under anesthesia, that deep palpation of all parts of the pelvis may be made. In such a case a deep recto-abdominal palpation of all the intra-pelvic structures, as well as the vagino-abdominal palpation, is usually advisable. This examination, upon which the question of operation turns, is a very im- portant procedure and requires much skill and much experience with this class of eases. If after a thorough examination, there is reasonable doubt as to the inoperability of the case, operation is indicated, for the patient is entitled to every chance possible in this otherwise fatal disease. In these doubtful cases, the operation is begun as an exploratory abdominal section. After the abdomen is opened, the pelvis is thoroughly explored as to the infiltration and thickenings and their character, and as to the presence of evident glandular metastases. If this intra-peritoneal examination shows the tumor to be an operable one, the radical operation is carried out at once. If the tumor is found to be inoperable, the abdomen is closed, with or without the execution of one of the palliative measures mentioned later. Operative Measures. In the operable cases, what operation should be chosen? In order to answer this question intelligently, let us see just what the operation must accomplish. In most of the cases the disease has passed the first stage before the patient con- sults a physician. There is already carcinomatous infiltration of the connective 44 676 MALIGNANT DISEASE OF THE UTERUS tissue near the uterus — not sufficient, perhaps, to be appreciable to the examining finger, but amply sufficient to cause recun-ence. This infiltration of the para- metrium in practically all cases that come to operation, is the cause of the lament- able failure of the old vaginal hysterectomy and the old abdominal hysterectomy as a cure for cancer of the cervix uteri. Occasionally a case was met with in the first stage (simply a small ulcer on the vaginal portion of the cervix or a small nodule in the interior of the cervix), and in these cases the ordinary vaginal or abdominal hysterectomy removed all the involved tissue and resulted in cure. However, the general effect of these occasional good results was detrimental rather than otherwise, for they prolonged the reliance on these inadequate opera- tions for the cure of the disease and postponed the devising of more effective operative measures. When physicians began, after the lapse of some years, to count up the perma- nent cures from the operations mentioned, the results were most discouraging and disheartening. It was found that five per cent of cures was all that could be reasonably claimed. Some operators who had had many cases could not present one permanent cure, and a few lost all hope and claimed that the disease could not be cured by operation. Careful investigation into the pathology of the disease brought out the cause of the failure of the operative measures then in vogue, and also pointed out the way to the methods which have proved successful and are proving more and more successful as they are used more and more in the early stage of the disease. The cause of the failure of the former methods was found to be due to the ex- tension of carcinoma cells into the parametrium in practically all cases when the patient comes for operation. It follows then logically and has been thoroughly established by extensive experience, that any operation that is to be used with a reasonable hope of success in carcinoma of cervix, must remove this infiltrated parametrium. Any operation in which the line of excision lies close to the uterus, as in the old vaginal and abdominal hysterectomy for cancer, can not be successful except in certain rare cases where the disease is just beginning. Jacobs, in 82 vaginal hysterectomies, saw recurrence in every one. Some series by the old vaginal or abdominal hysterectomy, show a few recoveries, past the five year limit — but they are very few and far between. McMonigle reported 481 hysterectomies for cancer of the uterus, with 479 deaths from recurrence or from the operation. Russel investigated the after condition of 48 cases of vaginal hysterectomy for cancer of the cervix, and found that almost invariably there was recurrence at the site of the scar, and not in the region of the lymphatic glands. Another important point in regard to the operation is that if transplantation METASTASES are to be certainly avoided, the iufiltration-area must not be cut into at any step of the operation — that is, it is not advisable to take out the uterus and then the infiltrated tissues around the uterus, but the whole infiltrated area, including uterus and parametrium, should be removed as one mass, the line of excision being everywhere placed in healthy tissue. When an incision is made through infiltrated tissue, cancer cells are liable to be canied into healthy tissue, TREATMENT OF CARCINOMA OF CERVIX 677 where they maj^ gi'ow. This has happened in several reported cases. Where an incision must be made through infiltrated tissue, it is safer to make it with the (.•auter}'', as that destroys all cells with which it comes in contact. It must be kept in mind also that it is impossible to be certain in any case that the parametrium is not involved, no matter how early the case nor how perfectly normal the parametrium feels. Sampson has demonstrated conclusively that in some cases the carcinoma sends out, by direct growth, very fine prolongations into the parametrium and, in other cases, the carcinoma cells make short excur- sions into the lymph spaces of the parametrium. In such cases, there is no change in the parametrium appreciable to the examining finger. It is evident then that any operation, whether vaginal or abdominal, that does not remove the parametrium, is not admissible as an operation for the cure of car- cinoma of the cervix, except in certain rare cases. Fig. 622. The Essentials for any Radical Operation for Cancer of the Cer\-ix Uteri. The excision of structures as here indicated must be carried out, whether the operation be abdominal or vaginal. (Kelly — Operative Gynecology .) Any operation, whether vaginal or abdominal, that does remove the parametrium, is admissable in that it fulfills one of the essential requirements. Whether the work is done by way of the vagina or by way of the abdomen, is a matter of sec- ondary importance. The essentials of the operation are shown in Fig. 622. One point to be kept in mind is the removal of the uterus and parametrium intact. The broad ligament, including the tubes and ovaries, should of course be removed. It is in the lower part of the broad ligament, however, that the infiltra- tion extends the farthest and that the principal operative difficulties are met with. I prefer the abdominal route as a rule in operating for cancer of the cervix, 678 MALIGNANT DISEASE OF THE UTERUS but I have no serious objection to the vaginal operation when it includes the technique required for the removal of the parametrium. It will hardly be neces- sary for me to take up the advantages and disadvantages of the various opera- tions proposed for this disease. I think it ^^Tll be well, however, to give an idea of what removal of the parametrium means. A brief description of certain points of any one of the really radical operations will do this. One of the best of the abdominal operations is that elaborated b}^ Wertheim. The essential steps are given in the followdng quotation from the report of a case upon which I operated in 1903 .'^ The patient was 33 years of age, the mother of five children and in good general health. The first symptom (some leucorrhoea, with prolonged menstrual flow) xv&s noticed just eight months before the opera- tion. Two months later a blood-streaked intermenstrual discharge began. The bleeding increased, pains and weakness came on and finally the patient, emaciated and weak from loss of blood, consulted Dr. H. H. Meyer, to see if there was any serious trouble. He examined her, made the diagnosis and referred her to me for operation. "Examination revealed a large bleeding mass springing from the cervix and filhng the upper part of the vagina. The mass was the size of a small fist and so obstructed the upper part of the vagina that it was impossible to make a satisfactory examination of the uterus and surrounding tissues. I advised that the patient submit to examination under anesthesia, when the obstructing mass could be cleared away and the extent of the parametria! involvement approximately de- termined. "Under anesthesia it was found, after the projecting tumor-mass had been re- moved, that the whole cervix was involved and that the growth extended a short distance along the anterior vaginal v/all. There was apparently some infiltration of the parametrium, particularly in the left side, but still the uterus was freely movable. "It was a case for radical operation, ^\■ith a fair chance of removing all of the involved tissue. "A few days later I removed the uterus and parametrium by the Wertheim method. The steps in the operation were as follows: "1. After the usual preparation for abdominal section, including saturation of the patient with fluid by giving her all the water she would take in small quantities at short intervals for two days before operation, the patient was anesthetized (ether) and placed in extreme Trendelenburg posture, the body being raised to an angel of almost 45 degi*ees. "2. The abdominal cavity was opened and the incision enlarged until it extended from the umbilicus to just above the pubic joint. The fundus uteri was then seized A\ith a heavy traction forceps and the organ drawn strongly upward and forward. "3. The left side of the abdominal incision was then retracted, the small intestine and the sigmoid flexure were held out of the way and an incision was made in the peritoneum a trifle below the point A\here the left ureter enters the true pelvis. *The Wertheim Operation for Cancer of the Uterus; Report of a Case, by H. S. Crossen, M.D. St. Louis Medical Review, June, 1903. TREATMENT OF CARCINOMA OF CERVIX 679 "The ureter was easily found and the incision in the peritoneum over it was continued down along the course of the ureter to the point where it entered the broad ligament. "4. Then a small silk ligature was passed from this incision around the left ovarian vessels and tied and the ligated structures were cut. The round ligament also was ligated and cut and then the clear peritoneum between the two liga- tures was cut through, thus laying open the broad ligament. The broad ligament was then opened well down toward its lower part and the few bleeding points caught wdth forceps. "5. Steps No. 3 and No. 4 were then carried out on the right side. "6. The peritoneum at the vesico-uterine junction was then cut across and the bladder was separated from the uterus. "7. Then a finger was passed along the right ureter from the point where it en- tered the broad ligament forward until the finger appeared in front of the liga- ment. In this maneuver the little pocket or archway, in which the ureter lies, was distinctly felt and served as a guide as the finger was forced forward. The finger, when through the ligament, had the ureter immediately below and in con- tact with it, while above were the uterine vessels and the parametrium surround- ing them. The opening was then enlarged outward and the end of a ligature carrier was placed on the tip of the finger and as the finger was withdrawn the ligature carrier was made to follow it. The ligature was then tied a little beyond the ureter. When this tissue was cut through, the right ureter could be seen all the way from the pelvic brim to its point of entrance into the bladder. The parametria! tissue lying to the inner side of the ureter and below it, was then dissected away, care being taken not to free the ureter all the way around, as I wished to avoid any interference with its nutrition. "The same procedure was then carried out on the left side. In the left side an enlarged lymphatic gland, the size of a bean, was found close to the uterine artery and somewhat to the outer side of the ureter. The ligature was, of course, placed outside of this gland. "8. The uterus and vagina were then freed from the bladder and rectum and lateral tissues for about one-third of the distance down the vagina, the connective tissue lying beside the cervix and vagina being included in the mass to be removed. "9. An assistant then cleansed the vagina, using first cotton-balls soaked in bichloride solution and then dry gauze repeatedly until the gauze was no longer soiled. Then a small piece of gauze was placed against the cervix and held there. "10. From the abdominal cavity I then compressed the vagina with a right- angled L-forceps, the blades being appiled just below the gauze and well below the lowest point of malignant infiltration. At the other side of the vagina another L-forceps was applied just below the first. Both of these forceps were clamped down hard, thus preventing any fluid from being squeezed past them. "The vagina was then cut across below the forceps, the stump of the vagina being caught temporarily with three or four artery-forceps. The excised mass, with the L-forceps still attached, was removed from the abdomen. Catgut sutures were then applied about the open end of the vagina suflB.cient to stop the hemorrhage and narrow the opening. 680 MALIGNANT DISEASE OF THE UTERUS "11. Search for enlarged glands was then made on each side, first about the iliac vessels and then forward along the pelvic wall to the obturator foramen, but no enlarged glands were found. "12. After all the bleeding in the pelvis had been checked, a narrow strip of gauze w^as laid from each side of the pelvic cavity to the open vagina, the ends extending into the vagina. The peritoneum was closed over the pelvic cavity in the usual way, all raw surfaces being turned down and shut off from contact Av-ith the intestines. The abdominal incision was then closed with tier sutures of catgut and tension sutures of silkworm-gut. "The operation was necessarily lengthy, but the patient stood it well. Conva- lescence was smooth and uneventful. The highest temperature was 100.8, re- corded the second day after operation. " There was no bladder paralysis, such as is sometimes present after this opera- tion. The patient was catheterized for three days. On the fourth day she voided the urine and continued to do so afterward without disturbance. ''Beginning the fifth day, the gauze strips in the vagina and pelvis were pulled out a little each day until about the tenth day, when the remaining portions were taken out entirely. "The specimen removed by operation was submitted to Dr. C. Fisch for micro- scopic examination for the purpose of determining, as far as possible, whether or not the malignant infiltration had extended beyond the line of incision. "Dr. Fisch reported that the growth was an epithelioma and that ' in all places examined the operative separation has taken place in healthy tissue.' "The point at which the cancer approached nearest to the margin of the re- moved mass was in the median line anteriorly, where the bladder was separated from the uterus. "During the operation the bladder separated from the uterus without the least difficulty and there was no indication of involvement of the bladder wall. The enlarged lymph node in the neighborhood of the left ureter showed no cancer ele- ments, but simply a marked hyperplasia. [The patient is now (4 years after the operation) in good health and ^vith no evidence of recurrence.] "As far as I know this is the first complete Wertheim operation for St. Louis. "In 1900 Wertheim made his first report of this operation-method. The results so far obtained have been encouraging, though not enough time has as yet elapsed to count the patients as cured. Last September, at the International Gyne- cological Congress at Rome, Wertheim reported 120 cases in which he had operated by this method. Of the 120 patients, 24 died from the operation. In his first series of thirty cases, it' had been two and a half to four years since operation. Of the eighteen of these who survived operation, five were not heard from, ten were in good health and in only three was there recuiTence. "The object of this operation is wide removal of the parametrium, and the points in the operation which seem particularly advantageous are: "a. Exposure of the ureter at a point where it is easily found, i. e., at the pelvic brim. "b. Incision of the peritoneum from this point, along the ureter to the base of TREATMENT OF CARCINOMA OF CERVIX 681 the broad ligament. This brings nearly all the pelvic portion of the ureter into view and locates accurately its point of entrance into the broad ligament. "c. Introduction of the finger through the base of the broad ligament close along the ureter. This allows the ligature about the uterine vessels to be placed well away from the uterus, outside the ureter, with perfect safety and without the delay incident to catheterization of the ureters. "d. The firm clamping of the vagina below the gi'owth by two L-forceps, one Ijelow the other. This closes the vagina, which is to be cut across, and permits the mass to be removed through the abdomen ^\^thout the possibility of any con- taminating fluid l^eing squeezed from the cervix. "e. All the work is done from the abdomen, largely under the eye and without change of posture, thus doing away with delay from change of posture and the increased danger of sepsis necessarily attendant on the 'combined,' or vagino- abdominal operations. "The contra-indications to this operation are: "1. Obesity. When the patient is very stout, the thick abdominal wall and the pelvic fat interfere with the proper exposure and dissection of the parts. "2. Any serious disease of the heart or lungs or kidneys or other organ that would render the patient probably unable to stand- a long abdominal operation. In some of such cases a vaginal hysterectomy, including, when necessary, Schu- chardt's incision beside the rectum, will give a fair chance of cure \\dthout unduly jeopardizing the patient's life. Much judgment as to choice of operation is re- quired in these cases. A mde removal of tissue, such as we get in the Wertheim operation, is much to be desired. But in a poorly conditioned patient this wide removal of tissue may be purchased too dearly. A fair probability of complete removal and a live patient is better than a greater probability of complete removal and a dead patient. "3. Cancerous infiltration extending beyond the ureters or involving the bladder or rectum. Such cases I do not consider suitable for radical operation. Of course, I am aware that some operators advise operation in these cases and re- move the infiltrated portions of the affected organs (bladder or rectum) . Sampson, of Johns Hopkins University, has adapted the Wertheim operation to these cases by extending the dissection outside the ureter and excising the involved portion of the ureter along with the main tumor. "Such extensive operations are experimental as yet. "I earnestly hope some procedure may be devised that will be efficient in these Bases of immovable uterus. "But until more hope can be held out than is justified by results up to the pres- ent time, I can not advise such a patient to submit to radical operation. "There is, however, one class of patients with uterine cancer and extensive in- filtration, rendering the uterus immovable, in which I urge operation, namely, those patients in which there is a probability or possibility that the parametria! infiltration is not malignant, but simply inflammatory. The broad hgament in- filtration is more likelv to be simply inflammatory if it is situated in the upper part of the ligament, if there is a mass about one or both tubes (salpingitis) and if there Is a long history of inflammatory trouble and a short history of cancer. 682 MALIGNANT DISEASE OF THE UTERUS "4:. Beginning cancer of the body of the uterus. Ordinarily, in such cases, vaginal hysterectomy is preferable, because it is less dangerous, while at the same time permitting removal of all tissue likely to be involved. "The same may probably be said of certain very early cases of cancer of the cervix, though that is still a mooted point. "I wish to thank Dr. F. J. Taussig for assistance in the case reported tonight. Dr. Taussig recently worked with Wertheim and to him I am indebted for the details of the operation as carried out at the present time by that teacher," Wertheim, at the time of his latest report, made during his recent visit to the United States, had operated on 345 patients by this method. Of the patients that survived operation 60 per cent remained free from recurrence at the end of five years (the usual time-limit for counting a cure). The primary mortality of the operation, which in the first 120 cases was 20 per cent, has been reduced to 8 per cent in the last hundred. M Most careful systematic microscopic examination of the parametrium and regional glands was made in all cases. As to the parametrium, in 22.8 per cent of the cases, the parametrium, though "soft and distensible, proved to be cancer- ous. On the other hand, in about 14 per cent of all cases, though there was con- siderable infiltration, no carcinoma was found." As to the regional glands, they were found enlarged and infiltrated with carcinoma cells in 28 per cent of the cases, and enlarged from inflammatory hyperplasia only, in 30 per cent. One distinct advantage of the abdominal operation, is the better opportunity it gives for accurate determination of the extent of the carcinomatous involvement before beginning the operation proper. After the abdomen is open, the pelvis may be thoroughly explored, and the advisability of doing a radical operation determined before beginning the same. In some cases that are apparently well suited for radical operation, this intra- peritoneal examination shows that such an operation would be utterly useless and hat only palliative measures are permissible. On the other hand, in apparently advanced cases, this thorough exposure of the pelvic interior may show that much of the supposed extensive malignant infiltration is only an inflammatory mass or a fibroid or other non-malignant gi'owth, and that radical operation is fully justified. Recurrence after operation. The frequency of recurrence has been mentioned. The facts show that the prognosis must in every case be very guarded, no matter how early or how thorough the operation. A recurrence may be a local recur- rence (in or near the scar of the operation) or lympli-gland recun-ence (in some of the lymph glands in the pelvis or lower abdomen) or a distant metastatic recur- rence (in some organ to which cancer cells have been carried by the blood-stream). A local recurrence is amenable to treatment. The preferable treatment, usually, is thorough and wide excision with the thermo-cautery. As an additional pre- caution, X-ray treatment may be used following the excision. The diagnosis of recun-ence rests on the same symptoms and signs as the diagnosis of the primary growth. Lymph-gland metastasis is not amenable to cautery treatment, but the pain may frequently be considerably relieved by palliative measures, including TREATMENT OF CARCINOMA OF CERVIX 683 X-ray treatment, electricity as applied for the relief of pain, and the general and local measures for diminishing pelvic congestion. The patient should be given morphine or other preparation of opium in sufficient quantities to prevent suffering. Carcinoma Complicating Pregnancy. Pregnancy may take place in a women with beginning carcinoma of the cervix or carcinoma may develop after impregnation. In either case the effect of the pregnancy is to markedlj^ hasten the gi-owth of the cancer. Carcinoma compli- cating pregnancy is rare, being found only three times in a collecti^'e series of 54,833 labor cases. The treatment depends on whether or not the carcinoma is operable. Carcinoma operable. When there is a fair chance of cure by radical operation, that should be earned out at once, "irrespective of the viability of the fetus." Carcinoma inoperable. When the carcinoma of the cervix is inoperable, the life of the child is the thing of principal moment, and the treatment should be palliative and directed toward preserving the life of the mother until the child has advanced far enough to have good chance of independent existence. The details of the treatment and the time to interfere in an operative way must be determined by a careful study of the conditions present and the probable developments in each case. INOPERABLE CASES In the third stage, only palliative measures are permissible. The palliative meas- ures are as follows: 1. Tonics and Stimulants. Give tonics and stimulants as indicated, such as iron, strychnia, etc. Administer sedatives in sufficient c^uantity to give rest — first the milder sedatives (such as bromides and phenacetin) and later mor- phine. The cases usually come to opium in some form sooner or later and, though it should be used only when necessary, it should be used as freely as re- quired to relieve the pain and make the patient as comfortable as possible in her last months of life. Give laxatives as freely as necessary to prevent constipation from the opium. Regular and thorough bowel movements will save the patient much discomfort. Attention to nourishment, as in other wasting diseases is of course imjDortant. 2. Ergot and other uterine astringents lessen the amount of blood in the uterus, and in some cases seem to diminish the swelling and pain and hemorrhage. They are given the same as recommended for bleeding in fibromyoma. 3. Douches. Antiseptic and astringent douches constitute an important part of the palliative treatment. Hot bichloride douches (1-5000) wash away the vagi- nal discharge, diminish decomposition in the vagina and by the heat diminish the pain. These may be given one to four times daily, depending on the amount of discharge. If the odor persists in spite of these douches, lysol may be used (two teaspoonfuls to the quart of water). This is usually very effective in checking the odor, but must be used sufficientl}^ often to keep the vagina approximately clean, for the odor depends on decomposition. Weak formol (1-5000 to 1-2000) 684 MALIGNANT DISEASE OF THE UTERUS makes an excellent douche in these cases. Begin with the weaker solution and advance to the stronger, if it does not cause smarting. If there is a marked hemorrhagic tendency, the astringent douche of alum and zinc sulphate (see Formulse) or a tannic acid douche (see Formulee) is indicated. 4. Applications. On account of the discharge or hemorrhage, strong astringent applications are often needed, such as tannic acid and xeroform (half and half) or liq. ferri subsulphatis. The uterus is exposed T\dth the speculum and the ap- plication made to the affected area. The astringent powders are effective if held in place by a tampon. Iodoform and tannic acid, equal parts, held in place by a tampon, make a splendid astringent dressing for this purpose. When the odor is marked, iodoform and charcoal are useful. By means of the tampon capsules (see page 327), the desired powder may be applied by the patient at home as often as required after a douche. She is directed to fill the top of the capsule with the powder before introducing it. Formol (25% to 50%) applied as a cauterizing and hardening agent to the cancer- ous tissue tends to check the bleeding and foul discharge. Zinc chloride also is an effective cauterant in these cases and has been long used for the purpose. Many other cauterant and hardening agents have been used from time to time with benefit. In the use of all these agents care must be taken to prevent cauterization of the vaginal wall. Of course, these agents are much more effective when used immedi- ately after a thorough curetting-away of the broken-down bleeding tissue. The principal beneficial effect is then due to the curetment. But when the area is curetted under anesthesia I think the best application to make immediately after- ward, is the actual cautery, as explained below. The other applications may be used with l^enefit later. 5. Curetment followed by cauterization of the affected area, constitutes one of the most beneficial of the palliative measures. In some exceptional cases this may be carried out satisfactorily without an anesthetic. Under anesthesia, however, the curetment may be made much more thorough, antl ragged portions of cervix and vagina may be clipped off. The cauterization also with the Paquelin or electric-cautery, is made much more thorough — the walls of the cavity being thoroughly charred for quite a distance below the surface, care being exercised, of course, not to cause deep sloughing toward the liladder or rectum, if adherent. After the baking of the surfaces, the cavity is packed with the iodo- form gauze, and the vagina is packed with the same. The effect of the curet- ment and cauterization under anesthesia is much more marked than without anesthesia. In doubtful ca.ses, where an examination under anesthesia is to be made to determine the advisability of a radical operation, it is well to have the things ready so that if the carcinoma is found to be an inoperable one, palliative curetment may be at once carried out. The improvement from a thorough curetment and cauterization is usually marked. The constant discharge and loss of blood is checked temporarily and tVie patient picks up considerably, sometimes becoming well enough to take up TREATMENT OF CARCINOMA OP CERVIX 685 work formerly dropped. Repeated cauterization, as indicated by the recur- rence of bleeding or foul discliarge, is very beneficial. In some cases the extensive scar tissue formation from repeated cauterization exercises a remark- able inhi])itory effect on the cancer — checking- its growth and, in rare cases, even causing retrogression. At the St. Louis meeting of the American Medical Association (June, 1910) a number of cases were reported in which this apparent retrogression was so marked that the supposed inoperable carcinoma of the cervix became, after repeated cauterization, operable and was then removed by radical operation, with joermanent cure. Wliile such a result is very exceptional, yet the possibility of its occurrence must be kept in mind and should encourage careful and persistent treatment. 6. Curetment followed by acetone applications has given excellent results. It was proposed l)y Dr. G. Gellhorn. It has the distinct advantage that, in suital)le cases, the foul odor and the bleeding may be kept away without the repeated anesth.esia necessary where dependence is placed on curetment and cauterization at intervals. It is applied as follows: With a sharp curet all the broken down tissue is cleared out, leaving a cavity with firm walls. This thorough curetment is best made under general anesthesia. The cavity is sponged clear of blood and debris, and then quickly packed with gauze wrung out of very hot water. This tends to check the oozing and is to be held firmly in place while the patient's hips are elevated to the Trendelenburg posture in preparation for the acetone application. Then the vulva and vaginal walls are coated with vaseline, the hot packing is removed and a tubular speculum large enough to surround the greater part of the raw cavity is introduced and pressed firmly against the cervix. The pure acetone is then poured into the speculum (through a funnel or simply from the bottle) in sufficient quantity to fill the end of the speculum for an inch or so. Keep the acetone thus in contact with the raw surface for thirty minutes. Then the acetone is removed by soaking it up with cotton in forceps or by lowering the table and allowing it to run out of the speculum. After the cavity is dried with cotton, a tampon is introduced through the speculum and held in place as the speculum is with- drawn. This tampon may be left in place for several hours, to absorb any acetone left and thus prevent irritation of the vaginal wall. The coating of the vulvar and vaginal surfaces with vaseline is to prevent irritation by stray drops of the acetone. The acetone application, without curetment, is to be repeated twice weekly until the cavity is well contracted, and after that occasionally as needed to prevent bleeding and odor. The application may last 30 to 45 minutes — the longer the better as a rule. • The speculum is to be held in place all this time. Usually the patient can steady the speculum in place after having been shoM^n how to do so. 7. Partial or complete vaginal hysterectomy as a palliative measure is of service in suitable cases. By this means a large part of the cancerous mass is removed, the discharge and hemorrhage are checked, pressure in the pelvis is relieved and the patient is made more comfortable for several months and sometimes longer. ggg MALIGNANT DISEASE OF THE UTERUS Partial extirpation by the cautery, after the method of Byrne, is the prefer- able plan usually. A large part of the cervix, with as much of the body as seems advisable, is extirpated by the cautery and the remaining surfaces are thoroughly baked. The effect of the heat seems to have some influence extend- ing a considerable distance beyond the cauterized tissues, as indicated by the long freedom from recurrence on the cauterized surface, though the deeper portions of the infiltration may continue to grow. When applied thoroughly in a way to secure satisfactory results, amputation is almost as formidable an operation as vaginal hysterectomy and should be used only when every- thing is at hand to meet the dangers and difficulties that may arise. 8. Ligation of the ovarian arteries and other easily accessible arteries sup- plying the region of the tumor, together with the removal of the adnexa, may be made use of in some cases. For example, where there has been an explor- atory abdominal section and the carcinoma is found inoperable, the vessels mentioned may be ligated to diminish the blood supply and retard the growth. The effect as a rule is not very marked. Kosler reports several cases treated by ligation. There was some temporary improvement, but the hemorrhage returned in a short time. 9. X-Ray Treatment. This relieves the pain and bleeding in some cases, but the high claims as to curative results in cases of carcinoma of the cervix have not been sustained. It may be used as a palliative measure in inoperable cases, but even then it is not likely to produce as good results as a partial excision of the uterus by cautery or even as a thorough curetment and cauterization of the cavity. It is still on trial, its exact status as a palliative measure hav- ing not yet been thoroughly established. The effect of the Finsen Light seems to be less than that of the X-Ray. The effect of Radium treatment is practically nil. 10. Interstitial Injections. Injections of various substances into the cancer- ous mass to cause sloughing is sometimes used with benefit. It is an uncertain method, however, and it is very questionable if as much can be accomplished as by a thorough curetment and cauterization. The same may be said of various substances used for the dissolving of fungus cancerous tissue. 11. Toxins. Much work has been done with the idea of developing a toxin or antitoxin or serum that would check the growth of malignant tumors, but so far nothing satisfactory has been created. Coley's toxin (made from a culture of the streptococcus and the bacillus prodigious) has produced occa- sional beneficial effects, principally in sarcoma. But the results in carcinoma have not been such as make its use Avorth wbile. Doyen's cancer serum proved a failure. It is to be hoped that the present wave of investigation into the causes of malignant disease will produce something of real value. CARCINOMA OF THE CORPUS UTERI. Adeno-carcinoma is the variety usually found here. It begins in the endo- metrium, consequently the tumor tissue is accessible to the curet at a very early stage. The growth is for a long time confined to the tissues imme- CARCINOMA OF THE CORPUS UTERI 687 diately about the uterine cavity, the extension to the periuterine tissue being slow usually in carcinoma of Ihe corpus uteri — hence the chance of cure is Fig. 623. Beginning Carcinoma of the Corpus Uteri. There is no external sign of the growth at this stage, except an occasional streak of blood in the leucorrhoeal discharge. The diagnosis must be made by curetment. (Cullen — Cancer of the Uterus.) Fig. 624. Adeno-carcinoma of the Corpus Uteri in an advanced stage. (Ciillen — Cancer of the Uterus.-) 688 MALIGNANT DISEASE OF THE UTERUS much better. Cancers of the corpus uteri constitute a distinct class, having a better prognosis than cancer of the cervix uteri, and requiring as a rule less extensive operative treatment. A carcinoma of the corpus uteri, still in an early stage, is shown in Fig. 623, and one far advanced is shown in Fig. 624. Chorio-epithelioma is a peculiar form of carcinoma arising from the fetal cells covering the chronic villi. A striking feature is the early penetration of blood-vessels, with resulting metastases to distant organs, which makes it an exceedingly fatal growth, even when removed comparatively early. Care should be taken to exclude it whenever there is persistent bleeding coming on some weeks or months after confinement or miscarriage. It is especially liable to occur following hydatidiform mole. Such was the history of the specimen shown in Fig. 625. This patient was brought to me some months after the Fig. 62.5. A Chorio-epithelioma of the Uterus. The uterus, which is about one-half larger than normal, has been opened from the posterior surface and spread out. Projecting from the endometrial surface on the right side near the fundus is a nodule which has been incised. It is the size of a walnut and extends into the waU almost to the peritoneum. Sections from this nodule show the characteristic structure of chorio-epi- thelioma. The fact that in chorio-epithelioma there is early erosion of the blood vessels and early metastasis to distant organs should in nowi.se discourage operation in this class of tumors, but should simply stimulate us to greater endeavor to make the diagnosis at the earliest possible moment. This patient was heard from more than five years after the operation, and was still well and with no evidence of recurrence. expulsion of a large hydatidiform mole. The immediate cause of the consul- tation was repeated uterine hemorrhage, difficult to control. Curettage gave tissue that showed malignant disease of the -corpus uteri. I then did a hysterectomy, and sectioning of the removed uterus showed a typical chorio- epithelioma. Malignant adenoma and endothelioma are rare forms of malignant disease, which do not require special description here. SARCOMA OF THE UTERUS 6g9 Symptoms, Diagnosis, Treatment. The symptoms and diagnosis are much the same as for carcinoma of the cervix, and are presented in detail on pages 670 to 672. In the early stage a positive diagnosis can ])e made only by curettage and microscopic examination of the curettings. Chronic endometritis, particularly that associated with senile changes, is the affection with which it is most likely to be confounded. A very practical question is, "In what cases is it advisable to do curettage in order to exclude malignant disease of corpus uteri?" In all cases in which llie bloody uterine discharge persists in spite of treatment for endometritis. AVhen a patient, near the menopause, comes complaining of irregular men- struation or irregular bloody discharge, and examination shows no trouble Avith the cervix, no uterine fibroid and no periuterine disease, I assume that the bleeding is due either to chronic endometritis or to beginning malignant disease of the endometrium. If the cervix is somewhat open, I try, in the office examination, to secure some tissue from within the uterus. If this is not practical and the probabilities are in favor of endometritis, I put the patient on the ergotin capsule (see Formulae) and watch for two or three weeks. If the bloody discharge ceases, that points to endometritis and the treatment is continued. If the bloody discharge persists or if it returns after cessation, tlien I insist on curettage. In such a case, if tissue showing positive evidence of malignancy can be secured in the office examination, it obviates double anesthesia. On the other hand, malignant disease ordinarily can not be ex- cluded except by a thorough curettage under anesthesia, which means sys- tematic removal of endometrial tissue from all parts of the uterine cavity. Another important point is that all the curettings must be preserved and sub- jected to the microscopic examination. For points in regard to collecting and transmitting curettings see page 96. The treatment for carcinoma of the corpus uteri is complete hysterectomy at once. When the disease is discovered early, ordinary hysterectomy, either abdominal or vaginal, will practically always suffice to remove all involved tissue. In the advanced cases removal of more or less of the parametrium and other periuterine tissues is required. SARCOMA OF THE UTERUS. A sarcoma is a malignant growth arising from connective tissue or con- nective tissue derivatives. The cause of sarcoma, like that of carcinoma, is not known. About the same theories have been brought forward to account for it. Sarcoma differs from carcinoma in that it may occur at any age (though more frequent from the age of 40 to 60), and furthermore it is not especially asso- ciated with child-bearing. Sarcoma may appear as a general infiltration of the endometrium or as a distinct tumor. By edematous change, grape-like masses may form, either in sarcoma of the cervix (Fig. 311) or in sarcoma of the body of uterus. The sarcomata beginning in the endometrium are generally of the round-cell 690 MALIGNANT DISEASE OF THE UTERUS variety. Sarcomata of tlie muscular part of the uterine wall usually come from sarcomatous degeneration of jEibromyomata. The sarcomata grow rapidly or slowly, depending on the character of the particular tumor. They infiltrate adjacent tissues like the carcinomata and cause death in about the same time. Fig. 626. Beginning Sarcoma of the Corpus Uteri. At this stage there is no external evidence, except blood streaks in the discharge. Tlie diagnosis must be made by curetment. (Kelly — Operative Gynecology.) The symptoms, diagnosis and treatment of sarcoma of the uterus are prac- tically the same as for carcinoma. A beginning sarcoma is shown in Fig. 626, and one more advanced in Fig 627. It sometimes occurs in children. Occa- Fig. 627. Advanced Sarcoma of the Corpus Uteri. (KeUy^Ojxnitivr Gi/necologij.) sionally it appears in the form of a grajx^-lih'e mass attached io the cervix, as shown in Fig. IHl. A ix'diculated safcoiua, jii'ojecting into the vagina is shown in Fig. .110. A sarcoma originating in a tibi-oid is shown in Figs. 613 and 614. 691 CHAPTER X. PELVIC INFLAMMATION. Pelvic inflammation is the term applied to inflammation in tlie pelvis outside the uterus. The inflammatory process may be located in the Fallopian tubes, in Avliich case it is called "salpingitis," or it may be in the ovary, in which case it is called "oophoritis," or in the peritoneum, where it is known as "pelvic peritonitis," or it may be in the connective tissue, where it constitutes "pelvic cellulitis." The cause of these various forms of inflammation is the same — viz., infection — the symptoms are much the same, the treatment is in many respects the same, and two or three of the lesions are usually associated — in some cases so intimately associated that it is difficult to determine which is the most important. Consequently, from a practical standpoint, it is best to consider all these lesions together under the one comprehensive term "pelvic inflammation." Before taking up the disease proper, I wish to call attention to some points in the anatomy of the structures involved. POINTS IN ANATOMY Of Fallopian Tubes, Pelvic Peritoneum, Pelvic Connective Tissue. FALLOPIAN TUBES. The Fallopian tubes, or oviducts, are two small muscular tubes, one on either side, which extend from the fundus uteri outward in the upper part of the broad ligament toward the pelvic wall (Figs. 4, 5). Each tube has a small central cavity extending its whole length (Fig. 531). The inner end of this cavity communicates with the uterine cavity and the outer end opens into the peritoneal cavity. Thus there is a direct opening from the outside of the body into the great peritoneal sac, through the vagina, uterus and Fal- lopian tubes (Fig. 628). This is why infection of the genital tract in a Avoman leads to peritonitis so much more frequently than infection of the genital tract in a man— the infection in the vagina simply extending along this mucous tract directly into the peritoneal cavity. The tubes vary considerably in size and somewhat in shape in different individuals. The length of each tube is three to five inches and the direction is outward, backward, downward and inward — somewhat resembling a shep- herd's crook and partly surrounding the ovary (Fig. 4). That portion of the tube lying in tlie uterine wall is knoAvn as the interstitial portion or uterine portion. It has a very narrow lumen (Fig. 531). That portion of the tube extending from the margin of the uterus to the beginning 692 PELVIC INFLAMMATION of the curve is called isthmus. It is about the diameter of a slate pencil and is firm. The lumen is small, but becomes gradually larger toward the outer end. The outer curved dilated portion of the tube is known as the ampulla. It is about the size of a lead pencil and the lumen also is much larger than that of the isthmus (Fig. 531). The outer end of the tube is kno^vn as the = o sa*i Fig. 628. A Diagrammatic Section of tlie Cenital Canal. Notice the continuous opening from the ^•ulva through the vagina, uterus and Fallopian tube.s to the peritoneal cavity. This is the rea.son genital infection extends to the peritoneal cavitj' so much more frequently in women than in men. (Waldeyer — Dns Bccken.) fimbriated extremity or the infundibulum. This consists of a funnel-shaped expansion surrounded by a fringe of slender, finger-like processes called "fimbriae." One of these extends to the ovary and is attached there and is called the "ovarian fimliria. " In structure the wall of the tube is largely muscular, resembling the uterus. POINTS IN ANATOMY 693 In fact it is derived from the same fetal organ as the uterus (Fig. 704). The tube lies beneath tlie peritoneum of the upper margin of the broad ligament and its wall presents three layers — peritoneal, muscular and mucous. The peritoneal layer does not differ materially from peritoneum elsewhere. It is composed of fiat endothelial cells lying on a basis of firm connective tissue. Immediately beneath the peritoneum is a layer of connective tissue sometimes called the subperitoneal layer. In this run blood vessels and lym- phatics. The interstitial portion of the tube has, of course, no peritoneal layer, as the muscular tissue of the tube is in immediate contact with the muscular tissue of the Avail of the uterus. The muscular layer of the tube is composed of involuntary muscular tissue, disposed in two strata, an outer longitudinal and an inner circular. Both these strata are continuous, with similar muscular strata in the uterus. The internal stratum sends prolongations of muscular tissue into the four principal folds of the mucosa. The muscular layer is thinner at the abdominal end than at the uterine portion of the tube. The increased thickness of the wall at the abdominal end of the tube is due to the many folds of mucosa. The mucous layer of the tube, like the uterine mucosa, is placed directly upon the muscular layer — there is no intervening submucosa. The surface of the mucous membrane is formed of a layer of ciliated cylindrical cells. The cells are somewhat taller than those lining the body of the uterus and not so tall as those lining the cervix uteri. Beneath the epithelial layer the mucosa is composed of "stroma cells," very much like those found in the uterus, except slightly smaller. Between the stroma-cells is a delicate con- nective-tissue framework. There are found also capillary blood vessels and small lymph channels. There are no glands in the tubal mucous membrane. The depressions which look like glands are due simply to the folds of the mucous membrane. As there are no glands in the tube, there can be no mucus secretion, such as takes place in the uterus. The fluid by which the tube is distended in certain pathological conditions is inflammatory exudate and not glandular secretion. The mucous membrane is much folded longitudinally (Fig. 531). There are four principal folds into which prolongations of the muscular tissue take place. There is no muscular tissue in the many smaller folds. In the interstitial por- tion and in the isthmus the folds are few and simply longitudinal (Fig. 629), but in the outer portion of the tube (the ampulla) they become very complex and fill the tube with folds extending in every direction (Fig. 630) — so much so that it is sometimes difficult to decide which is the main canal of the tube. The cilia of the epithelium project into the lumen of the tube and by their movement toward the uterus aid the passage of the ovum in that direction. In the presence of this delicate and much-folded mucous membrane, inflam- mation in the tube quickly causes serious changes. The cilia are lost, the folds become adherent, pockets of serum or pus form, and the picture of the tubal interior may be so changed as to be hardly recognizable. Vessels and Nerves. The blood supply of the tube comes from the ovarian 694 PELVIC INFLAMMATION arterr tlirougli several small brandies. The uterine artery helps to supply the tube in some cases. The veins open into the pampiniform or ovarian Fig. 629. Cross Section of a Normal Fallopian Tube, near the Uterine End. (Penrose, after Beyea — Dis- eases of Women.) plexus and pass into the broad ligament. The lymphatics join with those from the ovary. The nerve supply comes from the pelvic plexus of each side. Fig. 630. Cros.s Section of .the Fallopian Tube, near the Fimhri;tte>l Extremity. (Penrose, after Bevea — Diseases of Women.) POINTS IN ANATOMY 695 Physiology. The primary rimction of the Fallopian tube of each side is to convey ova from the corresponding ovary to tlie utenis. It is supposed to require several days for the ovum to ]);iss the leiij^th of the tube. In addition to this, the tidie conveys speriiuitozoa in the opposite direction, and it is usually in the tube that the union of the ovum and the spermatozoon takes place. The mechanism by which the ovum is carried from the ovary into the tube is complicated. After the Graafian follicle in the ovary l)ursts, the liquor fol- lictdi causes the ovum to adiiere slif,ditly to th<; surface of tin; ovary. Some of the fimbriae are in contact with the surface of the ovary and, when an ovum comes in contact with one of them, tlu; cilia carry it towards the entrance of the tube. Besides this action of the cilia directly on the ovum, the constant movement of all the cilia causes a slight current of peritoneal fluid toward the interior of the tube from all directions. This helps to carry the ovum or any other small particles into the tube. The fact that there is such a cur- rent towards the interior of the tube has been demonstrated by the injection into the pelvic peritoneal cavity of animals of numerous small insoluble par- ticles, which were found later in the tubes. It has been suggested that the fimbriated extremity of the tube grasps the ovary when an ovum is discharged, but this has not been proven. Normal Changes in the Tube. In studying the anatomy of the uterus it was found that that organ, particu- larly the mucosa, was subject to normal changes under three conditions — namely, menstruation, pregnancy and the menopause. Now, in the Fallopian tube also, we find normal changes, due to menstruation, to pregnancy and to the menopause. Speaking generally, it may be said that these changes are like those occurring in the uterus, but less marked. During menstruation there is congestion of the tube and possibly a slight effusion of blood into the interior of the tube. If this does take place, how- ever, it is slight and is of no importance when considering the source of the menstrual blood. Practically all of tlie menstrual blood comes from the uterus. In a case of removal of the uterus by operation and the fastening of one of the tubes in the vaginal incision, a slight bloody flow was noticed at the menstrual periods for a few months. But such tubes are pathologic, and it is an open question whether or not a bloody flow Avould take place from a normal tube. In pregnancy (normal pregnancy, not tubal pregnancy) the tube wall and mucous membrane become thickened and the folds enlarged. The vessels also become larger, especially the veins and lympliatics. After confinement the tube undergoes involution along with the uterus. After the menopause the tube shows certain senile changes. There is dis- appearance of the cilia, diminution in the size of the tube, shrinking of the connective tissue and shrinking of the mucosal folds. The tube becomes smaller and firmer, and is no longer a functionating structure. 696 PELVIC INFLAMMATION PELVIC PERITONEUM. The pehdc peritoneum is that portion of the wall of the peritoneal sac which lies in the peMs. It is attached more or less closely to the pelvic organs and its free surface comes in contact with the peritoneal surface of the intestines as they move about in the lower abdomen. To get an idea of the distribution of the peritoneum in the pelvis, imagine a piece of thin cloth laid over the pelvic organs and tucked down firmly around them (Fig. 550 j. Starting from the abdominal wall, the peritoneum passes onto the bladder^ and from the posterior surface of the bladder to the uterus (Fig. 3). The height of the abdomino-vesical fold of peritoneum varies much Avith the vary- ing size of the bladder, which fact is of much importance in surgical work. The distance to which the peritoneum extends do^vn the anterior surface of the uterus varies considerably in different persons. Usually it extends to the level of the internal os and is about an inch above the anterior vaginal fornix. When the bladder is distended, the peritoneum is drawn upward somewhat. This vesico-uterine fold of peritoneum forms the two so-called "vesico-uterine ligaments."' The peritoneum then folds over the uterus and tubes and round ligaments, covering these structures and forming the ''broad ligament" of each side. All the posterior surface of the uterus is covered with peritoneum, except that portion lying ^\dthin the vagina. The fold of peritoneum extends a consider^ able distance below the point of attachment of the vagina to the uterus (Fig. 3) before being reflected on to the rectum. The deep pouch of peri- toneum thus formed is called the ''cul-de-sac of Douglas" (Fig. 4). It is known also as the "posterior cul-de-sac" and as the "posterior peritoneal pouch" and as the "recto-uterine pouch." This posterior cul-de-sac is very important surgically. A collection of exudate or a tumor in this situation can be easily felt from the posterior vaginal fornix. This is the point of incision in posterior vaginal section, and it is usually the first place that the peritoneal canity is entered in vaginal hysterectomy. The peritoneum, as it is reflected from the uterus to the rectum, helps to form the "sacro-uterine ligaments." The sacro-uterine ligaments, two in number, one on each side, extend backward from the lower part of the uterus aroimd the rectum to the sacrum. They are composed of connective tissue, a few muscular fibers and peritoneum. The cul-de-sac of Douglas dips down between them for a considerable distance (Fig. 4). The expanse of peri- toneum extending from the sacro-iliac ligament to the broad ligament of eacli side forms a kind of shelf. The two together are sometimes called the "recto- uterine shelves." Tliere is also a fold or shallow poiich of peritoneum on eacli side between the Fallopian tube and the round ligament. A small portion of the uterus at the sides and in front is not covered with peritoneum (Fig. 539). The structure of the pelvic peritoneum is much the same as of peritoneum elsewhere. It is a very thin and smooth membrane, formed of a basis of delicate fibrous and elastic tissue, supporting large endothelial cells. I POINTS IN ANATOMY 697 PELVIC CONNECTIVE TISSUE. Between the peritoneum and the reeto-vesical fascia there is connective tissue. This is distributed so as to fill in all the spaces (Figs. 539, 631). AVhen it is necessary for organs to change their relation to each other in physiological activity, the connection is open and loose so as to permit free movement and much stretching. The principal collections of connective tissue are at the sides of and in front of the cervix uteri and at the base of each broad ligament. The areas of connective tissue are exceedingly rich in lym- Fig. 631. The Connective Tissue of the Pehis. Left side of pehis — section through cervix, showing the large area of connective tissue at side of ce^^ix. Pught side — section at higher level, showing how the broad ligament becomes thinned, lea^-ing only a small amount of connective tissue at side of corpus uteri. phatics and veins. Inflammation taking place in the connective tissue is called "pelvic cellulitis." The connective tissue about the uterus is often spoken of collectively as the "parametrium" of parametrial tissue, and inflammation of the same is accordingly called "parametritis." This is a very convenient term, but is likely to be confounded with the similarly sounding word "perimetritis." The latter means inflammation of the structures about the uterus, particularly, however, of the peritoneum and adnexa. In writing, these two terms may be 698 ACUTE PELVIC INFLAMMATION safely used, but in conversation they are very liable to be confounded, as they sound so much alike. It was formerly supposed that nearly all inflammation in the pelvis outside the uterus was inflammation of the connective tissue (i. e., pelvic cellulitis), but it has been found that in the majority of cases the inflammation invades first the tube and later the peritoneum, and that usually the involvement of the connective tissue, if present at all, is a late development and of only secondary importance. There are exceptions to this rule — for example, those inflammatory conditions resulting from tears of the cervix or from operation on the cervix. Also in puerperal infections, particularly streptococcic, the inflammation very frequently extends directly through the wall of the uterus in the pelvic connective tissue. ACUTE PELVIC INFLAMMATION. Coming now to the consideration of tlie disease itself, we find that pelvic inflammation may be acute or chronic. Let us consider first the acute variety- The inflammatory process may be in the Fallopian tubes (salpingitis), or in the ovaries (oophoritis), or in the peritoneum (pelvic peritonitis), or in the connective tissue (pelvic cellulitis). ETIOLOGY. The cause of acute pelvic inflammation is infection. The infection may be with the ordinary pus germs (staphylococcus and streptococcus) or with the gonococcus. Practically every case of primary acute pelvic inflammation in the adult can be traced to infection from labor, from abortion, from instru- mentation or from gonorrhoea. Secondary inflammation of the genital organs may be caused by extension from an inflammatory focus in some adjacent organ — e. g., the appendix or the bladder. In a large proportion of the cases of pelvic inflammation, particularly the gonorrhoeal cases, the infection extends by way of the uterine mucosa to the Fallopian tubes, and through the tubes to the peritoneum and other pelvic structures. In puerperal metritis (streptococcic or staphylococcic) the infec- tion more often extends by Avay of the lymphatics directly through the wall of the uterus, from tlie endometrium to the connective tissue around the uterus, and to the peritoneum. Another avenue of entrance is through the thrombosed sinuses of the puerperal uterus. Infection of these sinuses leads to infective thrombosis of the broad-ligament veins, resulting in broad-liga- ment abscess or .general pyaemia or both. The fact that nearly every case of pelvic inflammation is due to an infected endometritis emphasizes the importance of checking endometritis at once when present and of preventing it whenever possible. PATHOLOGY g99 PATHOLOGY. The pathological changes are varied. There are hardly two cases exactly alike and the same case presents a very different picture at diiferent periods. However, the cases may be divided somewhat into classes, as foUoAvs : 1. Mild Salpingitis. The inflammation is very slight. There is some round cell intiltratiou of the wall of the tube, Avith slight thickening and hardening, and a few^ fimbriae bound together. Both ends of the tube are open. This is Ihe miklest form of pelvic inflammation, and as a rule gives rise to very few sym[)loms. A more severe type of the same class is that in which both ends of the tube are occluded and the flmbriae are matted together, and the tube distorted and often adherent to the ovary or to some other structure. Tlie Avail of the tube is thickened, but the cavity contains no appreciable amount of fluid. 2. Salpingitis with Exudate. In the cases of this class there is a large amount of exudate, binding together the tubes, ovaries, intestines and uterus. But there is no distinct collection of pus. 3. Pyosalpinx (Tubal Abscess). The tube is distended with pus (Fig. 416) and there are the usual evidences of inflammation within and without the tube, but no pus outside the tube. There may or may not be a large mass of exudate. In exceptional cases the infection may localize in the ovary instead of in the tube, causing an ovarian abscess. In still other cases the abscess caAdty involves both the tube and the ovary, forming the tubo-ovarian abscess. 4. Diffuse Suppuration in Pelvis. In this fourth class the pus itself has extended outside the tube, the fibrinous exudate always extending before it and shutting it off from the general peritoneal cavity. This may result simply in an abscess low in the pelAds, which can be easily reached and CA^acuated from below, or the inflammation may extend until all the pelvic organs are bound together in an irregular mass, with pus lying in the spaces betAveen them and burroAving into the connective tissue. In such a case there are present all the lesions of pelvic inflammation — salpingitis, oophoritis, peri- tonitis and cellulitis. 5. Acute Diffuse Peritonitis. In cases of this class the infection is so viru- lent and spreads so rapidly that but little limiting exudate is formed. The infection quickly involves the general peritoneal cavity and causes a fatal peritonitis. This is an unusual form of pelvic inflammation and is found principally in cases of severe sepsis folloAving labor or abortion. 6. Cellulitis (Fig. 386). This is largely a lymphangitis of the connective tissue about the uterus. It is due usually to the streptococcus, the staphylo- coccus or the colon bacillus — rarely, if ever, to the gonococcus alone. Cellu- litis is favored by deep laceration of the cervix, AA^hieh opens up the con- nective area beside the uterus. Pehdc cellulitis, like inflammation of con- nective tissue elsewhere, may end in resolution or abscess formation or gen- eral sepsis. If resolution takes place or if an abscess forms and is opened, ihe inflammation subsides, leaAing only infiltration and scar tissue, Avhich 700 ACUTE PELVIC INFLAMMATION causes but few symptoms aside from distortion of the parts. The inflamma- tion may, however, extend to the peritoneum, in which cases there are added the evidences of pelvic peritonitis. Fig. 632. PehicThrombo-phlebitis. The left broad liRainent has been laid open, and thesiteof the upper and lower group of thrombosed veins indicated. The right ovarian vein is shown thrombosed almost to its termination in the vena cava. 7. Septic Thrombosis (Fig. 632). This comes from infection of the normal thrombi tilling the uterine sinuses after labor. It constitutes a severe and SYMPTOMS 701 often fatal funu of puerperal sepsis. In tlie effort to limit the infective and destructive process in the sinus or vein, nature causes another thrombus to form proximal to the infected one. If the infection extends into the new thrombus, a portion of the vein proximal to that in turn becomes thrombosed. This process may keep on until the veins of the broad ligament become exten- sively throm])osed. If the infection enters through the upper part of the uterus (the usual placenta! site), it affects the ovarian veins in the upper part of the broad ligament (Fig. 632, left side). If it enters through the lower portions of the uterus, the resulting septic thrombosis affects the uterine veins lower in the broad ligament (Pig. 632). If nature succeeds in limiting the process to this region, pockets of pus may form in the thrombosed veins and break into the connective tissue, form- ing a pelvic abscess, which can be recognized and opened. If nature does not succeed in limiting the process, it extends centrally — along the ovarian veins (Fig. 632) toward the vena cava, or along the lower veins to the internal iliac, the common iliac and finally to the vena cava. When the common iliac is involved, the process extends downward also along the external iliac vein, pro- ducing the usual signs of external iliac thrombosis (so-called "milk leg"). It must be kept in mind, however, that external iliac thrombosis may or may not be septic thrombosis, many cases occurring without any evidence of sepsis. At any stage of the septic process in the veins, infected particles may become detached and pass into the general circulation, giving rise to metastatic foci in various parts of the body, and constituting general pyaemia. SYMPTOMS. A patient with acute pelvic inflammation complains of pain in the lower abdomen, increased by movements, such as walking or turning over or sitting up. She is usually confined to bed. There may be moderate fever (101° to 103°) or there may be high fever (105°), the high temperature being found most frequently in pelvic inflamm.ation following labor or miscarriage. There is usually a vaginal discharge, due to the coincident inflammation of the endometrium, and there is a history of a recent labor or abortion, or instru- mentation or gonorrhoea, or a history of a chronic endometritis due to one of these causes. On abdominal examination the lower abdomen is found to be tender on pressure. This tenderness may be confined to one or both tubal regions or it may extend over all the lower abdomen. On account of this tenderness the abdominal muscles are held more or less tense, thus preventing deep palpation. In the vaginal examination the character of the discharge is determined, indicating to some extent the etiology of the trouble, and there is noticed also the presence or absence of evidences of recent labor or miscarriage. iManipu- lations in the upper part of the vagina cause pain. This tenderness on vaginal palpation and bimanual palpation is found both in the body of the uterus and about the tube of one or both sides. If a mass of exudate is present, it may be felt to one side of the uterus or behind it. If the exudate is low in the 702 ACUTE PELVIC INFLAMMATION pelvis — for example, in the posterior cul-de-sac or about a prolapsed ovary or tube — it may be easily felt back of the uterus just above the posterior vaginal formix. If the exudate is situated high in the pelvis, it may require very deep bimanual palpation to detect it, and the deep bimanual palpation may be im- possible at first on account of the tension of the abdominal muscles. The mass of exudate is distinguished hy its being more resistant (firmer) than the sur- rounding tissues and more tender on pressure. The exudate may extend all around the uterus, fixing that organ as though plaster of Paris had been poured into the pehds and had hardened there. In these cases of extensive distribution of the exudate the sensation imparted to the examining fingers is that of a firm roof across the pelvis just above the vagina (Fig. 401). The uterus projects through this roof of exudate and is held firmly by it. If there is a collection of pus of considerable size, fluctuation may be de- tected, the soft area being surrounded by a firm area of exudate which has not yet broken down. If there is only a small collection of pus, not large, enough to give fluctuation, its presence is indicated by persistent fever and its location is shown by a point of marked tenderness. When there is an in- flammatory exudate in the posterior cul-de-sac, fluctuation may in some cases be detected earlier by rectal than by vaginal examination, the rectal finger being able to palpate the posterior surface of the mass. In septic thrombosis without other involvement and in puerperal pyaemia there may be no evidence of pelvic peritonitis nor of pelvic cellulitis — simply repeated chills and high fever without any palpable local lesion of sufficient extent to accoumt for them. There is tenderness in the region of the veins affected, and in some cases distinct induration may be made out, particularly where there is more or less peri-venous inflammation. If the infection has come through the upper part of the uterus (which is the usual location of the placental site and hence of the area of penetration), the ovarian veins are the ones most likely to be aft'ected. In many cases they alone have been found involved (Fig. 632, right side). When the infection penetrates the lower part of the uterus, the uterine veins and broad-ligament veins generally become affected, and later the internal and common iliac veins. DIAGNOSIS. The disease that may l)e confused witli acute pelvic inflammation and that must therefore be taken into consideration in the differential diagnosis are as follows : Acute endometritis. . Tubal pregnancy. Appendicitis. A tumor which has become gangrenous from twisted pedicle. A suppurating tumor (usually a dermoid cyst or a necrotic fibroid). In acute endometritis the bimanual examination shows that the tenderness is limited to the uterus. There is no marked tenderness in the peri-uterine structures, nor is any mass found there. DIPFERENTIAI, DIACNOSI.S 703 Tubal pregnancy has hern so many limes mistaken for ui-clinary peh'ie in- flammation that the differential diagnostic points shonkl be considered in detail (see Tul)al Pregnancy). In appendicitis the pain is more likely to start as a general abdominal pain, the point of greatest tenderness and the inflammatory mass, if there is one, being in the appendix region instead of in the tubal region. In appendicitis also there is frequently a history of stomach or bowel disturbance preceding or associated with the attack of pain, while in salpingitis there is usually a history of uterine disturbance — dysmenorrhea, prolonged menstruation, vagi- nal discharge and other indications of a previous or coincident uterine dis- ease. In girls and in unmarried women an attack of inflammation low in the right side is much more likely to be appendicitis than salpingitis. In some patients both structures are involved. In all right-sided inflammations keep in mind appendicitis. One having his mind too intent on pelvic disease may overlook this. This fact is very well illustrated by a case in which I was called in consultation by a physician in this city. A few days before, the physician had operated for laceration of the cer^dx. Following the operation the patient developed pain in the lower abdo- men and rapid pulse, and nausea and fever. The symptoms were persistent and progressive, and in three days the patient's condition became alarming. Fearing acute pelvic inflammation from infection at the site of operation, he asked me to see the patient. Examination showed the cervical wound to be in good condition and I could find nothing in the immediate vicinity of the uterus to account for the serious symptoms. But on searching further I found the patient had appendicitis, with peritonitis. The vomiting and intra-abdomi- nal disturbance following anesthesia had evidently stirred to renewed activity an old focus of inflammation about the appendix. The patient had general peritonitis at the time I saw her and she died before the consent of her people to an operation could be secured. In the case of a tumor which is gang'renous from twisted pedicle, the tumor has existed a long time, and one can usually get a history of pelvic disturbance caused by it, and in some cases a clear history of a tumor can be obtained. When the turning of the tumor with torsion of its pedicle takes place, that causes a sudden onset of serious symptoms — severe pain, extending more or less throughout the abdomen, and symptoms of shock. Later, as the tumor begins to degenerate on account of the cessation of its blood supply, local peritonitis comes on, causing fever. The local peritonitis may spread and be- come general peritonitis, and at this stage the origin of the trouble is much obscured. Absence of evidence of infected endometritis is another important point in the differential diagnosis of this condition from ordinary pelvic in- flammation, as is also the absence of fever at the onset of the trouble and for several hours afterward. A suppurating- tumor is usually a dermoid cyst, connected with the ovary, and lienr-e gives rise to a mass in the same region in which an inflammatory mass from salpingitis would be found. When suppuration takes place in an 704 ACUTE PELVIC INFLAMMATION ». -^ 1 u1 most of the cases of well-marked cellulitis are due to extension of infeetion directly from the uterus into this region. Etiology. Chronic cellulitis is due to a preceding acute cellulitis and conseciuently has the same causative factors. It is usually due to infeetion following labor Fig. 651. Double Hydrosalpinx. The .sectioned right tube indicate.s clearlj' the marked thinning of the wall found in these case.s. or miscarriage, the bacteria passing directly through the wall of the uterus into the connective tissue or through tears of the cervix. In other cases it can be traced to operation on the cervix, to operation within the uterus, to instrumental examination of the interior of the uterus, or to attempts at 736 CHRONIC PELVIC INFLAMMATION abortion. Cellulitis alone (without tubal involvement) is usually due to the streptococcus, staphylococcus or colon bacillus — practically never to the gon- Fig. 652. Nodular Salpingitis. Tliis form of chronic salpingitis is usually bilateral, and is often accom- panied by prolapse of the tube or o-\ary on one or both sides. Fig. G53. Multiple Adhesions from Chronic Pelvic Inflammation. This illustration represents a posterior view of the pehac organs, with the intestinal coils pushed upward and to the sides to show the numerous ad- besions. CHRONIC PARAMETRITIS 737 ococcus. This point is further discussed under the subject of the operative treatment of these masses. Pathology. Pelvic cellulitis, like inflammation of connective tissue elsewhere, is essen- tially an acute or subacute lymphangitis, running its course and ending in resolution or abscess formation, or a mass of unabsorbed exudate and infiltra- tion, which may or may not conceal a focus of pus in its interior. Occasionally the infection will progress through the wall of the uterus as a thrombo- phlebitis and later break through the broad ligament veins into the connective -n'tfMaifeftr'iigttiltlfeifttiirr'' ' Fig. 654. Pehic Cellulitis (Parametritis.) The broad ligament inflammatory mass is represented as sec- tioned longitudinally on the right side and transversely on the left side. The former (right side of pehis) in- dicates how the infiltration extends down along the cer\'ix and vaginal wall, and the latter (left side) indicates how it extends forward to the bladder and backward to the peritoneal cul-de-sac, causing a convexity toward the ca%1ty of the cul-de-sac. tissue. The condition in any particular case may vary from a small area of induration on one side of the cervix to extensive induration, involving the con- nective tissue all around the uterus and extending out to the pehdc wall on each side (Fig. 654). The process may extend forAvard into the connective tissue beside the bladder, or backward along the sacro-uterine ligaments. Fig. 655 shows various situations in which the mass may be found. Symptoms. The symptoms are much the same as those due to salpingitis — namely, back- ache, pain in the lower abdomen, tenderness in pelvis and menstrual dis- 738 CHRONIC PELVIC INFLAMMATION turbances. The severe exacerbations, so characteristic of salpingitis, are not present usually in cellulitis, unless there is complicating salpingitis. On examination, induration of extreme hardness is felt very low in the pelvis and closely attached to the sides of the cervix — the portion of the uterus in contact with the connective tissue (Fig. 654). The marked indura- tion may extend out to the pelvic wall, and may be so intimately attached to the bone and so hard as to appear to be a bony or cartilaginous outgrowth from the wall of the pelvis. Other points in the differential diagnosis between a parametritic mass and a tubal mass are given on page 753. In some cases Fig. 655. Indicating the Various Situations in which a Parametritic Mass may be found. A, close to the side of the cervix; B, at the middle of the broad hgament; C, at the outer portion of the broad Hgament; D, in the sacro-uterine ligament close to the cervix; E, in the posterior portion of the sacro-uterine ligament; F, at the side of the bladder; G, in the anterior portion of the pelvis. in which it is difficult to determine certainly whether the induration is in the connective tissue or about the tube, the history of the trouble— its cause and subsequent course — will help in distinguishing between the two. (C.) CHRONIC OOPHORITIS. Chronic inflammation of the ovary may be secondary or primary. Second- ary inflammation of the ovary is due, as a rule, to extension from a salpingitis. The inflammation about the outer end of the tube involves the adjacent per- itoneum and ovary. When this takes place the following conditions in the ovary may result : 1. One or more points of infection, with inflammation, infiltration and CHRONIC OOPHORITIS 739 swelling — the mflammation involving both the follicles and the interfollicular connective tissue. It may or may not progress to the stage of abscess forma- tion. "When an ovarian abscess forms, it is usually in connection with tubal suppuration, hence it was considered along with salpingitis (page 730) and Fig. 650). 2. The ovary, instead of becoming infected, may simply become surrounded by exudate, which compresses it, damaging it and causing cellular infiltration of the connective tissue (both the capsule and stroma). In time this round cell infiltration forms scar tissue, and as it contracts it further interferes with the Graafian follicles, so that they atrophy or form small cysts. From this process the functionating part of the ovary becomes reduced in size, and the organ may come to consist simply of a mass of fibrous tissue with small Fig. 656. Cystic Ovary. This affection is usually bilateral, and the chronically inflamed and heavy ovary is often prolapsed. cysts scattered through it. This condition is called cirrhosis, and ovaries thus affected are designated as "cirrhotic ovaries." Primary inflammation of the ovary is due to infection carried by the blood or to active hyperaemia (from excessive sexual excitement or suppression of menses), or to interference with the circulation (from malposition, or from chronic inflammation of the uterus or tubes, or from a tumor of the uterus, or from other pelvic tumor). In the case of infection the inflammation runs the same course as in oophoritis, secondary to salpingitis. In the case of oophoritis due to circulatory disturbance without infection, the process is really not inflammation, but a nutritive disturbance accom- panied with chronic irritation. There is chronic congestion of the ovary, round-cell infiltration and enlargement, with dilatation of the Graafian fol- 740 CHRONIC PELVIC INFLAMMATION licles. This produces a large, heavy, tender "cystic ovary" (Fig. 656). The heavy ovary is very liable to sink down back of the uterus, low in the pelvis, a condition known as "prolapse of the ovary." Later, owing to the con- traction of the newly-formed connective tissue, the ovary may shrink and become cirrhotic. The normal changes in the ovary, incident to the rupture of the Graafian follicles and subsequent scar formation (see Chapter XII), produce appear- ances which are sometimes mistaken for inflammation. The symptoms of infective inflammation of the ovary are about the same as those of salpingitis. In the non-infective inflammatory disturbances above referred to (hyperplasia of ovary, cystic ovary, cirrhotic ovary, prolapse of ovary) ' the symptoms are much the same as in a chronic salpingitis, but without the severe exacerbations, confining the patient to bed for one or two weeks. The symptoms approach those of a neuralgic rather than an inflammatory character. The patient is rarely, if ever, confined to bed more than a few hours, except in some cases at the menstrual periods. Examination shows no mass of exudate about the tube, but one or both ovaries are enlarged and very tender, and possibly prolapsed. In a later stage the enlarged ovary may shrink and become smaller than normal (cirrhotic ovary). DIFFERENTIAL DIAGNOSIS OF CHRONIC PELVIC INFLAMMATION. The diseases which may be confounded with chronic pelvic inflammation, and which therefore must be taken into consideration in the differential diagnosis, are as follows : Chronic endometritis. Fibromyoma of the uterus. Tubal pregnancy, with chronic symptoms. Tuberculosis of the tubes and peritoneum. Syphilis of the pelvic structures. Ovarian and broad ligament tumors. Chronic appendicitis. Mucous colitis. Bladder and rectal affections. Pelvic neuralgia. Neurasthenia. Hysteria. , In chronic endometritis, without pelvic inflammation, the trouble is con-^ fined to the uterus, and consequently there is no marked tenderness nor any inflammatory mass outside the uterus. A fibroid tumor of the uterus usually presents the following points: a. The symptoms are of gradual onset, and consist principally of menstrual disturbances, particularly increased flow. b. Absence of fever and absence of attacks of pelvic peritonitis. . c. The mass is hard, has a definite and rounded outline, is intimately connected with the uterus and not attached to the pelvic wall. DIAGNOSIS OF CHRONIC PELVIC INFLAMMATION 741 d. There is not the marked tenderness that is found in pelvic inflamma- tion. e. There is no fixation unless the tumor is large enough to impinge on the pelvic wall. The uterus and tumor are movable together, but not separ- ately. f. If necessary to sound the uterus, it will usually be found increased in depth. Ovarian and broad ligament tumors present the following characteristics : a. Gradual onset of symptoms. b. Absence of fever and of marked menstrual disturbance and of severe attacks of pelvic peritonitis. c. Large tumor mass without particular tenderness and without fixation. In the case of an ovarian tumor the mass can usually be moved about in the lower abdomen. d. Distinct fluctuation without marked tenderness, indicating that the fluid is not pus. Tuberculosis of tubes and peritoneum. The distinguishing characteristics of tuberculosis of the tubes and peritoneum are : a. Decided symptoms of pelvic inflammation in a young woman who has had no opportunity to contract pelvic inflammation — that is, in a woman who has never had endometritis. b. Gradual onset, usually, and persistent progress without the marked improvement usually following the treatment of ordinary pelvic inflammation. c. Encysted ascites — a collection of fluid shut oil from the general peritoneal cavity by adhesions — without the marked pain and fever that would come with a collection of pus. d. Evidence of tuberculosis elsewhere. c. Emaciation, gradual, but marked and persistent — more so than would be accounted for by the pain, fever, etc. Syphilis of the tubes and peritoneum sufficient to cause symptoms is rare, but it should always be borne in mind in patients presenting marked evidence of syphilis, especially if there is severe ulceration of the genitals or rectum or if there is stricture of rectum. All such patients presenting symptoms of chronic pelvic inflammation should be given a thorough course of potassium iodide before operation is decided upon. It is the cellular deposit of the tertiary stage that attacks these structures. The symptoms pointing to such trouble are: a. Evidence of syphilis elsewhere in the body. b. Gradual onset of the trouble, usually in connection with some other active evidence of syphilis in the third stage. c. Less decided fever and tenderness than in ordinary inflammation. d. No fluctuation, but extensive adhesions, which bind the organs together in such a way as to form distinct masses, which may be mistaken for masses of plastic exudate. e. The recently developed reactions for syphilis (Wassermann, Noguchi) 742 CHRONIC PELVIC INFLAMMATION and, where a portion of affected tissue can be excised, esamination for the spirochete pallida. Though this syphilitic condition in the pelvis is rare, it occasionally occurs and must be watched for in syphilitics. In more than one such patient the abdomen has been opened, only to find the case not a proper one for operation — the abdomen being closed and the patient placed on anti-syphilitic treatment, which should have been given before operation. Chronic appendicitis may be difficult to differentiate from chronic salpin- gitis of the right side. The facts pointing to appendicitis are as follows : a. High location of the painful area, at McBurney's point, without a painful area at the site of the Fallopian tube. b. Stomach and intestinal, disturbance, preceding and accompanying an attack. Also pain in region of the umbilicus, rather than in the back. c. High location of the mass of exudate — not felt so well from vagina as would be a mass about the Fallopian tube. d. Absence of endometritis and absence of a history of previous uterine sepsis or gonorrhoea. e. No marked increase of the trouble at the menstrual periods. Even appendicitis may show some increase then, but it is not so marked as in salpingitis. In a case of inflammation in the right lower abdomen in a girl, or in a woman who has never been pregnant nor had any uterine infection, the trouble is more likely to be appendicitis. On the other hand, in a case of inflammation in that locality in a woman who has once had infection of the uterus, the probability is in favor of salpingitis. In some cases it is impossible to make a positive differential diagnosis until the abdomen is opened. In fact, it not infrequently happens that both structures are involved in the inflammatory process, the inflammation beginning in the tube and extending to the appendix or beginning in the appendix and extending to the tube. Other intestinal diseases also must be excluded. Mucous colitis is the one which has most frequently been mistaken for chronic tubal or ovarian inflam- mation (see page 300). . The points that distinguish mucous colitis from chronic pelvic inflammation are (a) the character of the pain (resembling intestinal cramps and extending throughout the lower abdomen), (b) the passage of characteristic masses of mucus in some of the attacks and (c) the absence of any palpable pelvic lesion. There are also diseases of the urinary organs that may be confounded with chronic pelvic .inflammation. All those affections must be excluded by a knowledge of the symptoms and signs that accompany them. In pelvic neuralgia and in neurasthenia and in hysteria, without complicat- ing pelvic inflammation, there is no abnormal mass within the pelvis. In pelvic neuralgia the tenderness may be localized along the pelvic nerve trunks (Figs. 87, 88). TREATMENT OF CHRONIC PELVIC INFLAMMATION 743 TREATMENT. In the treatment of chronic pelvic inflammation (chronic salpingitis, chronic oophoritis, chronic pelvic peritonitis, chronic pelvic cellulitis, and all combi- nations of these lesions) there are certain general measures that are appli- cable to practically all cases, and there are also special measures that are applicable to special conditions only. GENERAL MEASURES. 1. Laxatives as needed to overcome chronic constipation. Cascara sagrada is an excellent laxative for this purpose after the bowels have been thorough- ly moved by some more active purgative. I have used with much satisfaction the laxative pills containing aloin, belladonna, strychnia and cascara (see Formulae), one pill each night or one each night and morning. 2. Attention to the general health, as indicated by anemia, lithemia or other abnormal condition. This is particularly important in chronic pelvic diseases if satisfactory results from treatment would be secured. Just because the patient has some pelvic disease, do not jump at the conclusion that treatment of that alone will cure her. There may be an affection in some other part of the body that has far more to do with the patient's ill health. And even considering the effect on the pelvic affection only, the general health should be built up as much as possible. 3. Rest at the menstrual periods. If the patient suffers much, she should go to bed and have hot applications made to the lower abdomen. If this does not give relief, she should be given sedatives as necessary, but avoid opium. 4. Hot vaginal douches, one to three times daily. To secure the best result, these must be given according to the special directions detailed in Chapter III. 5. Applications to the vaginal vault. Ichthyol (10 per cent.) in glycerine, and applied by means of tampons every second or third day, aids some in relieving the pain and hastening the absorption of the exudate. 6. Applications to the lower abdomen. These consist principally in counter- irritation by means of tincture of iodine applied over the tubo-ovarian region of one or both sides. This is useful particularly in chronic or subacute oophoritis and in ovarian neuralgia. The patient is given a prescription for an ounce bottle of the tincture and a camels-hair brush. She is directed to paint the iodine over the painful region once daily until the skin becomes tender, then stop for a few days until the skin irritation subsides, then use the iodine again until the skin becomes tender, and so on as long as desired. By this means mild counter-irritation may be kept up over the painful ovary for weeks, with decided diminution of pain in some cases. SPECIAL MEASURES. 1. If there is a collection of pus low in the pelvis, open and drain it by vaginal operation, according to the technique given in detail under acute 744 CHRONIC PELVIC INFLAMMATION pelvic inflammation (see page 705). In the after-treatment the drainage- tube will have to remain in longer than for an acute abscess of the same size, for the chronic abscesses have thicker walls and hence collapse more slowly. 2. If there is an inflammatory mass high, which probably contains pus or which continues to give serious trouble after a thorough trial of the general measures (that is, after those measures have been used faithfully for several weeks along with rest in bed as thought best), then comes the question of abdominal operation. Intimately associated with this is another important question, namely: What is the Preferable Time for Abdominal Operation for a Chronic Inflammatory Mass in the Pelvis? In a considerable proportion of the cases of chronic suppuration in the pelvis the pus is sterile at the time of operation. In 634 cases examined bacteriologically (collected by Andrews and comprising series by Charrier, Hartman and Morax, Kelly, Koch, Legros, Martin, Menge, Orthmann, Proch- ownik, Reichel, Schafi^er, Schauta, Schenk, Schmitt, Stemann, Strassmann, "Wertheim, Westermark, "Whiteside, "Witte, Zweifel, Rist, Mackenrodt, Durck, Bellei, Walsh, Frommel, and Andrews) the results, excluding tubercular cases, were as follows: Sterile 55. per cent. Only saprophytes 6. per cent. Gonococcus 22.5 Streptococcus and staphylococcus 12. Pneumococcus 2. Bacillus coli communis 2.5 In a later resume, by Hyde, comprising nearly three thousand cases (2973 cases, excluding tubercular), the bacteriologic findings were approximately as follows: sterile, 1998; gonococcus, 579; other bacteria and mixed infec- tions, 456. It is interesting to note the steps in the development of this knowledge. Long ago it was observed that, of the patients subjected to abdominal operation for pelvic suppuration, the old cases usually recovered promptly, while the recent cases frequently developed fatal peritonitis — that is, operation in the acute stage was far more dangerous than operation in the chronic stage. The splendid advance in gynecologic work in the last few decades is based on facts ascertained in two ways. Some facts came to the surface largely through pathologic and bacteriologic investigation, while others were ascer- tained by experience at the operating table and the bedside. The fact above referred to belongs to the latter class ; it was learned by experience, often bitter experience, and many lives were lost before the lesson was fully learned. This fact, after having been clinically established, was the occasion of much CLASSIFICATION OF INFLAMMATORY MASS 745 curiosity, as the explanation was not at hand. It seemed paradoxical that long continuance of a debilitating disease should put the patient in better condition for a serious operation for the same. "What could be the explanation? Why did chronic inflammation confer such immunitj^ from peritonitis after operation? One early theory was that the immunity was due largely, if not wholly, to the local effect on the adja- cent peritoneum, choking its absorptive channels so that serious septic absorp- tion could not take place so readily, and modifying the membrane so that it was not as good culture ground for the bacteria. According to another hypothesis the body resistance generally became "accustomed" to the local irritation in the pelvis and consequently was less disturbed by the added irritation of operation, and also, owing to the preparedness, so to speak, of the general resistant forces of the body, they were better able to combat in- vasion. These explanations were but gropings in the dark, but nevertheless they contained truths which have been verified and elucidated by the epoch- making investigation into the resistant functions of the leucocytes and the blood-serum, and into the modus operandi of antitoxin and vaccine therapy. The decisive step in the solution of the riddle was the inauguration of systematic bacteriologic examination of specimens removed in operations for pelvic suppuration. These bacteriologic examinations were undertaken primarily for the purpose of determining the etiology of salpingitis, particu- larly what proportion of the cases were due to the gonococcus and what proportion to other bacteria. The results were disappointing. In a con- siderable proportion of the cases no bacteria could be found and hence in those cases the etiology of the trouble could not be bacteriologically determined. But, though disappointing so far as concerned the definite etio- logical classification of cases, the facts thus ascertained were very illuminating in regard to the important and puzzling question as to why immunity was secured by waiting. In many cases the bacteria had died and disintegrated and the pus was sterile — that was the reason why serious inflammation seldom followed abdominal section for old tubal abscesses, even though con- siderable pus often escaped among the pelvic structures during the enuclea- tion. On the other hand, in fresh cases the least peritoneal contamination by the contained pus was often followed by fatal peritonitis because the bacteria were not dead, but active and virulent. Another fact ascertained was that in many of the old cases in which bacteria were still present they were so attenuated that the pus was practically sterile. Persistence of Virulence — Classification of Cases. It ha^nng been established that sterilization gradually takes place within a reasonable time in most cases, the next problem is to determine the period of time required for the automatic sterilization or effective attenuation in the different classes of cases. The persistence of virulence depends largely on the character of the infection. The two principal infectious agents in pelvic inflammatory masses 746 CHRONIC PELVIC INFLAMMATION are the gonoeoceus and the streptococcus. These two differ widely in the persistence of virulence and also in certain clinical characteristics which can be distinguished before operation. For the purpose, then, of considering the persistence of virulence in a prac- tical way — i. e., as a guide to treatment — the cases of chronic pelvic suppura- tion (tubercular excluded) may be divided into two classes — the gonococcic and the streptococcic. To be useful, this classification must be made before operation — that is, it must be a clinical rather than a strictly bacteriological classification. Of course, from a bacteriologic standpoint there are other cases, due to other bacteria, but in the present state of knowledge these other cases can not, as a rule, be distinguished before operation, and, even if they were distinguished, not enough information has accumulated to show the average persistence of virulence in such cases. Consequently, when confronted with a case of non-tubercular chronic pelvic inflammation, the endeavor should be to decide whether it belongs to the gonococcic or streptococcic class, ignoring for the time the fact that it may possibly be due to other bacteria, which in point of virulence lie between these two extremes. How may the gonococcic and the streptococcic cases be distinguished be- fore operation? What diagnostic facts are available at that time? Bacte- riologic examination of the urethral or uterine or other discharge is of assist- ance in only a small proportion of these chronic cases, for as a rule the bac- teria have disappeared from the discharge. Neither is there at present any well-established specific diagnostic reaction in gonoeoceus or streptococcus cases corresponding to the tubercular reaction in tubercular cases. Hence we must depend on other information obtainable before operation. Fortun- ately the gonorrhoeal cases and the streptococcal cases differ usually in two particulars — namely, (a) in the apparent cause of the trouble and (b) in the location of the lesion. As a rule these distinguishing points may be settled and the case definitely classified by an accurate inquiry into the onset of the trouble and a careful bimanual examination. Uncertain cases are to be classed with one or the other, as the preponderance of evidence warrants, and are to be given treatment accordingly. After operation, bacteriologic examination may show other bacteria, either alone or associated, and, if accurate records are kept of the histories and bacterio- logic findings in large series of cases, it may be possible later to form a third clinical class, comprising one or more of the miscellaneous or mixed infec- tions. For the present, however, the two classes, gonococcic and strepto- coccic, are all that can, as a rule, be satisfactorily distinguished before operation. Gonococcic Class (Clinical). In the gonococcic class (clinical) the distinguishing points are: (1) that the pelvic inflammation is preceded by evidence of gonorrhoea or comes on with- out apparent cause, and (2) that the lesion is located in the tube, extending thence to the ovary or adjacent peritoneal surfaces, but not involving the con- GONOCOCCIC INFLAMMATORY MASSES 747 nective tissue (parametrium) to any decided extent. As so much diagnostic importance is attached to these two points, it is necessary to consider them somewhat in detail. a. Apparent cause or mode of onset. As a general proposition it may be said that the gonococcus is the only germ that will spontaneously invade the normal, non-puerperal uterus and tubes. There are exceptions. Reidel re- ported that of 56 girls under ten years of age operated on for appendicitis, five had peritonitis due, not to appendicitis, but to acute salpingitis. He states positively that the infections reached the tubes by way of the vagina and uterus, and that gonorrhoea was excluded in every case. Cultures showed the ordinary pus germs. The inflammation was virulent and every patient died in spite of operative treatment. He observed the same clinical picture in two girls past ten years of age, both of whom died. In contradistinction to these cases in children, he states that he has never seen such penetration of normal genitalia by streptococci or staphylococci in the adult. General experience is in accord with this statement in regard to adults. Purulent inflammation beginning in a normal adult non-puerperal vagina or uterus, and later extending out into the pelvic cavity, may be set down as almost certainly gonorrhoeal. The patient must of course be questioned closely enough to eliminate an early miscarriage and also any intrauterine instrumentation (curetment, intrauterine treatment, sounding in examina- tion, etc.) The probability of gonorrhoea is increased if the purulent dis- charge ("free leucorrhoea") began within a few weeks after marriage. Again, in a large proportion of the cases of gonococcal leucorrhoea there is urethritis, causing burning on urination and increased frequency of urina- tion. This discharge and disturbance of micturition may last a few days or much longer. It may precede the pelvic inflammation by a few days or a few weeks or a few months. A history of abscess of one of the vulvo-vaginal glands has about the same significance as a history of urethritis. These struc- tures are frequently involved in gonococcal leucorrhoea, but very seldom in leucorrhoea from other causes. In those cases where the vaginal and uterine gonorrhoea did not cause sufficient disturbance to be noticed, the pelvic inflammation began without apparent cause. A considerable proportion of the gonorrhoeal cases give such a history. Here, again, one must be careful not to overlook an early miscar- riage or some intrauterine instrumentation. Also, it is important to trace the inflammation back to its very beginning, for some cases of puerperal in- fection are very mild in outward manifestations and do not cause much trouble until there is an exacerbation after several weeks or months. In these cases, however, there is usually a history of some disturbance during the puerperium, from which the patient recovered to a large extent, but not en- tirely. On the other hand, an inflammatory trouble, at first apparently due to a miscarriage or full term delivery, may on careful ciuestioning be found to antedate the pregnancy and to be due to a preceding gonorrhoeal infection. In the examination a search should be made about the external genitals for 748 CHRONIC PELVIC INFLAMMATION evidences of an old gonorrhoea — signs of previous inflammation of the urethra or of the vulvo-vaginal glands, such as red spots (maculae gonorrhoea) in these situations, or secretion that can be pressed from the structures. Bac- teriologic examination of discharge from the urethra, vulvo-vaginal glands, vagina or cervix may show gonococci. Negative findings, however, do not exclude gonorrhoea, for in many of the chronic causes the causative bacteria have disappeared from the discharge. In a certain proportion of cases of gonococcic pelvic inflammation the ex- tensions of the gonococci into the uterus and beyond took place during the puerperium. It has been shown that the gonococcus may lie practically dor- mant in the lower part of the genital tract for a long time and extend up- ward after a labor or miscarriage. Sanger examined 389 pregnant women and found the gonococcus in 100. Steinbuckel examined the lochia in 274 women in which the puerperium was normal and found the gonococcus in 18 per cent. In Leopold's clinic, 25 per cent of the puerperal infections were of gonorrhoeal origin. In 179 cases of puerperal sepsis examined bacteriologic- ally by Kronig, 50 cases were gonococcal, 50 belonged to the sapraemic group (miscellaneous saprophytes, most of which did not grow in ordinary culture media) and 79 were due to the ordinary pus bacteria. Puerperal in- fection due to the gonococcus is nearly always of a mild type, as shown in an instructive article by Taussig. A history indicating that the attack of puer- peral sepsis was mild may help some in differentiation, though it must be kept in mind that puerperal infection from other bacteria may also run a mild course. In the cases of puerperal origin, therefore, without positive evi- dence of gonorrhoea, the decision must rest largely on the location of the lesion. b. Location of the lesion. The extension of gonorrhoeal inflammation is almost invariably along the uterine mucosa into the tube (Fig. 657), and any further extension is toward the ovary and the peritoneal cavity. Gonococci very seldom extend through the uterine wall into the parametrium. Even when they do extend into the connective tissue, they are not likely to form an inflammatory mass there. Steinschneider and Schaefer injected pure cul- tures of gonococci into connective tissue, but no decided inflammatory action resulted. Though parametrial abscess may occasionally result from gono- cocci, as demonstrated by Wertheim and others, it is so rare as to be a curiosity. The characteristic lesion, therefore, of gonorrhoea in the pelvis is pyosal^ pinx, with or without the complicating oophoritis and pelvic peritonitis. The great majority of all pus-tubes are due to gonorrhoeal infection, known or unknown. In 106 cases of purulent salpingitis examined by Menge the find- ings were as follows : sterile pus in 68, gonococci in 22, tubercle bacilli in 9, staphylococcus in 1, anaerobic bacteria in 2, and streptococci in 4. As we shall see later, the gonococcus often dies out within a comparatively' short time, so it is probable that most of the sterile cases originate from the gono- coccus. When this fact is taken into consideration it becomes apparent what GONOCOCCIC INFLAMMATORY MASSES 749 a large proportion of the cases of purulent salpingitis are due to the gono- coeeus and what a small proportion to other bacteria. In a recent article on this subject* I gave the details of a series of cases of the gonococcic class (clinical), showing the two principal diagnostic points be- fore operation, the interval of time from infection to operation, the bacteria found at operation, and the degree of virulence (as indicated by the result of the operation). The cases thus tabulated in detail may be taken as typical of the hundreds of cases of this common class, which include probably five-sixths of the chronic inflammatory masses in the pelvis. These cases are so common and run such a uniform course that but few are reported in sufficient detail to Fig. 657. Gonococcal Infection of Uterus and Resulting Lesion. Gonococcal inflammation extends along the mucosa to the tube (as indicated in left side), and causes pyosalpinx (right side). show definitely the apparent cause, the interval of time from infection to operation, the location of the lesion and the bacteriological findings. It would be well if several series from the larger clinics were reported, so as to show the points mentioned, that the pre-operative diagnosis of the character of the infection and the probable virulence may be more clearly defined. It will be noticed in the article mentioned that in some of the cases belong- ing clinically to the gonococcic class, bacteriologic examination showed other bacteria instead of the gonococcus. But they are placed in this clinical class because of the apparent cause and the location of the lesion — the only de- cisive information usually obtainable before operation. It is only by such ♦Published in Surgery, Gynecology and Obstetrics, October, 1909. 750 CHRONIC PELVIC INFLAMMATION careful classification of the cases before operation and careful bacteriologic examination after operation, that a useful classification can be established and errors gradually eliminated. The lessons to be drawn from the consideration of the cases of the gono- coccic class (clinical) may be stated briefly under three heads, as follows: Reliability of the Diagnostic Points Available before Operation. From the cases here cited, wliich are typical of the hundreds belonging to this class, it is evident that the two points mentioned (the apparent cause and the loca- tion of the lesion) may be depended upon to eliminate the virulent strepto- coccal cases. Where these two clinical signs agreed, bacteriological examina- tion of the pus found showed either the gonococcus or absence of bac- teria, with but one exception. This exceptional case was rather acute and appeared gonorrhoeal. The trouble began shortly after marriage with a puru- lent vaginal discharge and local irritation. The discharge was not examined bacteriologically. An adnexal mass appeared on each side and extended into the cul-de-sac. The pus pockets in the pelvis were evacuated by vaginal in- cision. Pus was found in the cul-de-sac and in both tubes. It was supposed to be gonorrheal. Bacteriologic examination showed pneumococci in abund- ance, but no gonoccoci. In the cases where the two points did not agree, there were various bacteriological findings. In uncertain cases the location of the lesion was principally depended upon for classification. Except where the trouble was clearly from puerperal sepsis, a marked tubo-ovarian mass with- out parametrial involvement admitted the case to this clinical class. In no instance did such a case show streptococci. In the cases due to puerperal sepsis great care should be exercised in exclud- ing streptococci before admitting the case to the gonococcic clinical class. The apparent location of the lesion helps, but can not be depended upon en- tirely in these puerperal cases. A few cases showing streptococci presented masses at first supposed to be purely adnexal. ]\Iost of these, however, on more thorough examination at the time of operation, jhowed that the process was located partly in the connective tissue. Streptococcal pyosalpinx without associated parametritis is certainly very rare. Miller, who reported a number of streptococcal infections and investigated bacteriologically more than a hun- dred cases of pelvic inflammation at Johns Hopkins Hospital, stated that he had never encountered a frank pyosalpinx due to the streptococcus. White- side and Walton, in a series of thirty cases of pyosalpinx examined for bacteria, found the streptococcus in three, but the question of coincident parametrial involvement does not seem to have been investigated. In a series of 106 eases of suppurative salpingitis, Menge demonstrated the streptococcus in 4, but nothing definite is said as to the parametrial involvement in these cases. Persistence of Virulence. In the clearly gonococcic cases the bacteria were found to be absent or attenuated, as a rule within two to four months after infection. In some cases gonococci were found after several months or a year or even several years, but they had lost their virulence. Hartman and Morax state that all their specimens showing gonococci were from patients STREPTOCOCCIC INFLAMMATORY MASSES 751 with rather recent inflammation, the duration of the trouble varying from three weeks to four months, and averaging four to five weeks. Gonocoeei may die and disappear within a few weeks. In two cases de- tailed, where examination of the pus showed it to be sterile, the duration of the trouble was only two months in one case and five weeks in another. Gonococcic pus confined in the tube may become sterile in six or eight weeks, but it may, on the other hand, continue active for a considerably longer time. Radical operation, therefore, should ordinarily be postponed to at least three months from the onset of the trouble. Why Wait for Sterilization or Attenuation in Gonococcal Cases. There are two reasons. In the first place, a considerable proportion of the pelvic in- flammatory masses disappear without operation if nature is given a chance for three or four months. Many cases of supposed pyosalpinx so recover. The expression "supposed pyosalpinx" is used advisedly. I do not care to enter into the controversy over the possibility of the spontaneous cure of pyosalpinx, hence I limit my statement to the inflammatory masses supposed to be pyosalpinx, of which undoubtedly a considerable proportion disappear when nature is given a reasonable chance. The second reason for waiting for automatic sterilization or effective atten- uation of the pus within the quiescent mass, is that active gonorrhoeal pus is by no means harmless. General peritonitis due to the gonococcus is not so rare as formerly supposed. ITunner and Harris collected eighteen cases sup- ported by bacteriological proof, and seven of these patients died. They found also twenty-one cases in which, though bacteriological proof was lacking, the clinical evidence indicated strongly that the peritonitis was gonococcal, and five of these patients died. Again, peritonitis is not the only danger from operation on a quiescent but still active collection of gonorrhoeal pus. Price reports a case in which such an operation caused general dissemination of the bacteria, with involvement of the joints and endocardium and finally death fifteen days after the operation. There was no evidence of peritonitis. A number of cases of general dissemination of the gonococcus have been re- ported. Hunner cultivated gonocoeei from the blood taken from the arm of a patient five days after abdominal section for supposed gonococcal peritonitis, and in a fatal puerperal case Harris and Dabney demonstrated gonocoeei in the valves of the heart. Streptococcic Class (Clinical). The distinguishing characteristics are (1) the apparent cause of the trouble and (2) the location of the lesion. a. Apparent cause. Nearly all the streptococcic inflammatory masses in the pelvis can be traced to sepsis following labor or miscarriage. In the adult, streptococci do not spontaneously penetrate the non-puerperal uterus. Aside from labor or miscarriage, streptococcus infection may be due to curetment or other uterine operation, to intra-uterine application or sounding, to a stem pessary, to abnormal conditions caused by cancer or fibroid, or chronic in- 752 CHRONIC PELVIC INFLAMMATION flammation. If a pelvic inflammatory trouble can not be traced to one of the causes above mentioned, it is almost certainly not streptococcic. In taking the history, care must be exercised not to miss an early miscarriage or an intra-uterine treatment. Care must be taken also to trace the trouble back to its very beginning, otherwise an exacerbation remote from the casual mis- carriage or labor may be mistaken for the beginning of the trouble. On the other hand, not all puerperal cases are streptococcic. About 25 per cent of puerperal infections are gonococcal. They are usually of a mild type and subside quickly, but it must be kept in mind also that other puerperal infections (staphylococcic and even streptococcic) may run a mild course. Consequently the mildness of the preceding septic attack must not be given too much weight. Outside of external evidences of gonorrhoea (about the vulva or in the discharge), most dependence is to be placed on the location of the lesion. Streptococcus lesions are usually parametrial, while gonococcus lesions are usually tubo-ovarian. Another complicating factor in these puerperal cases is that there may be a mixed infection, causing both kinds of lesions to be present. Stone and McDonald reported such a case. This case furnished also a beautiful and striking illustration of the fact that the gonococcus spreads by way of the mucous membrane and the streptococcus by way of the connective tissue. The gonococci occupied the right tube and extended thence into the peritoneal cavity, while the streptococci occupied the right broad ligament and extended thence into the peritoneal cavity, where the two forms of bacteria met. An- other possibility in these puerperal cases is that the two forms of bacteria may be mixed in one lesion — e. g., in a pyosalpinx. This is evidently very rare, but it has occurred, and the possibility of it should make us always sus- picious of a post-puerperal inflammatory mass wherever located. In such a case the evidences for and against the presence of streptococci should be most carefully canvassed before deciding to subject the patient to abdominal section. b. Location of the lesion. A chronic lesion in the pelvis of streptococcic origin is nearly always in the connective tissue (parametrium). Unlike tliQ gonococcus, the streptococcus does not progress along the mucosa into the tube, but penetrates the wall of the uterus and extends into the connective tissue (Fig. 658). It not infrequently extends from the connective tissue to the peritoneum, causing peritonitis. Of course, in exceptional eases strep- tococci may pass from the uterus into the tube, but in such cases they are likely to pass on through the tube and cause fatal peritonitis. Conse- quently, in the streptococcic eases that survive the acute attack, and come later for treatment for an inflammatory mass, the lesion nearly always in- volves the connective tissue (parametrium). As before mentioned, Menge found the streptococcus in four cases of pyosalpinx, while Whiteside and Walton found it in three, but parametritis was not excluded. The last men- tioned authors endeavored to produce streptococcus salpingitis experi- mentally by injecting into the uterus in rabbits pure cultures of streptococci and also mixed cultures of streptococci and staphylococci. In no instance did STREPTOCOCCIC INFLAMMATORY MASSES 753 salpingitis result. One rabbit died of acute streptococcus septicaemia, while the others simply developed a purulent vaginitis for a few days and then re- covered, and when replaced in the rabbit pen became pregnant and bore lit- ters of six rabbits each. Miller, in the bacteriological examination of 127 cases of pelvic inflammation, found the streptococcus 7 times, but in no case was the lesion a pyosalpinx alone. There are very few exceptions to the rule that streptococcal masses in the pelvis are parametrial in whole or in part. Are all parametrial inflammatory masses streptococcic? Nearly all. That parametrial suppuration is usually due to the streptococcus is substantiated by Rosthorn, Bumm, Doleris, and Bourges, "West, Cullingworth and others. Hartman and Morax found it in 21 cases of parametrial abscess. In every Fig. 658. Streptococcal Infection in Uterus and Resulting Lesion. Streptococcal inflammation extends through the uterine wall into the connective tissue (as indicated in left side), forming a mass in the broad liga- ment. such ease operated on by Fritsch the streptococcus was found to be the cause. It is only occasionally that staphylococci and other bacteria are found either alone or associated with the streptococcus. As parametrial inflammation is nearly always due to the streptococcus, every case presenting a para- metrial mass should be placed in the streptococcic class until it is definitely proven to be due to some other cause. The distinguishing characteristics of a parametrial mass (chronic) are : (a) its situation in the connective area, usually in the broad ligament; (b) its low situation in relation to the uterus, often coming far down beside the cervix; (c) its intimate blending with the uterine wall, as though it were a part of the same; (d) its intimate blending with the pelvic wall, as though it were an outgrowth from that structure; and (e) its hardness, often being 754 CHRONIC PELVIC INFLAMMATION SO hard as to simulate a cartilaginous or bony tumor growing from the pelvic wall. A tubo-ovarian mass, on the other hand, is distinguished by its being situated high in the tubo-ovarian region, or prolapsed into the cul-de-sac ; by its not blending so intimately with the uterine wall, a distinct groove usually marking the point where the two come in contact; by its not blend- ing so closely with the pelvic wall ; by its presenting to the examining finger a portion of the rounded outline of the tube or ovary ; and by absence of the cartilaginous hardness often seen in chronic parametrial masses. In the article previously mentioned (page 749) I gave the details of a series of cases of the streptococcic class (clinical), showing the two principal diag- nostic points before operation, the interval of time from infection to opera- tion, the bacteria found at operation and the degree of virulence (as indicated by the result of the operation). From this series of cases of the streptococcic class (clinical) the following facts may be adduced : Reliability of the Two Diag-nostic Points Available before Operation. When the history showed that the trouble originated from labor or abortion and the examination showed a well marked parametritis, streptococci were found in every case except one. This one exception (ease 16) was Hunner's case, and he was not altogether satisfied with the bacteriologic examination, but stated that he regarded the case as streptococcal in spite of the negative findings. When the two points do not agree, then the principal weight should be given to the location of the lesion. But not a sufficient number of carefully observed cases has accumulated to define accurately how great a dependence may be placed on the location of the lesion in these uncertain cases. This is a point to be further investigated. For the present these uncertain cases should be considered with great care in order that no streptococcic case be allowed to slip into the gonococcic (abdominal section) class. Persistence of Virulence. The virulence of the streptococcus persists in- definitely. Miller reports one case in which the bacteria persisted for six years and another in which they persisted for twelve years. IMartin states that streptococci have been found fully virulent in a pelvic inflammatory mass after nineteen years. In one instance (case 19) streptococci apparently disappeared in six months, but the pus also disappeared. The case was one of severe sepsis following labor. On the eighth day vaginal incision into a pelvic abscess evacuated pus containing streptococci. Six months later, a mass persisting, a A^aginal incision was made into the cul-de-sac and the mass. No pus was found, but there was serous fluid showing staphylococci alone. Automatic sterilization of a streptococcus abscess is perhaps possible, but it is so rare that it is not to be counted on. A streptococcal mass in the pelvis is always dangerous, and abdominal section for the same at any time is likely to be followed by a fatal peritonitis. The cases tabulated in the article men- tioned give striking proof of the seriousness of intra-peritoneal operation in these cases. OPERATION FOR INFLAMMATORY MASSES 755 Character of Operation. The only safe way to operate for streptococcal pus collections is by the extra-peritoneal method. If possible, the pus collec- tion should be reached and evacuated per vaginam. If this can not be accom- plished, it may be practicable to drain the abscess by extra-peritoneal opera- tion above Poupart's ligament, as was done in some of the cases mentioned. Intra-peritoneal operation in these cases should be undertaken only when the patient's life is threatened by the severity of the inflammation and it is impossible to reach the mass in a less dangerous way. Conclusions. 1. In more than half of the cases of chronic suppuration in the pelvis the pus is sterile at the time of operation, showing that sterilization of the in- fected focus takes place automatically within a reasonable time in the ma- jority of cases. 2. Abdominal removal of the mass while the bacteria are active and viru- lent results in fatal peritonitis or localized infection in many of the cases. Abdominal removal of the mass after the bacteria are dead or greatly attenuated is almost never followed by infection, even though there is ex- tensive escape of pus into the pelvis. Hence abdominal operation for a chronic inflammatory mass in the pelvis should not be undertaken before the period of probable sterilization, except in those rare cases in which, in spite of palliative measures, the patient's life is threatened by the severity of the inflammation and the infected focus can not be satisfactorily drained extra-peritoneally. 3. The time required for the death of the bacteria or effective attenuation of the same varies greatly in the different cases. The persistence of virulence depends largely upon the character of the infection. The two infections con- cerning which definite information has accumulated as to persistence of virulence are the gonococcal and the streptococcal. In the gonococcal cases the bacteria are dead or attenuated to practical sterility within three or four months from the beginning of the trouble. In such cases abdominal section may be safely undertaken after this period. In the streptococcus cases, on the other hand, the bacteria live and retain their %arulence indefinitely. In some cases there seems to be a diminution in the virulence, but this is erratic and not to be depended upon. Abdominal sec- tion for a mass of streptococcus origin is never safe. Such an operation at any time, even years after the infection, is liable to be followed by fatal peritonitis. 4. These two classes may be distinguished before operation in most cases, the distinguishing characteristics of each being found in the apparent cause of the trouble and the location of the lesion, as already explained, in detail. 5. What is the preferable time for abdominal operation for a chronic in- flammatory mass in tlie pelvis? a. In a case that is clearly gonococcic (agreement on the two points — the apparent cause of the trouble and the location of the lesion) abdominal opera- 756 ' CHRONIC PELVIC INFLAMMATION tion may be considered safe after three or four months from the onset of the trouble. If after this time the mass is a source of serious irritation in spite of palliative treatment, it should as a rule be removed. On the other hand, if there is marked improvement, it is better to wait, as nature may bring about recovery without operation. b. In a case that is clearly streptococcic (agreement on the two points) abdominal section is never safe. Even where the temperature and pulse are normal and everything quiescent, intra-peritoneal operation for the mass is liable to cause the patient's death from streptococcal peritonitis. c. In a case that is doubtful (disagreement on the two points) a most careful study should be made of all the features of the case and every helpful diag- nostic method should be brought into use to aid in reaching a positive con- clusion. No intra-peritoneal operation should be undertaken until the strep- tococcus is excluded with reasonable certainty. In a doubtful case in which the abdomen is opened on the supposition that the mass is tubo-ovarian and it is found before adhesions are much disturbed that the mass is principally in the connective tissue (parametritic), the route of attack should be changed to extra-peritoneal (per vagina or above Poupart's ligament) and the abdomi- nal wound closed. Such a lesion probably contains streptococci and the adhesions of omentum and bowel, which causes the deceptive mass high in the tubal region, constitute nature's barrier between the virulent bacteria and the peritoneal cavity. When this barrier is broken down, the way is opened for a fatal peritonitis. 6. There are three reasons for calling special attention to this subject: a. A matter of such vital importance should, I think, be given more promi- nence in text-books and in instruction to students, and in society proceedings and discussions concerning pus collections in the pelvis, b. Lives are still be- ing sacrificed by operators who seem unaware of the great danger of abdomi- nal operation for inflammatory masses following puerperal sepsis, c. Further investigation (with careful recording in large series of cases of the apparent cause of the trouble, the location of the lesion, the interval of time from in- fection to operation, the bacteriologic findings, and the result of operation) is required, that the definite classification of the cases before operation, as above indicated, may be firmly established and errors eliminated. 3. Avoid radical operation in those cases in which the examination shows only a somewhat thickened and tender tube (catarrhal salpingitis), or a slightly enlarged and sensitive and perhaps prolapsed ovary (cystic ovary)? or adhesions with som-C induration and fixation, but with no distinct mass. Give a thorough trial to the non-operative measures previously mentioned, with such additions and modifications as the peculiarities of the case may sug- gest. In those cases in which all signs of active inflammation have subsided, leaving only adhesions binding the uterus or ovary in abnormal position or distorting the tube, much benefit may sometimes be derived from pelvic mas- sage, with stretching of adhesions, or from pressure treatment, or from the two in combination. In cases with troublesome uterine discharge and ex- PROGNOSIS IN CHRONIC PELVIC INFLAMMATION 757 cessive menstrual flow or painful menstruation, thorough dilatation and curettage is advisable. This tends to diminish the discharge and menstrual suffering, and in some cases it has a decided beneficial effect on the adjacent adnexal trouble. Furthermore, it gives a chance for a thorough examination under anesthesia, by which the exact condition of the ovaries, tubes and uterus can be more accurately determined. In cases with persistent pain without decided palpable lesion — i. e., those cases in which the nervous ele- ment is marked and in Avhicli the affection approaches the character of a neuralgia or neuritis — electricity may give some relief (see page 353). It is in these cases also that a tonic regimen (with general massage, brush rubs, salt rubs, etc.) and antineuralgic remedies are especially indicated, and often pro- duce a cure with little or no local treatment. Careful study should be made of the patient generally — of all the organs. In some such cases it will be found that the principal trouble is some general disease or some local disease in another portion of the body, the pelvic disor- der being of secondary importance. If nothing is found outside the pehas to account for the patient's symptoms and all other measures fail to relieve the pelvic distress, open the abdomen and ascertain the exact condition of the pelvic organs and vermiform appendix and then correct, as far as possible, the pathological conditions found. 4. In the operative cases, when the patient is under forty years of age and the pathological condition will permit, preserve enough ovarian tissue to con- tinue menstruation and enough Fallopian tube to make pregnancy possible. In those cases where all active inflammation has disappeared, leaving only adhesions and exudate, it is often possible to preserve in place part of an ovary and part of a tube, which by proper treatment may continue their func- tions. This conservative work is a comparatively recent development of pelvic sur- gery, but several cases of pregnancy have already been reported from such, remnants of ovary and tube preserved. Even if pregnancy does not take place, the simple fact that it may take place — that it is possible — leaves the patient in a much better frame of mind. If the uterus must be removed, one ovary at least should be preserved, if it is not diseased, because the preservation of any ovary, or even part of an ovary, tends to prevent those troublesome nervous symptoms which fre- quently accompany the artificial menopause and which sometimes become serious. PROGNOSIS. What are the ultimate results in cases of chronic pelvic inflammation? What answer shall be given to the patient who asks, "Doctor, will the pro- posed treatment make me a well woman?" Now, the results differ much in various cases, and in order to answer this question in a comprehensive way it is necessary to divide the cases into two great classes— the first including those cases in which the symptoms are ap- 758 CHRONIC PELVIC INFLAMMATION parently all dependent on an evident lesion, and the second including those eases in which there are symptoms the cause of which is not clear. 1. "Where there is a marked lesion in the pelvis of such nature as to account for all the symptoms and the patient is otherwise in good health, proper treatment will in all probability effect a cure. The treatment must, of course, be carried out carefully and vigorously according to the indications in the particular case. And in any case it will extend over several months, for even in the cases in which the pelvic legion can be largely removed by operation the patient will require careful after-treatment to put her in good health. As to the promises you make to the patient, be careful. You must give the patient all the encouragement possible, for encouragement helps in the cure, but you must not commit yourself in such a way that, if something unfore- seen prevents a cure, you will be in the position of having promised some- thing that you can not give. This subject of prognosis and promises to pa- tients is one of the most trying in medical and surgical work. Most diseases may, by treatment, be either cured or improved so much that the patient thinks them cured. Advertising quacks take advantage of this fact and prom- ise certain cure in all cases — ^"Cure guaranteed." Some of the patients are, no doubt, really cured, and others are so much improved for the time being that they think themselves cured and shout accordingly, while those who are not improved are so ashamed of having gone to a quack that they say nothing about it, and so the imposter goes on Avithout hindrance. But the reputable physician must be careful with his promises. We deal in facts, not deceptions. Our duty is to employ the best possible means for the relief of the patient and the cure of her disease, and at the same time to give her all the encour- agement possible. There are, hoAvever, so many uncertainties that enter into the problem that it is, in most cases, best to say but little about the prog- nosis unless the patient asks directly concerning it. If the patient requests a definite statement as to just AA''hat chance she has of permanent relief, prom- ise her all that the circumstances Avill Avarrant — giving the most favorable construction to all phases — but ahvays Avith this proviso, said to the patient herself or to a near relative, that in spite of the best treatment there is a pos- sibility of the development of conditions which would give a different result. This caution in promises is particularly important in surgical work, for many patients are prone to expect from an operation the cure of every existing dis- turbance, Avhether it comes AAdthin the scope of the operation or not. 2. In cases where there is no marked pelvic lesion, or Avhere, in addition to a marked lesion, there are symptoms that are not accounted for by the pehdc disease, the prognosis' is uncertain. The fact that there are symptoms without apparent cause means that there is a hidden factor in the case, and that hid- den factor may continue to cause much trouble after the obvious lesion is re- moved. Promise as much as you can count on safely, but no more. Sometimes very serious or troublesome symptoms will subside after correction of 3,n ap- parently slight pelvic disorder. Many symptoms, particularly nervous symp- toms, apparently not closely connected with the pelvic disease, disappear ojq PROGNOSIS IN CHRONIC INFLAMMATORY MASSES 759 the cure of the pelvic disorder, much to the delight of the patient and of the physician. On the other hand, many symptoms, particularly nervous symp- toms, apparently due to well marked pelvic disease, persist after the removal of the disease, much to the disappointment of the patient and the physician. In some of these cases the troublesome symptoms had no connection -with the pelvic trouble, but were caused by some entirely separate disorder. In other cases the nervous symptoms were really caused by the pelvic disease, but through long continuance of the irritation there was produced in the nervous system a pathological condition capable of persisting long after the removal of the causative lesion. Then, again, there are certain cases of hereditary tendency to insanity in which a serious pelvic disease is sufficient to cause a breakdown and the de- velopment of mental disorder. In such a ease, though you may hope for im- provement, you can not promise much, for the mental disorder, once excited, may persist in spite of the removal of the exciting cause. Again, occasionally a patient with this tendency to mental disturbance will get along very well until subjected to operation for some disease, pehdc or otherwise, and then the added strain of the operation upsets the mental bal- ance and she becomes insane. These are, of course, exceptional circumstances. I mention them simply to show how many things the physician must think of — what a broad view of the subject he must take — in giving a prognosis as to the ultimate result. 760 CHAPTER XL OTHER AFFECTIONS of Fallopian Tubes, Pelvic Peritoneum and Pelvic Connective Tissue. PELVIC TUBERCULOSIS. Pelvic tuberculosis is tuberculosis of the Fallopian tubes or pelvic perito- neum or ovaries, or of all these structures together. It is known also as "tubercular salpingitis," "tubercular pelvic peritonitis" and "tubercular oophoritis." ETIOLOGY. The same factors are operative here as in tubercular lesions elsewhere — namely, tubercle bacilli and lowered tissue resistance. As to how the tubercle bacilli reach these deep-seated structures, and v/hy they locate here, is an in- teresting story and one not yet completed. The following factors have a bearing on the etiology of the affection : 1. Tubercular lesions in distant organs — for instance, in the lungs. From these distant lesions the bacilli get into the blood stream and are carried to various parts of the body, frequently to the Fallopian tubes. In some cases the FaUopian tube lesions constitute the only secondary lesion found. 2. Tubercular lesions in adjacent organs, as the bladder, rectum, intestines or abdominal peritoneum. The most frequent are tubercular appendicitis and tubercular ulceration of the small intestine. In the former the process ex- tends directly along the peritoneal surface to the pelvic peritoneum and the Fallopian tubes and the ovaries. In the latter there may be an adhesion be- tween the irritated peritoneal surface over a tubercular ulcer of the in- testine and the surface of a tube or ovary, or of the pelvic peritoneum. After adhesion the process gradually extends through the intervening tissue. In tuberculosis of the bladder or rectum, penetration of intervening tissue may take place, thus bringing the bacilli in contact with the structures under consideration. 3. Occasionally the tubercular infection may come by way of the genital tract from lesions lower — for example, from tuberculosis of the uterus, or of the vagina, or of the vulva. This, however, is very rare, the process usually extending from above downward instead of from below upward. PATHOLOGY. The cases of pelvic tuberculosis may be grouped roughly into two classes (A) those in which the peritoneum is principally involved and (B) those in which the process is located principally in one or both Fallopian tubes. FORMS OF PELVIC TUBERCULOSIS 761 (A.) Peritoneal Tuberculosis. Peritoneal tuberculosis begins as a deposit of fine tubercles in the pelvic peritoneum. This deposit may take place slowly or rapidly. If it takes place slowly, the disturbance may be slight and the symptoms hardly noticeable. If the deposit takes place rapidly, it produces the condition known as acute miliary tuberculosis of the pelvic peritoneum. In this marked miliary form the whole pelvic peritoneum covering the various structures may be closely studded with the tubercles (Fig. 659). This produces pelvic peritonitis. The peritoneum about the deposits is in- jected, reddened and lacks its normal luster. Ascitic fluid appears and the fluid may have a bloody tinge. The fluid may be free in the peritoneal cavity, with no limiting adhesion, or there may be adhesions that form pockets in which the fluid is confined (encysted fluid). In this form the tubercular proc- ess is usually widespread, involving a large part of the general peritoneum. The intestinal coils may be adherent to each other or to the parietal peri- Fig. 659. Pehic Tuberculosis— Peritoneal Form. {Kelly— Operative Gynecology.) toneum, or to all the pelvic structures. The adhesions are usually frail and bleed easily upon being separated, but the bleeding soon stops. On account of the tendency to peritoneal efi'usion in this miliary form of tuberculosis, the adhesions are not usually extensive. After development to this stage the tubercles may pursue either of two courses. a. The tubercles may undergo fibroid change. The active symptoms disap- pear, the fluid is absorbed, and the diseased areas become scar tissue. This is called "fibroid tuberculosis." It is a limitation of the tubercular process and constitutes a temporary cure of the disease. b. Instead of the tubercles passing into this quiescent condition, they may spread and coalesce and break doAvn, and thus the process becomes pro- gressively destructive. The tubercular areas undergo necrosis and caseation, dense adhesions take place, collections of tubercular pus form, and all the pehdc structures become bound together into an irregular mass, with broken- down tubercular lesions scattered throughout. 762 PELVIC TUBERCULOSIS (B.) Tubal Tuberculosis. In tuberculosis of the Fallopian tubes the process, instead of appearing first in the peritoneum, may start in the interior of a tube. In this situation three forms are recognized — (a) miliary tuberculosis, (b) chronic fibroid tuberculosis and (c) chronic diffuse tuberculosis. a. Miliary tuberculosis of a Fallopian tube presents the same character- istics as miliary tuberculosis of other mucous membranes — ^that is, there are fine tubercles scattered beneath the epithelium and not yet broken down. Owing to the structure of the tube, the miliary" tubercles readily escape obser- vation unless the removed tube is examined miscroscopically. This form Fig. 660. Pehic Tuberculosis — Tubal Form. (Kelly — Operative Gynecology.) of tuberculosis may give rise to but few symptoms, and may cause so little disturbance that there is no suspicion of serious disease. b. If these tubercles fail to pass on to the stage of caseation, but instead become surrounded by a large amount of connective tissue and pass into a quiescent state,- we have the condition known as "fibroid tuberculosis of the tube." The tube is someAvhat thickened, and hardened and enlarged by the infiltration, but there is little or no breaking doAvn of the lesions. c. If, on the other hand, the tubercles progress to the stage of caseation and break down, there results the condition known as "chroniC' diffuse tuberculosis of the tubes." The tube is disorganized and contains a col- lection of caseous tubercular material (Fig. 660). SYMPTOMS AND DIAGNOSIS 763 The appearance of the tube varies of course witli the severity of the disease. In advanced cases the tube is greatly enlarged and on cutting it open the yellow broken down material is seen — the so-called "caseous pus." This varies much in consistency, being in some cases rather thin and in other semi-solid. AVhen this is removed, the mucosa of the tube is seen to be studded with tubercles, in all stages of breaking down, and there are also irregular, ragged ulcers, with small yellowish tubercles in their walls. When the peritoneal surface of the tube also is involved, it is studded with small tubercles and is usually adherent to some of the surrounding organs. Occasionally the tubercular areas undergo calcification. Tubal tuberculosis is also one of the common causes of general tuberculous peritonitis, a point of importance which will be further considered under treatment. Pelvic tuberculosis has been found to be present in from six to eight per cent, of the cases of abdominal section for pelvic inflammation, but in only about a quarter of these is it so marked as to be easily recognized. In the remaining cases it is recognized only by microscopical examination of sections of the tube. No period of life is exempt from genital tuberculosis. It has been found at all ages, from the infant of a few months to the aged woman past eighty. But the period of life in which it occurs most frequently is from the age of 20 to that of 40 years — i. e.. during the period of greatest sexual activity. SYMPTOMS AND DIAGNOSIS. The symptoms of pelvic tuberculosis are much the same as those of chronio pelvic inflammation. In fact it is a pehdc inflammation of a special kind. In a large per cent, of the cases the diagnosis of tuberculosis is made only after the abdomen has been opened, the operation ha^dng been undertaken for what was supposed to be ordinary pehdc inflammation. In not a few cases, however, a positive diagnosis of tuberculosis is possible before operation, and in some cases it is easj''. The conditions that point to pehdc tuberculosis are as follows : 1. Symptoms of chronic pehdc inflammation in a girl or young woman who has had no e^ddence of uterine infection. 2. Gradual onset ^vithout previous uterine disease, and persistent progress, ^vithout the periods of marked improvement usually present in ordinary pelvic inflammation. 3. Emaciation, gradual and persistent, without a corresponding severity of the inflammatory trouble. 4. E^ddences of tuberculosis elsewhere. :\rost cases of pelvic tuberculosis occur in patients having pulmonary or intestinal tuberculosis. 5. Tuberculin reaction. In a doubtful case this may aid materially in the diagnosis. The injection method or the cutaneous test may be employed. The ophthalmic test is dangerous to the eye and had best be avoided. 764 EXTRA-UTERINE PREGNANCY TREATMENT. If there are no contra-indicating lesions elsewhere, the affected tubes should be extirpated, preferably, by abdominal section. The operation should be preceded and followed by antitubercular remedies and regimen. If there are marked lesions elsewhere, or if the local trouble has advanced too far for radical operation, employ palliative measures. The palliative measures include the administration of antitubercular remedies internally, the drainage of fluid collections by operation and other measures mentioned under chronic pelvic inflammation. In some cases of extensive peritoneal tuberculosis, an apparent cure has followed simple abdominal section. It is still a question why such a change for the better should sometimes follow the mere opening of the abdomen in these cases, but the fact that such results are secured has been demonstrated many times, and patients that are in suitable condition should be given this chance for improvement. The affected tubes, however, should always be removed when possible. Pelvic tuberculosis often eventuates in general peritoneal tuberculosis. General tubercular peritonitis can usually be traced to a tubercular appendi- citis, or to tubercular salpingitis, or to tubercular ulceration of the intestine. In operating for tubercular peritonitis it is important to find and remove the focus if it can be done without too much traumatism. Mayo has done great service in insisting on this and in demonstrating the marked increase in the percentage of cures resulting therefrom. EXTRA=UTERINE PREGNANCY. Extra-uterine pregnancy is pregnancy outside of the uterine cavity. With few exceptions the developing embryo is, in the beginning, located in the Fallopian tube, consequently the term "tubal pregnancy" is applicable in most cases. The developing ovum may lodge at any part of the tube (see Fig. 661). ETIOLOGY. The cause of extra-uterine pregnancy is some interference with the down- ward progress of the fertilized ovum. The ovum and spermatozoa meet normally in the tube, and after fertilization the ovum passes along the remainder of the tube and into the uterus, where it becomes attached and develops, constituting a normal pregnancy. Now, if the progress of the fertilized ovum is interfered with so that it remains in the tube and develops there, extra-uterine pregnancy is the result. This interference with the downward progress of the ovum is usually due to some obstruction in the narrow proximal portion of the tube, though the obstruction may be situated anywhere between the ovary and the uterine cavity. The tubal obstruetioij must, of course, not be so marked as to prevent the upward progress of the PATHOLOGY 7g5 spermatozoa; consequently extra-nterino pregnancy is impossible when both tubes are completely occluded by iuflaminatiou or other process. The conditions which interfere more or less with the downward progress of the ovum are as follows : 1. Mild salpingitis. Slight iiiflammation may lead to destruction of the cilia. The action of the cilia is sni)posed to be necessary to the normal prog- ress of the ovum from the abdominal to the uterine end of the tube, the peristaltic action of the tube being of secondary importance and not sufficient in itself to carry the ovum along. Again, such inflammation leads to swelling of the tubal mucosa and mechanical obstruction in the narrow portion of the tube. This obstruction, while not marked enough to prevent the upward progress of the active spermatozoa, may prevent the downw^ard progress of the passive ovum. 2. Adhesions, from inflammation originating in the tube or elsewhere, may so distort the tube by bending or pressure as to partially obstruct its lumen. 3. Tumors within the tube wall or arising from other structures may by pressure narrow the lumen of the tube. 4. Malformations. Abel agrees with Freund that some of the spiral twists which are normally present in the tube in the embryo may persist to adult life and cause sufficient obstruction to lead to extra-uterine pregnancy. Diver- ticula may lead off from the lumen of the Fallopian tube. If a fertilized ovum lodges in one of these blind canals, tubal pregnancy will result. There may be also accessory tubes. These are usually connected to the normal tube, but sometimes by a cord only without any lumen. In such a case, if a fertilized ovum enters this accessor}^ tube, it will remain there. A rudimentary tube which is not open all the way to the uterus may be entered by an ovum which has been fertilized by a spermatozoa entering from the normal tube of the opposite side. The fertilized ovum is, of course, stopped at the impervious portion of the deformed tube, and a tubal preg- nancy is the result. Kelly figures an interesting case in which this same series of events occurred in a rudimentary uterine horn, the horn being so separated from the remainder of the uterus that it resembled part of the tube (Fig. 409). PATHOLOGY. The fertilized ovum may lodge at any part of the Fallopian tube, as show^n in Fig. 661. When the ovum becomes attached to the tube w^all, certain changes begin. First, there is marked hyperemia, which leads to some swell- ing of the structures and to increased growth of all the tissue elements of the tube wall. In the mucosa in tubal pregnancy the stroma cells enlarge and become decidua cells, though they do not become so large or so closely packed together as in the uterine mucosa. There is some hypertrophy of the muscular tissue near the attachment of the ovum. Very soon there appear certain interesting changes that have a bearing on the early rupture of the pregnant tube. As the fetal elements reach into the tubal tissues, seek- 766 EXTRA-UTERINE PREGNANCY ing nourishment, the wall of the tuBe becomes penetrated by wandering cells called "trophoblasts. " These trophoblast cells work into the muscular layer of the tube and weaken it, and gradually penetrate all the way through the wall. This growth of fetal elements into and through the wall of the tube causes early rupture of the tube and serious internal hemorrhage. Pathologically and, in a measure, clinically, the causes may be divided into the following classes : 1. Before Rupture. The developing embryo with its membranes is still completely surrounded by the unbroken tube. 2. Intraperitoneal Rupture with Single Moderate Hemorrhage. The blood gravitates into the cul-de-sac of Douglas. Adhesions bind together the structures above, thus forming a roof which shuts off the blood-filled cul-de-sac from the remaining part of the peritoneal cavity. This condition is known as ''pelvic hematocele" (Fig. 662). The blood may be gradually absorbed Fig. 661. Diagram Representing the Sites for the Various Forms of Tubal Pregnancy. 1, Interstitial pregnancy. 2, Isthmial pregnancy. 3, Ampullar pregnancy. 4, Infundibular pregnancy. 5, Tubo-ovariah pregnancy. (Gilliam — Practical Gynecology.) without further disturbance or the hematocele may require drainage, as de- scribed under treatment. The very early embryo with membranes, having been completely cast off from its point of nourishment, perishes and is usually absorbed without causing further trouble. 3. Intraperitoneal Rupture with Repeated Moderate Hemorrhage. The membranes usually remain partially attached within the broken tube, and hence the extruded embryo continues to grow, causing trouble later. The first hemorrhage leads to peritoneal exudate, with resulting adhesions, which bind together adjacent structures. Thus the blood mass and broken tube and growing embryo are surrounded by a wall of exudate and adherent intestine. This wall lessens the danger temporarily. But after a few days or a few weeks the continued growth causes further rupture of the tube or of the other limiting tissues, with accompanying fresh intraperitoneal hemorrhage of small or large amount. More exudate is then thrown out about the new blood mass, lessening the danger for a time. This process may be repeated PATHOLOGY 767 many times witliin the course of a few months, provided the patient does not in the meantime succumb to hemorrhage or peritonitis. Thus there is found in this chiss of cases a gradually increasing mass (Fig. 663), accom- panied by freciuent attacks of pelvic pain and marked soreness. This class includes the majority of cases of extrauterine pregnancy that come to opera- tion. Whether or not the patient's color and pulse are much atfected depends upon the severity of the hemorrhages. In many cases the recurring pain and Fig. 662. Pelvic Hematocele. Indicating the condition where there has been a tubal abortion and the blood from it has gra\itated to the cul-de-sac and become surrounded by exudate. soreness are the most evident features, and at the bedside such eases are often mistaken for ordinary pelvic inflammation. 4. Intraperitoneal Rupture with Profuse Hemorrhage. There is a free rupture of the tube (Fig. 664), and blood pours out into the peritoneal- cavity rapidly and in great quantity. It extends among the intestines and in some cases practically fills the abdominal cavity, as indicated in Fig. 665. The patient at once passes into a condition of severe shock. She is blanched, almost pulseless and, with the air-hunger and extreme pain, presents a most 768 EXTRA-UTERINE PREGNANCY distressing picture. The cases of this class have been fittingly designated as the "tragic" cases. This severe and persistent hemorrhage is most likely to occur when the developing ovum is situated near the uterus, in that portion of the tube kno^\T2 as the "isthmus." In the vast majority of cases the bleeding ceases when the patient passes into complete shock, which is nature's provision for checking the hemorrhage. In exceptional eases, how- ever, the patient does actually bleed to death, either from the first free flow Fig. 663. Blood Mass about Tube. Indicating the condition where there has been rupture of the tube, with repeated slight hemorrhages, resulting in a large mass of blood and exudate, which surrounds the tube. or from a renewal of the bleeding due to vomiting, l)Owel movement, sitting up or otlicr disturbance of tlie newly formed clot. 5. Tubal Abortion. If the place of lodgment of the fertilized ovum happens to be near the outer end of the tube (Fig. 661), the resulting enlargement of the lumen of the tube by the developing eml)ryo opens the ends of the tube, and the embryo with its membranes is likely to be extruded from the end of the tube into the peritoneal cavity. This is called "tubal abortion" (Figs. 666, 667). Tubal abortion is accompanied Avith more or less intraperitoneal bleeding and gives rise to practically the same symptoms as tubal rupture, PATHOLOGY 769 except not usually so severe. A considerable proportion of cases of supposed tubal rupture are really eases of tubal abortion, particularly those resulting in pelvic liematocole or a sliglit mass higher about the tube. 6. Rupture Into Broad-Ligament. When tlie break in the tube wall takes Fig. 66-1. Tubal Pregnancy, with Rupture into the Peritoneal Ca\ity. (Gilliam — Practical Gynecology.) Fig. 665. Tubal Pregnancy with Intra-peritoneal Rupture, showing the blood in the peritoneal ca\-it.y among the intestinal coils. (Dickinson — American Text-book of Obstetrics.) place between the layers of the broad-ligament, the hemorrhage is into the connective tissue of the pelvis — forming a "hematoma," as shown in Fig. 668. The hemorrhage may be moderate, forming a hematoma in one broad-ligament, or it may be severe, forming a hematoma which gradually extends until it fills most of the connective tissue space in one or both sides of the pelvis. If 770 EXTRA-UTERINE PREGNANCY the extruded embryo coutinues to grow in the broad-ligament, then arises the condition designated as "broad-ligament pregnancy." 7. Interstitial Pregnancy. Ti'hen the ovum lodges and develops in the inter- Fig. 666. Tubal Pregnancy, \sith abortion through the abdominal end of the tube into the peritoneal ca%ity. The end of the tube is dilated, but the structures have not yet been extruded. (Kelly — Operative Gynecology.) Fig. 667. The Clots, ^Membranes and Embryo ex- truded into the peritoneal ca^ity in the case of Tubal Abortion shown in Fig. 666. (Kelly — Operative Gyne- cology.) stitial portion of the tube (Fig. 661 j, the resulting condition is known as "interstitial pregnancy." This is peculiar in that the development takes place "udthin the wall of the uterus, though outside the uterine cavitj^ (see Fig. 668. Hematoma. In the left broad ligament is indicated a small hematoma from rupture of the tube In the right broad ligament is indicated a much larger hematoma. PATHOLOGY 771 Fig. 371). In this form of tul)al pregnancy, rupture of the gestation sac usually does not take place until much later than with the ordinary form. Also, the rupture may in some cases be into the uterine cavity. Consequently there is a possibility of this form of tubal pregnancy terminating as a normal (intra-uterine) pregnancy. Interstitial pregnancy in the early stages ap- proaches in symptoms and signs very close to normal pregnancy, and hence presents more difficulties in diagnosis than a pregnancy farther out in the tube. It is difficult and sometimes impossible before operation to distinguish between interstitial pregnancy and pregnancy in a rudimentary horn of the uterus (cornual pregnancy). The latter is an intra-uterine pregnancy in an abnormally shaped. uterus and does not belong to the affection now under consideration (extra-uterine pregnancy), though it may require the same operative treatment, as, for example, in the case shown in Fig. 409. Fig. 669. Mother and Child in a case of Extrauterine Pregnancy, operated on at full term. (Cragin — American Gynecological and Obstetrical Journal.) 8. Ovarian Pregnancy. If the developing ovum is found "vvithin the ovary, it constitutes ''ovarian pregnancy," of wiiicli a few well-substantiated cases have been reported. 9. Wandering Pregnancy. If the pregnancy is found in the peritoneal cavity without any apparent connection with the tubes, or uterus, or ovary, it is called a "wandering pregnancy," after the manner of designating fibroids which have lost their connection Avith the uterus. Such a pregnant mass (fetus and surrounding membranes) may be attached to and receive blood supply from various structures. In an interesting case reported by Tuholske the placenta was attached to the liver, creating a most serious condition. "Abdominal pregnancy" is a general term which has been used to designate cases of pregnancy developing in the peritoneal cavity, with or without connection with the tube or ovary. 772 EXTRA-UTERINE PREGNANCY 10. Extrauterine Pregnancy Carried to Near Term. The fetus may develop to term or nearly so. The embryo and membranes remain attached to the tube and derive nourishment there, and the fetus develops in the peritoneal cavity almost the same as in the uterus. Again, the embryo and membranes may be extruded entirely from the tube and find attachment to some adjacent structure, from which nourishment is derived, or to some distant structure — for example, the liver, as in the case above mentioned. Tuholske reported a most interesting case in which the placenta was attached to the liver. In this class of cases, if the patient survives long enough and the fetus continues to grow to term, false labor pains come on and the child dies, and it then consti- tutes a foreign body in the abdomen (Fig. 422). This may lead to peritonitis and death of the mother, or the dead child may become somewhat encapsulated and remain for months or years, constituting a "lithopedion" (Figs. 423 and 424 show such a case). In rare instances of extra-uterine pregnancy carried to near term the child has been saved alive by operation. Fig. 669 shows the child and the mother in one such case. SYMPTOMS AND DIAGNOSIS. Before Rupture. The first rupture of the tube with slight bleeding takes place within a few weeks after the lodgment of the fertilized ovum. Previ- ous to this primary rupture the symptoms are practically those of an early pregnancy. The patient goes over her menstrual time without the menstrual flow appearing. There is some nausea, usually most marked in the morn- ing, and perhaps some tenderness of the breasts. Pain is not necessarily present. There may be some soreness in the pelvis, either general or localized to one side, but this is rarely troublesome enough to arouse suspicion of any- thing abnormal, for some soreness through the pelvis is very common in normal pregnancy owing to the marked congestion and the enlarging uterus. Pelvic examination at this stage shows some tenderness about the adnexa of one side, and perhaps a small mass, due to the enlargement in the tube. However, the normal ovaries are usually tender, especially when congested, as in early pregnancy, and the tenderness is frequently more marked on one side. The small mass in the tubal region is really the only positive evidence of any abnormal condition within the pelvis, and as far as known this mass may have been there for a long time, due to some previous trouble. Unless a previous examination has shown the pelvis to be clear, making it certain that the little mass is of recent development, the diagnosis of tubal pregnancy is hardly justified, for there is not sufficient evidence to establish it. A diag- nosis based upon such insufficient evidence will prove erroneous in the great majority of cases, as has been amply demonstrated by the operative results from such hasty diagnoses. In exceptional eases the soreness will be so well localized to one side and so marked, particularly on exertion, and the tenderness of the little mass so very pronounced on palpation, in a patient previously perfectly well, that a diagnosis of tubal pregnancy with operation for the same before rupture may be safely made. But such cases are very SYMPTOMS AND DIAGNOSIS 773 rare, the conditions so closely simulating normal pregnancy that no suspicion of abnormality is aroused, or, it' aroused, tlie examination signs are not positive. I am satisfied that a large proportion of the cases set forth as diagnosed and operated on "before rupture" are really not seen until after the primary rupture. There may not be much disturbance from this first rupture, only a very sliglit hemorrhage taking place. But this is sufficient to give the few sharp pains, and the persistent soreness, and the markedly tender mass without apparent cause — the three symptoms that occupy such an important place in the diagnosis of tubal pregnancy after rupture. Be careful (1) to make a pelvic examination in every case of early preg- nancy in which there is sufficient pain or soreness in the pelvis to arouse suspicion of some abnormality, (2) to make no positive diagnosis of tubal pregnancy unless the physical signs justify it, and (3) to pronounce no case "before rupture" which shows blood in the pelvis, or recent plastic exudate and adhesions about the tube, or damage to the peritoneal coat of the tube at the time of operation. Rupture with Repeated Moderate Hemorrhages. In the majority of cases tubal pregnancy after the primary rupture presents the symptoms and signs of ordinary acute or subacute pelvic inflammation (salpingitis), but with certain peculiarities. Suppose that you are called to see a patient with pain in the pelvis and lower abdomen, and a tender mass beside the uterus or behind it. Is the trouble ordinary pelvic inflammation or is it tubal pregnancy with resulting inflammation ? As ordinary pelvic inflammation, in the form of salpingitis, is the more common affection, it is to be assumed that the trouble is ordinary pelvic in- flammation and not tubal pregnancy, unless there are special symptoms point- ing to the latter. The special symptoms pointing to tubal pregnancy (but not pathognomonic of it) are as follows: 1. A Missed Menstruation. The patient, previously regular in her menstrua- tion, fails to come unwell at the proper time. She goes overtime a few days or a week, or several weeks. 2. Sudden Onset of Pain. After going overtime for a few days or a few weeks, the patient is suddenly seized with pain in the pelvis, usually severe enough to confine her to bed, and in exceptional cases she is completely prostrated and in collapse. 3. Bloody Vaginal Discharge. Usually within a few days of the onset oi the pain a blood-stained vaginal discharge appears. The patient regards this as the return of the menstrual flow. But generally it is not so free as the regular menstrual flow, and does not stop in a few days as the menstrual flow should, but persists as an irregular bloody discharge for a week or two — some days present and other days absent. In some cases there are shreds of mem- brane and blood-clots in the discharge, leading to the supposition that a miscarriage has taken place. 4. Only Slight Fever. The temperature may go up to 102° or even higher 774 EXTRA-UTERINE PREGNANCY at the onset of tlie trouble, but after that it usually ranges about 100° and may go to normal. The absence of marked fever is one of the strong points in distinguishing tubal pregnancy from early abortion, -with persistent bloody discharge and infection and salpingitis. 5. Evidence of Internal Hemorrtiag'e. This Trill, of course, vary with the amount of blood lost internally. If the internal hemorrhage is free, the patient may be in collapse within a few minutes after the onset of the pain. In other cases the internal bleeding is so slight as to produce no effect on the patient's pulse or color — but it causes pain. 6. Exacerbations of Pain without Apparent Cause and without Decided Elevation of Temperature. This is characteristic of those cases of tubal preg- nancy in which there are repeated slight internal hemorrhages. In salpingitis, with the patient c^uiet in bed, such exacerbations of pain could be caused only by an increase in the inflammatory process, and this would be accompanied by a decided rise in temperature. 7. Signs of Pregnancy. Some of the early signs of pregnancy may be present — for example, stomach disturbance, or pain in the breasts, or softening of the cervix uteri. 8. Absence of Intrauterine Pregnancy. It may be very difficult to deter- mine, in a given case, whether the trouble is tubal pregnancy with slight hemorrhage, or an incomplete abortion with persistent bleeding and mild sepsis and salpingitis. In such a doubtful case the uterus may be cleared out with the curet and the scrapings examined. If there has been recent pregnancy within the uterus, the microscopic examination of the tissues removed will show chorionic villi. If the trouble is tubal pregnancy, there will be no fetal structures in the scrapings. This procedure is somewhat dangerous, for, if tubal pregnancy be present, a fresh hemorrhage and a serious one may be started by the manipulations. Consequently, curetment should be employed in these doubtful cases only when serious symptoms make a positive diagnosis necessary at once. In such a case the operator should have arrangements made so that immediate abdominal section may be carried out should threatening symptoms indicating internal hemorrhage arise during the process of curetment. Usually in tubal pregnancy the internal hemorrhage is not severe at first, and there may be a number of these slight hemorrhages at intervals of a few days or a few weeks. The hemorrhages are not severe enough to affect the patient's pulse appreciably. They cause only pain and the evidences of peMc inflammation. The symptoms and diagnosis in this class of cases are well shoA^Ti by the follo"wing typical case : Patient thirty-se , v^n years of age. General health good, riau one child seven years ago. No pregnancy since. Never had any uterine or pelvic trouble. Menstruation was regular, every twenty-seven days, until about two months before I saw her. The last regular menstruation occurred December 3. The flow was in every way normal and at the right time. December .30 was the time for the next flow to appear, but it was missed entirely. The patient felt well and there was no reason why the menses should stop, aside from pregnancy. There was some nausea, the breasts began to enlarge SYMPTOMS AND DIAGNOSIS 775 and were somewhat painful, and the patient supposed herself pregnant. She felt well up to January 26. That was the day for her menses to appear, supposing she had not missed. The previous day she had been doing extra work, but slept well. In the morn- ing she arose and went about her usual household duties, feeling well. About 8 a. m., while still engaged with her light work, she was seized with a sudden severe pain in the pelvis. The pain was intense. She managed to get to the bed and threw her- self across the foot of it. Her physician was called and found it necessary to give morphine and to repeat it. This, of course, relieved her very much, but still the least change of position increased the pain and not until evening could she be moved enough to remove her dress and arrange her in bed. Her temperature as then 102°. In questioning her later, I could get no history of shock. The patient did not remem- ber having felt particularly weak or faint or nauseated — she noticed only the severe pain. Morphine and other preparations of opium were continued in small doses occa- sionally for several days. . Hot stupes were applied to the lower abdomen and frequent doses of salts were given to relieve the constipation. The pain and soreness gradually became less. The temperature varied from 101° to 99°. On the third day a bloody vaginal discharge appeared. This was not like the menstrual flow, but was scanty and irregular. It continued a few days and then stopped. There were no membranes or large clots noticed. In about a week the patient was feeling so much better that she sat up for an hour or two. The pain then reappeared and she was obliged to return to bed. More or less pain and soreness through the pelvis continued, and this time she remained in bed ten days. There was more vaginal discharge, but it was not profuse nor irritating. It was occasionally streaked with blood. After ten days in bed she felt so well that she sat up in a chair fcr a short time. No disturbance fol- lowing this, she sat up the next day a little longer. After five days she walked out to the dining room and helped about the table. She had then been free from pain for several days. The next day, however, the pain returned. It was not severe, but she remained in bed. The following morning the pain was worse, and I was then called in consultation — about three weeks after the beginning of the attack. I found the patient confined to her bed with pelvic pain and decided tenderness over all the lower abdomen. Good pulse, good color, temperature 99°. On vaginal and bimanual examination I found marked tenderness all about the uterus. In the right tubal region there was a small hard mass about the size of the ovary, but much harder and not movable. In the left tubal region there was a larger, softer mass, which apparently occupied nearly all the left side of the pelvis. It was so soft that the borders were not distinct. Both masses were situated rather high, but there was so much tenderness that I could not press into the pelvis deep enough to satisfactorily outline them. There was apparently no exudate in the cul-de-sac of Douglas. There was a slight vaginal discharge streaked with blood. Taking into consideration the history of the case and the findings on examination, I made a diagnosis of tubal pregnancy, with rupture three weeks previously and re- peated slight hemorrhages since. I could not tell which tube the pregnancy was in, for there was a tender mass on each side of the uterus, so I would not venture a diagnosis in that respect. However, I was inclined to think that the pregnancy was situated in the right side, as that mass was the firmer and its outlines more distinct. I advised that the patient be brought to the city at once for operation. You may think that rather risky advice for a case of ruptured extra-uterine pregnancy. But I was satisfied that the focus of disturbance was well surrounded by plastic exudate, and that a trip on the train with the patient flat on the stretcher all the time would not be attended with much risk, particularly in view of the fact that she had already been up and walking about. I had gone to the town prepared, of course, to do what- ever was necessary at the house, but I concluded that the increased safety of the operation in a hospital outweighed the danger of the trip. The trip to the hospital 776 EXTRA-UTERINE PREGNANCY caused no particular disturbance. When I opened the abdomen I found blood-clots and adhesions about the left tube. The outer part of the tube was enlarged to the size of a lemon and contained the fetus and membranes still attached. The situation of the mass of blood clots and exudate was rather unusual. It was principally in front of the uterus, over the bladder. The small mass in the right side had no con- nection with the tubal pregnancy. It was the right ovary surrounded and bound down by adhesions. After the left tube and ovary had been removed and the mass of blood- clots cleared out, the right ovary was freed from its adhesions and left in place. The patient recovered without incident.* In this case there was no evidence of sudden profuse loss of blood, and from my observations I am inclined to the opinion that this holds good in a large majority of cases of extra-uterine pregnancy. Rupture with Profuse Hemorrhage. In exceptional cases there is a sudden loss of a large amount of blood into the peritoneal cavity. In such a case the symptoms are striking and urgent. The patient's face is blanched, her nose and forehead and fingers are cold, the pulse is rapid and weak and fail- ing, a cold sweat appears on the face, respiration is short and labored — and over all is the intense pain, which is due to the blood spreading through the peritoneal cavity, and of which the patient complains as long as she has sufficient strength. These are desperate cases. This sudden profuse hemor- rhage may appear with the first attack of pain, or the first hemorrhage may be slight, the severe hemorrhage taking place after several hours or several days. The following case, from my records, gives a practical idea of the clinical features of the cases of this class : About nine o'clock one morning I was called by telephone to see a woman who, the message stated, was having severe pain in the abdomen. When I reached the house the pain had diminished considerably, but was still very troublesome. It was diffuse throughout the lower abdomen and was accompanied by marked tendei'ness over the same region. The abdominal muscles were tense. Movement of the patient in the bed or jarring of the bed increased the pain. Patient's color was good. Tempera- ture was 99°. Pulse was 76, full and regular. There was a bloody vaginal discharge, which had appeared the day before and which the patient thought was her menstrual flow a few days delayed. The history obtained was that the patient's previous health had been good, that menstruation had been regular (about every 28 days) and painless. Nothing out of the ordinary was noticed until one week before. It was then her time to come unwell, but the flow did not appear. She thought nothing of this, as she occasionally went a few days over time. She felt well and there was no nausea or other indication of preg- nancy. In a few days a bloody flow appeared. This was not so free nor so dark as the regular monthly flow. But the patient supposed it to be the menstrual flow, and she continued to attend to her household duties without discomfort. The morning I was called she had been superintending her household work as usual. While standing by a table she was seized with severe pain in the lower abdomen. She was lifted to a chair and the pain became less, and she ate breakfast. In an hour the pain had almost disappeared and she went upstairs, and felt very comfortable while sitting reading. She felt a desire to go to stool and during the bowel movement the pain returned with increased severity, so that she had to be helped to her room. ♦Report of Two Cases of Pregnancy Requiring Operation, by H. S. Crossen, M. D.— St. Louis Medical Re- view, August 24, 1901. DIFFERENTIAL DIAGNOSIS 777 When I sav/ the patient, about an hour hiter, she was in good general condition, as already explained, and with no decided symptoms except the abdominal tenderness and pain on movement. Vaginal examination showed the uterus slightly enlarged and softened, and the whole interior of the pelvis very tender. The least movement of the uterus caused pain. The pelvic tenderness was so marked that satisfactory bimanual examination was not possible. No mass could be felt to either side of the uterus nor behind it. The cervix was closed. The marked and widespread tenderness In the pelvis and lower abdomen showed there was something more serious than a simple miscarriage, which patient had concluded was the trouble. The sudden onset of intense pain, with complete absence of previous disturbance and without fever, excluded peritonitis due to inflammation of the tubes or appendix. There was no evidence of intestinal obstruc- tion, or volvulus, or intussusception. The pain and hyperesthesia were not due to any drug habit, for the patient had no such habit. The diagnosis of extra-uterine pregnancy was fairly clear, in spite of the fact that no pelvic mass could be located. I wished to get the patient to the hospital before operating, and, as the first hemorrhage had evi- dently been slight, I though that by keeping her perfectly quiet for a day or two she could be safely moved. I gave orders accordingly. The spontaneous pain in the lower abdomen subsided and the tenderness gradually diminished. By evening the patient was comfortable when perfectly quiet. The next morning the patient was much improved and was feeling comfortable — so comfortable that she did not consider herself very sick, and did not take kindly to the injunction to lie quiet in the bed and on no account to raise up. That afternoon the pain returned to some extent, but it was not severe, and I saw nothing to indicate that the patient would not be in good condition the next morning for the trip to the hospital, where a room had already been engaged for her. But near midnight I received a message that the severe pain had returned and that the patient was short of breath. Hurrying to the house, I found the patient in collapse. The pulse was small and rapid, the fea- tures were blanched and pinched — the greatest possible contrast to the rosy, robust appearance which she presented a few hours before. The extremities were cold, and a cold perspiration stood out on the face. Dyspnoea was present, but the patient com- plained only of the intense abdominal pain, which seemed to be increasing. The hemorrhage was still going on, as evidenced by the increasing widespread pain and the continued failing of the pulse. By the time the hasty preparations for the neces- sary operation were completed, the pulse was thready and at times scarcely per- ceptible. The patient told me afterwards that she believed she was dying, as she could feel the chill on the extremities creeping closer and closer towards the trunk. When preparations were completed, the patient was etherized and the abdomen opened. The peritoneal cavity was full of blood. The ruptured tube was quickly located by touch and clamped. That stopped the bleeding temporarily. The principal part of the blood was then cleared out of the abdomen, the affected adnexa removed, the peritoneal cavity flooded with hot normal saline solution and the abdomen closed. The patient was almost pulseless and continued in that condition for 40 hours in spite of all stimulating means. Good reaction then gradually came on and the patient im- proved rapidly and made a perfect recovery. Subsequently she informed me that late in the afternoon before the nearly-fatal hemorrhage she was feeling so well that she sat up in bed to take nourishment and to chat with friends, regarding my strict admo- nition to keep perfectly quiet on her back as "overcautious." DIFFERENTIAL DIAGNOSIS. This subject is of interest to every one called to make a diagnosis in acute abdominal affections, for in many cases diagnosticated and operated on as tubal pregnancy the operation revealed that the trouble was not tubal preg- 778 EXTRA-UTERINE PREGNANCY nancy, but some entirely different affection. There are many conditions that may simulate one or more of the principal symptoms of extrauterine pregnancy, and these must be taken into consideration in the differential diagnosis. The cardinal symptoms of early tubal pregnancy are (1) a missed menstrua- tion, (2) sudden onset of pain (with or without shock), (3) bloody vaginal discharge, (4) a tender mass beside the uterus, (5) only slight fever, and (6) exacerbations of the pain and enlargement of the mass without corre- sponding elevation of temperature. In atypical cases there may be decided fever or onset of pains mthout missed menstruation or other variations from the rule. Again, the internal hemorrhage may be very severe at first, requir- ing a diagnosis at once before the appearance of later confirmatory evidences. It may be impossible to feel a mass, for the liquid blood itself gives no well- marked resistance and yet causes so much tenderness that the enlarged tube can not be satisfactorily palpated. Freshly coagulated blood gives a boggi- ness, but not a distinctly outlined mass. After a short time there develops a distinct mass, due to the fibrin and adhesions and infiltration associated with the blood clot. The difficulties of differentiation are due largely to the fact that many cases of extrauterine pregnancy are atypical in symptomatology — ^present- ing some of the prominent symptoms, but lacking others. Now, there are other affections that may present two or three of the prominent symptoms of tubal gestation, and if the distinguishing characteristics of the other affection happen to be absent or obscured a mistake in diagnosis is probable. Space will not permit consideration of all the conditions that may simulate tubal pregnancy; only a few of the more common ones may be discussed. These may be grouped into two classes — first, those conditions in which the principal feature is a tender pelvic mass, associated with some of the other symptoms of tubal pregnancy, and, second, those conditions in which the principal feature is sudden abdominal pain and collapse without apparent cause — i. e., without the disturbances that usually precede or accompany col- lapse from other diseases. These two main groups may be further divided into sub-groups. 'My object here is to put the reader in practical touch witl- the more common conditions that may simulate tubal pregnancy, that he may be on guard against them and thus avoid mistakes. The most satisfactory way to do this is to give actual examples — i. e., to describe the conditions present in cases that have actually simulated tubal pregnancy so closely that they were mistaken for it. In each of the following cases the symptoms were so deceptive that they caused a mistake in diagnosis. There is space for only one example under each of the deceptive conditions. iMany other examples, with references, are given in a recent article* on the subject. ♦Conditions Simulating Tubal Pregnancy by H. S. Crossen, M. D. Read in the Section on Obstetrics and Diseases of Women of the American Medical Association, at the Sixtieth Annual Session, held at Atlantic City, June, 1909.— /our. Am. Med. Assn., Vol. LIV, p. 519. CONDITIONS SIMULATING TUBAL PREGNANCY 779 A Tender Pelvic Mass with Other Symptoms of Tubal Pregnancy. Gonorrhoeal Salpingitis. Witli no other disease have I experienced so much difficulty in diffcrontiatiou from early tul)al pregnancy as with salpingitis of gonorrhoeal origin. Typical cases of salpingitis are, of course, easily dis- tinguished from typical cases of tubal pregnancy. The difficulty lies in the fact that either may be atypical, and as they become atypical they may approach each other until their manifestations are practically alike — that is, gonorrhoeal salpingitis (atypical) may produce the symptoms and signs of tubal pregnancy (slightly atypical). Such cases are not very frequent, but they are encountered occasionally in the examination of a large number ot cases of supposed extrauterine pregnancy, and when encountered they prove most deceptive and misleading. Chronic Gonorrhoeal Salpingitis. — Patient, aged 32, referred to me by Dr. J. D. Beatty, of Troy, Mo. Last normal menstruation August 10. In September went over time ten days. Felt as well as usual and supposed herself pregnant. No stomach dis- turbance or breast pains. About September 20 had a scanty flow for two days. She felt well and there was no further bloody discharge for two weeks, when it started again. A day later she was seized with severe pains extending all through the lower abdomen. No shock, just pain, at times cramp-like. This pain continued off and on for a week. Patient was confined to bed and had to be given morphine. A physician was called and made a diagnosis of abortion. No membrane passed and there was only one small clot. Patient was then curetted, but not much was obtained — apparently only some thickened endometrium. No fetus or membranes or shreds of tissue were seen at any time. Pa- tient felt better after the curetment, but still continued sick, confined to bed with abdominal pain and tenderness. Temperature 99° to 100°. Twelve days later, as there was no material improvement, the uterus was curetted again, but without result. The trouble continuing, Dr. Beatty was called in consultation. The abdominal pains and tenderness continued and the temperature then (after the second curetment) ranged from 100° to 101°. Six days after the second curetment the patient was brought to St. Louis and placed under my care. Examination. — This showed the uterus retrodisplaced and fixed, and blended with a tender mass of adnexal origin extending into both sides of the pelvis. The average temperature was 100°; pulse, 98; respiration, 20. The lowest temperature was 99.2° and the highest 100.6°. Diagnosis. — There was evidently serious adnexal trouble of apparently recent origin, and any one of the following conditions was possible: (1) salpingitis following miscar- riage, (2) an acute exacerbation of a chronic salpingitis, and (3) tubal pregnancy with repeated slight hemorrhages. Against the first were the low temperature (much lower than consistent with an acute infection of sufficient severity to cause the symptoms) and the absence of evidences of miscarriage. Against the second were the low tem- perature with acute symptoms, no history of preceding severe symptoms indicating old suppuration in the pelvis (though there had been mild pelvic distress for some years) and the association of the trouble with missed menstruation, followed by sud- den onset of pain and the appearance of an irregular bloody vaginal discharge. If due to an old inflammatory trouble, one would expect the menstrual flow to be increased instead of missed, and the pain and other symptoms to be of rather gradual onset and increasing in severity as fluctuation appeared in the mass. In favor of the third (tubal pregnancy) were missed menstruation followed by sudden onset of pain, irregular bloody discharge, absence of positive evidence of a miscarriage, and the presence of fluctuation in the mass, associated with low temperature (much lower than was con- 730 EXTRA-UTERINE PREGNANCY sistent with a pocket of pus). It seemed a fairly clear case of tubal pregnancy — one of the class frequently met, in which there is no great loss of blood at one time, but re- peated slight hemorrhages with a gradually increasing mass. Accordingly that diag- nosis was made. Operation. — On opening the abdomen no tubal pregnancy was found. The trouble was chronic adnexal inflammation— there being a tubo-ovarian abscess on the left side, which gave the fluctuation, and chronic salpingitis on the right side, the remaining part of the mass being formed by adhesions and exudate. The damaged adnexa and the chronically inflamed appendix were removed and the uterus fastened forward. The patient made a prompt recovery with complete relief. Careful bacteriologic investigation of the removed adnexa showed no bacteria of any kind. This excluded recent infection. The case was evidently one in which there was a gonorrhoeal infection long ago (there were confirmatory facts in the history), the development of pyosalpinx with only slight symptoms of a mild character, the death of the bacteria (which commonly takes place in gonorrhoeal pyosalpinx), and the per- sistence of sterile pus in a sac which acted as an irritating foreign body in the pelvis. No evidence of pregnancy was found. Why the menstruation was missed I can not say. In some other cases of gonorrhoeal salpingitis I have encountered this misleading symptom. Acute Double Salpingitis.— Patient, aged 19, referred to me by Dr. George F. Chopin, of St. Louis. About two weeks after marriage she failed to come unwell properly. At the menstrual time there was a slight bloody discharge, but not a good menstrual flow. There was some soreness and pain in the pelvis. After this had continued a few days she was seized with sudden severe pain in the lower abdomen, accompanied by shock. With the weakness and faintness and pain she could hardly move, even to turn over in bed, for several hours. The severe pain gradually subsided, but marked soreness remained, so much so that the patient was obliged to lie very quiet. A physician who was called examined the patient and said that she was having a miscarriage. A par- tial curetment was carried out, but only a small amount of blood was removed. No fetus, membranes or large clot was passed at any time. The patient and her husband then became uneasy at the apparent seriousness of the trouble and the day after the curetment called Dr. Chopin, who asked me to see the patient. Examination. — The patient was confined to bed with pain in the lower abdomen and a bloody vaginal discharge. There was marked tenderness on abdominal and bimanual examination, and there was a boggy induration on each side of the uterus with marked tenderness. No membranes or shreds were found in the cervix or in the bloody dis- charge. The discharge was blood and mucus, without noticeable pus admixture. The trouble seemed to be around the uterus rather than in it. The temperature was low, fluctuating between 100° and 101°. Here was a patient, apparently previously healthy, seized with a severe abdominal pain and decided shock, associated with imperfect menstruation, an irregular bloody discharge, a tender mass partially surrounding the uterus, and low temperature. I made a tentative diagnosis of tubal pregnancy with some internal hemorrhage, but, not being entirely satisfied, I concluded to watch the case for a while. Under mild sedatives and strict confinement to bed the patient became very com- fortable. The temperature ran about 100°. After a few days she felt so much better that, without my permission, she began to go to the washstand. On one of these trips across the room she was seized with pain and almost fainted before she could reach the bed. There was then more pain and pelvic soreness and an increase in the tender mass about the uterus. I then insisted on the patient's removal to the hospital, where she was kept under observation for five days longer. On admission the temperature was 101.2°; pulse, 100; respiration, 24. There was considerable abdominal pain, re- quiring a sedative occasionally. The next day the temperature was 99° and for four days did not go above 99.6°. In the meantime the patient felt comfortable, could sleep CONDITIONS SIMULATING TUBAL PREGNANCY 781 well, her appetite returned, and the pelvic soreness diminished. The bloody discharge continued. The fifth day, without apparent cause, the abdominal pain returned and became very severe. The pulse rose to 132; temperature, 100.6°; respiration, 24. On examination the tender pelvic mass was found to be larger. The tentative diagnosis of tubal pregnancy seemed confirmed by the spontaneous recurrence of severe pain, the rapid pulse, and the continued enlargement of the pelvic mass with low tempera- ture. Operation. — When I opened the abdomen I found there was no extrauterine preg- nancy, but instead an acute double salpingitis, with leakage of pus into the peritoneal cavity and the formation of extensive adhesions. The tubes were so badly damaged that I thought best to excise them. After establishing free drainage of the infected area, I explored the interior of the uterus, thinking that possibly there had been a miscarriage after all, with infection following it; but- no evidence of pregnancy was found. The patient recovered without particular incident. Examination of the pus from the tubes showed gonococci in abundance and in pure cultures. The case was one of gonorrhoeal infection following marriage, the Infection affecting the vagina but slightly and passing rapidly up into the uterus and tubes and out into the peritoneal cavity. A striking fact, and perhaps the most misleading one in this particular case, was the absence of the usual evidences of acute gonorrhoeal vaginitis (burning on urination, vaginal tenderness, and free purulent discharge). These were so slightly marked that there was no suggestion of the trouble being acute gonorrhoea. The purulent character of the discharge was obscured by the blood in it. Had I examined the discharge microscopically, gonorrhoea would at once have been evident. It may be thought that some fever is enough to exclude tubal pregnancy as the causative factor, but such is not true, for in many cases of extrauterine pregnancy with hemorrhage the temperature will run up temporarily to 102° and higher. The following is a case in point: Mrs. P., aged 31, admitted to the Gynecologic Department of Washington University Hospital. On ad- mission her temperature was 101.4 and pulse 140. She gave a clear and typical history, and the diagnosis of ruptured tubal pregnancy was positive. The hemorrhage had been so severe, however, that she was in very poor condi- tion for operation. The hemoglobin had been reduced to 30 per cent., which made operation or even anesthesia alone very dangerous. As the hemorrhage had stopped and she was improving, it was decided to defer operation until it could be carried out ivith less danger. The waiting period was seven days. During that time the temperature went up to 102° nearly every day and one day reached 103.4. After seven days the blood condition had improved (hemoglobin above 40 per cent.) and she was so much improved otherwise that operation was carried out. There was no pus in the peritoneal cavity— simply the unabsorbed blood. The patient recovered promptly. Miscarriage with Abnormalities. Various conditions associated with mis- carriage may lead to a mistaken diagnosis of tubal pregnancy— for example, an old inflammatory mass or a tumor. Miscarriage and Ovarian Tumor.— Reported by Brown. A patient who had missed the menstruation for three weeks, and had all the symptoms of pregnancy, was at- tacked with pains through the lower abdomen. A physician was called and found the patient confined to bed, with abdominal pain, partial suppression of urine, tempera- ture of 102.5°, and evidently severe inflammation from some cause. 782 EXTRA-UTERINE PREGNANCY Examination. — The uterus was found pushed back by a large mass in the right side of the pelvis. The physician watched the case for four or five days, and felt con- fident that the trouble was tubal pregnancy, with rupture, hemorrhage, and resulting inflammation. Dr. Brown, who was asked to see the case, made the same diagnosis. Operation. — This revealed an ovarian cyst and general peritonitis. Exploration of the interior of the uterus showed that there had been a recent abortion. The mis- carriage was evidently the cause of the peritonitis, which eventually proved fatal. Miscarriage and Broad-Ligament Tumor. — Reported by Fortun. This case presented practically the same features as the preceding one — namely, missed menses, abdomi- nal pain, bloody discharge and a tender mass beside the uterus. Diagnosis, extrauter- ine pregnancy. Operation demonstrated that the symptoms were due to a tumor (sarcoma) of the broad ligament, associated with an abortion. Pregnancy with Abnormalities. There are various anomalous conditions that may cause an intrauterine pregnancy to simulate an extra-uterine preg- nancy. Pregnancy with Hydatidiform iViole. — Mrs. S., aged 21, came into my service at the St. Louis Mullanphy Hospital with a diagnosis of extrauterine pregnancy. There had been no menstruation for two months, and there were the usual symptoms of early pregnancy. Recently the patient had been having attacks of pain in the lower abdo- men, accompanied by a bloody discharge. These attacks of pain had been irregular — at times severe and confining her to bed, while at other times she was able to be about the house. Finally they became so disabling that she was brought to the hos- pital. Examination. — When I saw her she was confined to bed, with a mass the size of an orange pushing forward the anterior abdominal wall just above the pubes. The mass was firm, painful on pressure, partially fixed, and it was here that the patient located the pain and distress. There was a bloody vaginal discharge. Temperature, pulse and respiration were practically normal. On bimanual examination the deeper portion of the mass could be made out, and it was found to be the size of a child's head. Indis- tinct fluctuation was obtained. The body of the uterus could not be made out, but the impression obtained was that the mass lay in front of the corpus uteri, which was. pushed, backward and could not be felt on account of the mass. The forward projec- tion of the mass against the abdominal wall was very marked. I was inclined to agree with the diagnosis of extrauterine pregnancy, but was not entirely satisfied, as I had not located certainly the body of the uterus. I concluded to watch the case for a while. The patient was kept absolutely quiet and sedatives were given as needed for the pain. The patient was better for a time, but later the pain re- curred. It troubled her every day, at times quite severely, but could not be identified as uterine contraction pains. No variation in the consistency of the mass was noticed. The bloody discharge continued. A few very small clots were noticed, but no mem- branes or shreds. I continued the observation for ten days, and the longer I observed the more confusing the conditions became. The process, whatever it was, was pro- gressing rather rapidly. In the ten days the mass had enlarged decidedly and the pain had increased — so much so that at the end of the period it was evident that something must be done, as further prolongation of the trouble would seriously weaken the pa- tient, who was not very strong at the beginning. The crucial point, which so far I had been unable to decide, was whether the mass was uterine or extrauterine. Operation. — I decided to examine the patient under anesthesia, having everything ready to operate in case the mass proved to be extrauterine. Under the complete relaxa- tion of anesthesia I was able to determine that the cervix expanded symmetrically into the mass, which was thus identified as the body of the uterus. It was found, however, to CONDITIONS SIMULATING TUBAL PREGNANCY 783 be twice as large as it should be at that period ol" pregnancy. This abnormal enlarge- ment with the prolonged bloody discharge and the increasing pain made it evident that there was some serious pathologic condition within the uterus and not a normal preg- nancy. I dilated the cervix slightly, and there escaped several small cysts. That made the diagnosis plain, and I then dilated the cervix widely and removed from the uterus a beautiful specimen of hydatidiform mole. The uterine cavity was literally packed with the grape-like bunches of minute cysts characteristic of this condition. No trace of a fetus as found. The patient recovered without further trouble, and has since given birth to two children, the pregnancy, labor and puerperium in each case being normal. Pregnancy with Hysteria and Uterine Displacement. — While I was in charge of our city hospital for women (St. Louis Female Hospital) a patient was brought into that institution on a stretcher, suffering severe abdominal pain and apparently very sick. The suffering was so great that the history was obtained with difficulty. She had missed the menses about four months, and the usual symptoms of pregnancy had been succeeded by irregular attacks of pain, which culminated in the severe attack which caused her to be hurried to the hospital. Examination. — The abdomen was sensitive and the muscles rigid. In the right lower abdomen there was a distinct mass, very painful to touch. On bimanual examination it was found that this mass extended down into the right side of the pelvis, which it largely filled. It was about the size of a child's head, extremely tender, apparently fixed and presenting indistinct fluctuation. The cervix was somewhat softened. The body of the uterus could not be made out on account of the marked tenderness and the resulting muscular rigidity, which interefered with deep palpation. The pulse was rapid, but of fair volume. There was no fever. I was quite certain that the trouble was extrauterine pregnancy. Examination under anesthesia, however, showed that it was an intrauterine pregnancy. The fixed and tender mass in the right side was the pregnant uterus, which was freely movable under anesthesia. After the examination the symptoms largely disappeared and the patient was able to leave the hospital in a short time. The misleading features were the severe ab- dominal pain and tenderness, associated with a lateral pelvic mass, which was ex- tremely tender (hysterical hyperesthesia) and fixed (by the rigid condition of the abdominal muscles), and which could not be identified as the body of the uterus (be- cause of the marked softening just above the cervix, and also because of the impossi- bility of deep palpation). Anesthesia removed the difficulties at once and permitted a correct diagnosis. This case and the preceding one serve to emphasize the necessity of careful examination under anesthesia before operation in all such doubtful or un- certain cases. It must be kept in mind, however, that when tubal pregnancy- is suspected the patient should be placed in a hospital and prepared for opera- tion before the examination under anesthesia is made, for if the trouble is tubal pregnancy the manipulations of the examination may cause rupture and hemorrhage, requiring immediate operation. Pregnancy with irregular Softening of Uterus. — A patient with supposed extrauterine pregnancy was brought to St. Louis by her physician and placed under my care. About five months previously she had missed her menses and presented the usual symptoms of pregnancy. Three months later she had abdominal pains accompanied by a bloody discharge from the uterus. The bleeding stopped, but the pain recurred at irregular intervals and there was an enlarging mass, which could not be identified as part of the uterus. Her physician called several others in consultation and the consensus of opin- 784 EXTRA-UTERINE PREGNANCY ion was that the pregnancy was extrauterine; hence she was brought to St. Louis for operation. Examination. — I found a very puzzling condition. The body of the uterus was irregu- lar in shape and irregularly softened, and gave at first the impression of a fairly firm mass not connected with the cervix, the portion immediately above the cervix being so softened as to be hardly palpable. After examining for some time it was finally de- termined that the mass was the enlarged and pregnant corpus uteri. The rhythmical hardening of the uterine wall aided materially in the differentiation. By prolonging the examination I was able to feel the previously softened portion harden under the finger, and could then make out that the upper part of the cervix expanded sym- metrically into the mass in question. After working out the diagnosis I was able to demonstrate it satisfactorily to the patient's physician, who examined her with me. Pregnancy with Retroflexed Uterus. — Reported by Royster, aged 22, married sixteen months, missed her menses three times in succession, had nausea and vomiting, and also tenderness of the breasts. Then she had an attack resembling cholera morbus and a slight bloody stain from the genitals, but no distinct hemorrhage. The signs of pregnancy then became less marked. She complained of pain in the lower abdomen, especially in the left side, and of frequent and painful urination. Examination. — There was found a mass chiefly in the left side of the pelvis and pressing down the posterior vaginal fornix. It was boggy and tender to the touch. The uterus appeared to be pushed to the right side and was intimately associated with the mass. A sound was readily introduced into the uterus to the depth of three inches, indicating that the uterus was about normal in depth and was empty. A diagnosis of ex- trauterine pregnancy was made and the patient operated on accordingly. Operation. — This revealed a retroverted pregnant uterus, twisted somewhat toward the left, and with the wall softened irregularly. There was no extrauterine pregnancy. The uterus was brought into correct position and a small cyst of the ovary removed. The patient recovered without incident and the pregnancy continued. Pregnancy and Salpingitis. — Reported by Leopold. Patient, aged 32, mother of five children, missed menstruation and had abdominal pains and bloody discharge. Ex- amination showed a painful mass occupying the posterior cul-de-sac. Diagnosis, ex- trauterine pregnancy. Operation revealed an intrauterine pregnancy, with an asso- ciated salpingo-oophoritis, probably of gonorrhoeal origin. The mass formed by the inflamed tube and ovary was low in the cul-de-sac. Patient recovered. Pregnancy with Torsion of Enlarged Tube. — Reported by Morel. Patient, aged 32, mother of four children, missed menstruation. After a time she was seized with severe pain in the left lower abdomen, had vomiting, rapid pulse and no fever. The uterus was somewhat enlarged and softened, and a tumor was felt back of it. Operation showed a pregnant uterus with a posterior mass, as large as a turkey's egg, formed by the left tube. The pedicle of the enlarged tube was twisted six times and the interior was filled with blood (hematosalpinx). Tumor with Anomalous Symptoms. When a pelvic tumor, previouslj'- un- recognized, happens to be accompanied with missed menstruation and sudden pain and decided tenderness, the resemblance to tubal pregnancy may be most misleading. Broad Ligament Cyst, with Intracystic Hemorrhage. — Mrs. D., aged 26, admitted to the Gynecologic Department of Washington University Hospital. Married five months. Previous menstrual history normal — menses regular in appearance, duration four days, no pain. One month after marriage menstruation was missed for seven days. Then a bloody flow appeared. It was profuse, accompanied by clots and lasted about nine days. About two weeks later the patient had a fall, which was followed by pain in CONDITIONS SIMULATING TUBAL PREGNANCY 785 the left side of the pelvis and lower abdomen, and this persisted. The succeeding months there was a menstrual flow, but it was less than the usual amount. The pa- tient continued sick, and had to give up work and was obliged to lie down at times. There was loss of appetite and for two months decided nausea when riding in a car, but this became less. There was also tenderness of the breasts, which had diminished during the last month. There had been no fever. The patient complained of pain in the left lower abdomen. Temperature was 99°, pulse 90, and respiration 20. Examination. — The uterus was found forward, to the right and movable. The left side of the pelvis was occupied by a mass the size of a large orange, fluctuating and tender on palpation. The diagnosis was doubtful, with the probability in favor of tubal pregnancy. Operation.— This revealed a parovarian tumor (cyst) into which hemorrhage had taken place. The cyst was easily enucleated from its bed in the broad ligament, and sub- sequent examination of it in the laboratory positively excluded extrauterine pregnancy. The patient recovered without particular incident. Parovarian Cyst with Twisted Pedicle and Salpingitis. — Patient, aged 22, admitted to Gynecologic Department of Washington University Hospital, very 111 and complain- ing of pains through the lower abdomen. Examination. — A large mass was found, filling the right side of the pelvis and ex- tending up into the lower abdomen, half way to the umbilicus. This was painful on palpation and indistinct fluctuation could be made out. The uterus was pushed to the left. All the pelvic structures were apparently bound together and fixed by adhesions. Patient was pale and complained of a constant pain in the abdomen, of a dull char- acter. Temperature, 99°; pulse, 80; respiration, 20. For ten weeks past the menstrua- tion had been very irregular. For nearly a month there was a constant bloody dis- charge, then it stopped for a few days, then came on again for a few days, and then stopped entirely. For five weeks before entering the hospital there was no menstrua- tion, not even a trace of blood. There was free mucopurulent discharge. During the period mentioned there had been considerable pain throughout the abdomen, and two weeks before entering the hospital the patient had had a very severe attack of pain. She was confined to bed for a few days and had been lying down off and on ever since. The mass was too large and of too rapid development to be due to the inflam- mation, which was apparently of mild grade. There was no previous history of a tumor. There had been some pain, off and on, during the previous year, but nothing to suggest serious trouble. The patient was kept under observation for seven days. The temperature ranged from 98° to 99.4°, once going to 100°, but never higher. The pulse ranged from 80 to 92. The mass continued to enlarge and the pain increased, requiring sedatives, in spite of the fact that the patient was kept absolutely quiet in bed and that the temperature continued low. There had been a tentative diagnosis of tubal pregnancy, and this progress under observation and the continued absence of the menstruation tended to confirm it. Operation. — The mass was found to be a parovarian cyst with twisted pedicle, uni- versal adhesions and a complicating pyosalpinx of the same side. Free drainage was employed and the patient recovered. Abdominal Pain and Collapse. "When a married woman in the child-bearing period is seized with severe abdominal pains, without apparent cause, and passes into the condition of col- lapse associated with severe internal hemorrhage, we naturally think of rup- tured tubal pregnancy as the most probable cause. If there happens to be missed menstruation or some of the other symptoms of tubal pregnancy, and 786 EXTRA-UTERINE PREGNANCY the examination reveals nothing else to account for the pain and shock, a tentative diagnosis of tubal pregnancy and action accordingly is certainly justified. As prompt action may be necessary to save the patient's life, such action must sometimes be taken on evidence which would be considered insuf- ficient were the indications less urgent. Under such conditions the diagnosis of ruptured tubal pregnancy is largely a matter of exclusion, for, as previously stated, the pelvic examination often gives no definite evidence beyond the ten- derness. Hence the importance of carefully considering other conditions tha" may cause these symptoms. There are many such conditions, but I shall men- tion only certain ones which are especially liable to be confounded with rup- tured tubal gestation. Hemorrhage from Ovary. — Weinbrenner reports two cases in which hemorrhage into a corpus luteum, already in cystic degeneration, burst the wall of the cyst. Free hem- orrhage into the peritoneal cavity followed. In one instance the tendency to hemorrhage was increased by torsion of the pedicle of the cystic ovary. The clinical diagnosis in each case was extrauterine pregnancy, 'but microscopic examination of the removed specimen showed positively that there was no pregnancy. In cases of ovarian hemorrhage, care must be taken to exclude ovarian pregnancy at the site of the hemorrhage before deciding that it is due to some other condition. Some of the so-called "blood cysts" of the ovary are, no doubt, uurecognized instances of ovarian pregnancy. The following is a case in point : Reported by J. K. Kelly. He operated on a woman, aged 33, for supposed extrauterine pregnancy and found only a blood cyst of the ovary about the size of a plum. The ovary was removed and the case set down as one of mistaken diagnosis. Some months later, and quite incidentally, a microscopic section "\vas made through the wall of the little cyst, and exami- nation of this showed chorionic villi. A careful and systematic examination was then made of the small cyst and its surroundings, and it proved to be a beautiful specimen of early ovarian pregnancy. Ovarian Cyst with Rupture. — Reported by Vineberg. In his office he was examining a woman on account of discomfort in the lower abdomen associated with delayed men- struation. The patient was stout and the bimanual examination was difficult. The uterus was enlarged and to the left of it was a cystic mass the size of a small orange. While palpating this mass it suddenly ruptured and the patient promptly went into syncope. It was supposed that a tubal gestation sac had ruptured, with resulting in- traperitoneal hemorrhage. After a little time the patient rallied, and as the symptoms were then not so urgent she was kept under observation for a couple of days. Im- provement was so marked that it was decided that the ruptured mass must have been only a small cyst of the ovary instead of a tubal pregnancy. There was no fur- ther trouble. Hematosalpinx with Severe Bleeding. — Brettauer reported a case of severe internal hemorrhage, supposedly due to ruptured tubal pregnancy. The patient went into col- lapse and became too weak for operation. Later she rallied and the operation was car- ried out. A hemorrhagic swelling, the size of a walnut, was found in the middle third of one tube. From this the severe bleeding had taken place. The inner and outer por- tion of the tube were apparently normal. The swollen area had the appearance of a CONDITIONS SIMULATING TUBAL PREGNANCY 787 tubal pregnancy and was excised as such. When sectioned and examined microscopic- ally no tubal pregnancy was found. The specimen was then sectioned serially and examined most carefully, and the result was absolutely negative so far as evidence of tubal pregnancy was concerned. The fact is sometimes overlooked that tubal swellings of hemorrhagic character are not necessarily due to pregnancy in that situation. Since Tait's famous dictum, that "hematosalpinx is always due to extrauterine pregnancy," there has been a tendency among operators to look On this as a rule without exceptions. That there are excep- tions, however, there is abundant proof. A number of well-established cases have been reported. As a rule, such differentiation is not of great practical moment, for the rea- son that treatment of the two conditions is the same — namely, removal of the damaged tube. In some cases, however, it may be extremely important to determine certainly the character of the mass before expressing an opinion as to what it is. Such an inr stance came to my notice. I was not connected w'ith the case, but was apprised of the facts afterward. Some years ago a pupil nurse in one of our hospitals was attacked with serious abdominal disturbance requiring operation. When the abdomen was opened there was found a hemorrhagic condition of one tube resembling tubal preg- nancy. The operator at once pronounced it tubal pregnancy in the presence of several internes and nurses. The information spread through the hospital with a result to be easily imagined. The young woman recovered from the serious operation only to find herself in a situation almost unbearable, and she finally left. In the meantime, examination of the mass by a competent pathologist showed that it was not a tubal pregnancy and that a most serious mistake had been made in pronouncing it such. Tubo-ovarian Hemorrhage. — Bovee reported a case in W'hich, at operation, there was found a tubo-ovarian hemorrhagic mass, supposed to be tubal pregnancy, but which proved to be only infiammatory. Both the tube and ovary were distended with blood, and there was a small opening through the fimbriated extremity connecting the two cavities. The hemorrhage apparently originated in the ovary, and the free intraperi- toneal bleeding came through a small rupture in the wall of the ovarian blood-cyst. A thorough microscopic examination demonstrated that there was no pregnancy either in the tube or ovary. Bovee mentioned eases of tubal and ovarian liemorrliage, not due to ex- trauterine pregnancy, reported by Price, Newman, Griffiths, Briggs, Groom, Paul, Ruge, Goodell, Duncan, Pilliet, Maurange, Peucli and Doran. He re f erred also to cases occurring in virgins at an early age, reported by Fordyce ; to fatal cases reported by Walter, Lewis and Fowler; to cases successfully treated by abdominal section, reported by Boldt, Alloway, Knaggs, and Johnson, and to the celebrated cases of Scanzoni in wdiich at an autopsy on the body of a young girl, dying suddenly during menstruation, three liters of blood was found in the peritoneal cavity. These hemorrhages from the non-pregnant ovary (ovarian apoplexy, blood-cysts, follicular hemorrhage, etc.) and from the non-pregnant tube (hematosalpinx) are usually due to inflammatory changes, causing degeneration of the tissues and of the con- tained blood vessels. Occasionally a tumor of the ovary or tube is the causative lesion. Many other conditions have been mistaken for tubal pregnancy (on account of sudden collapse associated with abdominal pain) — for example, hemorrhage from a varicose vein of the broad-ligament, salpingitis with collapse, per- forative appendicitis with a pelvic tumor, and fulminating pelvic edema. 788 EXTRA-UTERINE PREGNANCY Numerous illustrative cases have been reported, but there is not space for these here. Fulminating pelvic edema will be considered later (page 795). Conclusions. 1. Gonorrhoeal pyosalpinx, after the acute symptoms subside, may lie dor- mant and unsuspected for a long period (four years in one reported case). During this quiescent period the pus-tube (containing sterile pus usually) is tolerated the same as a small tumor or other non-irritating body — the patient being practically well and without decided pelvic disturbance. Such a quiescent pus-tube may at any time give rise to an acute exacerba- tion, and the onset of the pain may be so sudden and apparently causeless as to suggest tubal pregnancy. This suggestion is strengthened by the con- tinued enlargement of the mass (from irritative exudate) without decided fever (for the pus is sterile). Accompanying the exacerbation or preceding it there are sometimes other symptoms that we associate with tubal pregnancy — viz., missed menstruation, stomach disturbance, tenderness of the breasts, and softening of the cervix uteri. The last three are accounted for by the peritoneal and periuterine irritation and congestion, but why there should be delayed or missed menstruation at this inopportune time I do not know. One would suppose that the irritation and pelvic congestion would cause the menstrual flow to be excessive rather than absent. It is possible that the temporary suppression of menstruation (from some nervous disturbance or other obscure cause) stands in a causative relation to the acute exacerbation with its subsequent symptoms. I offer this simply as a suggestion toward a possible explanation of this strange and misleading sequence of events (the missed menstruation followed by the other symptoms detailed). In cases of supposed tubal pregnancy of the type mentioned particular care should be taken to exclude chronic gonorrhoeal salpingitis, as follows: (a) by inquiring into the patient's history for evidences of specific vaginitis or urethritis, and for subsequent pelvic symptoms (an inquiry into the hus- band's history also may bring out valuable information) ; (b) by a careful examination for evidences of a chronic urethritis. Bartholinitis, endometritis or salpingitis; and (c) by staining for the gonococcus any suspicious discharge that may be obtained from the urethra, vulvovaginal glands, uterus or vagina. In chronic cases negative findings do not exclude gonorrhoea, for the gonococ- cus disappears from the discharge after a time. 2. In rare cases acute gonorrhoea may extend rapidly through the uterus to the tubes and peritoneum, with so little disturbance of the vagina and vulva as to arouse no suspicion of its presence. In such a case the acute peritoneal symptoms will come on suddenly and witliout apparent cause. If there hap- pens to be also delayed or scanty menstruation, tubal pregnancy may be sus- pected. And this suspicion is strengthened by the stomach disturbance, the softening of the cervix and the enlarging mass beside the uterus. In. my case above mentioned the diagnosis was further obscured by the curetment, which modified the discharge, and by the continued low temperature, which CONDITIONS SIMULATING TUBAL PREGNANCY 789 seemed to exclude acute inflammation. In all such doubtful cases with acute discharge it is advisable to examine for gonococci, even though the discharge be scanty and bloody and apparently non-purulent. 3. An early miscarriage, if associated with a tumor or followed by mild salpingitis, may very closely simulate tubal pregnancy. IMembranes may be passed in either condition. With a miscarriage there is an embryo, but it often passes unnoticed. If a shred of tissue is passed, it may be examined for chorionic structures. In a case which can not be decided otherwise, curet- ment is advisable to obtain tissue for microscopic examination for chorionic, villi. But in suspected tubal pregnancy such a curetment should not be carried out until the patient is in a hospital and prepared for abdominal sec- tion, for the manipulations may start internal hemorrhage, requiring opera- tion at once. 4. A pregnant uterus may present very misleading conditions — e. g., irregu- lar softening (so much so that the body seems to be a firm mass entirely separate from the cervix), displacement, backward or forward or laterally; hyperesthesia with displacement, or irregular softening or an associated lateral mass (salpingitis, etc.). If there is in addition an anomalous history, a mistake is quite probable. 5. An unsuspected tumor in the pelvis may give rise suddenly to severe disturbance, and if there happen to be present also some of the symptoms of early pregnancy, a diagnosis of extrauterine pregnancy is very probable. The cases mentioned above show that the early symptoms of pregnancy (missed menstruation, stomach disturbance, breast tenderness and softened cervix uteri) often appear without satisfactory cause and at most inoppor- tune times. 6. Ovarian hemorrhage or tubal hemorrhage, due to other conditions, may so closely simulate extrauterine pregnancy as to be indistinguishable before operation, and in some cases the matter is in doubt even after direct ex- posure and handling of the affected structures. In this connection there are three points to be kept in mind: (a) There may be slight hemorrhage from the tube or ovary, particularly at the period of menstrual congestion, not due to extrauterine pregnancy and not requiring operation, (b) In cases of tubal hemorrhage requiring operation the hemorrhagic condition of the tube is not necessarily due to pregnancy, and in doubtful cases should not be pro- nounced such until after confirmation by microscopic examination, (c) In a hemorrhagic condition of the ovary requiring removal of the same, a careful examination should be made to determine exactly the pathologic con- dition. Such a supposed simple "blood cyst" of the ovary may prove on careful microscopic examination to be an early ovarian pregnancy. 7. Salpingitis, appendicitis and perforations in the gastro-intestinal tract may, in rare cases, come on so suddenly and progress so rapidly as to sug- gest internal hemorrhage from extrauterine pregnancy. Usually in these conditions there are preceding or accompanying symptoms which point to the true nature of the disease. If these distinctive features are absent and 790 EXTRA-UTERINE PREGNANCY there happen to be some of the other symptoms of tubal pregnancy, a mis- taken diagnosis is probable. 8. Fulminating pelvic edema, with its sudden onset and the rapid develop- ment of alarming symptoms, may closely resemble extrauterine pregnancy. In my own case, cited later, the temperature was so high that it was easily distinguished as an inflammatory trouble and not a hemorrhage, but in other reported cases this feature was lacking and mistaken diagnoses of extrauter- ine pregnancy were made. In this, as in other conditions of non-hemorrhagic shock or depression, there is not the persistently blanched condition of the skin so characteristic of profuse hemorrhage. The pulse, also, though rapid, is likely to have better volume than after a severe hemorrhage. 9. It is evident that the diagnosis of extrauterine pregnancy must rest on the combination of several symptoms. No one fact is sufficient, and it is hazardous to depend on two or three facts unless they are especially strong and well marked. In most cases the diagnosis must be reached by a careful consideration of all the symptoms present and the definite exclusion, one by one, of other conditions which may produce similar symptoms. TREATMENT. In pointing out the treatment for extrauterine pregnancy, several clinical classes must be considered — namely (1) before rupture, (2) hematocele, (3) repeated moderate intraperitoneal hemorrhage, (4) profuse intraperi- toneal hemorrhage, (5) hematoma, and (6) advanced cases. 1. Before Rupture. The only safe line of treatment in this stage is ab- dominal section and removal of the pregnant tube as soon as the diagnosis is fairly certain. The patient is in constant danger of a sudden serious hemorrhage, hence the sooner she is operated on the better. If the tube is lying low in the cul-de-sac, it might be reached and ligated from below (vaginal section), but this is not an entirely safe undertaking. The manipu- lations may serve to start a sudden severe hemorrhage which could not be promptly checked from below, particularly as these pregnant tubes are fre- quently bound in place by old adhesions. The safest operation in this stage is removal of the pregnant tube by abdominal section. 2. Pelvic Hematocele (Fig. 662). In these cases the hemorrhage has long since ceased and the collection of blood in the pelvic cavity is well shut off from the general peritoneal cavity by plastic exudate and adhesions. The embryo and membranes have probably escaped from the tube, either through a rupture in the wall -or more frequently through the end of the tube by "tubal abortion, "and perhaps have been largely absorbed. Practically all that remains is the blood in the pelvis, with the exudate end adhesions around it. This forms a tender mass low in the cul-de-sac back of the uterus, without much disturbance higher. In such a case it is well to watch the patient for a while, in the meantime keeping her quiet in bed. In the course of a week or ten days there will probably be decided improvement, showing that nature is taking care of TREATMENT 79]_ the blood aud exudate and that the patient will prol)ably recover without operation, or renewed evidences of irritation will appear, showing that em- bryo and membranes are still growing or that the blood and exudate is act- ing as a persistent source of irritation. "When there is persistent irritation after this period of rest, operation is indicated. The choice of operation depends on the circumstances of the case. If the evidences of irritation (pain and tenderness) are all low in the cul-de-sac, the probability is that evacuation of the blood from the cul-de-sac by vaginal section will be all that is necessary. If the pain and tenderness extend into the upper part of the pelvis, abdominal section is the safer operation. "When the conditions are doubtful, the abdominal route should be chosen. In a case where a hematocele is to be evacuated by vaginal section, the patient should be prepared for an abdominal section also, for there is a pos- sibility of the vaginal manipulations starting an internal hemorrhage which could not be satisfactorily controlled from below. 3. Repeated Moderate Intraperitoneal Hemorrhage (Fig. 663). This class comprises the majority of the cases of tubal pregnancy. The usual course of such a case is well shown in the typical case previously described (page 774) , The treatment is abdominal section as soon as the diagnosis is positive and the patient can be gotten to a hospital and given the regular careful prepara- tion for that operation. 4. Profuse Intraperitoneal Hemorrhage (Figs. 664, 665). In these cases im- mediate abdominal section is advisable as a rule if the patient is within reach of an experienced abdominal surgeon and can be gotten into suitable sur- roundings. In the absence of an experienced operator and suitable facilities, operation had best be deferred. In operations for the various classes of cases of extrauterine pregnancy, as well as other conditions in which abdominal section is required, the patient's chance of recovery is greater if the operation can be conducted in a well- ordered hospital. Consequently, the patient should be taken to a hospital if possible. Even a trip on the train, with the patient on a stretcher and in a strictly recumbent posture all the time, is less hazardous than operation in poor surroundings. The marked emphasis which teachers and writers gen- erally have placed upon promptness of operation in extrauterine pregnancy has unfortunately led to considerable indiscriminate operating in these cases — operations on patients in which it would have been safer to wait a while, operations without adequate antiseptic preparation, operations by per- sons without sufficient surgical experience to handle the serious intra- abdominal conditions in a safe and effective way. Even in the restricted class of cases in which there is free intraperitoneal hemorrhage, the socalled "tragic" cases, it is probable that not many patients really die at once from the loss of blood. There are some that do, but they are comparatively few, as indicated by mortuary records and by the number of patients that come to operation later with a history of having passed through a severe attack of intra-peritoneal hemorrhage. It is the repeated hemorrhages, with the result- 792 EXTRA-UTERINE PREGNANCY ing peritoneal irritation and inflammation coming on within a few days or a few weeks, that constitutes the greatest menace and that causes the deatli, rather than the mere withdrawal of a certain amount of blood from the cir- culation at the primary rupture. This being the case, the patient has a better chance of surviving the primary loss of blood if simply kept quiet without operation, than if operated on at an inopportune time or without reliable antiseptic preparation, or by a person without adequate experience in ab- dominal surgery. In most of these cases the hemorrhage has ceased by the time the physi- cian reaches the patient. Whether this is the case can be determined with a fair degree of certainty, as a rule, by watching the patient for a short time. If the hemorrhage has ceased, it will be seen that the pain is dimin- ishing and the pulse getting better. If it is decided to defer operation until the patient has recovered from the shock and the acute anemia, the patient must be kept quiet in the horizontal posture absolutely and should make no voluntary movement; no sitting up, nor moving of the extremities nor straining; no enemata nor purgatives. If she is to be moved to a hospital, it must be with practically no more disturbance than if she were lying flat in bed. For the first 48 hours avoid bowel movement if possible and give very little food. The severe thirst, caused by the blood loss, may be relieved by small doses of water, and by saline solution per rectum by the drop method (proctoclysis). Pain and restlessness are to be relieved by sedatives hypodermically or by mouth. Guard against vomiting and avoid pelvic examination, for either is very likely to start up fresh hem- orrhage. After the first two or three days a little more freedom may be allowed as regards nourishment, enemata and movement of arms and legs. But the patient must maintain the horizontal posture strictly. The patient must be especially warned against straining in any way and against trying to sit up a little because she feels better. An attempt at sitting up in bed may undo all the good of the previous rest, as shown in the case mentioned on page 777. Where the hemorrhage has been very severe it Avill usually require ten days to two weeks for the patient to recuperate sufficiently to present a good margin of reserve force for the operative work. With a less abundant internal hemorrhage the patient may be in good condition for operation within a few days. It must not be forgotten that in these cases there is always the possibility of the hemorrhage starting up again suddenly, in spite of the care to pre- vent it. Consequently, I always feel better if the patient is in the hospital while waiting for her- '"'deferred operation." Then, if renewed hemorrhage develops, operation can be carried out promptly before the patient again passes into the condition of extreme collapse. These desperate cases, where the vital forces are at a low ebb, require much judgment and discrimination as to when to operate in a particular case and as to just what to do at the operation — on the one hand, to stop the bleeding and thus prevent the patient from passing into an absolutely hopeless condition, and, on the other hand, PELVIC HEMORRHAGE 793 to avoid snuffing out the little spark of life remaining by the added strain of intraperitoneal manipulations and anesthesia. The anesthesia and oper- ative work must be reduced to a minimum, both in duration and extent. Some cases can be satisfactorily operated on under local anesthesia, and occasionally there is a case in which the patient's sensibilities are so ob- tunded that practically no anesthesia is necessary for the work required. By the term "local anesthesia" I mean a true local anesthesia (as induced by cocaine or eucaine, or some similar preparation) and not general anes- thesia by hypodermic injection. I Avould warn particularly against the use of seopolamin (h3^oscin) in these cases where the depression is so marked. The induction of general anesthesia by hypodermic injection of this drug is not the simple and harmless procedure one might infer from the tenor of the flood of advertising literature which is being sent out by a certain inter- ested commercial house. A number of deaths have been caused by the use of this drug, and it is especially dangerous in these serious conditions with marked depression. When necessary to give something to relieve pain or produce general anesthesia in the class of cases under consideration, it is better to use some reliable drug the effect of which is uniform and can be accurately gauged and depended upon — such as morphine hypodermatically or ether by inhalation. 5. Pelvic Hematoma (Fig. 668). If there are any evidences of active or recurring hemorrhage, the preferable treatment is abdominal section, with removal of the damaged tube and the blood-mass. If there is simply a quiescent blood-collection in the connective tissue, keep the patient quiet and watch. If the blood-mass is gradually absorbed, keep the patient quiet till the mass has largely disappeared, and then she may be allowed up and be counted practically well. If the mass remains stationary and symptoms of pronounced irritation persist or arise later, the patient should be subjected to operation — abdominal or vaginal, as indicated by the location of the mass and the accompanying symptoms. 6. Advanced Oases. These cases vary so much that it is impossible to give a rule applicable to all. In some of them immediate operation is indicated, while in others it is advisable to wait for a time, either because the child has only recently died and the placenta and adhesions are still dangerously vascular, or, in rare cases, because there is good reason to hope for saving the child alive without "unjustifiable risk to the mother (Fig. 669). OTHER PELVIC DISORDERS. Hemorrhage. When there is hemorrhage into the pelvis from any cause, if the blood passes into the peritoneal cavity, it is known as "intraperitoneal hemor- rhage." If the amount of blood is small and becomes shut in the pelvic cavity by a roof of exudate and adhesions above, it is referred to as a "pelvic 794 OTHER PELVIC DISORDERS hematocele." If the blood, instead of passing into the peritoneal cavity, passes into the connective tissue, the resulting condition is called "pelvic hematoma. ' ' The usual cause of blood in the pelvis is extrauterine pregnancy, the char- acteristics of which have just been presented. Hemorrhage into the pelvis occasionally occurs, however, from other causes. A collection of blood in the pelvis, either in the pelvic peritoneal cavity or in the connective tissue, may be caused by any one of the following conditions : 1. Rupture of a varicose vein of the broad ligament. 2. Hemorrhage from a Fallopian tube, due to inflammation or to a polypus, or some other tumor of the tube (page 796). 3. Hemorrhage from an ovary, due to acute congestion or inflammation, or to a papillary growth (page 818). 4. Rupture of one of the dilated vessels on a large tumor. 5. Hemorrhage from injury due to a blow or fall. 6. Hemorrhage from injury due to forcible reposition of an adherent uterus. The diagnosis is made by the same symptoms that indicate hemorrhage in extrauterine pregnancy, but without the evidences of pregnancy. As in the vast majority of cases of spontaneous pelvic hemorrhage the cause is extrauterine pregnancy, this affection must be excluded in any par- ticular case before any other diagnosis is permissible. Sometimes this may be excluded by the circumstances of the case — for example, the patient may be a virgin, or may be past the menopause, or may have had no recent oppor- tunity of becoming pregnant. In some cases the differential diagnosis can not be made until the operation, when one of the causes above mentioned may be apparent, with absence of indications of tubal pregnancy. In a doubtful case the diagnosis should be reserved until the suspicious mass, removed at operation, has been submitted to microscopic examination. In a tubal preg- nancy, ruptured early and not operated on for several weeks, all naked eye evidence of the pregnancy may disappear. But by microscopic examination of the affected tube, evidence of the pregnancy may be found. The treatment of pelvic hemorrhage not due to tubal pregnancy depends on the circumstances of the case. If the hemorrhage is into the connective tissue (hematoma) and well circumscribed, palliative treatment only is indi- cated. This consists of perfect quiet in the recumbent position, elevation of the foot of the bed and an ice-bag over the abdomen, and sedatives sufficient to give rest. In intraperitoneal hemorrhage of slight extent, where tubal pregnancy can be excluded, the same treatment is indicated. In either ease the effused blood may be largely absorbed. If after a time it still remains and gives trouble or suppurates, the hematoma or hematocele, as the case may be, may be opened from the vagina, emptied and packed with gauze, the. same as a pelvic abscess. If there is serious intraperitoneal hemorrhage, it requires abdominal sec- FULMINATING PELVIC EDEMA 795 tion if the patient is in fit condition, the additional steps in the intra-al)domi- nal treatment depending upon the conditions found within the abdomen. Fulminating Pelvic Edema. Fulminating pelvic edema is the term applied to an intense and wide- spread edema of the pelvic interior, that comes on suddenly without appar- ent adequate cause. It is accompanied with serious symptoms and usually with extreme prostration. In fact, the sudden onset, the severity of the symptoms and the marked collapse suggest ruptured tubal pregnancy, and this mistaken diagnosis has been made in some of the cases. It is a rare con- dition and presents a puzzling problem in etiology and in diagnosis. Llost of the cases have been associated with chronic inflammatory lesions in the pelvis, but why the sudden edema and serious symptoms should develop without apparent cause has not been satisfactorily explained. Clinically, however, the condition must be recognized and treated; hence its inclusion here. The salient features in the pathology, symptomatology and treatment of this rare affection can best be presented by detailing some typical cases. Fulminating Pelvic Edema. — Last year I was called in consultation by Dr. S. T. Bas- sett, of St. Louis, to see a patient with pelvic disturbance. It was Sunday; the patient had attended church in the morning feeling fairly well, but while there became very sick and could scarcely get home. She had a chill, followed by severe headache and general aching, but no localizing symptoms. There was no apparent local trouble in any part of the body to account for the fever, which rose to 105.5°. By evening there was evidence that the pelvis was the seat of the disturbance and I was asked to see the patient. Examination. — I saw her about 10 p. m. The temperature had been reduced to 104°. The pulse was rapid, but of fair volume. The pelvis was filled with a tender mass which surrounded the uterus and fixed it firmly. There seemed to be acute pelvic inflamma- tion with extensive exudate. But there was no apparent cause, either recent or remote. The patient had always been rather nervous and this had been somewhat worse of late, but there had been no symptoms indicating pelvic disease of any kind. The next day the temperature was 104.2°, pulse 120, respiration 28, and there was much peri- toneal irritation. Operation at once was indicated, to check the rapidly progressing inflammation, if possible, and accordingly the patient was taken to the hospital. Operation. — When the abdomen was opened the pelvis was found filled with small encysted collections of fluid involving the tubes, ovaries, broad ligament and uterus. The cysts or pseudocysts were of various sizes, were filled with clear serum and seemed to extend deeply into the substance of the organs involved. From the appearance I sus- pected hydatid disease. I removed all the cysts that it was feasible to remove and then drained the pelvis through the abdominal incision. The temperature dropped within a few hours to 98°, and it did not again go high. During the first part of the period of convalescence it ranged from 99° to 100.2°, and later dropped to normal, where it remained. The wound and drainage tract healed rapidly and the patient had a smooth convalescence. Laboratory examination of the tissues removed showed no bacteria of any kind, no evidence of hydatid disease, and no specific pathologic process that would adequately account for the alarming symp- toms and the marked tissue change. Fulminating Pelvic Edema.— Reported by Briggs. A married woman, whose men- 796 OTHER PELVIC DISORDERS struation had been normal, came complaining of malaria and some pelvic pain. Pelvic examination showed nothing abnormal except a slight fullness about the left adnexa. Two days later the patient returned to the office, very sick. Her face was pale and pinched and anxious; pulse 120, small and weak; temperature, 100°. The pelvis was then completely filled with a fluctuating mass. The rapid development of the mass, with almost no fever, pointed to hemorrhage as the cause, and a diagnosis of tubal pregnancy was made. At the operation the pelvis was found filled with small cysts of various sizes, formed by collections of serum within the connective tissue. There was no tubal pregnancy. The pelvis was drained and the patient recovered. Fulminating Pelvic Edema. — Reported by Briggs. Patient's menstruation was de- layed four days, then came on scanty and was accompanied by paroxysmal pains, which caused the patient to think she was having a miscarriage. After some days the pain became more severe and the patient had two fainting spells. Temperature was normal, pulse 90 and small and compressible. The abdomen was sensitive. Sedatives were given, which diminished the pain, but the shock increased. The radial pulse be- came imperceptible and the skin and mucous membranes were markedly anemic. The uterus was enlarged, retroverted, fixed and sensitive, adnexa not felt. Liquid could be demonstrated in the flanks. Diagnosis, tubal pregnancy with rupture. Operation. — The pelvis and lower abdomen were filled with great blebs due to the collection of serum in the connective tissue, causing the peritoneum to pouch into the pelvis from all directions. Both tubes were chronically infiamed and the right ovary was enlarged and cystic. The patient's condition continued bad and she died some hours after the operation. The feature of the case was the enormous amount of serum pocketed in the connective tissue, without any evidence of recent infiammation. Fulminating Pelvic Edema. — Reported by Legueu. Shortly after a normal menstrua- tion, patient was suddently attacked with violent pelvic pain accompanied by syncope, extreme pallor and cold extremities. The abdomen was distended, hard and painful to pressure. Vaginal examination disclosed a fiuctuating mass in the cul-de-sac. Diag- nosis, retrouterine hematocele. On opening the abdomen a quantity of yellow serum escaped. There were large collections of serum in the tissues about the right adnexa, aggregating a pint. The patient recovered. Examination of the serum showed only leucocytes and peritoneal cells. Fulminating Pelvic Edema. — Reported by Jocet. Patient, aged 28, married eight years, no children, had, on three separate occasions, an attack of severe abdominal pain accompanied by an accumulation of fiuid in the right iliac fossa, which presented the characteristics of hematocele. Twice the mass terminated by resolution and the patient was perfectly well in the intervals. The third time, after the usual symptoms of the supposed hematocele had continued some weeks with improvement, the patient was suddenly seized with violent abdominal pain, accompanied by pallor, anxious facies and incessant vomiting. The mass enlarged and there developed features that pointed to inflammation rather than hemorrhage as the cause of the trouble. Operation showed the pelvis filled with encysted collections of serum, and finally, deep in the pelvis, there was found an old ovarian abscess, which was evidently the exciting cause of the surrounding edema. Tumors of Fallopian Tubes. Primary tumors of the Fallopian tubes are very rare. Fibromyoma, car- cinoma, and sarcoma may occur here, and they present the same structure and tendencies as elsewhere. If arising from the interstitial portion of the tube, they produce the- symp- toms of similar tumors of the uterus. If arising from the outer portion of the tube, they correspond in position to tumors of the ovary. VARIOUS VEINS IN PELVIS 797 It is interesting to note that chorio-epithelioma has been found in a tube fol- lowing tubal pregnancy. The diagnosis of tumors of the tube is usually made after the abdomen is opened. They present no definite distinguishing characteristics, and when felt in examination are usually taken for growths arising from those struc- tures in which tumors more frequently occur — namely, the uterus, the ovary or the broad ligament. The treatment of tumors of the tube is the same as for like growths in other pelvic organs. Varicose Veins of Broad Ligament. Occasionally the Veins of the broad ligament are found markedly dilated, and in the dilated veins are sometimes found thrombi and even small stones (phleboliths). The principal etiologic factors which have been mentioned are subinvolu- tion of the broad ligaments following pregnancy, relaxation of the tissues Fig. 670. Ligating Varicose Veins in the Broad Ligament. (Reed — Text-hook of Gynecology.) from poor general health, and obstruction of the venous circulation of the broad ligament by tumors, or by heart disease, or by loaded bowel, or by uterine displacement. The symptoms (weight and pressure when upright and relieved by the re- cumbent posture) are not distinctive — in fact, the condition is usually over- shadowed by more evident lesions. In most cases so far reported this con- dition was thought of only after the abdomen was open and the enlarged veins apparent. In cases of persistent pelvic pain without palpable lesion, this condition should be thought of, and if the symptoms are severe in spite of palliative measures it may be advisable to make an exploratory abdominal section, with the idea of correcting this condition if found. When phleboliths or thrombi (Fig. 406) are present, they may in excep- tional cases form masses that can be felt on bimanual palpation. The treatment is abdominal section and ligation of the enlarged veins at short intervals, as advocated by Reed (Fig. 670), and free incision and evacu- ation of the ligated portions. 798 OTHER PELVIC DISORDERS Echinococcus Disease of Pelvis. Ecliinococeus disease is occasionally found in the pelvis. For a descrip- tion of this affection see echinococcus disease of the uterus (page 593). When it affects other pelvic structures, it is supposed in most cases to come from the rectum by way of the perirectal connective tissue. Pseudo-tuberculosis of Peritoneum. This is a rare condition, in which the pelvic peritoneum is studded with small opaque, thickened spots, presenting the superficial appearance of peri- toneal tuberculosis. Microscopic examination of the involved tissue, however, shows no tuberculosis, but simply chronic inflammatory infiltration. 799 CHAPTER XII. TUMORS OF THE OVARY AND PAROVARIUM. Before taking up the tumors of the ovary and parovarium I wish to call attention to certain points in the anatomy and physiology of the structures involved. POINTS IN ANATOMY AND PHYSIOLOGY. THE OVARY. The ovaries are situated one on either side of the uterus near the pelvic brim and close to the outer end of the Fallopian tube (Fig. 3, 4). Each ovary projects from the posterior wall of the broad ligament of its respective side and the peritoneal fold thus formed is called the "mesovarium" (Fig 671). Fig. 671. Vertical Section through the Broad Ligament, showing the R,eIation of the Ovary to the same,. 5, Fallopian tube. 6, Round ligament. 7, Ovary. 7', Meso- varium, connecting the ovary with the broad ligament. (Jewett, from Testut — ractice of Obstetrics.) Fig. 672. Section of the Ovary of a Cat. 1, Peritoneal surface of the ovary. 1, Hilum. 2, Medullary portion ol ovary. 3, Cortical portion. 5, Small Graafian follicles. 7, 8, 9, Maturing Graafian follicles. 10, Corpus luteum. (Jewett, after Schoen — Practice of Obstetrics.) 800 TUMORS OF THE OVARY AND PAROVARIUM It is through this attachment to the broad ligament that the ovary receives its blood supply, this being the point where the vessels enter. The shape of the ovary is much like that of an almond. In size the ovaries vary much in different individuals, and even in the same individual the two ovaries may differ in size. Ordinarily the ovary is II/2 to 2 inches in length, about 1 inch in width, and about % inch in thickness. It weighs 75 to 150 grains. Structure. In structure the ovary is simply a bunch of ova, or microscopic eggs, supported and held together by the connective tissue which forms the Trex. Tint. D.. WQ, ^^=^^^S.^^\ 1 ; ^ >, / ^ . ^^ I, Fig. 073. A Graafian Follicle with its Contained Ovum, highly magnified. M. G., membruua mamilosa. The ovarian stroma is also well shown. (Williams — Obstetrics.) frame-work. Each ovum is contained within a minute sac, called the ovisac or Graafian follicle (Fig. 672)-. The connective extends between the follicles in all directions, and,' in addition to supporting and protecting them, it car- ries the blood vessels that nourish them and also the lymph vessels and nerves. This connective tissue constitutes the ovarian stroma and is j:)eculiar in that it is exceedingly rich in cells. These are spindle-shaped connective tissue cells, and they are packed so closely together that in an ordinary microscopic preparation the tissue seems to be made up exclusively of long, oval nuclei lying close together (Fig. 673). Near the peripliery of the ovary POINTS IN ANATOMY 801 the connective tissue fibers become more numerous and the nuclei fewer, so that there is here a rather dense capsule. This tibrous capsule of the ovary is known as the "tunica albuginea. " It is simply a condensation of the ovarian stroma and serves to protect the deeper structures of the ovary. Outside of this fibrous layer lies the epithelial covering. That portion of the ovary at which the vessels find entrance and exit is called the hilum (Fig. 672). Immediately about the hilum, and extending some little distance into the ovary, is the area known as the medulla or medullary portion. This is occupied by the blood vessels, lymph vessels, the nerves and supporting connective tissue. It contains no follicles. Fig. 674. Development of the Ovary (after Wiedersheim). A, an ingrowth of the germinal epithehum, forming a cell-cord, which breaks up into primitive Graafian follicles; B, a primitive Graaflan follicle, with its contained primitive ovum; C, D, E, later stages in the development of the Graafian follicle. The remaining part of the ovary contains the Graafian follicles, and is called the cortex or cortical portion (Fig. 672). The free surface of the cor- tical portion — that is, the peritoneal surface of the ovary — is covered with aylindrical epithelium, the remains of the germinal epithelium, from which the ova and Graafian follicles were formed by infoldings (Fig. 674). The Graafian follicles are very numerous and of different sizes. The small young follicles lie near the surface and number thousands. They are about 1/100 of an inch in diameter. The larger, older follicles lie deeper and are not so numerous. The largest of these measure 1/25 of an inch in diameter. The Graafian follicle is lined with an epithelial layer several cells thick, 802 TUMORS OF THE OVARY AND PAROVARIUM called the "membrana granulosa," and is filled with clear viscid flnid, the "liquor foUiculi. " The ovum lies within the follicle near one side and is completely surrounded by cells of the membrana granulosa (Fig. 673). Fig. 675. A Corpus Luteum, fifteen daj's from the beginning of menstruation. (Baldy — American Text-book of Gynecology.) Fig. 676. Ovary of a Virgin, shomng an unusually large corpus luteum. Notice what a large part of the ovary the corpus luteum occupies. (Piersol, after Hirst — American Text-book of Obstetrics.) As the Graafian follicle matures, it again approaches the surface and be- comes still larger. It gradually protrudes at the free surface of the ovary and when ripe it bursts, liberating the ovum on the surface of the ovary, from where it finds its way into the Fallopian tube. This ripening and bursting of Fig. 677. Section of a Corpus Luteum, showing the wavy line composed of lutein cells. (Williams— Obstetrics.) POINTS IN ANATOMY 803 the Graafian follicle and liberation of the contained ovum is called "ovula- tion," and is usually coincident with menstruation. After the ripened ovum is discharged, the ruptured follicle fills with bloody serum, which clots. The rent in the follicular wall soon heals and the blood clot becomes partially decolorized. Tliis follicle, filled with blood clot, is very prominent (Figs. 675, 676) and when encountered during tlie course of an operation has been mistaken for hematoma of the ovar}', though it is simply a recently ruptured follicle and consequently a normal structure. In a few days there appear certain peculiar cells containing pigment. These cells are large, reseml^ling decidua cells. They are formed first about the periphery of the -fibrinous mass, but they gradually increase in number and advance toward the center, until finally they fill nearly the wiiole interior Fig. 678. The Wavy Line in the Wall of the Corpus Luteum, highly magnified to show the lutein cells. (Williams — Obstetrics.) Fi, G/9 The Corp IS Albicans -Vfter the rup- tured follicle has passed through the various stages of the corpus luteum, there remains simply a wavy line of fibrous tissue, representing the final stage of the ruptured follicle. The retraction of this scar-tissue causes depressions, as shown in Fig. 680. (Williams— 06.s -." '^ i: » -nsr. A B Fig. 690. Indicating the difference between the cells lining a pseudomucinous cyst (A) and those lining a serous cyst (B), as explained in the text. cavity becomes filled with the pseudomucinous material, which is reformed again and again after removal. Most of these patients finally succumb to meclianical interference by the spreading pseudomucinous growth or to the secondary development of malignant disease. Pseudomucinous cysts rarely undergo malignant change, except as above stated. The cause of the pseudomucinous cyst is not known certainly. They probably start from the primordial follicles. This is indicated by the fact that in the small secondary cysts, in the Avail of the main cyst, perfect ova have been found. These ova were formed after ])irth. According to accepted theories, the only cells in the ovary capable of forming ova after birth are those of the primordial follicles. All the other cells have been differentiated past this stage. Serous Cystadenomata. These are known also as "papillary cysts" and as "cystadenomata iuvertens. " The contents of the serous cyst partakes PATHOLOGY OF PROLIFERATING CYSTS 817 of the nature of serum and does not present the gelatinous character of that of the pseudomucinous variety. On chemical examination the contents show a large amount of albumen and no pseudomucin. The contents of the serous cysts, like that of the other variety, may vary much in color and Fig. 691. A Papillary Cystadenoma of the Ovary. The papillary projections within the cyst grow to the opposite wall and then penetrate it. (Pfannenstiel — VeiVs Hand-Buch.) consistency — this variation being due to the amount of hemorrhage into the cyst. The cells apparently have no secretion, and consequently there is no marked intra-cystic pressure as there is in the pseudomucinous cyst. On account of this absence of internal pressure the cells, as they proliferate, ,>^ Fig 692. A Papillary Cystadenoma, sectioned and showing the papillary projections into the cyst cavity. (Penrose — Diseases of Women.) 818 TUMORS OF THE OVARY pile up, forming papillary projections into the interior of the cyst (Figs. 691, 692)— hence the name '^nvertens." These papillary masses (consisting of a layer of epithelial cells and some stroma), when they come in contact with the opposite wall of the cyst, penetrate the wall and appear outside as papillary growths on the external surface of the cyst (Fig. 693). Usually a few gland-like eversions may be found in the wall, but they are insignificant. Occasionally, however, a serous eystadenoma will present nearly altogether evertent growths (gland-like projections into the wall of the cyst) — serous eystadenoma evertens. The cells lining the serous cyst present the following characteristics: They contain no pseudomucin, hence they stain throughout (Fig. 690, b). There are no goblet cells — all plain columnar cells. They have cilia. Fig. 693. Papillary Cystadenoma of each Ovary. On the left side the internal papillary projections have grown through the opposite wall and appear on the external surface. On the right side the papillary growths have obliterated all resemblance to a cyst, and appear simply as a cauUflower growth in the region of the ovary. Notice tlie metastasis on the peritoneal surface of the uterus. (Penrose — Diseases of Women.) A serous cystadenoma may start as either a unicentral or a pluracentral growth. It does not form such a large tumor as the pseudomucinous cyst, and it is nearly always unilocular, except when it begins as a pluracentral growth. Serous cysts are usually bilateral and in this they dilfer markedly from the pseudomucinous variety. A striking feature of tliese serous cysts is that local metastases usually take place. When- such a cyst ruptures, extensive local metastases form on adjacent peritoi^eal surfaces, producing papillomatous growths. These growths show no malignant structure, but they may kill the patient by ex- tensive local groAvth, tliough they do not penetrate adjacent organs nor cause distant metastases. They may, however, and in fact very frequently do, undergo malignant change, in which case they become ordinary carcinomata. The origin of the serous cysts is not settled. Some authorities hold that THE TWO KINDS OP PROLIFERATING CYSTS 819 tliey arise from the membrana granulosa of tlio Graafian follicle. It is held by others that they arise from parovarium duet-remnants in the ovary, and there are some facts that tend to support this theory. In structure they resemble closely certain parovarian cysts, and remnants of parovarian ducts are found in the ovary near the hilum, which is just the part of the ovary from which these cysts apparently take their origin. ]\Ioreover, they differ from the common form of ovarian papilloma, which originates from tlic surface layer of epithelium (the germinal epithelium), though the term ''ovarian papilloma" is sometimes applied to the papillomatous growth re- sulting from the early rupture of a serous cyst and in which the cyst charac- ter has largely disappeared. The characteristics of the pseudomucinous and serous cysts may be pre- sented and contrasted concisely as follows : Proliferating Cysts. (Cystadenomata.) Pseudomucinous Cyst. (Cystadenoma Evertens). 1. Contents gelatinous and secreted by the cells lining the cyst — may be any color. 2. Secondary growths consist of gland- like projections outward (evertent) from the cavity into the wall, form- ing small cystic cavities in the wall. 3. Lining cells contain pseudomucin, are columnar, with some goblet cells, and are not ciliated. 4. Nearly always unilateral. 5. Rarely rupture spontaneously. 6. Rarely cause peritoneal metastases. 7. Rarely undergoes malignant change. 7. 8. Very common. 9. Cause unknown. Probably start from primordial follicles. Serous Cyst. (Cystadenoma Invertens), 1. Contents serum-like and not secret- ed by the cells lining the cyst — may be any color. 2. Secondary growths consist of pap- illary projections iuAvard (invert- ent) from the wall into the cavity, forming papillary masses which ex- tend across the cavity and pene- trate the opposite wall. 3. Lining cells contain no pseudomu- cin, are plain columnar, without goblet cells, and are ciliated. 4. Nearly always bilateral. 5. Usually rupture at an early stage, because of perforation of the wall by the papillary ingrowths. 6. Usually cause peritoneal metasta- ses, consisting of widespread papil- lary growths. Frequently undergoes malignant change. Rare. Cause unknown. Prol)al)ly start from parovarian tube-remnants in the ovary. 820 TUMORS OF THE OVARY Taking up the clinical manifestations of the proliferating cysts (both pseudomucinous and serous), it is found that they may occur at any age, but are most frequent during the period of greatest ovarian activity — i. e., be- tween the twentieth and fiftieth years. Either ovary may be affected. They are bilateral in only about 3 per cent, of the cases, while malignant tumors of the ovary are bilateral in about 75 per cent, of the cases. As I mentioned be- fore, the serous or papillary proliferating cysts are usually bilateral, but they constitute only a small proportion of proliferating cysts — most of such cysts being of the pseudomucinous variety. In shape, a proliferating cyst may be spherical and regular in outline, indi- cating a single large cyst, or it may be irregular, presenting nodules indicat- ing a multilocular cyst. In size these cysts vary from a small tumor the size of an egg to a large tumor filling the whole abdomen. As to appearance when exposed by abdominal incisions, the wall of the cyst presents a white, glistening appearance. The thinner portions are straw- colored or green or black, according to their fluid contents. The surface of the cyst may be perfectly smooth or may be covered by a papillary growth, or may be bound to adjacent structures by adhesions. The tumor usually has a distinct pedicle. The cysts are divided into three classes according to their internal struc- ture — unilocular, multilocular and areolar. Unilocular cysts may be very large, but they are found to consist of only one large cyst. However, the in- terior frequently shows remains of trabeculae, indicating that they were at one time multilocular cysts. Multilocular cysts contain two or more cysts of medium size, besides a large number of smaller cavities (Fig. 689). Areolar cysts are made up of a large number of small cavities of various sizes and shapes. The cyst wall consists of three layers — an outer and inner firm fibrous layer, with a middle layer of looser tissue between them. In the middle layer of loose connective tissue the vascular supply is distributed. Those vessels which come near the outer surface may often be plainly seen, and they are frequently very large. The external surface of the cyst-wall is covered with columnar epithelium, derived from the germinal epithelium covering the sur- face of the ovary and differing from the endothelium of the peritoneum. The internal surface is lined with low columnar cells. The lining membrane is often covered with vegetations and irregular growths, both cystic and solid. The contents of cysts present marked contrast in consistency and in color. The contents may be thin like water (serous cysts), or thick and viscid and of gelatinous consistency (pseudomucinous cyst). The contents may be almost colorless or straw-colored or a dirty yellow, or green or black. The color de- pends on hemorrhage into the cyst. The coloring matter of the blood becomes the coloring matter of the cyst contents. As these cysts enlarge they bear various relations to adjacent structures. If they rise out of the pelvis and enlarge in the abdomen, they may attain a very large size before producing serious symptoms. They there have plenty of DERMOID CYSTS 821 room and expand freely, pushing aside the surrounding organs. If they be- come caught under the pelvic brim and develop in tlie pelvis, they soon begin to cause pain and other disturbances from pressure and distortion of the organs. The proliferating papillary cysts, or serous cysts, before described, usually rupture rather early and fill the pelvis with papillary growths. In such a case the first impression, when the abdomen is opened, is that the pelvis is filled with a cancerous mass, which cannot be removed and which will soon cause death. Accordingly, in not a few cases, the operator, after scraping out some of the papillary bleeding growth, has closed the abdomen and told the pa- tient or her friends that there was an inoperable cancer and that she could not long survive. Some such patients get entirely well after the operation. In other cases malignant change has already begun or begins later and the patient dies of carcinoma. In still other cases the growth itself becomes so extensive as to interfere with the functions of adjacent organs and thus causes death. Dermoid Cysts of the Ovary. Dermoid cysts are those in which are found skin or mucous membrane, associated with structures generally connected with the epidermal tissues. The structures most frequently found are hair, teeth, bone, muscle-fibers, skin and small balls of sebaceous material resembling fat (Figs. 694, 695, 696, 697). Fig. 694 Portion of the Wall of a Dermoid Cyst of the Ovary, a, Wall of cyst, b, Mass of cutaneous tissue c, Hair, d, Teeth. (Thomas and Munde, after Ziegler — Diseases of Women.) 822 TUMORS OF THE OVARY Fig. 695. A small Dermoid Cyst, showing teeth, hair, sebaceous material and firm fat-tissue. The teeth, shown in the right side, are unusually well developed and constitute a point of special interest in this specimen. (Specimen of Dr. F. J. Tau.ssig.) Fig. 69G. Hair, five and a half feet long, from a Dermoid Cyst. (Thomas and Munde — Diseases of Women.) Fig. 697. Bails of Sebaceous Material from a Dermoid Cyst. (Thomas and Munde — Diseases of Women.) SYMPTOMS OF OVARIAN CYSTS g23 Dermoid tumors may appear at any age. They have been found in chil- dren at birth and in women of ninety years. Dermoid tumors of the ovary are comparatively small, rarely getting larger than a child's head. But they are more dangerous than the ordinary large cysts, for the dermoid cysts usually present more and firmer adhesions, and their contents are more irritating, so much so that the escape of any of the contents into the peritoneal cavity is likely to cause a fatal peritonitis. They are much more liable to suppuration and consequent abscess formation than the ordinary cysts. SYMPTOMS AND DIAGNOSIS of Ovarian Cysts. As the simple cysts seldom give rise to serious trouble and the dermoid cysts are rare, the symptoms to be mentioned belong to the proliferating cysts and principally to the pseudomucinous variety, as the vast majority of cystic ovarian tumors belong to this class. An ovarian cyst usually develops slovs^ly and may attain considerable size before it is discovered. Often it is noticed then only by accident. The earliest symptoms are a feeling of v^eight and pressure in the pelvis, bladder irritability, slight menstrual disturbance, constipation and perhaps some pain with bowel movement. The symptoms are not distinctive, but sim- ply indicate some disturbing factor in the pelvis. As the tumor increases in size, distinct pressure-symptoms appear and the general nutrition becomes affected. There is enlargement of the abdomen, swelling of the feet from pressure on veins, pain from pressure on nerves and dyspnoea from pressure on the diaphragm. There appear, also, stomach disturbances, emaciation and progressive weakness. In some cases there are attacks of local peritonitis, with severe abdominal pain and some fever, but these inflammatory symp- toms are due to complications and do not belong to the natural history of the tumor. Ovarian cysts grow slowly, usually taking several years to reach a large size. But they seldom stop growing. They persistently enlarge until the pa- tient finally dies from exhaustion brought about by pressure-effects on vital organs. The diagnosis in typical cases is easy, but in complicated cases it may be very difficult, and in exceptional cases a positive exact diagnosis is impossi- ble before operation. Tapping the cyst through the abdominal wall as an explorative measure should not be employed. An adherent coil of intestine may be punctured, or cyst contents may leak into the peritoneal cavity and cause fatal peritonitis. In a doubtful case an exploratory abdominal section is safer and far more satisfactory in diagnostic results. In taking up the differential diagnosis of ovarian cysts, it is at once appar- ent that the symptoms and diagnostic points are different in the different- sized tumors. 324 TUMORS OF THE OVARY Small Ovarian Cyst. Considering tlie small ovarian cyst according to the "Points in the Differ- ential Diagnosis of Various Masses in the Pehis and Lower Abdomen" (Diagnostic Table, page 287), it is found that an ovarian cyst of this size pre- sents the following characteristics (the numbers refer to the "Points" in the Diagnostic Table). 1. Is situated in the lateral part of the pelvis, though in exceptional cases it may drop down directly behind the uterus or in front of it. 2. The small ovarian cyst is the size now under consideration — about as large as the fist or a little larger. 3. Is approximately spherical, though may be made uneven by secondary cysts. 4. Contains fluid (fluctuates). 5. Is not tender, unless complicated hy inflammation or by torsion of pedicle. 6. Is freely movable, unless complicated by adhesions or caught under the sacral promontory. 7. Is attached in the lateral part of the pelvis. 8. Apparently arises from the tubo-ovarian region. 9. Lies beside the uterus, but is not attached to it and does not ordinarily modify it in any way, except to cause some displacement towards the opposite side. 18. Occupies the tubo-ovarian region. 36. Symptoms slight, unless complicated. Xo history of fever or of attacks of pehuc inflammation. 50. Progressive increase in size, without inflammatory symptoms. 57. Fallopian tube lies close to the mass, but can in some cases be distin- guished from it. The ovary is not found because incorporated in the mass. The uterus is of normal size, though it may be somewhat displaced. The mass is freely movable, unless complicated, and can be separated from the uterus and from the pelvic wall and from the Fallopian tube and from most of the broad ligament, but not from the ovary. The following conditions may be confounded with a small ovarian cyst and must therefore be taken into consideration in the differential diagnosis; a. Inflammatory ]\Iass (salpingitis with exudate, pyosalpinx, hydro- salpinx). b. Tubal Pregnancy. c. Fibroid Tumor of the Uterus. d. Retroverted Pregnant Uterus. e. Broad Ligament Cyst. a. Inflammatory Mass. There are three kinds of masses resulting from in- flammation or allied conditions that must be taken into consideration. Salpingitis with exudate presents a mass which is (1) situated in the tubo- DIFFERENTIAL DIAGNOSIS 825 ovarian region, (2) irregular in shape, (3) firm, (4) very tender, (5) fixed by adhesion, (6) attached to both the pelvic wall and the uterus, (7) appar- ently originates in adnexal region, (8) attached to upper lateral part of uterus, but a sulcus can be made out between the uterus and the mass, (15) uterus fixed, but not otherwise modified except perhaps somewhat dis- placed to the opposite side, and (16) there is discharge from the uterus due to the preceding endometritis. The tube and ovary are (18) included in the mass, (19) the mass is adherent to the pelvic wall, (23) there may be a mass about the opposite tube, (32) there is fever if the trouble is acute, there is a history of (36) sudden onset, with pain in the lower abdomen and fever, and confinement to bed following labor or miscarriage or instrumentation, or gonorrhoea or chronic endometritis, (37) remissions and exacerbations with pelvic pain and disability, (38) menstrual disturbance (usually painful men- struation), (40) leucorrhoea, (41) backache practically all the time and ache- ing in pelvis, with sharp pain in pelvis during the exacerbations, (42) fever more or less during the exacerbations, (43) some disability all the time and usually confined to bed for a few days or longer during the exacerbations. Any increase in size (50) is accompanied by inflammatory symptoms. If the patient is examined under anesthesia, it is found that (51) the mass occupies the region of the tube and, usually, includes the ovary also, (53) is firm throughout, (54) is fixed by adhesions, (55) is attached to surrounding or- gans, (56) originates from the tube or ovary, (57) the mass can be differen- tiated from the uterus, but not from the tube and usually not from the ovary, and (58) the uterus is normal except for the leucorrhoeal discharge and the fixation, and perhaps some displacement towards the opposite side. Pyosalpinx presents practically the same symptoms and signs, except that the one or more points of fluctuation are present and the tenderness is more marked, and the inflammatory symptoms and exacerbations are more severe. In hydrosalpinx the inflammatory symptoms have practically disappeared, leaving the distended fluctuating tube with some adhesions. It differs from the ovarian cyst in that (3) the mass in typical cases is elongated and ''sau- sage-shaped," (6) is less movable than the ovarian tumor, (7) is attached to the pelvic wall and to the uterus, though in some cases the attachment is not very close, (8) appears to arise from all along the upper margin of the broad ligament, (18) the tube is included in the mass, while the ovary can in some cases be differentiated, (36) there is a history of previous pelvic inflamma- tion, (38) menstrual disturbance and other evidence of previous inflamma- tion in the uterus, and (57) if patient is examined under anesthesia it may usually be determined definitely that the tube is involved in the mass and that the ovary is separate. b. Tubal Pregnancy presents the pain, disability, tenderness and fixation of an inflammatory mass, with little or no fever, but with the addition of the special evidences of extra-uterine pregnancy given in the previous chapter (page 773). c. Fibroid Tumor of uterus presents a mass which differs from an ovarian 826 TUMORS OF THE OVARY cyst in that it is (1) situated near the center of the pelvis, (3) irregular in shape, (4) firm throughout, or if it is a cystic fibroid the larger part of the mass is firm, (6) not movable separately from the uterus, but the mass and the uterus are movable in the pelvis, (7) attached to the uterus, (8) appar- ently arises from the uterus, and (9) is so intimately associated with the uterus that it seems to be part of the organ. The uterus is usually (10) dis- placed somewhat by the mass, (11) increased in size, (12) irregular in shape and (16) presents some discharge from the accompanying endometrical dis- turbance. There are (23) likely to be other masses projecting from the uterus and there is a history of (38) menstrual disturbance (usually ex- cessive menstruation), (40) leucorrhoea, (41) pressure and aching in the pelvis and (57) if the patient be examined under anesthesia it is found that the mass is intimately associated with the uterus and that the tubes and ovaries are separate, unless the mass is so large as to obscure these structures. d. Retroverted Pregnant Uterus. This would cause confusion in diagnosis only when incarcerated in the pelvis so that it could not be raised sufficiently to be brought forward nor satisfactorily outlined. It would then differ from an ovarian cyst in that the mass is (1) situated in the median line, (4) partly solid, (5) tender, (6) not movable, (7) filling posterior part of pelvis, (8) seems to be a continuation of the cervix uteri and (9) apparently the ex- panded uterus containing fluid. There is softening (13) of the cervix and cor- pus uteri and (17) venous discoloration of the cervix and vagina. There is a history of (38) amenorrhoea, (46) morning sickness and (47) pains and tenderness in the breasts. If the patient is examined under anesthesia (57), the mass is identified with the uterus (enlarged, softened, retroverted and containing fluid), and the tubes and ovaries are distinguished as separate un- less the mass is so large that it obscures them. e. Broad Ligament Cyst. This differs from the ovarian cyst in that it is (1) situated deeper in the pelvis, (6) not so movable, (7) attached to pelvic wall and uterus, (8) originates in the lateral pelvic region, (9) extends down the side of the uterus toward the cervix, (10) displaces the uterus markedly toward the opposite side and (15) fixes the uterus to some extent. If the pa- tient be examined under anesthesia, it is found (57) that the mass is located in the broad ligament below the tube, and the tube and ovary can be dis- tinguished as separate unless obscured by the mass. Large Ovarian Cyst. A growth large enough to" cause the abdomen to be prominent must be dif- ferentiated from the following conditions : a. Tympanites and ''Phantom Tumor." b. Obesity. c. General Ascites. d. Pregnancy (normal, with hydramnios, extra-uterine). e. Cystic Fibroid of Uterus, DIFFERENTIAL DIAGNOSIS 827 f. Distended Bladder. g. Tiinior of some al)(l()iiiiii;il oi-^'aii. li. Tul)ercii]ai' Peritonitis. a. Tympanites presents resonance over all the abdomen. The vagino-abdomi- nal examination shows that there is no abdominal mass in the pelvis or lower abdomen (P^ig. 132). "Phantom tumor" is a term applied to certain condi- tions produced by irregular contraction of the abdominal muscles (forcing tympanitic intestines into some locality in such a way as to give the appear- ance of a tumor), accompanied with marked hyperesthesia. It occurs usually in hysterical subjects and the apparent tenderness may be so marked as to prevent satisfactory palpation, either abdominal or bimanual. Usually it can be made out that there is distinct resonance over the swelling and that there is no abnormal mass in the pelvis. "When in doubt, examine the patient under anesthesia, when the muscular tension and the consequent "tumor" will disap- pear. b. Obesity may produce marked prominence of the abdomen and has been mistaken for ovarian cyst (Fig. 122). Resonance may be obtained in deep, percussion over all the abdomen, showing that there is no mass betw^een the intestines and the abdominal wall Also, in picking up the wall to test its thickness (Figs. 119, 120) it is found that most of the prominence is due to the thickness of the waU. On vagino-abdominal examination no abnormal mass is felt in the pelvis or lower abdomen. c. General Ascites presents ordinarily, when the patient is lying on her back, resonance at the top of the abdomen and dullness in the flanks (Figs. 185, 186). "When the patient changes posture the outline of dullness changes, as the free fluid goes to the lowest part of the peritoneal cavity (Fig. 188). There is a percussion wave in ascites (Figs. 35, 36). Vagino-abdominal ex- amination shows that there is no mass in the pelvis or lower abdomen. The presence of disease of the heart or liver or kidneys sufficient to account for the ascites is a point in favor of the same. d. Preg'nancy. Normal pregnancy presents missed menses, morning sick- ness, enlarged breasts, vaginal and cervical discoloration and softening of the cervix. The examiner can usually distinguish the fetal parts and may be able to feel fetal movements or hear the fetal heart sounds. In pregnancy with hydramnios the symptoms and signs are about the same as in normal preg- nancy, except that there is more fluid, and consecjuently it is the more difficult to feel the fetus or to get the fetal heart sounds. In extra-uterine pregnancy there are the usual symptoms of pregnancy, with the addition of certain anomalous symptoms, indicating that the pregnancy is in the peritoneal cavity instead of within the uterus. Also, in the early history of the trouble there are indications of pelvic inflammation, with the added special character- istics of tubal pregnancy enumerated in the preceding chapter (page 773). e. Cystic Fibroid. This presents an irregular mass situated in the central part of the pelvis, and apparently it arises from or is a part of the uterus, from which it can not be separated. A large part of the mass is firm. It dis- g28 TUMORS OF THE OVARY torts the uterus and increases the length of the ca^dty. There is usually a history of excessive menstruation and of leucorrhoeal discharge. f. Distended Bladder. It has happened that a distended bladder went un- recognized until rupture of the bladder and death of the patient. In a case of distended bladder the history shows first difficulty in passing urine and later constant dribbling of urine due to the overdistention. There may be symptoms of uremia. When the patient is catheterized the supposed tumor dis- appears, but it may require a very long catheter to reach the urine because of the distortion and lengthening of the urethra. g. Tumor of Some Abdominal Organ. This presents the fixed or least movable portion at some organ in the abdomen, the rounded free border ex- tending toward the pelvis or into the pelvis. The mass may be displaced up- ward into the abdominal cavity and then the pelvis is clear. There are symp- toms associated with the organ involved, and no particular symptoms of dis- turbance of the pelvic organs. h. Tubercular Peritonitis. There is fluid in the abdominal cavity, either free or encysted, associated with evidences of tubercular inflammation in the pelvis (page 763) or in the abdominal cavity or in both. There are frequently evident signs of tuberculosis elsewhere, usually in the lungs or in the intes- tines. The tuberculin reactions may aid materially in determining whether the intra-abdominal trouble is tubercular. COMPLICATIONS. Having determined that an ovarian cyst is present, we must then consider certain complications that may be present or that may appear later. These complications are as follows : 1. Local peritonitis, forming adhesions. 2. Hemorrhage into the cyst. 3. Rotation of the cyst, producing torsion of the pedicle. 4. Inflammation and suppttration of the cyst. 5. Rupture of the cyst. 6. Ascites accompanying the tumor. 7. Intestinal obstrtietion. 1. Local peritonitis is accompanied with some pain and tenderness over a part of the tumor. There may be some fever, but usually this symptom is not marked; the process consists simply of irritation at some portion of the outer surface of the cyst and .tlie formation tliere of plastic exudate, binding the cyst to some adjacent organ or to the abdominal wall. In a few days tbe pains disappear, 'l)ut the exudate remains, becomes organized and forms an adhesion, whidi may iulciTcre more or less with the subsequent operation. 2. Hemorrhage into the cyst is what gives tlie various colors to the cyst contents. This liemorrliage tisnally takes place slowly in small (inantities and without clinical symptoms. Occasionally, however, a copious hemorrhage takes place, usually from some interefence with the venous return, such as COMPLICATIONS 829 twisting of the pedicle or pressure of an enlarged uterus, or it may follow tapping of the cyst. The hemorrhage may be so severe as to cause collapse of the patient. 3. Rotation of the cyst may take place where the pedicle is long (Pigs. 427, 698). The amount of rotation varies from a half turn to several corn- Fig. 698. Rotation of an Ovarian Cyst. The turning of the tumor twists the pedicle, bIocl. IS aierramf Fig. 703. Diagram Illustrating the Changes that Take Place in the Development of the Male Generative Organs. (Piersol, after Thompson — American Text-book of Obstetrics.) MALFORMATIONS The Wolffian body forms the ovary and also contributes the transverse tubules of the parovarium. The upper part of the Wolffian duct remains as the ''head tube" of the parovarium (Fig. 682). The lower part of the Wolffian duct sometimes remains in whole or in part, and is then known as "Gartner's duct" (Fig. 682). These parovarium tubules are all atrophic Fig. 704. Diagrammatic Representation of the Development and Malformations of the Uterus. 1, Show- ing the difTerent stages in the vmion of the MuUerian ducts to form the uterus and vagina and Fallopian tubes. 2, Uterus unicornis. 3, Uterus bicornis. 4, Uterus septus. 5, Uterus duplex. (Gilliam — Practical Gynecol- ogy.) structures of but little importance. The ovary is the important organ formed from the WolfKan body in the female. In the male the Wolffian tubules and Wolffian duct contribute the im- portant system of excretory tubes represented by the vas deferens and the POINTS IN DEVELOPMENT 839 epididymis, while the IMullorian duct is atrophic, its ends alone remaining. Its outer end forms the "hydatid of ^Morgagni," closely connected with the epididymis, and its inner end forms the "sinus pocularis," or "uterus mas- culinis," opening into the prostatic portion of the urethra (Figs. 701, 703). at gr --9f ---99 A Vag p i^"' """w^i^ B Fig. 705. Development of the External Genitals (after Ecker-ZieKler models). A, indifferent stage (eighth week); gt, genital tubercle; gr, genital ridge; gf, genital fold; z's, genital groove. B, female type; cl, clitoris; 1. maj., labia majora; v, vestibule; 1. rain, labia minora; vag, vagina; p. [perineum. C, male type; gp, glans penis; pr, prepuce; r, raphe; s, scrotum. External Genitals (Fig. 705). "Until the ninth or tenth week the ex- ternal genitalia afford no positive information as to sex" — they are indiffer- ent. They then begin to differ and "usually by the end of the third month the external sexual organs are characteristic beyond doubt." Up to the sixth §40 MALFORMATIONS week the external opening of the intestine and of the urinary apparatus are received within a common cloacal recess whose recto-uro-genital orifice is surmounted by a small conical elevation, the "genital tubercle." The lower and posterior surface of the genital tubercle is divided by a furrow— the "genital groove" — bounded by thickened edges called the "genital folds." Gradually a septum develops, separating the rectal opening from the genito- urinary opening. The "genital tubercle" forms the clitoris and the "genital folds" form the labia. The vestibule is formed by the cloaca or common opening of the intestinal tract and urinary tract in the early embryo. The perineum, developing, sep- arates the rectum from this common vestibule. And the septum (hymen) closing the end of the rudimentary vagina (fused Miillerian ducts) breaks, allowing the vagina to open into the vestibule. This opening through the septum varies much in size, shape and situation, giving the various forms of opening found in the hymen (Fig. 209). It is usually small, and roughly crescentie in shape. The vagina is formed by the fusion of the lower portions of the two Miil- lerian ducts and the absorption of the longitudinal septum between the cavities. The uterus is formed by the fusion of the middle portions of the two Miillerian ducts and the absorption of the septum between the cav- ities. The Fallopian tube of each side is formed by the upper portion of the Miillerian duct of that side. The ovary of each side is formed from a portion of the "Wolffian body of that side. The parovarium consists of the "transverse tubules," which are formed from the AVolffian body, and the "head tube," which is formed from the Wolffian duct. The paroophoron, lying in the broad ligament near the parovarium, is the atrophic remains of the lower segment of the Wolffian body. ANOMALIES OF DEVELOPMENT. The more common anomalies of development are as follows: 1. The septum between the embryonic vagina and the sinus uro-genitalis may fail to break down, in which case there results imperforate hymen (Figs. 226, 227). 2. ]\Iore rarely, perfect canalization does not take place in the fused ]\Iiil- lerian cords (each of which develops a central canal and becomes a Miil- lerian duct), resulting in a closed place at some point in the canal, giving atresia of vagina or atresia of cervix (Figs. 381, 390). In very rare cases all of the lower part of the fused cords fails of canalization, causing absence of vagina (Fig. 229). ' 3. The septum which normally separates the urinary tract (urethra) from the vagina may be defective, forming the anomaly known as hypospadias. 4. The septum between the two fused Miillerian duets may persist all the way to the hymen, in which case there exists double vagina (Figs. 230, 231). 5. The septum may persist into the uterine portion of the J\Iiillerian tract, forming a uterus septus (Fig. 704 J. I IMPERFORATE HYMEN 841 6. The middle portions of the IMiillerian ducts may fail to fuse, giving a doiible uterus (uterus didelphys) (Fig. 104., ). 7. They may fuse only imperfectly, giving a uterus with rudimentary horns. There may be either two well-marked horns (uterus bicornis) (Fig. 704.,), or a fairly well-developed uterus with one rudimentary horn (Figs. 704,, 409). 8. The Wolffian duct may persist to some extent, giving a duct lying alongside the vagina called Gartner's duct (Figs. 681, 682). This may extend all the way along the vagina and open near the hymen, or there may be only remnants of the tube here and there. These remnants sometimes develop so as to form small vaginal cysts. Such cysts are situated in the vaginal wall along the course of the atrophic Wolffian duct. The above are the principal gross developmental anomalies ordinarily met with. There are many other rarer anomalies, of which lack of space prevents mention. These vary in each organ all the way from slight modification to complete absence. The ovary is probably the least frequently affected by anomalies, and yet, as rare as they are, they have produced many surprises in abdominal work. I refer especially to the pregnancies following the sup- posed complete removal of both ovaries. This means of course that some ovarian tissue remains, and it is usually said to be a ''third ovary." While the development of three normal ovaries is not impossible, the condition present in the cases under consideration is, as a rule, ''lobulation" of the ovary of one or both sides, and not the presence of a complete third ovary. The lobulated ovary may show only a marked constriction, or it may be divided into two or three or many separate lobules, with considerable space between various lobules. Bovee mentions a case of his which the ovary of each side was represented simply by numerous small particles of ovarian tissue scattered over a large area of the posterior surface of the broad liga- ment, and resembling verrucal excrescences. It is evident that in such a case some outlying nodules of various tissue would almost certainly be missed, especially if obscured by an inflammatory exudate. The malformations most commonly requiring treatment are: Imperforate Hymen. Atresia of Vagina. Double Vagina. Malformations of Uterus. Pseudo-hermaphro ditism. IMPERFORATE HYMEN. The origin of this malformation has just been explained. The condition causes no disturbance until puberty. After puberty there is a collection of menstrual blood back of the imperforate hymen. This gradually increases in amount and distends the vagina. If the obstruction is not relieved, there 342 MALFORMATIONS is gradual dilatation of the uterus (Fig. 227) and even of the Fallopian tubes (Fig. 228), forming a cystic mass, the contents of which is blood and the walls of which are formed by the vagina and uterus. The symptoms are characteristic. At the age of puberty no menstruation appears, but about every four weeks the patient has a spell of feeling ill, with pain in the lower abdomen and the usual disturbances accompanying menstru- ation. The mother supposes that the girl is going to menstruate, but there is no flow. This is repeated month after month. As the collection of blood increases, the pain and disturbance become more marked, the patient's health begins to sutfer, and a tender mass appears in the lower abdomen. Finally the patient becomes so sick that the physician makes a local examination. He finds that there is no vaginal opening (Fig. 226), but instead there is a fluctuating mass occupying the position of the vagina and uterus (Figs. 227, 228). The treatment is crucial incision of the distended hymen, and, if the mem- brane is thick, excision of the most of it. The cavity above should be washed out with normal saline solution and then packed with sterile gauze. Great care is necessary to prevent infection. The decomposing blood that necessar- ily remains along the walls of the cavity favors the rapid growth of pus germs, and, though the operation is a simple one, patients have died from it, or rather from the infection following. ATRESIA OF VAGINA. The method of origin of this malformation has been explained. The con- dition may vary all the way from a thin septum blocking the canal to complete absence of the canal. The external genitals and hymen may be normal. On making the vaginal examination, an obstruction is met with at some point in the vagina. If there is a collection of menstrual blood back of the septum, fluctuation may be detected. Digital examination per rectum will give some idea of the extent of the atresia and the amount of blood behind it. If the patient is well past the age of puberty, and there is no fluid above the atresia, the probability is that the uterus is anomalous, so much so that menstruation could not come on even though the obstruction in the vagina were removed. So, before undertaking an operation for making a vaginal canal, recto-abdom- inal examination, under anesthesia if necessary, should be made to establish the size, shape and probable development of the uterus. In cases of apparent absence of the uterus, recto-vesical examination (see page 95) may be of as- sistance in locating a small nodule in the situation of the uterus. The treatment depends on the circumstances of the case. If only a tliin septum is present, it sliould be treated practically the same as an imperforate hymen— i. e., incised, to let out the blood, and then partially or wholly ex- cised. If a considerable proportion or the Avhole of the vaginal canal is missing, the treatment requires extended operative measures according to the special conditions present. It may be necessary to build up nearly a whole new vagina. DOUBLE VAGINA 84S Acquired Atresia. A considerable proportion of the cases of marked stenosis of the vagina, amounting ahnost to atresia, are acquired. Such a condition may result from injuries in childhood or inflammation, par- ticularly the gonorrhoeal vaginitis of childhood, and severe inflammations following the exanthemata. Congenital syphilis also may cause the same, following severe ulceration. In later life, scar-tissue resulting from injuries in labor is the most frequent cause of narrowings in the canal and bands, and constrictions and distortions. Other causes in the adult are syphilitic ulceration, injuries and severe destructive inflammations. A pessary left in the vagina for several years may lead to such a result. In rare cases even complete atresia may result from some one of these causes. The at- rophic vaginitis or "adhesive vaginitis'' of old age (senile vaginitis) leads to adhesion of the walls of the vagina and stenosis and partial obliteration of the canal (see page 417). The treatment for acquired steno.sis or atresia of the vagina is practically the same as for the congenital. The acquired form, however, is, when extensive, likely to be more difficult of satisfactory treatment on account of the large amount of scar-tissue in the vicinity. DOUBLE VAGINA. This consists usually simply in a longitudinal septum dividing the vagina into tw^o canals (septate vagina). The vagina with entirely separate walls is a much rarer condition. The longitudinal septum is the persisting fused wall of the two Miillerian ducts, as already pointed out. It may extend the whole length of the vagina, giving two openings at the vestibule, and half the cervix in each upper end (Figs. 230, 231). On the other hand, it may con- sist simply in a septum extending part way. Even when the septum extends the full length of the vagina, one canal is usually so much smaller than the other and placed so far to one side that it does not interfere with coitus or pregnancy. In fact the opening of one canal may be so flattened out at the side of an apparently normal vaginal opening that it is not noticeable except on very close inspection. In such a case, however, when the slit beside the vaginal opening is noticed, further examination may reveal a rudimentary canal of considerable size, sometimes almost as large as the patulous one (see page 185). At the upper part of each vagina is one-half of the cer^-ix. When labor takes place in a case of double vaginal canal, the septum is likely to be torn, partially or completely, converting the two canals into one. Portions of the septum may remain as a partial septum at the upper part of the vagina or as irregular bands and tags. I recall one case of septate vagina and uterus seen in the first pregnancy. The patient passed through labor without par- ticular incident, except that the cervix (half cervix) was very slow in dilat- ing. The lower part of the vaginal septum near the vaginal entrance was torn, but the greater part remained and seemed to occasion no trouble. Later, the patient returned to the hospital \ATith gonorrhoea affecting the vaginal and uterine cavity of each side. Still later, I was obliged to curet both uterine cavities. g44 MALFORMATIONS The treatment of double vagina is simple. If the septum is causing any obstruction or disturbance, it is divided or, better still, largely excised, so that the two vaginal canals are converted into one. MALFORMATIONS OF THE UTERUS. Double Uterus. The malformation may consist of simply a partial or com- plete septum in an otherwise normal uterus (uterus septate. Figs. 704^, 372), or a rudimentary horn with a nearly normal uterus (Fig. 409), or a uterus with a body divided into two horns (uterus bicornis, Fig. 7043), or a double uterus, with the body and cervix of one side separate from the body and cervix of the other side (uterus didelphys, Fig. 704^), or a "unicorn uterus" — i. e., uterus made up of the Mtillerian duct of one side only, the other being absent or nearly so (Fig. 704^. The most severe grades of deformity are very rare, though they are to be thought of in the diagnosis in puzzling eases. A septum in an otherwise normal uterus is discovered only by intra- uterine manipulation, such as curetment or the introduction of the hand after labor for the removal of adherent placenta or for other reason. No treatment for double uterus is required ordinarily, with the exception of the precaution, when curetting the uterus, to be certain that both cavities are clear. It is appreciated, of course, that in this connection, and also in double uterus, pregnancy may take place in each of the two cavities, and at different times, producing various surprising results. Rudimentary Horn. The uterine malformation of most practical interest is that of a rudimentary horn with an otherwise nearly normal uterus. This is not so very infrequent and many are the diagnostic difficulties that re- sult therefrom. Such a rudimentary horn extends outward from the main body of the uterus, and receives at its outer extremity the attachment of the Fallopian tube and round ligament of that side. The point of attachment of the round ligament is, in some cases, the only decisive gross evidence as to whether the mass in question is an enlarged Fallopian tube or a rudimentary horn of the uterus. The cavity of the rudimentary horn may be complete, extending all the way from the Fallopian tube to the main cavity of the uterus, or it may be only partial, being absent at some part (Fig. 409), or the cavity may be entirely absent, the horn existing merely as a musculo-tibrous cord connecting the Fallopian tube and round ligament with the uterus. Most of the trouble resulting from a rudimentary horn comes from infection in it or pregnancy in it (Figs. 408, 409). The symptoms and diJBFerential diagnosis and treatment are the same as for similar affections of the Fallopian tube, with the following special points : 1. The mass is usually connected to the uterus by a much broader at- tachment. 2. There is more enlargement of the uterus and distortion of its cavity. 3. The mass may become much larger without rupture (if pregnant) or without adhesions (if inflammatory). 4. There may be a communication with the main uterine cavity. In most PSEUDO-HERMAPHRODITISM 845 cases the condition is not thought of until found during the course of an operation for what -was supposed to be some one of the more common affec- tions. Even "when thought of, a diagnosis is rarely possible (except in an examination under anesthesia), for it produces the symptoms and signs of more common conditions, and the trouble is naturally supposed to be some one of these more common affections. In some cases, however, there are anomalous symptoms or signs that make diagnosis difficult and doubtful, and arouse suspicion of this malformation. Sometimes there is decided resemblance to a fibroid. I recall one such case. The symptoms and signs were anomalous and puzzling. I made a diagnosis of probable fibroid \vith complications. Operation revealed a rudimentary uterine horn, with the remains of an early pregnancy in it. There was no fibroid. PSEUDO-HERMAPHRODITISM. A true hermaphrodite is, according to Ahf eld's definition, "an individual with functionating active glands of both sexes, provided with excretory ducts." No such case has been reported in which the diagnosis has been fully accepted, though there is considerable dispute among authorities con- cerning some. Several cases have been recorded in which, among other anomalies, there were glands that on microscopic examination presented some of the characteristics of both ovary and testicle. But that condition does not constitute a double set of glands and excretory ducts. A pseudo-hermaphrodite is an individual of one sex presenting some of the local characteristics of the other sex. Many such cases have been recorded and not a few of them have presented a most difficult problem in regard to the diagnosis of the sex. The individual himself (or herself, as the case may be) does not seem to be able to help much in determining the real sex in the most difficult cases. Neugebauer was able to collect 942 cases of pseudo-hermaphroditism. In at least 41 of the pseudo-hermaphrodites the true sex was positively determined only after abdominal section, though in only four eases was the operation undertaken specifically for diagnostic pur- poses. Numerous cases are recorded where the individual dressed and lived for many years as a man or as a woman, and then ascertained that the real sex was the opposite one. The most celebrated ease, perhaps, is that of Carl Hohmann, a masculine pseudo-hermaphrodite, who from infancy to the age of forty-six years was considered a female and lived as such. The true sex being then ascertained, he assumed male attire and married as a man. The space available is not sufficient to permit the subject of pseudo-hermaphodit- ism to be taken up in an extended way. It is sufficient to mention some of the more practical points. When a child presents any anomaly of the genital organs, a most careful examination should be made and all the possibilities considered, in order to determine positively the real sex. Steps in the development of the external genitals are shoAvn in Fig. 705. Most of the pseudo-hermaphrodites are really males (have testicles in the abdomen or scrotum), the resemblance to the fe- 846 MALFORMATIONS male external genitals being due to some form of hypospadias accompanied with an abnormal opening or pocket that is mistaken for a vagina (Figs. 706, 707). The principal anomaly in female pseudo-hermaphrodites, that causes some resemblance to the male sexual organs, is hypertrophy of the clitoris (Fig. 269), accompanied with adhesion of the labia minora or labia majora over the vaginal opening (Fig. 225), or with imperforate hymen (Fig. 226), or with labial hernia (Fig. 281), or hydrocele or other labial swelling covering the vestibule. Fig. 70G. MalePseudo-herniaphroditism. The appearance of the external genitals in marked hypospadias. Fig. 707. A section explanatory of Fig. 706. B, bladder; R, rectum; P, penis with lower urethral wall absent ; H, abnormal condition constituting hypospadias and requiring a care- ful examination to determine the sex of the child ; X, sinus pocularis, enlarged and open- ing on perineum, and consequently likely to be mistaken in the new-born for a vagina. In some eases the positive determination of the sex is very difficult and may even be impossible except by abdominal section. The general rule in cases of doubt is to class the pseudo-hermaphrodite as a male until unmistak- able evidence of the opposite sex appears. This will avoid a mistake in the great majority of instances. In the case of four supposed female pseudo- hermaphrodites who were subjected to abdominal section, three of them proved to be males. 847 CHAPTER XIV. DISTURBANCES OF FUNCTION. I shall consider here not only those disturbances which we designate as "functional" because no organic lesion is apparent, but also those disturb- ances of function due to various organic diseases — that is, I shall consider all "disturbances of function," whether accompanied by evident organic disease or not. These conditions are, of course, only symptoms. They are not dis- eases and must not be taken to constitute a diagnosis. They are only indi- cations of some disease, and the physician must determine the nature of that disease by further investigation. The subjects will be taken up as follows: Disturbances of Menstruation. Points in Physiology (Normal Menstruation). Absence of Menstruation (Amenorrhoea). Scanty Menstruation. Excessive Menstruation (Menorrhagia). Painful Menstruation (Dysmenorrhoea). Irregular Menstruation. Precocious Menstruation. Vicarious Menstruation. Disturbances of Sexual Intercourse. Dyspareunia. Sexual Impotence. Disturbances of Child-bearing. Sterility. Discharge from the Genitals. Leucorrhoea. Bloody Discharge. POINTS IN PHYSIOLOGY (NORMAL MENSTRUATION). As a prelude to the menstrual disturbances proper, it is well to call at- tention to some points in the physiology of normal menstruation. Menstruation is the regular periodic discharge of blood from the uterus, 848 DISTURBANCES OF FUNCTION recurring about every four weeks from puberty to the menopause, except during pregnancy and lactation. This definition, however, does not express all there is of menstruation. The menstrual flow is simply the outward sign of important internal changes, and we must inquire what these internal changes are and what they mean in the life of the woman. In dealing with this subject there must be taken into consideration the fol- lowing three phenomena : Puberty and the beginning of menstruation. Menstruation when fully established. The menopause or "change of life." 1. Puberty and the Beginning of Menstruation. Puberty is the period at which the girl matures and becomes capable of child-bearing. This period is marked by a very rapid development of the sexual organs. The ovaries, uterus, vagina and external genitals enlarge, hair appears in the pubic region and in the axillae, the breasts become more prominent, the pelvis enlarges and the whole body becomes somewhat larger and its outlines more rounded and graceful. These physical changes are accompanied by mental changes, which are indicated by modesty, sexual desire and allied phenomena. These changes take place usually between the eleventh and sixteenth years. When the proper development has been reached, the menstrual flow appears. This flow is the sign that development has taken place and that ovulation has begun. Ovulation, no doubt, occurs before menstruation appears, sometimes long before, but, as the menstrual flow is the outward sign of the internal sexual preparation, the period of sexual activity is counted as beginning with the first menstrual flow. The age at which the first menstruation appears varies in different races and under different environment. Climate has long been thought to in- fluence the beginning of menstruation — the colder the climate the later the first menstruation. This holds good as a general rule, the Laplander begin- ning to menstruate at about 18, while the inhabitant of hot climates at from 9 to 11. Englemann has shown, however, that in some of the most northerly tribes menstruation appears as early as in the tropics. The mode of life has some influence, as has also the general health of the girl. Girls raised in the city begin to menstruate earlier, usually, than those raised in the country. In addition there are the personal inherited tendencies, about which we know very little, but which exercises a marked influence on the phenomena of life. Occasionally the beginning of menstruation is long delayed without any apparent cause. Hirst had a patient who menstruated for the first time at the age of 33, had four periods in the next two years, and then conceived two months later. He records also a reported case of a woman, married at 34, who menstruated for the first time at the age of 45, and bore a child at 46. In the United States a girl is expected to begin to menstruate when she is twelve or thirteen or fourteen. Not infrequently the menstrual flow begins at the age of ten or eleven, and hence M^hen a girl reaches about the age of ten her mother should explain to her that a slight bloody floAv may be ex- POINTS IN PHYSIOLOGY 849 pected and that it is nothing that need frighten or worry her, but entirely natural. The period of puberty is sacred to the physical development of the girl. During these years (i. e., from the age of 10 to that of 16) she should live in a free and healthful way — plenty of fresh air and outdoor exercise, with proper rest at menstrual periods, an abundance of plain nourishing food, regular hours of sleep, only a moderate amount of school work and other mental training — in short, a regimen that favors free physical development, unhampered by exhausting mental work or by indolent habits. Some of the distressing disturbances, pelvic and otherwise, that appear later in life are due to, or increased by, neglect at this developmental period. Girls are per- mitted to rise late and sit around the house, doing little else than read, when they should be at some healthful physical work (house-work, outdoor exer- cise, etc.), or, on the other hand, they are given exhausting school studies, immoderate piano practice, and other acquisitions of modern life that keep the body too much indoors and in one posture, and that develop mental ac- tivity at the expense of physical strength. 2. Ordinary Menstruation. The phenomenon is known under a variety of names — for example, "menses," "monthly sickness," "monthly period," "monthlies," "periods," "regular sickness," "catamenia. " Patients usually refer to their menstruation as the time when they were "unwell." The menstrual flow is accompanied by certain changes in the endometrium, already described (page 528). These consist principally of engorgement and swelling of the endometrium, hemorrhagic infiltration and the casting off of cells over small areas. Gebhard has demonstrated conclusively that there is no wholesale destruction of the endometrium, as was formerly taught. There are also some changes in the general assimilative and excretory proc- esses of the body. The amount of urea excreted is diminished, the appetite is poor, and there is usually more or less aching and lassitude. The menstrual discharge consists of blood mixed with secretion and epi- thelium from the uterus and with epithelium from the vagina. This admix- ture with mucus and epithelium takes place to such an extent by the time the vagina is reached that the blood does not clot. It is dark and rather viscid or stringy from its admixture with cervical mucus. The menstrual discharge has also some odor, due to slight decomposition, which takes place during its passage through the vagina. Menstrual blood taken directly from the interior of the uterus has no odor and it clots like ordinary blood. The amount of blood lost at each menstruation varies greatly in different individuals, the usual amount being probably from five to ten ounces. The rate of flow — i. e., whether or not the flow is too free — is estimated usually by the freciuency with which the napkins have to be changed. The usual flow re- quires a change about three times daily during the height of the menstrua- tion. If more frequent changing is necessary, the flow is too free. There is considerable variation in the duration of the menstrual flow, the average being three to four days. Some perfectly healthy women, however, g50 DISTURBANCES OF FUNCTION menstruate only one or two days and others six to seven days. T^.e seai -y menstruation or the profuse menstruation, as the case may be, seems to be normal for that particular individual. The duration of the flow in t>3 same individual is usually about the same at the different periods. The periodicity of the flow is more uniform, the flow recurring about every 28 days. However, many healthy women menstruate at periods somewhat longer or shorter than this. In one series the duration from beginning to be- ginning was 28 days in 70 per cent of the cases, 30 days in 13.7 per cent, 27 days in 1.4 per cent, and 21 days in 1.6 per cent (Krieger). Menstruation ceases during pregnancy and lactation. Exceptions to this rule are frequent. A few women menstruate for one or two periods after con- ception, and very often the menses return while a woman is still nursing her child. The principal physiological, significance of menstruation is that it is a prepa- ration of the uterus for the reception of a fertilized ovum. As to the exact significance of each step in the menstrual process, and as to whether it has to do with other important functions (eliminative), there is still much dispute. The old conception of menstruation as a general cleansing process has long since disappeared, but recently some interesting arguments have been put forth to show that menstruation assists in the elimination of the supposed ovarian "internal secretion." The hygiene of the menstrual period is the same as the hygiene of any other period, except that there should be a little less physical and mental strain. Even when menstruation is perfectly normal, there is usually some feeling of general discomfort and a disinclination to extra physical or mental exertion, and this feeling should be favored in so far as it does not interfere with the general healthful routine of life. Exercise, tepid bathing, an abundance of sleep, regular meals and nourishing food are all as necessary at this time as at any other. 3. Menopause. In a healthy woman menstruation ceases at the age of 44 to 47. There is considerable variation in this respect, the menses sometimes ceasing three or four years before that age or continuing three or four years afterward. It is very exceptional, however, for menstruation to cease before forty or to continue after fifty. This period of cessation of menstruation is known variously as the ''menopause," the "climacteric," and the "change of life." The changes that take place in the uterus during and after the meno- pause have already been described (page 528). They are similar to those oc- curring in all the genital structures — namely, a gradual atrophy of the func- tionating part (endometrium and muscular tissue), a general fibrous change and a slow, but decided, diminution in size. The menses usually cease gradually — that is, the flow may be less free or may continue a shorter time than usual, or the flow may be missed entirely for one or two periods. This partial and irregular absence of the menstrual flow, may continue for one or two or three years before it ceases entirely. This o-radual diminution of the menstrual flow is natural and there are frequently slight AMENORRHOEA 851 neivons JiSturbanGes ("hot flashes," etc.) that can hardly he classed as patho- logical. But many of the symptoms that rre ordinarily considered as part of the "change of life" are really not so — for example, increased menstrual flow, bloody discharge between the menstrual periods, leucorrhoea, pelvic pain, and marked nervous disturbances. These are due to pathological conditions. They mean that something is wrong, and they require investigation, that the trouble may be remedied. This is important especially in the case of vaginal discharge, whether bloody or leucorrhoeal. It seems to be the general im- pression among women that irregular bloody discharges are natural during the "change of life." But such discharges are not natural — they usually mean either inflammation or cancer. One of the saddest things in gynecological work is that a large proportion of the cases of cancer of the uterus are beyond the possibility of a cure when first examined. In such a case it is supposed by the patient and her friends that the slight bloody discharge which at first ap- pears is "natural to the change of life," and so no attention is paid to it. Later, too late, they find that it is due to serious disease, which, because of neg- lect, has progressed to such an extent that it is beyond cure. ABSENCE OF MENSTRUATION (AMENORRHOEA). Amenorrhoea is the absence of menstruation for one or more periods be- tween puberty and the menopause. You will notice that the definition includes the absence of the menses from pregnancy and lactation. This is known as "physiological amenorrhoea." Pregnancy must always be taken into consideration in a case of amenor- rhoea, and before the amenorrhoea is attributed to any other cause pregnancy must be eliminated — by the circumstances of the case or by questioning the patient or by an examination. Amenorrhoea from other causes is found principally in girls and young women in whom the function of menstruation has not yet been completely es- tablished. The age of puberty — i. e., the beginning of menstruation — varies within normal limits considerably. Girls begin to menstruate, as a rule, at the age of twelve or thirteen or fourteen. The beginning of menstruation may be postponed until the age of 16 or 17 without disturbance. Usually, however, after the age of 16, and often before that, if the menstrual flow does not ap- pear, there are disturbances that indicate some departure from normal health, and the patient may be said to have amenorrhoea. Amenorrhoea is not a disease, but only a symptom. It may be an indication of any one of several entirely distinct conditions, just as a cough may be an indication of laryngitis or bronchitis, or pneumonia or tuberculosis. When a patient comes complaining that she does not menstruate, the first thing to do is to determine why she does not menstruate — i. e., what disease or condi- tion lies back of this symptom. In practice it is convenient, for purposes of diagnosis and treatment, to di- vide the cases of amenorrhoea into two classes — one class including those 352 DISTURBANCES OF FUNCTION patients who have never menstruated and the other class including those who have. (A.) WHEN THE PATIENT HAS NEVER MENSTRUATED. A mother brings her daughter, aged 15 or 16 or perhaps 18, to you, stating that the girl has never come unwell. The mother is anxious to know why the girl does not come unwell and, of course, what should be done for her. Causes. In such a case the absence of menstruation may be due to one of three causes, as follows: 1. Poor general health, with pronounced anemia. 2. Some obstruction in the genital canal. 3. Imperfect development of the uterus. "Which of the causes is present in this particular patient? That you must find out by investigation, and the first step in that investigation is to deter- mine the state of the patient's general health. Is she pale, weak, lacking in vigor, always tired, easily exhausted by light work ? If so, the amenorrhoea is probably due to the first cause mentioned. 1. Poor General Health, with Pronounced Anemia. The next step is to search carefully for the cause of the poor vitality, with its resulting anemia. The mother usually thinks the poor health is due to the absence of the menses, while the fact is that the absence of the menses is due to the poor health, and the poor health is due to some general or local disease, the nature of which it is your province to ascertain. Now, it would be out of place here to attempt to take up in detail the differ- ential diagnosis of all the diseases which may cause deterioration of the gen- eral health, with marked anemia and amenorrhoea. All I can do is simply to point out some of the common causes. a. Tuberculosis is a very frequent cause of amenorrhoea. It may appear in the form of tuberculosis of the lungs, or of the intestines or of the peritoneum, or of the glands or of the bones, or of the urinary organs — any of the various forms of tuberculosis. The proper questions must be asked to elicit the in- formation necessary to establish the presence or absence of this disease. b. iMalaria, particularly in the chronic form, is a frequent cause of anemia in malarial regions. c. Acute disease, such as typhoid fever, pneumonia, diphtheria, and the exanthemata occurring at puberty, may Aveaken the patient so much as to delay the beginning of menstruation for many months. d. Heart disease following rheuiiialisni in cliildhood may cause persistent and severe disturbances of nutrition. e. Digestive disturl)ances or kidney lesion, or diseases of the ner\ous sys- tem, may cause a depression of vitality to such an extent that the patient does not menstruate. AMENORRHOEA 853 f. Confinement indoors, exhausting studies, overwork, poor food, lack of exercise — any of these things may cause anemia with amenorrhoea. g. Chlorosis. In some cases we can find no definite local or general disease to account for the blood condition — the pronounced anemia. In this class come the cases of chlorosis, and of pernicious anemia and of the other so- called "pinmary" anemias. The differential diagnosis of these forms of anemia l)elongs to general medicine, and the diagnostic points are described under diseases of the blood. Chlorosis occurs so frequently in girls and young women that it is sometimes classed as a gynecological affection, but it belongs to general medicine the same as the other blood diseases. Suppose, however, that our patient is not anemic, but is rosy, robust and apparently in good general health. What then causes the anemia? 2. It may be due to some obstruction in the genital canal. The obstruction is due to some malformation, such as imperforate hymen, or atresia of vagina or atresia of cervix uteri. These malformations are rare, the most frequent being imperforate hymen (page 841). Obstruction in the genital canal gives rise to no symptoms until puberty is reached. At the age of 13 or 14 or later the patient begins to feel very bad each month. At intervals of about four weeks she notices marked lassi- tude and loss of appetite, feels somewhat feverish and out of sorts, has pain in various parts of the body, more particularly in the back and lower abdo- ment. She complains just as a woman does when she is about to be unwell. Her mother thinks she is coming unwell, but no flow appears. After a few days the pain and other disturbing symptoms subside and she feels fairly well until the next month. After several months the pain and accompanying disturbances last longer — in fact, may become almost continuous — and the patient's general health be- gins to suffer. A swelling may appear in the lower abdomen or at the vagi- nal entrance. Such a history makes a local examination imperative. In the local exami- nation, if the condition be imperforate hymen, the vaginal entrance is found closed. There may be a bulging of the hymen due to the pressure of menstrual blood behind it. If the atresia is situated high in the vagina, the vaginal en- trance is found open, but after the examining finger has been introduced for a short distance it meets an obstruction, consisting of a wall of tissue block- ing the vagina. If there is a collection of menstrual blood behind the obstruc- tion fluctuation may be obtained. Digital examination by the rectum will give additional information as to the location and length of the vaginal atresia and as to the amount of menstrual fluid collected behind it. In long-standing cases the vagina and uterus and even the Fallopian tubes may be distended with blood. In cases of atresia of the vagina there are very liable to be other malforma- tions higher, and sometimes the uterus is entirely absent. If the patient is past the age of puberty and no collection of blood is found above the vagina! g54 DISTURBANCES OF FUNCTION atresia, the strong probability is that the uterus and appendages are either absent or so poorly developed that menstruation would be impossible even though the vaginal obstruction were removed. Careful examination should be made to determine certainly whether or not the uterus is present. But suppose the girl is healthy— good color, good general health, and no local malformation — what then causes the amenorrhoea? 3. It may be due to imperfect development of the uterus. This poor devel- ment of the uterus may be simply part of a general under-development, or it may be limited to the uterus and appendages, the patient being otherwise strong and fully developed. In some cases the imperfect development is so marked that it can be proven by examination (body of uterus very small). In other cases the imperfec- tion is less marked — the uterus and appendages are apparently normal, as far as can be determined by ordinary bimanual palpation, and still the de- velopment has stopped short of perfection, as is shown by the fact that the patient does not menstruate and that treatment directed toward stimulating development brings on the menstrual flow. Treatment. The patients now under consideration are girls and young women who have never menstruated. If there are no marked local symptoms pointing to ob- struction, the first step in treatment is to put the patient in the best possible general health. A local examination is not indicated at first in the absence of local symptoms. The anemia should be corrected, and the general health improved and the normal function stimulated by the following measures : 1. The long continued administration of iron, accompanied by arsenic or strychnia or other tonics, as indicated by the conditions present. 2. Curtail exhausting school duties, immoderate piano practice and other acquisitions of modern life that keep the body too much indoors and in one posture, and that develop mental activity at the expense of physical strength. The mind should be trained of course, but it should be trained in a way that does not interfere with the development of the body. The age of puberty is sacred to the physical development of the girl and nothing should be al- lowed to interfere with it. A step in the right direction is the introduction of regular gymnastic exer- cises in the curriculum of the public schools. This needs to be extended and combined Avith a certain ainouni of outdoor exercises. The course «of study in the public schools should be under such medical supervision 1hat tlic pupils be not unduly taxed, and when it is seen that a girl is not doing well j)hysically, her parents should be advised to take her out for a time and let her live the outdoor life that she needs. Such a step in time would turn many a girl from the path of imperfect development and life- long invalidism, and cause her to become a healthy, ro])ust and useful woman — an omament to society and a blessing to all around her. AMENORRHOEA 855 3. Regular and Moderate Exercise. There are excellent general works on the various forms of exercise, and I would advise a study of this sul)ject, for, in many affections, well-directed exercise is one of our best remedies. I will here speak of only a few points. a. Take five to ten minutes' exercise with a Whitcly exerciser, or other good exerciser, each night after the clothing is loosened for retiring. The ex- ercise should be taken regularly — every night without fail. It should be moderate at first, not more than five minutes, and the time lengthened as the patient becomes used to it. It should not be violent. Begin with correct standing and walking and then pass to the arm movements and the move- ments that involve the chest muscles, the expansion of the chest, etc. As the patient gets used to the work and can extend the time, other movements may be taken up, movements involving the abdominal and back muscles and the muscles of the hips and lower extremities. I think it is a good plan, however, to always take the arm movements, either at the beginning or end of each exercise period. b. Take a walk of 5 to 10 blocks (^A to % mile) each day. It is best to have a regular time for this. This exercise should be regular and moder- ate, and deep breathing should be remembered (a deep breath every 8 to 10 inspirations) and correct easy position in standing and walking. With this as with the indoor gymnastic exercise, it is not the length or amount of exercise so much as the regularity of it that accomplishes the de- sired result. c. Other forms of outdoor activity, such as horseback riding, driving, row- ing and the various outdoor sports, are excellent, as they keep the patient out in the open air and sunshine and at the same time necessitate considerable muscular activity. They are particularly invigorating because they add to the necessary exercise a healthful interest and anticipation and enjoyment But these things should not be allowed to interfere with the regular walk and gymnastic exercise — in fact, at the first regular gymnastic exercise and walk will probably be all the patient can take without fatigue, and it is only after these have been practiced for a time that the more active out-of-door sports can be undertaken without harmful fatigue. These latter are to be taken only in addition to the other when the patient is ready, and not in place of them. 4. Regular Meals and Suitable Food. An abundance of good nourishing food should be taken at regular intervals. At first the patient's appetite will probably be capricious and she will not care for much substantial food. Do not try to stuff her and do not tell her she must eat a great deal of this or that article of food, of which even the thought perhaps destroys what little appetite she has. Eather give the exercise that will after a time give her an appetite, and, after she gets so she is really hungry, tell her what article of diet she can not have, leaving her to find her food from the other articles or go hun- gry. Thus by giving her an appetite and cutting off the unwholesome articles with which she has perhaps been accustomed to pamper herself, she will soon g56 DISTURBANCES OF FUNCTION be taking an abundance of good substantial food and be glad to get it. The re- sult will be good blood, strong muscles, sound sleep, graceful carriage, healthy color, clear mind, sweet temper and a general attractiveness which can never be supplied by cosmetics and indolent luxury. 5. After the patient is well started on this regimen, say after one or two months, she may be given some of the emmenagogue preparations, provided the menstruation has not already begun. In some cases as soon as the patient is put in good general health the menstruation begins normally. In other cases the menstruation does not appear, even when the patient has been re- ■ stored 'to apparently good general health. In such a case the tonic regimen is continued and in addition some em- menagogue preparation is given, such as manganese dioxide, apiol, or some of the other preparations mentioned under Formulae. If after two or three months of this treatment the menstrual flow does not appear, or at any time if marked local symptoms develop, make a vaginol and bimanual examination and determine if there is any obstruction to the flow or any other pathological lesion needing correction. If an obstruction (imperforate hymen or atresia of vagina) is found, it must be treated as described elsewhere under the organic lesion. If no obstruction is found and the organs are apparently normal, it is then to be assumed that the trouble is due to imperfect development of the uterus — that is, that the organ has stopped short of perfection. We then employ) measures to stimulate the uterus to functional activity. The tonics, the exercise, the emmenagogues and the other measures men- tioned tend in that direction. One of the local measures frequently used for stimulating a poorly developed uterus is electricity in its various forms, both galvanic and faradic. If the symptoms recur at regular intervals, indicating that that is the timi: that the menstrual flow is nearly taking place, use hot sitz baths, hot foot baths, and warm applications to the lower abdomen. The propriety of intra-vaginal measures depends somewhat on the patient. In some patients the vaginal opening is large and the patient is not particu- larly nervous, and local treatmSit may be carried out without special trouble. In such a case applications of silver nitrate solution (4% to 10%) to the cer- vix may be made every other day at the time when the precursory symptoms of menstruation appear. The hot douche also may be used two or three times daily. If these are still ineffective, vagino-abdominal applications of elec- tricity may be tried. In the case of a patient who is nervous and distressed by the local treat- ment, and particularly if the vaginal opening is very small, no intra-vaginal treatment should be employed without anesthesia, except the introduction of the small vaginal electrode or the giving of hot vaginal douches. In such a case no intra-uterine treatment is used unless there is some indication ' for giving the patient an anesthetic. It may be that an anesthetic is required to make a careful examination to AMENORRHOEA 857 determine whether or not there is any serious abnormality of the organs. In such a case it is well to have instruments ready for dilating the cervix, as that seems to act as a stimulant to menstruation in these cases. In some eases euretment is indicated as a local stimulant. Occasionally there is anteflexion with atrophic endometritis, and, if that con- dition be present, the uterus had best be curetted at the same time that the cervix is dilated. During this treatment under anaesthesia the vaginal en- trance and cervix uteri should be well dilated, so that an intra-urine elec- trode may be used later, if necessary. In a case of amenorrhoea where the girl is engaged to be married, the Cjuestion of the propriety of marriage sometimes comes up — the parents or the patient desiring to know whether it would be right for her to marry when she has never menstruated. The answer is, that if there is no organic lesion, which in itself is a bar to marriage, marriage is perfectly proper, just the same as though the girl were menstruating regularly. In such a case th4 absence of menstruation is simply a functional disturbance, which will prob- ably soon disappear under the influence of a happy married life. (B.) WHEN THE PATIENT HAS MENSTRUATED. When the patient has menstruated one or more times, the absence of men- struation is due to one of the following causes : Causes. 1. Some condition connected with pregnancy. 2. Some other form of physiological amenorrhoea. 3. Poor general health, with anemia. 4. Acute general disease. 5. Local (pelvic) disease. 6. Operative removal of essential structures. 7. Obesity. ." . 8. Nervous impressions. 9. Suppression of menses. 1. Pregnancy, a. Normal Pregnancy. — If the patient has previously been regular in menstruation, is in good health and has had an opportunity to be- come pregnant, the natural supposition is that she is pregnant, and until it is proven that she is not pregnant, nothing should be done that could in any way interfere with pregnancy. The patient may assert positively that she is not pregnant, may even deny any possibility of pregnancy, but when after examination there is any sus- picion in your mind, postpone all local treatment until after the next men- strual flow. If you doubt the patient's honesty — that is, if you think she may return and tell you that she menstruated when in fact she did not — tell her that she must come during the flow, that you may determine the character 858 DISTURBANCES OF FUNCTION of the flow. In this way you can establish certainly whether or not she really menstruates. 1,1 • i In this matter of the question of pregnancy it requires considerable judg- ment and tact to, on the one hand, detect the cases of pregnancy, and, on the other hand, avoid wounding the feelings of innocent persons by lU-advised questions. Concerning the question of pregnancy, the cases may be divided into three classes. In the first class come the girls and unmarried women in which, from the character of the trouble or from the known character of the patient, the possibiHty of pregnancy may be at once eliminated. These correspond very closely with the patients Avho have never menstruated and require the same treatment. In the second class come the married women. In these an examination may be made at once and the diagnosis of pregnancy settled thus. If the diag- nosis is still doubtful after examination, the patient is told that it is too early yet to be certain about it and she is directed to come again after a month or six weeks. In the third class come the girls and unmarried women about whom you know but little— they may be all right or they may be all wrong ; you simply do not know and hence must be cautious. In this class come also widows, divorced persons, women living apart from their husbands — all of whom, if pregnant, might wish to conceal the fact. Some of these patients are per- fectly truthful with the physician, telling him their fears or leaving a clear opening for the asking of questions that would bring out the information. In other cases the patient gives the whole history of her case without any inti- mation of a misstep. Occasionally the patient tries deliberately to deceive the physician, hoping that in his examination or treatment something may be done that will bring about an abortion. In such uncertain cases it is usually best for the physician to keep his thoughts to himself, and not to intimate any suspicion of pregnancy until some good evidence of it is found. Do not depend too much upon the history the patient gives. Just keep in mind that it may be all truth and it may be all falsehood. If the patient is a girl or unmarried woman, an examination need not be made at once. She may be placed on tonic treatment that will not interfere with pregnancy. This will put her in better condition for men- struation and in the meantime the case may be observed and developments watched for. If after several weeks menstruation does not appear, an ex- amination may be suggested.. If the patient was formerly married, or has taken local treatment or has had an examination made, an examination may be advisable at once. If the examination signs are not decisive either way, the patient may be kept on tonic treatment and another examination made after several weeks. In this way the physician protects himself and at the same time gives the patient good treatment. If it turns out that no pregnancy is present, the patient need never know that pregnancy was suspected. On the other hand if it turns out that pregnancy is present, nothing has been done that could AMENORRHOEA 859 possibly interfere with it. He has done what was right for the patient and has protected himself, and accordingly prevented the patient from making a fool of him, as some of the deluded "smart" ones try to do. b. Extra-uterine Pregnancy. — The evidences of tubal pregnancy have already been given (page 773). 1. Other Forms of Physiological Amenorrhoea. a. Lactation. — As a rule, a woman does not menstruate while nursing a baby. There are, however, many exceptions to this rule, especially after the first six months. Quite frequently a patient, while nursing her child, Avill begin to menstruate within five or six months after labor and occasionally witliin two or three montlis. This happens most freciuently in those cases in which the mother has only enough milk to partly nourish the baby. b. Beginning Menopause. — The age at which the menopause begins varies much in different persons. The average age is about forty-five, but it often begins somewhat earlier, in exceptional cases before forty. If the patient is past forty and the menstrual flow has been getting gradually less for sev- eral months, the menopause is probably beginning. There are two separate phenomena that usually accompany the climacteric and that may aid in the diagnosis — the "hot flashes" with some irritability and other e^adences of nervousness, and the tendency to increase in the subcutaneous fat deposit. Neither one of these is pathognomonic, but both of them occurring in a patient past forty, with menstruation gradually diminishing, make the diagnosis of the climacteric fairly certain. 3. Poor Health, with Pronounced Anaemia. There is poor blood, poor gen- eral health and want of tone, secondary to some wasting disease or to chlo- rosis. The cause is determined by a careful general examination of the patient, including, w^hen necessary, examination of the urine and of the sputum and of the blood. It is usually due to some chronic disease. It may come from any of the conditions mentioned under anemia in patients who have never menstruated (page 852) or from other troubles that reduce the patient's vitality. Among the latter may be mentioned prolonged lactation, pregnancies too close together, close confinement indoors with housework or children, and sameness of work day after day without stimulating variety. 4. Acute Disease. Acute diseases, such as typhoid fever, pneumonia, the exanthemata, influenza or even a severe cold, may delay menstruation or cause it to be missed entirely, particularly if the attack comes at about the menstrual time. On the other hand, the beginning of an acute disease may cause the menstrual flow to appear too soon or to be too free. 5. Local (Pelvic) Disease. The local diseases that may cause amenorrhoea, independent of their general effect on the blood, are those diseases that affect the integrity of the endometrium (from which comes the menstrual blood) or that affect the integrity of the ovaries (from which come the menstrual impulse). a. Hj^erinvolution of Uterus.— The process of involution following preg- nancy and labor may continue farther than normal, reducing the uterus ggO DISTURBANCES OF FUNCTION below normal size and so modifying the endometrium as to interfere with menstruation. This is a rare condition, but must be kept in mind in consid- ering a case of amenorrhoea in a patient who has given birth to a child within a year or two. In one of my cases the patient was 28 years of age. Three years before she had had a severe infection following the birth of her child and there had been no menstruation since. Bimanual examination showed the uterus to be very small. On account of other trouble it was necessary to open the abdomen, and I had the opportunity of inspecting the internal genital organs. Everything was atropliic — the uterus, ovaries, tubes . and round ligaments. The uterus was about half the normal size. Hyper- involution may occur also following simple curetment for chronic endometri- tis, though that is even more rare. b. Cirrhosis of the Uterus. — This is the last stage of chronic metritis, that stage in which the wall of the uterus and the endometrium are largely con- verted into scar-tissue. There is loss of the functionating elements, marked diminution of the blood supply and consequent cessation of function before the appointed age. c. Destruction of Ovaries by Disease. — The ovaries furnish the menstrual impulse, and when they are so damaged by disease that all of the functuating elements (Graafian follicles with contained ova) are destroyed, menstruation ceases. This rarely happens, for even in extensive and destructive pelvic inflammation, enough of one ovary usually sur^dves to continue menstruation, providing the patient 's general health is not too much affected. 6. Operative Removal of Structures. The structures essential to continu- ous regular menstruation are the uterus and some funtionating ovarian tissue. a. Hysterectomy. — The removal of the uterus ordinarily means cessation of menstruation. In certain cases of supravaginal hysterectomy for fibroids, sufficient of the lower part of the corpus uteri may be preserved to continue menstruation (Chapter XV). Of course such an operation constitutes only a partial amputation of the corpus uteri. The removal of the cervix uteri alone has practically no effect on menstruation. b. Double Oophorectomy. — The complete removal of both ovaries (removal of all ovarian tissue in the pelvis) causes menstruation to cease, either at once or within a few months. In many cases, even with both ovaries badly dam- aged, enough ovarian tissue may be left to continue menstruation. In suit- able cases this is the practice ordinarily followed. To secure the desired result, however, the ovarian tissue left must continue to functionate. On the other hand, in exceptional cases, when both ovaries have supposedly been completely removed, the patient has continued to menstruate and has even become pregnant. That means, of course, that some ovarian tissue was left. Some part of the normal-shaped ovaries may have been unwittingly left or there may have been lobulation of one ovary. Islands of ovarian tissue, from malformation of ovary, are occasionally found in the pelvis, either close to the normal site of the ovary or at some distant part of the broad ligament (page 841). AMENORRHOEA ggj The removal of one ovary has little or no effect on menstruation, provided the other continues to functionate. The removal of one or both Fallopian tubes has practically no eft'ect on menstruation. 7. Obesity. The condition of the system associated with the excessive deposit of fat very frequently causes diminution in the menstrual flow and may cause it to cease altogether for a time. Tliis may occur with obesity in girls as well as in older women. 8. Nervous Impressions. Nervous impressions may delay or stop the menses for a few months, or delay their appearance if occurring at puberty. Among these may be mentioned: a long journey (particularly on shipboard), change of residence from country to city or vice versa, extraordinary grief, joy, or anxiety, or exciting work, study (as in prepjaring for examination), taking up a new occupation, financial troubles, love affairs and ditHculties in home life. Any of these may cause an expected menstruation to be missed. Treatment. The treatment required is indicated by the particular abnormal condition present. The methods of treatment for the various organic diseases are given in the appropriate chapters. In anemia employ the course of tonic treatment followed by emmenagogues, previously described for anemia in patients who have never menstruated (page 854). In married women, with no decided organic lesion, the poor general health may be due to prolonged lactation, to pregnancies coming too close together, to the worry and care of children, with, perhaps, too much housework besides, or to too close confinement indoors with monotonous housework. Close con- finement in the house, with the same round of housework day after day and month after month, without a diverting change of work or a stimulating ob- ject to be attained, is enough to produce digestive disturbance, malnutrition, anemia and general depression, both physical and mental. In the same way the woman who devotes her time largely to society may, by the constantly repeated round of social exactions, become completely "fagged out." Also, the woman who does office work may be worn out by having to do the same work day after day for months and years. In all such cases, besides the regular tonic course, a change or break in the regular routine is advisable. This change should be a decided one. It should produce not only a change in physical activity, but also should change the current of thought and furnish a new direction for mental activity. The prescription to bring about these changes will vary much in different cases, depending to a large extent on the circumstances and inclinations of the patient. With some it will be a prolonged trip abroad, leisurely visiting places of interest; with others, a trip to the seashore or to the mountains for a few weeks or several months. In the cold, cloudy months of the winter a sojourn in the South may be advisable; while, to escape the heat of sum- mer, the northern lake resorts are available in addition to the mountains 862 DISTURBANCES OF FUNCTION and the seashore. * In other cases a few weeks' rest in the country will answer the purpose, or a prolonged visit with friends in another city, or the employ- ment of help, so that the patient has less routine housework or office work, and more time for rest, amusement, outdoor exercise and some diverting- leisure pursuit, such as photography, painting, music, fancy work, or one of the many other things which furnish physical and mental diversion. A change of thought and action for a few weeks or a few months, as the case may he, is one of the best tonics, and, when combined with suitable medication and hygiene, it may make one "feel like a new person." The regular work can then be taken up with interest and pleasure, and can be executed with vigor and satisfaction. Keep in mind, however, that, to continue in good health, the patient must take time for proper rest, nourishment, exercise and relaxation. Obesity. When the patient is considerably heavier than she should be, particularly if she has increased in weight recently, she should be placed on treatment for correcting the faulty metabolism that results in fat deposi- tion. The systematic treatment of this condition belongs to general medicine and cannot be considered in detail here. I Avill say only that I have obtained good results in these cases from the granular effervescent Vichy and Kis- singen salts given on alternate days — one day the Vichy and the next day the Kissingen, etc. This should be continued for two or three months and combined with a more or less strict diet. Even when the weight is not notice- ably reduced, the metabolism is improved, the patient is placed in better general health and hence in better condition for menstruation. Of course, when the stout patient is anemic, she requires a course of iron along with the other treatment. When the amenorrhoea is apparently due to nervous impressions (a long journey, change of environment, grief, joy, anxiety), no treatment is required except for accompanying disturbances. When the patient becomes accustomed to her neAv surrouudiugs, the menses will probabty return. In the meantime any symptomatic disturbance should be treated — a sedative if needed, a tonic if indicated, an emmenagogue at once if thought best, or later if the menses do not appear. Supppression of the menses requires rather active treatment. First satisfy yourself tiiat you are not l)eing deceived — i. e., that no pregnane^'' is present. Then employ measures to produce pelvic congestion and to overcome the nervous inhijjitory influence which has been started by exposure to cold or nervous shock, or whatever it was that caused the sudden suppression of the flow. If the patient is very nervous or in pain, give sedatives in sufficient doses to set the nerves at rest. Have the patient take a warm sitz bath (a iiinstard foot bath may be given at the same time), then have her put to bed, covered up warmly and liot applications made to the lower abdomen and genitals. Hot drinks, that tend to start up the secretory action of the skin and other organs, are tlien advisa])le. If the bowels have not moved well, direct a large enema of warm water or warm soap water. MENORRHAGIA 863 As to medication, that is largelj^ symptomatic. In sudden suppression of the menstrual flow (from exposure to cold or nervous shock), accompanied by full pulse and feeling of fullness in the head and in the pelvis, give drop doses of tincture of aconite every half hour until the circulatory tension is re- lieved. Used in conjunction with the measures above mentioned, this often causes the flow to return in a few hours. Tincture of Pulsatilla, given in two- drop doses every 3 hours, is sometimes effective in relieving the distress and restoring the flow. If there is severe pain, the phenacetin and codeine cap- sules (see Formulae) may be required. SCANTY MENSTRUATION. A diminution in the menstrual flow, or a too slight flow from the beginning of menstruation, is caused by the same condition that leads to absence of the menses (with the exception of those obstructive lesions that prevent the escape of any blood), and the treatment also is practically the same (page 854). EXCESSIVE MENSTRUATION (MENORRHAGIA.) The menstrual flow may be too free or it may last too long. In either case the condition is known as excessive menstruation or menorrhagia. The nor- mal duration of the flow and the amount of blood lost varies much in dif- ferent patients. With each patient, however, the duration of the menstrual flow and the amount of blood lost is fairly constant — that is, the patient menstruates about the same length of time and loses about the same amount of blood at each normal menstruation. If there is decided increase in the amount or in the duration of the flow, the patient may be said to menstruate excessively, though the same amount and duration of the flow in another individual might be normal if usual with her. Each patient is somewhat of a law unto herself in this respect. Therefore, to make the diagnosis of ex- cessive menstruation, we need to know something of the patient's menstrual history. CAUSES. Excessive menstruation is due to those conditions which cause congestion of the pelvis, especially those which cause congestion of the uterine mucosa. It may be caused by any of the following conditions: 1. Simple Hypertrophic Endometritis. This is the usual cause of menor- rhagia occurring in virgins. As explained in a previous chapter (page .583), this form of endometritis is not real inflammation as that teriU is ordinarily understood, but is simply a nutritive change. The causes, diagnosis and treat- ment of simple endometritis are given on pages 583 to 586. 2. Infected Endometritis. Inflammation of the uterus, ^eiiher acute or chronic, tends to cause uterine congestion and consequent increase of the menstrual flow. gg4 DISTURBANCES OP FUNCTION 3. Subinvolution, without infection, is a rather frequent cause of prolonga- tion of the bloody lochia after child-birth, and of excessive menstruation later. 4. Malposition of uterus, particularly marked retrodisplacement, is likely to cause excessive menstruation— in fact, this is one of the prominent symp- toms in a large proportion of the cases of backward displacement of the uterus (page 600). 5. Cervical polypi may cause excessive menstruation and also bleeding be- tween the menses. It is surprising how much bleeding will be caused in some cases by one or two small polypi in the cervix. 6. Fibro-myoma of uterus causes menorrhagia when intramural or sub- mucous. This excessive loss of blood during menstruation is one of the promi- nent symptoms of fibroid (page 631) and is rarely absent in the classes men- tioned. 7. Cancer of Uterus. IMalignant disease of the uterus in any form, whether affecting the cervix or the corpus uteri, is likely after a time to show extra menstrual bleeding. In the early stage, however, the bleeding is more likely to appear as an occasional streak of blood between the menses, noticed af- ter coitus or after extra walking or lifting (page 670). 8. Pelvic inflammation, both acute and chronic, causes periuterine and uterine congestion, with resulting excessive menstruation. 9. Ovarian and broad ligament tumors interfere with the return of blood from the uterus and in that way cause uterine congestion, with resulting ex- cessive menstruation. 10. Obstructive Diseases. Diseases that interfere with the return of blood from the pelvis, such as heart disease with failing compensation, obstructive liver diseases and abdominal tumors, necessarily tend to uterine congestion and consequent menorrhagia. Diseases tliat cause frequent straining efforts, such as constipation, chronic diarrhoea, stricture of rectum and chronic cystitis, lead to pelvic congestion and excessive menstrual flow. 11. Functional Pelvic Congestion. In some cases no lesion is found on ex- amination and the prolonged menstruation is evidently due simply to func- tional pelvic congestion. This functional pelvic congestion may be caused by many conditions, among wliicli are the following: a. Work that favors pelvic congestion, such as standing for hours (as clerks must do), or running a sewing machine for hours (as is done by the seamstress), or lifting and working about the sick (as is done by the nurse), may lead to excessive menstruation. b. Excessive or violent exercise, as is sometimes taken in the excitement of outdoor sports. c. Recent marriage. In \hv. first few months after marriage there is fre- quently some increase in the menstrual flow, but ordinarily it need cause no alarm, for it usually disappears as the pelvic organs become accustomed to the changed conditions. MENORRHAGIA 865 It must be kept in mind, also, that an early abortion coming about the men- strual time, or an early tubal pregnancy with rupture or tubal abortion at the menstrual time, may very closely resemble an ordinary menprrhagia, with some extra pain and a few blood clots. TREATMENT. It is convenient to divide the treatment into (A) treatment during the flow and (B) treatment between the periods. Treatment During- the Plow. You are called to see a patient who is menstruating, the flow being too free or having lasted too long. By questioning the patient it can usually be de- termined certainly that it is a regular menstrual flow and not bleeding con- nected with an early abortion or threatened abortion, or tubal pregnancy. As the patient is menstruating, of course no examination is made unless there are indications of serious trouble. If the questioning shows clearly that the trouble is simply excessive or prolonged menstruation, the patient may be given some uterine astringent internally. 1. Internal Uterine Astringents. Ergot, in its various forms, is one of the most reliable of the uterine hemostatics for internal use. A satisfactory way of administering it is the ergotin and nux vomica capsule (Formulae), one capsule every 4 to 8 hours. Or the fluid extract or other preparation may be given. Ergot is efficient in all forms of uterine bleeding, except when preg- nancy is present. It must never be given when there is a suspicion of preg- nancy. Another reliable uterine hemostatic is stypticin. It may be given in the prepared % gr. tablets. I usually order it in i/o gr. to 1 gr. doses in combina- tion "with ergotin in capsules, one capsule to be taken every 4 to 8 hours, de- pending on the amount necessary to control the bleeding. Stypticin is cotarnine hydrochloride. Cotarnine is derived from narcotine, which is a product of opium. Stypticin is a yellow powder of very bitter taste. It is conveniently given in capsules, the dry powder being placed directly in the capsules. It is expensive to the patient, and, for that reason, I freciuently give the ergotin capsules for the intermenstrual period and the stypticin only during the flow. A later and allied product is styptol, a combination of cotarnine with phthalic acid. It has about the same action and indications and dosage as stypticin. Hydrastis is an old remedy much used as a uterine hemostatic. Its action is not so prompt and marked as that of ergot, but is frequently more lasting, and, in addition, it is an intestinal tonic. Hydrastinine, an alkaloid from hydrastis and closely allied chemically to stypticin, is frecpiently used to check menor- rhagia. It is expensive, usually costing about twenty cents per grain. Cal- cium chloride, also, is used as an internal hemostatic. Strychnia and other tonics tends to tone up relaxed muscular tissue and may thus diminish bleeding. 866 DISTURBANCES OF FUNCTION 2. Laxatives. At the beginning of the treatment the bowels should be moved well with a saline purgative, and after that laxatives should be given as needed to secure one or two good bowel movements daily. 3. Rest in Bed. The patient should stay in bed during the flow if possi- ble. If the bleeding is at all severe, this is imperative. The employment of the three measures above mentioned will usually di- minish the flow decidedly within twenty-four hours. 4. Sedatives. If the patient is nervous and restless or if there is dys- menorrhoea (a very frequent accompaniment of menorrhagia) , give potas- sium bromide, 15 gr. every 3 hours, as needed to give rest and sleep. This makes the patient much more comfortable, and, in addition, the bromides (particularly potassium bromide) are supposed to aid somewhat in check- ing excessive menstrual flow. If the pain is severe, the bromides will probably not be sufficient to relieve it, and then opium is indicated. Besides checking the^atient's sufferings, the opium has a decided effect toward temporarily checking the uterine bleed- ing. "When opium is given, it should be in such form that the patient does not know what she is taking. A very good formula is ergot in one grain and opium one-half grain, given in a pill and repeated every six to eight hours as needed (see Formulae). 5. Medicine for Special Indications. If there is heart trouble with failing compensation, digitalis or other heart stimulant is indicated. If there is a troublesome cough, or bladder or rectal disturbance, or other affection, give medicine for the same. 6. Vaginal Tamponade. Another method and a very efficient one for tem- porarily cheeking a serious loss of blood during menstruation is to tampon the vagina firmly, the same as for hemorrhage from any other cause. This temporarily stops the loss of blood from the relaxed atonic uterus and pre- serves that much for the anemic patient, Avho can ill afford to lose it. This packing may be removed in one or two days, and another applied. The systematic use of this method in suitable cases was brought before the profession by Dr. E. C. Gelirung, who, from an extensive experience with it, states that no ill-effect follows this arbitrary checking of the menstrual flow after a proper amount of blood has been lost. It is a useful temporary expedient for preserving to the anemic patient, over a few menstrual periods, the ])lood which she can ill afford to lose by stopj-ting the flow after the third or fourth day of mcpstrnation. In this way the downward course of the trouble may becheckoci and the patient's condition held stationary, while other measures are employed to overcome the cause of the excessive menstrua- tion. (B.) Treatment Between Menstrual Periods. Having checked the flow temporarily, the next thing is to prevent the re- currence of the excessive menstruation. The indications in such cases are : DYSMENORRHOEA 8g7 To reduce congestion of Ihc ulci-iis and other pelvic slruetures. To tone up the uterus. To put the patient's blood in good condition. To correct local diseases. The measures for accomplishing these objects are as follows: 1. Laxatives. There should be one or two good bowel movements daily, and at the menstrual period the bowels should be given a special clearing out. 2. Uterine Tonics. Ergot is one of the best drugs for toning up an atonic uterus. It produces also some constriction of the blood vessels and thus di- minishes the amount of blood in the organ. This has a marked effect in checking excessive loss of blood. The ergotin and nux vomica capsule (see Formulae) is an excellent form in which to give the ergot. This may be given three times daily, between the periods. It is a good general tonic. At the menstrual period it is well to increase the frequency to every 6 hours. Stypticin, styptol or the other hemostatics mentioned under "treatment during the flow" may be administered during the intermenstrual period. 3. General Tonic Remedies. Menorrhagia is not a disease. It is only a symptom, and the physician must find what is back of it as an etiological factor. If anemia is present, the cause must be sought and the patient placed on the required tonic regimen and medication. If there is heart disease, portal obstruction or any other condition that in- terferes with the return of blood from the pelvis, it must receive appropriate treatment. 4. Correction of Local Disturbances. Any local disease present should be determined and treatment instituted accordingly. This is a very important part of the treatment of menorrhagia and tends more than anything else to bring about a permanent cure. The pelvic disorders that may cause menor- rhagia have just been enumerated and the various methods of treatment are given in the appropriate chapters. Often the correction of a retro-displacement and the retention of the uterus in proper position, by pessary or otherwise, will effect a cure of menorrhagia. In some cases of hyperplasia of the endometrium from simple endometritis or subinvolution or fibromyoma, astringent intra-uteriue applications, made once or twice weekly in the intermenstrual period, may suffice to overcome the excessive menstrual floAV. In other cases it Avill be necessary to employ curetment. Intra-uterine treatment (applications or curetment) should al- ways be accompanied by such assisting measures as are indicated. [Metrorrhagia (bleeding between the menses) is considered on page 904.] PAINFUL MENSTRUATION (DYSMENORRHOEA). Dysmenorrhoea is the most troublesome of the menstrual disturbances, causing many women to suffer from one to several days every month. In 868 DISTURBANCES OF FUNCTION some cases the suffering is so severe that menstruation constitutes a monthly- torture, which, aside from the immediate pain, leaves the patient worn and weak for many days afterwards, and she lives in constant dread of the next menstrual period. Even in the milder cases the constant recurrence of pain and physical and mental depression may gradually induce a serious con- dition of malnutrition and neurasthenia. Dysmenorrhoea is not a disease, but only a symptom. It is caused by a great variety of conditions and is a symptom of many pelvic diseases. How- ever, no one organic lesion has been shown to be the essential or sufficient cause of menstrual pain, for every condition so considered at one time or another has been found to exist in some instances without accompanying menstrual pain. It is apparent that in practically every case, dysmenorrhoea is due to a combination of abnormal conditions, either local or general or both. The work of the physician in each case is (a) to determine the abnormal condi- tions present in that particular case, (b) to form an estimate of the rela- tive importance of each in the causation of the menstrual distress and (c) to treat the patient accordingly. It has been customary to group the cases of dysmenorrhoea into four classes as follows, each class supposedly representing distinct etiological fac- tors: Neuralgic or Ovarian Dysmenorrhoea. Congestive or Inflammatory Dysmenorrhoea. Obstructive or Mechanical Dysmenorrhoea. Membraneous Dysmenorrhoea. Neuralgic dysmenorrhoea is simply neuralgia of the ovarian, uterine and other pelvic nerves, coming on at the menstrual period because of the in- creased pelvic congestion and the greater impressionability of the nervous system generally at that time. The pain is neuralgic in character — i. e., sharp and variable. It radiates from the ovarian region of one or both sides to the uterus and to the iliac, abdominal, lumbar and sacral regions. Not infrequently it extends down the tliighs. In a large proportion of the cases there is a severe attack of head- ache at some part of the menstrual epoch and occasionally a distinct neural- gia in some other part of the body. The pain appears to be independent of the character of the menstrual flow. It may l)e most intense a day or two before the flow or it inay come on after the flow, or it may come and go during IIm^ whohvtiine. Tluis it is erratic and is likely to vary much in the difi'crcnt mcnstrnal periods witliout apparent cause. This form of dysmenorrlioea 0(;curs usually in women of a neuralgic or rheumatic diathesis. Neuralgic or rheumatic pains are often felt in the in- termenstrual periods, either in the pelvis or elsewhere. Hyperesthesia' over the abdominal surface and pain are frequently noticeable, and this is much increased at the menstrual time. DYSMENORRHEA ggQ This form of dysmenorrlioea is lia])lo to he associated with anemia, in- digestion, neurasthenia, liysteria and allied disturl)ances. Patients with rheumatism and gout are also particularly prone to menstrual pain without apparent causative lesion in the pelvis. In the cases of so-called "neuralgic" dysmenorrhoea, ovarian pain usually plays a prominent part — so prominent that this is sometimes. referred to as "ovarian dysmenorrhoea." Congestive or inflammatory dysmenorrhoea is due to congestion within the pelvis, particularly congestion of the uterine mucosa. This congestion may be due to some inflammation in the uterus or around it, or it may be due to some non-inflammatory condition, such as uterine displacement, or a tumor of the uterus or vicinity, or a functional pelvic congestion (page 864). The pain is that of inflammation, and is felt as a soreness or throbbing pressure in the pelvis or back. It may radiate into the iliac regions, or up the spine or down the thighs. If the inflammation is principally in one side of the pelvis, the pain is most severe there. The pain is usually most severe the first day or two of the flow, but may last all the time. The pain may begin a day or two before the flow, and this is especially liable to occur in those cases of inflammatory trouble involving the ovary. There is also much general soreness through the pelvis, which is increased by walking or standing. The diagnostic sign of this variety of dysmenorrhoea is the character and constancy of the pain and the fact that there is trouble between the menses — evidence of inflammation or displacement, or tumor or something that keeps up chronic pelvic congestion. The various causes of pelvic congestion are mentioned in detail under menorrhagia (page 863). Obstructive or mechanical dysmenorrhoea is, as its name implies, depend- ent on the obstruction to the outflow of the menstrual blood. The obstruc- tion may be due to circular stenosis of the canal from imperfect development, or from cicatricial narrowing or from spasmodic constriction of the circu- lar muscle fibers, or from swelling of the uterine mucosa. It may be due also to a sharp bend in the canal due to flexion of the uterus — usually an anteflex- ion, occasionally a retroflexion. The obstruction is usually found about the internal os, though in very exceptional cases it may be at some other point along the canal or at the external os. The canal may be narrowed by a tumor situated in the cervix or outside the uterus. A small polypus within the uterus may drop into or against the internal os and block it. Again, the men- strual blood may contain clots, which are expelled with difficulty even when the canal is of normal size. The characteristic of mechanical dysmenorrhoea is that the pain is par- oxysmal in character, apparently corresponding to painful uterine contrac- tions brought about by the effort of the uterus to force the blood past the obstruction. The pains are periodical — very severe at times, with intervals of rest between— somewhat on the order of the pains of a miscarriage. When the menstrual flow is freely established, the severe pain usually disappears. Dysmenorrhoea due entirely to mechanical causes, or obstruction, is rare. 870 DISTURBANCES OF FUNCTION There are usuallv complicating conditions that are as important as, if not more important than, the obstrnetion. The drsmenorrhoea of young women, so freqnentlv associated with anteflexion, was for a long time supposed to be due to obstruction in the canal. But it is now known that the obstruction is only one of the factors, and in most cases one of only secondary im- portance, as explained later ("page 871). Membraneous dysmenorrhoea is the term applied to that form of painful menstruation accompanied by the expulsion of membrane from the uterus. The membrane is usually passed in small pieces, though occasionally it is thrown oif as a complete cast of the interior of the uterus. It consists of the superficial layers of the uterine mucous membrane, and is thrown off as the result of nutritive changes which are not yet understood. The pains come with the flow and are paroxysmal — of the same character as the pains of mechanical dysmenorrhoea, but very severe, resembling labor pains. After these have continued for several hours or a day or two, pieces of the membrane are expelled. There is then relief unless other pieces pass. The membrane, mixed with the menstrual flow, is the diagnostic sign of this form of dysmenorrhoea. Care must be exercised not to confound it with mis- carriage. It usually recurs every month or so and may last for years. The cause is not definitely known. In regard to the above classification, with the exception of the cases of membraneous dysmenorrhoea, it does not make a very satisfactory grouping of the eases. In a few patients the dysmenorrhoea apparently belongs en- tirely to one of the forms mentioned — i. e., neuralgic or inflammatory or obstructive. In most cases, however, there is such a mixture of neuralgic, congestive and obstructive features that it is impossible to assign the case ex- clusively to any one of these classes. For the purposes of diagnosis and treatment, it is convenient to divide the cases of dysmenorrhoea into two groups — the fir.st group including the cases of dysmenorrhoea in the virgin and the second group including the cases of dysmenorrhea in the married woman. (A.) DYSMENORRHOEA IN THE VIRGIN. The patient, a girl or unmarried woman, comes complaining of pain at the menstrual periods. The pain may be so severe that the patient is obliged to go to bed for one or two or three days at each menstrual period, or it may be less severe, so that she is able to be up and about, but is miserable. Some- times the pain is very severe, but going to bed gives no relief. The pain may have been marked from the first menstruation or it may have been slight at first, with gradual increase since. There is usually a decided difference in the pain in the different menstrual periods, being much more troublesome at some periods than at others. In many cases the pain begins a day or two before the flow. It is usually much relieved within 2-i hours after the flow is well established. DYSMENORRHOEA IN THE VIRGIN 87]^ Along with the menstrual pain there may be loss of appetite, nausea, lassitude and neuralgias. There is nearly always decided weakness during the flow and for one to several days thereafter. ^Menstruation may be other- wise normal, or there may be scanty menstruation or exce.ssive menstruation. In many cases the patient has no particular disturbance during the inter- menstrual period. Causes of Dysmenorrhea in the Virgin. The causes are varied, but there is one group of conditions that overtops all others in the frequency of occurrence. I shall consider it first. 1. Neurotrophic Dysmenorrhoea. In the majority of cases of dysmenor- rhoea in the virgin there is a combination of conditions, comprising anteflex- ion of the cervix, some stenosis of the cervical canal and marked hyperes- thesia of the uterine tissues, especially in the neighborhood of the internal OS. This condition is a very important one on account of the frequency of its occurrence and the suffering it causes and the stubbornness with which it resists treatment in many cases. What is the Cause of the Pain in These Cases? It was for a long time supposed to be due to the narrowing of the canal at the internal os by the anteflexion present, with the consequent obstruction to the outflow of menstrual blood. That the obstruction does play some part is shown by the fact that when the obstruction is removed the pain is usually considerably diminished. But simple removal of the obstruction (dilatation of cer^dcal canal) does not always relieve the patient entirely, and in some cases the relief from this measure is slight or wanting, showing conclusively that the obstruction is not the only factor in the case. Again, it is a matter of common observation that some patients, with as much or more anteflexion and obstruction as are found in these cases, have no dysmenorrhoea. In 37 cases of decided anteflexion, reported by A. M. Judd, nine were "^vithout menstrual pain, 19 had menstrual pain beginning before the flow and nine had only premenstrual pain. In 26 cases of anteflexion in the unmarried, reported by C. E. Hyde, five had no menstrual pain, 20 had menstrual pain beginning before the flow and one had pain only after the flow. So the essen- tial disturbance must be sought further. Endometritis has been put forward as the cause of the pain — at least of that portion of it which is not relieved by the removal of the obstruction. But this hypothesis also fails. In not a few cases of dysmenorrhoea persisting after dilatation the mucosa, removed by curetment, has been found to be practically normal. On the other hand, many patients with decided endometritis have no particular menstrual pain. There is one pathological condition that seems to be fairly constant in the class of cases under consideration, and that is h^^)eresthesia or marked irrita- bility of the nerves of the uterine mucosa and muscles, especially in the neighborhood of the internal os. This is noticeable on sounding the uterus and especially on dilating the internal os without anesthesia. It is indicated 872 DISTURBANCES OF FUNCTION also by the painful muscular contraction or uterine "cramps" occurring witH- out apparent cause. The theory that the essential or underlying condition in these cases is hyperesthesia of the mucosa and muscle due to a nutritive disturbance, affecting the nerves and other tissues, seems to be the most tenable one. It explains better than any other hypothesis yet advanced the various phenomena observed. It shows why the symptoms may persist to a greater or less extent after removal of the obstruction at the internal os and after removal of the hyperplastic mucosa. It shows why the symptoms occur in patients with no obstruction and with no decided structural change in the mucosa. It shows why measures directed toward improving nutrition and allaying nerve irritability will sometimes produce -decided improvement with- out any local treatment. In short, it explains wh^it has already been worked out clinically — that the narrowing of the canal and thickening of the endome- trium are simply complications that may or may not be present. When they are present they aggravate the trouble and require treatment. But unless the nutritive disturbance of the uterine muscle and mucosa is also improved sufficiently to restore the nerves to fairly normal condition, the pain will con- tinue to a considerable extent. The marked effect of pregnancy and parturition is these cases points strongly to its being largely a nutritive disturbance. Pregnancy has a most profound influence upon the nutrition of the uterus. To be sure, the parturi- tion effectively overcomes the stenosis, but this does not account for the uni- form and marked benefit, for we have already found that in many cases the stenosis is not an important factor. The beneficial effect of curettage in these cases is likev.dse due, to a large extent, to its marked stimulation of the nutrition of the uterus. Another point in favor of the supposition that this trouble is essentially a nutritive disturbance affecting the whole uterus (both muscular tissue and mucosa) is the fact that it is very frequently accompanied by evidences of imperfect development. Such cases are referred to as cases of "infantile uterus." The evidences of imperfect development are late beginning of the menses, irregular menstruation and decided anteflexion of the cervix (failure of the cervix to take its proper direction across the vaginal canal). In fact, the association of imperfect development Avith tliis form of dysmenorrhoea is so common that some writers attribute the dysmenorrhoea to the imper- fect development. It seems to me, however, that a better view of the matter is that the imperfect development and the dysmenorrhoea are both due to the same cau::e — viz., poor nutrition. I think we may go a step further and say that these two conditions— im- perfect development and neurotrophic dysmenorrhoea— are due to poor nutrition largely at a certain period of life— namely, at the period of puberty. The victims who suffer most are usually women who during puberty were poorly nourished from a physical and developmental standpoint and were subjected to influences that wouhl rotnrd uterine development (see page 854). In many cases this poor nutrition persists, and is only too apparent DYSMENORRHOEA IN THE VIRGIN 873 when the patient comes to the physician to secure relief from the dysmenor rhoea. In other cases the patient, having been for some time out of school and taking more fresh air and sunshine and exercise, has acquired good blood and a good color. But that has not been sufficient to correct the evil effects of a pernicious regimen during puberty — a regimen which promoted mental activity at the .expense of physical development. 2. Membraneous Dysmenorrhoea. This form of dysmenorrhoea, or rather the meaning of the term, has been explained (see page 870). The cause and exact pathology are still in doubt. It is sometimes designated as "exfoliative endometritis," though careful examination of the exfoliated membrane has shown that in some cases no endometritis is present. Membraneous dysmenorrhoea is a comparatively rare affection. It usually appears early in sexual life, though some cases have been reported in which the disease first appeared in middle life. It usually extends over several years. At certain menstrual periods the endometrium is cast off and appears in the menstrual discharge as shreds. Occasionally the mucosa is cast off as one piece, forming a cast of the uterine cavity. The detachment and ex- pulsion of a membrane with the menstrual flow (decidua menstrualis) may take place when the endometrium is practically normal in structure or when it is the seat of one or more of the several inflammatory and nutritive changes already described. The expelled pieces will, of course, exhibit whatever struc- tural change is presnt in the endometrium ; consequently in a series of cases of membraneous dysmenorrhoea, examination of the membrane may show many dift'erent inflammatory and nutritive changes, none of which are peculiar nor distinctive of membraneous dysmenorrhoea, but due to independent patho- logical conditions in the endometrium. Membraneous dysmenorrhoea is undoubtedly due to a marked nutritive change, but just what lies back of this nutritive change has not been certainly determined. F. F. Lawrence, in reporting a number of cases, advanced the idea that the condition is usually due to pelvic inflammation following an attack of one of the exanthemata near puberty. He reported 42 cases of membraneous dysmenorrhoea in which there was present tubal or ovarian disease requiring operation. In 19 cases the disease was unilateral and in the remaining bilateral. In 33 of the 42 cases the trouble appeared, from the history, to have started from an attack of scarlatina, measles, mumps, rheu- matism or small-pox. In nearly all (the report is not definite) there was no further membraneous dymenorrhoea after the removal of the pelvic disease. He concludes that membraneous dysmenorrhoea is due to trophic changes in the endometrium secondary to adnexal disease, and that this adnexal disease is usually a sequel of one of the exanthemata occurring near puberty. He concludes also that the adnexal disease is usually unilateral at first and may be prevented from extending to the other side by prompt attention. As a result of these conclusions, he holds (a) that tubal and ovarian complications occur- ring with the exanthemata near puberty should be watched for and treated, (b) that in every case of membraneous dysmenorrhoea a careful history should 874 DISTURBANCES OF FUNCTION be gotten ^vith that point in \ievr, (c) that when unilateral adnesnal disease is found, prompt operation should be carried out to prevent the trouble be- coming bilateral, and (d) that the facts in the case "would seem to warrant removal of the tubes and ovaries on one or both sides when shreds or casts are a part of painful menstruation. The facts brought out above are certainly interesting, and study along this line may help to clear up part of this subject. "With the last conclusion, however, I must differ most decidedly. Eemoval of the adnexa on one or both sides should, as a rule, be made only for a distinct adnexal lesion and not simply for painful menstruation, whether accompanied by shreds or not (page 888). The fallacy of operating simply for the dysmenorrhoea is shown by the fact that the dysmenorrhoea may be as severe after operation as be- fore. This fact was brought out in the discussion of the above paper by L. H. Dimning, who stated that "one of the most severe cases of membraneous dysmenorrhoea he ever saw occurred in a woman after he had removed bilat- eral pus tubes and both ovaries. She menstruated for two years afterward and had membraneous dysmenorrhoea." In a pre^aous paper Dr. Dunning had reported a case of membraneous dysmenorrhoea which persisted after abdominal section and treatment of the adnexal disease, and finally yielded to intra-uterine applications of electricity. Concerning diagnosis of membraneous dysmenorrhoea in the virgin, the passage of shreds of membrane with the menstrual flow establishes the diagnosis. There is no other affection of \-irgins presenting such symptoms. It is well, however, to have some of the membrane saved for inspection and microscopic examination, for the patient may be deceived by blood clots or shreds of bloody mucus. It must be kept in mind, also, that in certain cases the supposed virgin maj' not be a virgin, and that, consequently, the sup- posed "decidua menstruaUs ^ ' may be a decidua of a different character (page 858). 3. Atrophy of Uterus. In certain cases in virgins past 30 years of age and also in sterile married women there seems to be some atrophy of the uterus, which has failed to receive the stimulus of pregnancy. The patient had no particular pain in her earlier years, but gradually menstrual suffering has appeared, and examination shows no lesion, except a rather small at- rophic) cervix, with more or less stenosis. This is really a form of neurotrophic dysmenorrhoea, but is due to trophic disturbance in later years instead of during the developmental period. This is one of the classes in which the stem pessary is sometimes advisable (page 882). 4. Backward Displacement of the Uterus. Painful menstruation is one of the symptoms freqm-ntly produced by marked retrodisplacement of the uterus. Kelly found that of 229 consecutive cases of dysmenorrhoea admitted to Johns Hopkins Hospital, 41 per cent, were associated with retrodisplace- ment of the uterus, 37 per cent, with pelvic inflammatory disease, and 11 per cent, with fibromyoraata. The proportion of cases of retrodisplacement is, of course, much larger in patients who have borne children than in virgins. DYSMENORRHOEA IN THE VIRGIN g75 In 184 cases of retrodisplacement of the uterus, reported by A. M. Judd, 108 suffered with menstrual pain, either during the flow or immediately before it. A slight retrodisplacement of the uterus, less than the second degree, does not give rise to particular disturbance and should not be accepted as the cause of dysmenorrhoea. 5. Fibromyomata of the Uterus. Painful menstruation is a frequent symp- tom in uterine myoniata, particularly when the nodules are interstitial or submucous. 6. Chronic Pelvic Inflammation (salpingitis, oophoritis, cystic ovary). Sal- pingitis is comparatively rare in the virgin, for the various causes of pelvic inflammation in the married woman are not present. Chronic oophoritis from local circulatory and nutritive disturbance is more frequent and may give rise to some dysmenorrhoea. 7. Pelvic Tuberculosis. This is not so rare as was formerly supposed, and should be thought of whenever there are evidences of chronic pelvic inflam- mation in a virgin. 8. Ovarian or Broad Ligament Tumors. These may arise in the virgin and give rise to the usual symptoms and signs, which are detailed in the appro- priate chapter. 9. Inflammation of Adjacent Organs — bladder, rectum, appendix. Any adja- cent inflammatory trouble is likely to be considerably aggravated by the menstrual congestion. Occasionally the trouble is so slight as to be hardly noticeable except during the menstrual exacerbation. In such a case it may at first be considered one of the usual varieties of dysmenorrhoea, but careful watching will show symptoms pointing to the organ involved, and evidence of such disturbance may be found in the intermenstrual period. Chronic ap- pendicitis not infrequently presents decided menstrual exacerbations. And in some eases the intermenstrual symptoms are so slight or indefinite that the true nature of the affection is not suspected until abdominal examination shows tenderness at McBurney's point and other evidences of chronic appen- dicitis. 10. Functional Pelvic Congestion. Chronic functional congestion of the pelvis, due to constant standing, long walking or other causes (page 864), may cause very troublesome dysmenorrhoea. 11. Reflex Dysmenorrhoea. There are occasional cases of dysmenorrhoea apparently due to reflex disturbance from a distant part of the body. One of the most striking of such reflex connections is that from within the nose. In certain cases, dysmenorrhoea has apparently been due to some pathological intranasal condition and has been relieved by treatment of the same. These are sometimes referred to as cases of "nasal dysmenorrhoea." In certain other cases, menstrual pain has been relieved by cocainization of particular areas of the normal nasal mucosa. This fact was first brought to the attention of the profession by Fliess, a German rhinologist, who in 1897 presented to the Berlin Obstetrical Society a paper detailing his experiments in that direc- tion. He found that in some cases of dysmenorrhoea the pain disappeared 876 DISTURBANCES OF FUNCTION within a few minutes after the application of a 20 per cent, cocaine solution to certain areas in the nose. These areas were the anterior end of the inferior turbinated bone of each side, and a spot just opposite this on the septum, some- times referred to as the tuberculum of the septum. Fliess in his experiments divided the cases of dysmenorrhoea which he encountered into two classes — first, those in which the pain ceased as soon as the menstrual flow began, and, second, those in which the pain continued along Avith the flow. In the first class he noticed no particular effect from the intranasal cocaine application. In the second class, those in which the pain continued during the flow, the effect of the application of cocaine to the areas mentioned was striking. Usually within five to seven minutes after the application the pain ceased, and did not reappear during that menstrua- tion. In some cases there was a pathological condition involving the areas mentioned, but the same result was obtained in many cases in which no dis- ease was apparent. To eliminate "suggestion" as a factor in the case, the application of cocaine was made to other intranasal areas, instead of to those mentioned, and there was no result. Again, the designated areas, which are sometimes referred to as the "genital spots," were touched with an inert solution and there was no result. Again, in those cases in which temporary relief followed the application of cocaine to the intranasal genital spots, cauterization of those areas produced a cure, either permanent or lasting several months. Good results have since been obtained by other reliable observers in various parts of the world and this measure has been established as useful in the treatment of certain cases of dysmenorrhoea. It has also served to call atten- tion to the fact that certain pathological conditions in the nose may give rise to troublesome dysmenorrhoea, and hence in a case of dysmenorrhoea that persists without apparent cause a careful rhinological examination should bei made to exclude nasal trouble or to discover and remove it. 12. Neurasthenia. The neurasthenic individual is prone to pains in the pelvis, as in other parts of the body, and, of course, they are likely to be most severe at the menstrual time. These pelvic pains occur without any ap- parent local cause. The cases usually present the characteristic of "neuralgic dysmenorrhoea." Such patients are often subjected to ineffectual treatment for many months — until the practitioner grasps the fact that he is dealing, not with a local condition, but with a widespread affection of the nervous system. 13. Hysteria. In patients with hysteria the disturbances may be much increased at the menstrual time. In some cases the hysterical manifestations between the periods are so slight that hysteria is not suspected until a careful examination is made. Treatment of Dysmenorrhoea in the Virgin. In a case of dysmenorrhoea in a virgin a local examination is not called for at first, unless the patient has taken a course of treatment without decided DYSMENORRHOEA iN THE VIRGIN 877 benefit or there are symptoms indicating some decided local lesion. If there are no symptoms between the menses, indicating some gross lesion, it is to be assumed that the menstrual pain is due to that most frequent cause — defective nutrition with uterine hyperesthesia, anteflexion of cervix and more or less stenosis of the cervical canal. This condition may, for convenience, be designated as "neurotrophic" dysmenorrhoea (page 871). The management of tlie cases may be conveniently divided into two parts — treatment during the menstrual flow and treatment between the periods. Treatment During the Flow. Suppose you are called to see the patient while she is menstruating and in much pain. The first thing to do is to relieve her immediate suffering. 1. General Measures. Put the patient to bed and have hot stupes applied to the lower abdomen, and the bowels freely opened by an enema or a purga- tive or by both. In some cases you will find that the patient has already car- ried out this part of the program and has also taken hot drinks of various kinds, having found by experience that these measures diminish the pain. 2. Sedatives Internally. For further relief, if the pain is troublesome in spite of the above measures, give some sedative. The time-honored viburnum prunifolium will often give considerable relief. It may be given either as the plain fluid extract or in the form of one of the less nauseating and more effective preparations supplied by reliable manufacturing drug houses — for example, Liquor Sedans (P. D. & Co.), which contains 4 gr. of viburnum, 8 gr. of hydrastis, 4 gr. of Jamaica dogwood and 5 gr. of cascara to each teaspoon- ful. If the pain is severe, this is not sufficient for immediate relief. For the severe pain I usually prescribe phenacetin and codein (Formulae). There are a number of other preparations that are sometimes used with benefit, among them camphor, fluid extract of cimicifuga and aromatic spirits of ammonia. In those cases in which nervousness is a prominent feature I give sodium bromide in 10 gr. to 20 gr. doses every three hours until the general nervous irritability subsides. The ''dysmenorrhoea mixture" containing postassium broniid, guar ana and celery (Formulae) is highly spoken of. Morphine is rarely necessary. "When the pain cannot be otherwise relieved, morphine may be given for temporary relief, but it should be given in such a way that the patient does not know what she is taking. The above measures usually give the patient relief, but she should stay in bed as long as there is any tendency of the pain to be severe. 3. Intranasal Applications. This may be tried in those cases in which the pain persists after the flow is well established. Schiff found this treatment effective in 35 out of 41 cases in which it was tried. Ephraim reported 18 successes in 24 cases, and Linder 10 successes in 16 cases. It has proved suc- cessful in some cases that persisted in spite of dilatation and curetment and various kinds of internal medication. On the other hand, it has failed com- pletely in cases that apparently should have been relieved by it. It is uncer- g7g DISTURBANCES OF FUNCTION tain, but is worthy of trial in selected eases. When using this treatment re- member the following points: a. The application is m.ade in each nostril, to the region including the an- terior end of the inferior turbinated bone and the adjacent portion of the septum. b. The strength of the cocaine solution usually used is 20 per cent., though possibly a Aveaker solution (e. g., 10 per cent.) would do. c. The application should be made by the physician only, and the patient should not, as a rule, know what is being applied. The solution should not be given to the patient for use at home, as it might lead to the formation of the cocaine habit. d. In those cases in which the cocaine application stops the pain, the "gen- ital areas" in the nose should be cauterized by a rhinologist, that the reflex feature of the dysmenorrhoea may be cured or relieved for some months. Treatment Between the Menstrual Periods. After the pain is relieved for that menstrual period, then comes the ciuestion of treatment in the interval, to prevent or diminish the pain of succeeding periods. In the virgin a local examination is not called for at first in the absence of decided local symptoms between the menstrual periods. The first thing to do is to put the patient on a regimen of general measures and internal treat- ment that will put her in first-class general health. 1. General Measures. The general measures are directed toward improv- ing the general muscular tone, correcting anemia and overcoming constipa- tion. They have been given in detail when speaking of the treatment of amenorrhoea (page 854). 2. Internal Treatment. The patient is placed on some good iron tonic (Formulae), with or without the addition of arsenic or strychnine or quinine, as thought best. She is given also such other medicines as are indicated by special symptoms present — e. g., by indigestion or cough, or sleeplessness or neuralgias. Remember that in gouty or rheumatic patients, dysmenorrhoea is sometimes much relieved by remedies directed towards overcoming the nutritional disorder manifested by the gout or rheumatism. Laxatives also are important when there is any tendency to constipation. Give some tonic laxative (Formulae) in sufficient doses to give one or two good bowel move- ments daily. Some antispasmodics- liave a particular effect in overcoming menstrual pain. Decided benefit is often secured by the viburnum preparations pre- viously mentioned, given in moderate doses, tliroe times daily continuously and increased to every four or six hours during the flow. Apiol is useful, especially when the dysmenorrhoea is accompanied with scanty menstrual flow. It may be prescribed in pill form in doses of 8 to 5 gr. in ready- filled capsules. The active principle known as apioline is supplied in capsules DYSMENORRHOEA IN THE VIRGIN 879 containing three minims each. These are very convenient and in some cases seem to be active. Potter states, however, that the capsules of foreign make are unreliable and are usually inert. If there is excessive flow, the ergotin and cannabis Indiea capsules may be used (see Styptics under Formulae). These are administered continuously for some months. The other preparations used especially for excessive menstruation, stypticin and styptol (page 865), have a tendency also to diminish the menstrual pain. Two-drop doses of tincture of Pulsatilla, given three times daily for several days before the flow, has removed dysmenorrhoea in several cases. Many other preparations belonging to the general class of antispasmodics, and mentioned in works on materia medica and therapeutics, have been used from time to time for dysmenorrhoea — with marked relief to some patients and with no relief to others. As a general proposition, those remedies which are beneficial in neuralgias are beneficial also in dysmenorrhoea. Thyroid extract has been used with benefit in some series of cases — one series showing marked benefit in 80 per cent, of the eases. 3. Intranasal Examination. In cases where there are any nasal symptoms, and also in the cases relieved by intranasal applications, a rhinological ex- amination should be made. If some nasal disease is present, the removal of it may so improve the menstrual pain that the patient is saved much suffering and is spared the embarrassment of a pelvic examination. 4. Pelvic Examination to determine local lesion. If there is no decided benefit from the measures already mentioned after two or three menstrual periods, or at any time if severe local symptoms develop, the patient should be examined to determine if there is any local lesion. The details of the examination of a virgin have been given (page 74). In many cases it is best to make the examination under anesthesia, for the reasons there stat- ed. When examining a patient under anesthesia for dysmenorrhoea or for menorrhagia, preparation should be made for dilatation and curetment, so those therapeutic measures could be at once carried out under the examina- tion-anesthesia should the examination reveal a condition requiring it. Also, if a retrodisplacement is found, an attempt to correct it by manipulation may be made carefully Avhile the patient is under the anesthetic. The subsequent treatment will depend, of course, upon the conditions found on examination. If there is backward displacement of the uterus, treatment for that is required (page 603) ; if there is a fibroid tumor of the uterus, the treatment is for that (page 637) ; if there is pelvic tuberculosis, the treatment is for that, as indicated; if the trouble is neurotrophic dysmenorrhoea, that must receive the proper attention, and so down the list of possible conditions. The treatment for these various conditions will be found in the appropriate chapters. The condition styled neurotrophic dysmenorrhoea belongs especially to this chapter. The local measures of treatment for this condition are, in gen- eral, measures directed toward overcoming the stenosis and removing an un- healthy endometrium, with such nutritional change as would necessarily follow 880 DISTURBANCES OF FUNCTION this instrumentation. I will mention these measures as a continuation of the treatment of the dysmenorrhoea in cases where no more marked local lesion is found. 5. Thorough Dilatation and Curetment under Anesthesia. As previously explained, this should as a rule be the first local measure employed in the virgin, as it is not ad^dsable to employ any local treatment unless it is of such character that it will have some decided effect. If the patient is to be anesthetized for examination, preparation should be made so that dilata- tion and euretment could be carried out at the same time if found ad\'isable. I think the euretment is important, for it enhances the nutritive effect of the dilatation — and the benefit from the procedure is due to its nutritive ef- fect on the uterine tissues as well as to the removal of obstruction. The de- tails of this operation have been given (pages 571 to 582). If the patient is engaged to be married soon, the examination under anes- thesia with the dilatation and euretment should not ordinarily be carried out. Wait until several months after marriage before emplojdng any local measures. In the meantime pregnancy may take place, and that will do more toward a permanent cure of the trouble than the most radical operative measure. The marked effect of pregnancy in these cases of neurotrophic dysmenorrhoea is an additional indication that it is largely a nutritional trouble. Pregnancy exercises a most profound influence upon the nutrition of the uterus, both of the muscular tissue and of the mucosa. It has been argued that pregnancy and parturition produce the marked curative effect in these cases by overcoming the stenosis. Without doubt it does overcome the stenosis better than any other known measure, but, as has already been explained, the stenosis is only one feature of the trouble and the removal of the stenosis alone does not always effect a cure. We may confidently expect considerable relief from thorough dilatation and euretment in the great majority of the cases. The duration of the im- provement is variable. In a majority of the cases there is a return of the trouble after periods varying from a few months to several years, though it usually does not become so severe as it formerly was. In 95 cases, reported by H. A. Kelly, 32 were relieved (19 completely and 14 largely), with no return of the trouble — the period of observation extending from one to twelve years; in 7 cases there was relief for a period varying from one to nine years, the dysmenorrhoea finally returning; in 28 cases there was relief for a few months, but the dysmenorrhoea returned within a year; and in the remaining 28 cases there "was no relief. With the dilatation and euretment in these cases, I think it Avell to pack the dilated cervix firmly with gauze and leave the packing in place for forty- eight hours, so as to hold the internal os well open until tlie reparative infiltration begins, in order that the dilatation may be made as prolonged as possible. Along with this local treatment and folloAving it, the various gen- eral measures previously recommended should ])e used. In order to make the dilatation more lasting, II. D. Frye advocated the DYSMENORRHOEA IN THE VIRGIN 881 immediate use of a hard rubber drainage plug or intra-uterine stem. He states that immediately following the dilatation and euretment, "a Wylie drainage plug as large as will readily pass is inserted into the cervical canal and held in position by a Smith pessary. For a number of years I was ac- customed to leave the plug in place for six days, but following the sugges- tion of Dr. Wylie I now^ allow it to remain from three to six weeks and the result is better. I usually keep the patient in bed two or three weeks after operation, and, if no discomfort be experienced, permit her to get up and go around, wearing the plug several weeks longer. I believe the use of the hard rubber drainage plug does much to add to the permanency of the relief ob- tained. When retained sufficiently long, it causes the formation of a cica- tricial ring of tissue at the point of constriction, which insure patulency. I have not seen any bad results follow its use. In a few cases it causes pain, and on that account must be removed sooner than the specified time." It must be kept in mind, however, that w^hen we leave a foreign body in the uterus for several days, particularly immediately after opening up the lymph spaces by euretment, we take great risk of causing inflammatory trouble, which may extend to tubes and become far more serious than the menstrual pain. In exceptional cases one may be justified in taking this risk. The cases which are particularly amenable to dilatation are, of course, those in w^hich the obstructive feature is prominent — i. e., the pain is severe and cramp-like, is most severe just as the flow is starting and largely disap- pears when the flow is well established. When there is a tendency to later return of the obstructive features of the dysmenorrhoea, then is the time for the use of partial dilatation or electricity — or stem pessary in suitable cases. 6. Partial Dilatation of the Cervical Canal in the Office. This is rarely ad- visable in the virgin for the reason that in such a patient it is difficult, pain- ful, ineffective and subjects the girl to a pelvic examination without much chance of benefit. As a rule, when the measures previously mentioned fail, it is better to give the patient an anesthetic and dilate thoroughly and curet as above explained. Occasionally, however, in an unmarried woman this par- tial dilatation is practicable and gives much relief. The patient is placed in the Sims posture, the Sims speculum introduced, the cervix caught and brought into view, and, with the antiseptic precau- tions necessary in all intra-uterine work, the graduated metal dilators (Fig. 101) are introduced into the cervical canal and past the internal os — begin- ning Avith the smallest size that the canal will accommodate and passing to the largest. After dilatation the vagina is again cleansed with the antisep- tic solution, the speculum removed and the patient directed to lie doAvn for a time after she gets home and to be rather quiet the remainder of the day. This dilatation is made each month just before the menstrual time. It is well to dilate four or five days before the fiow is expected and then again the day before the flow. The closer the dilatation to the beginning of the flow, the better the effect, but, if one waits until the day before the expected flow for the first dilatation, the flow may come a day or two too soon, and thus the dilatation is missed entirely. 882 DISTURBANCES OF FUNCTION 7. Stem Pessary or Wire Spring. Like partial dilatation, this is not ap- plicable in most cases of clysmenorrhoea in the virgin until after the cervix has once been thoroughly dilated under anesthesia. In the exceptional cases in which partial dilatation is practicable and ef- fective temporarily, but must be repeated every month, the stem pessary or the wire spring may be used to maintain the dilatation. The use of the stem pessary must be attended with great caution. It was formerly used fre- quently and led to serious pelvic inflammatory trouble in many cases. The harmful results Avere so frequent that the use of the stem pessary was prac- tically dropped by careful workers. Later it was found that in certain ex- Fig. 708. stem pessary Stem Pessaries; u, Outerbridge's cervical spring; b, liard-rubber stem pessary; c, aluminum ceptional cases nothing would take its place, and that in these carefully se- lected cases and under proper technique it could be used with comparatively little risk. Its field of usefulness is to overcome the obstruction or stenosis in those cases without other pelvic lesion and in which this feature causes much suf- fering in spite of the employment of less undesirable measures. As was well emphasized by J. IT. Car.stens, who has done much to popularize the proper use of the stem pessary, it must never be used in a case where there has been any tubal or ovarian or other form of periuterine inflammation, or when there are adhesions. This is very important, for the use of a stem pessary in DYSMENORRHOEA IN THE VIRGIN 883 such cases may lead to serious results. Active inflammation in the uterus should also be excluded. The use of the stem pessary in the virgin has also the same objections that hold for partial dilatation or any other local treat- ment. Its use should as a rule be reserved for those cases in which the severe pain returns after thorough dilatation and curetment under anesthesia. In the married woman, where the objection to local treatment is not present and where also the cervix is likely to be softer and more easily dilatable, it is more frequently advisable, along with partial dilatation, as a treatment pre- ceding thorough dilatation under anesthesia. The cases, however, must be carefully selected, as previously pointed out. A foreign body remaining in the uterus for weeks at a time is a hazardous condition, and such treatment should be employed only with a definite understanding of the indications and contra-indications, and then only in cases when the advisability of this treatment rather than some other is clearly established. It must be kept in mind also that other therapeutic measures must also be used, as indicated by the conditions present. The established effect of the stem pessary is simply to overcome the stenosis — though it is possible that it has some stimulating effect on the local nutrition and on the muscular develop- ment (Carstens). The pessary is applied after partial dilatation (page 881) and under the same strict antiseptic precautions used in sounding the uterus (page 87). The preferable time to apply it is a few days before the menstrual flow. If the menstrual pain for that period is relieved, the pessary may be left in place continuously for some months, providing no symptoms of irritation ap- pear. The patient should take a mild antiseptic douche every day or two to prevent the possible growth of germs in the vagina that might ascend along the open cervical canal. The intra-uterine stem should always have openings or grooves along which the uterine secretion may freely escape. Useful forms are shown (Fig. 708). Outerbridge's intra-cervical spring tends to hold open the canal without occupying much of the lumen. A. H. Goelet, also, ad- vocates the use of the intra-uterine stem pessaries and illustrates a glass stem with a hollow center and a flange at the bottom, to be held in place by vaginal gauze packing. He states that "it is never kept in the uterus, how- ever, for a longer period than one week, and during that time the patient is confined to bed." 8. Electricity. Intra-uterine applications of electricity may give consider- able relief in cases where the trouble returns after the cervical canal has been once thoroughly dilated. The application of electricity may be carried out along with the partial dilatation just before menstrual periods, the electrode being used to effect the dilatation of the cervix. With the galvanic current, use the negative pole in the uterus, under the antiseptic precautions necessary in all intra-uterine treatment. The electrode may be used to dilate the canal. Introduce the small size electrode (page 354) as far as it will pass easily and then turn on the current, making the internal electrode the negative pole. Use a weak gg4 DISTURBANCES OF FUNCTION current, about 10 to 15 milliamperes. Make a steady gentle pressure on the electrode, and as the tissues relax about the electrode it passes further and further along the canal until it extends past the internal os. Then use the larger sizes until the cervix is well dilated. Then an intra-uterine applica- tion of the electricity is made, using 15 to 20 m. a. at first and continuing the application five to ten minutes. The applications are given once or twice weekly. If no result is observed from this, the strength is increased to 30 or 40 or 50 m. a. If there is a tendency to menorrhagia as well as dysmenor- rhoea, it is well to follow the employment of the negative pole with the em- ployment of the positive pole for 5 to 10 minutes. In cases that do not do well under the negative pole, it is weU to employ the positive pole altogether. Some cases do better under the faradic current, and Avhen one method does not suffice the various other methods may be tried. Electricity has, of course, the dangers and contra-indications common to other forms of intra-uterine treatment. It has an admirable effect in some cases, while in other cases there is apparently no effect. It has given relief in many obstinate cases, and is worthy of trial in those cases where there is no objection to vaginal and intrauterine instrumentation. It is useful also in certain cases of that most obstinate form of menstrual pain — viz., men- braneous dysmenorrhoea. L. H. Dunning relates a case which persisted in spite of a course of local applications, divulsion and curetment, abdominal section with breaking of adhesions, and excision of a diseased ovary and ventro-suspension, but finally yielded to intra-uterine applications of elec- tricity — 20 to 50 m. a. negative pole for five minutes, and the current slowly turned off and then on again with positive pole for five minutes. This was repeated twice weekly. The first menstruation after the applications showed less pain. At the second the membrane, which before had been a cast, was reduced to shreds. After the third menstruation no membrane passed. The report was made four months later, at which time there had been no return of the trouble, which before had been so severe and persistent in spite of all measures that the patient meditated suicide. The electricity was continued two or three times monthly as a preventive against recurrence. In the dis- cussion, L. R. Brown reported a case of membraneous dysmenorrhoea which resisted repeated thorough dilatation and curetment, and the patient's suf- fering was so severe that she was a nervous wreck. As a last resort he used electricity — galvanic current, positive pole in the uterus, 12 m. a. continued for eight minutes, and repeated three times per week. At the first menstrual flow there was no improvement. At the second menstruation she passed no membrane, and after that the improvement was continuous, with no relapse during the several months the patient was under observation. The menstrual flow, which formerly lasted ten days, was reduced to four (effect of the posi- tive pole). In regard to choice of pole, remember that the positive pole has a con- stricting effect, diminishes congestion, dries the tissues about the electrode, and hence causes the electrode to stick where it is. It is not suitable for di- DYSMENORRHOEA IN THE VIRGIN 885 lating a canal. Before using the positive pole the electrode should be carried all the way into the uterine cavity. The negative pole, on the other hand, increases congestion, softens the tissues and aids in dilating the canal (see also pages 356, 357). 9. Excision of Tissue from Internal Os. (Theilhaber Operation). The cer- vix is dilated thoroughly, and curetment is carried out if desired. The cervix is then split laterally, on each side, to near the internal os. Then ■v\ath a small knife, inserted under the direction of the finger-tip carried to the internal os, a small wedge of tissue is removed from the anterior and from the posterior portion of the circulating ring. This wedge of tissue extends about one-third through the thickness of the uterine wall. The work is much A B Fig. 709. Splitting the Cervix for Dysmenorrhoea (Dudley operation). A, showing the sharp bending of the canal from the anteflexion of the cer\ix; B, showing the unobstructed exit secured by splitting the posterior Up of the cenix and sewing it open. facilitated by a knife of special design. The preliminary incisions, splitting the cervix, are then closed by sutures. This removal of wedges of tissue from the constricting ring at the inter- nal OS enlarges the opening and overcomes the obstruction. Series of cases have been reported with excellent results in nearly all cases as far as reliev- ing the obstruction. I have employed the operation with satisfaction, but prefer the Dudley operation, which gives greater probability of permanently overcoming the obstruction. The small wedge-shaped grooves left by the excision of tissue in the Theilhaber operation are likely to fill up ^vith scar tissue and the opening again become small. There is nothing about it to in- sure permanent enlargement of the opening. 10. Splitting Cervix and Sewing it Open. (Dudley Operation— Fig. 709). 886 DISTURBANCES OF FUNCTION This is applicable to those eases of anteflexion of the cervix in which the se- vere menstrual pain persists after- thorough dilatation and curetment under anesthesia. In some cases in which the cervical anteflexion is particularly- marked it is advisable to employ this as the primary operative procedure. The steps of the operation are as follows : a. The cervix is dilated thoroughly and the uterus curetted in the usual way. b. The posterior lip of the cervix is then split longitudinally up to the Fig. 710. Dudley Operation. Dividing the posterior wall |of tiiecer\ix. (Dudley — Practice of Gynecology.) Fig. 711. Dudley Operation. The posterior wall of cervix divided and the principal suture passed. Before passing this suture a wedge-shaped piece of tissue is excised from the cervix on each side of tlie wound, as indicated by the dotted lines. (Dudley- — Practice of Gynecology.) vaginal vault, the incision being carefully continued internally up to and past the internal os. The constricting ring about the internal os should be di- vided sufficiently to readily admit a linger. Care is necessary to avoid cut- ting too deeply into tlic ulorino wall at this point, for, if the wall is cut through and the peritoneal cavity opened, there is danger of peritonitis. Ordinarily, there is no necessity for opening the peritoneal cavity. In some DYSMENORRHOEA IN THE VIRGIN 887 cases, however, the posterior peritoneal pouch comes very low or the inter- nal OS is situated unusually high. In either case, it may be advisable to de- liberately open the peritoneal cul-de-sac in order to properly complete the operation. The division of the intravaginal portion of the cervix may be most conveniently made with long scissors (Fig. 710). The careful division of the ring about the internal os is made with a bistoury under the guidance of the finger. c. A wedge of tissue is then cut out of each lip, as indicated by the dotted Fig. 712. Dudley Operation. The operative work on the postenor part of the cer\ix has been completed. Also, the redundant portion of the anterior lip of the cervix has been excised, and sutures passed for closing the wound (Dudley — Practice of Gynecology.) x .. 'J V. lines in Fig. 711, so that each of the two cut edges will fold well on itself when the principal suture is tied. d. A strong silk-worm gut suture is then passed as shown in Fig. 711. This, when tied, folds the cut surface of each lip upon itself in such a way that the ends (where the tenacula are caught in Fig. 711) are brought into the angle of the wound, and this tends to permanently hold apart the divided tissues about the internal os. Before this main suture is tied, however, sec- ondary sutures of catgut should be passed in sufficient numbers to close the lateral portions of the wound and prevent any hemorrhage. The main suture DISTURBANCES OF FUNCTION is then tied, and lastly the secondary sutures. It is important to pass the sutures deeply enough to catch the bulk of the divided tissue to prevent rub- sequent oozing. In one of my cases persistent oozing followed the operation and this increased after several hours to a flow of blood, which firm vaginal packing failed to stop and which affected the patient's pulse, and assumed such serious proportions that I was called to the hospital in the mid- dle of the night. I placed the patient in Sims' posture, removed all the pack- ing and passed two or three strong catgut sutures deeply through the cer- vix in such a way as to effectually constrict all the tissue from which the bleeding might come. This was done without anesthesia and without disturb- ing the other sutures. This stopped the bleeding and the patient conva- lesced without further trouble. e. In cases where the anterior lip of the cervix is very long it may be ad- visable to shorten it so as to allow the cervix to better assume its normal backward direction, instead of being again bent forward by pressure of the posterior vaginal wall. This is accomplished by excising the redundant por- tion of the anterior lip and closing the resulting raw surface by sutures passed transversely, as shown in Fig. 712. This draws a good wedge of tissue into the angle between the cervix and corpus uteri and tends to push the cervix back toward its proper direction. 11. Abdominal Incision of Uterus. This method (proposed by Dr. C, W. Barrett) consists of opening the abdomen by regular supra-pubic incision, making a longitudinal incision through the posterior wall of the uterus at the internal os, spreading this incision laterally so that it extends trans- versely and then suturing it in this position. It accomplishes enlargement of the internal os and consequent relief of the obstruction. As a rule, however, the patient may be sufficiently relieved without subjecting her to the danger of abdominal section. When the abdomen must be opened on account of ac- companying disease of the adnexa or persistent retrodisplacement of the uterus, then this method of enlarging the internal os and correcting the for- ward flexion of the cervix may be considered. 12. Operations for Diseased Adnexa. Of course, where there is tubal or ovarian or other form of peri-uterine disease, that should receive proper treatment, operative or otherwise. In many cases, painful menstruation is simply a symptom of some such pelvic disease, and is relieved by removal of the same. In membraneous dysmenorrhoea, also, search should be made for chronic ovarian or tubal disease. The removal of practically normal ovaries or ovaries that are not seriously damaged, for the relief of dysmenorrhoea, is to be most strongly condemned. There are many things that are far worse than some pain for a few days each month, and the removal of both ovaries in a young woman is one of them. Pain may be relieved temporarily l)y some of the various palliative meas- ures already described, and then there is always the possibility that the pain will diminish or cease from the lapse of time and the continual employment of therapeutic measures. But when the ovaries are once removed they are DYSMENORRHOEA IN THE VIRGIN gg9 gone irrevocably, and in a certain proportion of such cases the last condition of such patient, mentally and physically, is worse than death itself. Not that the removal of the functuating ovaries in a young woman necessarily or al- ways has such a marked mental and physical effect, but in certain cases it has, and we can never be certain that such will not be the result in the par- ticular case under consideration. Of course, it is possible that there may be certain rare cases in which, in spite of every other measure, the patient's suf- fering from menstruation is such as to justify this risk, but I have never met such a case. (B.) DYSMENORRHOEA IN THE MARRIED WOMAN. Causes. This may be due to any of the twelve conditions already described as causes of dysmeuorrhoea in the virgin. It may be due also to one of the fol- lowing additional conditions : 13. Infected endometritis, acute or chronic. 14. Salpingitis (acute or chronic) or one of the other forms of pelvic in- flammation (oophoritis, pelvis cellulitis, pelvic peritonitis). A. M. Judd reported 217 cases of endometritis, accompanied with more or less laceration of cervix and pelvic floor, of which 108 suffered menstrual pain and 109 did not. He reports also 177 with diseased tubes and ovaries, of which 107 had menstrual pain and 70 did not. . In married women, membraneous dysmeuorrhoea must be distinguished from early abortion and extra-uterine pregnancy, in both of which condi- tions there may be bloody discharge, with much pain and the passage of shreds of membrane. If this happens to take place near the menstrual time, the patient naturally supposes it is simply a menstruation somewhat delayed. In membraneous dysmeuorrhoea there is usually a history of the expulsion of membrane at several menstrual periods, whereas with abortion there is the history of a missed menstruation and of morning sickness. Also the blood-clots are much more numerous in abortion, and with the membrane can usually be found a small sac and embryo. The bleeding from abortion persists indefinitely until the uterus is emptied, whereas in membraneous dysmeuorrhoea it lasts only about the usual menstrual time. Microscopic examination of an expelled membrane or of shreds removed by curetment in abortion shows chronic villi. In extra-uterine pregnancy there is no pre- vious history of membraneous dysmeuorrhoea and the patient, previously regular, has usually gone over time for one or more weeks. The pain is due to intraperitoneal bleeding and presents the characteristics of the same. Treatment. The treatment during the flow is the same as detailed for the virgin (page 877). The treatment in the interval is determined by the local trouble found in the examination. 890 DISTURBANCES OF FUNCTION INTERnENSTRUAL PAIN. The interesting subject of pain occurring at a certain time every month in the intermenstrual period has received considerable attention from investi- gators, and the conclusion has been reached that it is not an indication of any- particular lesion, but is a pelvic neuralgia due to different conditions in dif- ferent cases. In a careful study of the subject by Rosner, of France, it was found to be most common in arthritic subjects and was supposed to be due to some abnormal action of the ovaries. The periodicity of the pain — that is, its appearance each month a certain number of days after the cessation of the menstrual flow — is probably dependent in some way on the menstrual variations in blood pressure, and generally due to chemical or other influence proceeding from the ovaries (page 806), as indicated by Van de Velde. He shows that there is direct enlargement of the uterus at the time of the intermenstrual pain. Malcolm Storer, who reported 20 cases of his own and 25 additional cases collected from literature, found that in 10 of the cases there was a marked increase in the leucorrhoea at that time, indicating con- gestion of the uterus. The pain usually appears about midway between the menstrual periods; hence it usually corresponds with the lowest part of Stephenson's menstrual wave. In the 45 cases reported by Storer the pain appeared with regularity in all cases, practically every month unless preg- nancy was present. In 22 cases it appeared always at the same time (in most cases about two weeks) after the beginning of last menstrual flow. In 13 cases there was a variation of two days, in four cases there was a variation of four days, and in two cases of irregular menstruation it would appear on a certain day before the menstruation. In 37 out of 41 cases the pain ap- peared from twelve to sixteen days after the beginning of the last menstrua- tion and in 20 of them it began exactly on the fourteenth day. In 2 cases it came from the seventh to the tenth days, in 1 case on the seventeenth day and in 2 cases on the eighteenth day. As to treatment, that should proceed on the same general lines as the treatment laid down for menstrual pain — i. e., the correction of general con- ditions first, and the employment of local measures, especially of operative measures, only in cases where there are well-defined indications and after other measures fail. As H. C. Coe has pointed out, the assumption that in- termenstrual pain is always associated with cystic ovaries, and is therefore an indication for operation, is not tenable. Cystic disease of one or both ovaries is found in some cases, but the diagnosis of cystic ovaries or an opera- tion for the same must always be based on distinct examination findings (page 888) and not simply on periodic pain. IRREGULAR MENSTRUATION. The menstrual flow may come too soon, the interval being only ten days or two weeks. Again, the flow may not come soon enough, running over time VICARIOUS MENSTRUATION g91 from one to two weeks. It is sometimes difficult to determine positively whether the irregular flow complained of is really menstruation or simply a bloody discharge from some disease of the vagina or uterus. Unless the bleeding resembles closely the menstrual flow in character and onset and du- ration, it should be regarded as a pathological discharge, and an examina- tion should be made to determine its cause, that proper treatment may be instituted. PRECOCIOUS MENSTRUATION. Precocious menstruation is the appearance of menstruation at an early age. For genuine menstruation to take place, there must be considerable devel- opment of the genital organs, and this very rarely occurs before the age of ten. Rare cases have been recorded in all ages, even in infancy. It has been known to begin in infancy and continue regularly. There is usually pre- cocious development of the breasts and of the external genitals. Great care is necessary, however, in establishing the fact of precocious menstruation in a given case. Every stain of blood does not mean menstrua- tion. The blood may come from some inflamed or irritated area or ulcer, or growth on the vulva or in the vagina, uterus, rectum or bladder. In in- fants a slight bloody uterine discharge occurs not infrequently within the first week or two after birth. It is not a menstrual flow and it soon disap- pears. Again, a red stain on the diaper, which the mother supposes to be blood, is often made by urates from a concentrated urine. VICARIOUS MENSTRUATION. Vicarious menstruation is the discharge of blood from other parts of the body at the menstrual time. The uterine discharge may or may not be wholly or partially suppressed. The bleeding usually takes place from the nose or from some open sore, though it may come from almost any mucous surface, such as the lungs or stomach, or bladder or rectum. Much more rarely some area of the cutaneous surface is affected, the axilla and the groin being the most frequent. At the affected site there appears an ecchymosis and later a distinct flow of bloody serum. The vicarious flow is likely to be irregular, appearing only at some menstrual periods. Allied closely to this is the monthly discharge of milk from the breasts sometimes observed. Vicarious menstruation in any form is rare. Goffe records a very interest- ing case in which the vicarious discharge came alternately from the nose and the axilla, and seemed to be associated with periods of ungratified sexual de- sire. Vicarious menstruation is found principally in nervous women in which there is imperfect development of the uterus or imperfect performance of its functions. The treatment consists in the correction of any peMc disease present, and in applications to the site of bleeding if necessary. 892 DISTURBANCES OF FUNCTION DYSPAREUNIA. The two principal disturbances of sexual intercourse are dyspareunia (dif- ficulty in coitus) and sexual impotence (absence of sexual orgasm in coitus). Difficulty in coitus (dyspareunia) varies from a slight discomfort hardly noticeable to pain so severe as to make coitus unbearable. CAUSES. The more common causes of dyspareunia are as follows: 1. Some Obstruction to Normal Coitus, a. Imperforate hymen. — In such a case there would be present the history of amenorrhoea and also the dis- turbances that come from retained menstrual blood. You may think there would be a history of no coitus, and such is usually the case, but in some cases coitus has taken place through some adjacent opening — for example, through a dilated urethra. b. Organic Stenosis of Vaginal Orifice. — The opening is large enough to permit the regular escape of menstrual blood, but it is not large enough to permit coitus. The obstructing tissue is so firm that it does not rupture as ordinarily on attempted coitus. This obstruction may be due to a very strong, firm hymen, or to some distinct malformation, such as a vaginal septum from double vagina. Usually with double vagina, each vagina is large enough for coitus or the septum is placed so far to one side that it does not interfere. But it may be so placed as to interfere decidedly with coitus and to require division. Again, an organic stenosis here may be due to scar-tissue from se- vere burn or other injury, or from laceration in labor, with extensive scar- tissue formation. c. Spasmodic Stenosis at Vaginal Orifice. — In some cases there is marked hyperesthesia about the vaginal orifice, and every attempt at coitus causes un- bearable pain or causes spasmodic contraction of adjacent muscles to such an extent that coitus is impossible. This marked hyperesthesia may be due to inflammation, such as vulvitis or vaginitis, or it may be due to sensitive abrasions about the vaginal entrance. In other cases it is due to that pecu- liar condition known as ''vaginismus," a reflex contraction of the levator ani and adjacent muscles without apparent cause. In exceptional cases this is so severe and persistent as to altogetlier prevent coitus. d. Severe Pain on Attempted Intercourse. — There is no stenosis or spasm, but just pain, so severe that coitus is impossible. This may be due to inflam- mation about the external genitals or inflammation witliin the pelvis. 2. Simple Inflamed Abrasions About the Vulva. Tliis is not an infrequent cause of much suffering immediately after marriage. The small abrasions that naturally accompany rupture of the hymen at the first intercourse may become inflamed after a day or two, making subsequent coitus painful. This sometimes causes much alarm to the patient and her husband, who fear some serious trouble. The treatment is abstinence from coitus for a few days, Math DYSPAREUNIA g93 the frequent use of some mild antiseptic wash (1/2%' car])olic sohitionj, fol- lowed by drying with absorbent cotton and the use of a soothing ointment, such as carbolized vaseline. It is well to keep the parts covered with a pad of absorbent cotton, to keep the clothing from contact with the painful areas and also to protect the abrasions from infection. 3. Venereal Sores (chancroid, syphilitic). These abrasions also may be found soon after marriage or at any other time. Care should always be taken not to give a positive prognosis in a case of abrasion or sore which has not yet had time to develop its characteristics. 4. Gonorrhoeal Inflammation. This is an altogether too common cause of painful coitus in the first few weeks following marriage. The pain may be due to the vulvar inflammation, or to the urethritis or to the vaginitis, or to painful abrasions or to the inflammation of the vulvo-vaginal gland of one or both sides. 5. Other forms of inflammation of vulva or vagina, or vulvo-vaginal glands. 6. Inflammation of uterus (acute or subacute). 7. Inflammatory lesions around the uterus, in which pain is caused by the impact of the male organ or by the sexual congestion. When the ovary is prolapsed into the cul-de-sac and bound there by adhesions, sexual inter- course may cause much pain. I recall one patient in whom it was finally necessary to open the abdomen, break up the adhesions and fasten up the prolapsed ovary in order to relieve the suffering in coitus. In the more serious pelvic inflammatory conditions, this is frequently a prominent symp- tom. 8. Retrodisplacement of the uterus, with inflammation. It is surprising how much displacement of the uterus, with forward projection of the cervix and apparent blocking of the vagina, can take place without occasioning any particular disturbance in coitus. But if inflammation appears, then dys- pareunia is often marked — much more so than from the same amount of in- flammation without displacement. 9. Bladder or rectal diseases occasionally cause painful coitus, particu- larly inflammatory diseases. TREATMENT. P'he treatment of dyspareunia is indicated by the particular condition present, as determined by a careful examination. 1. If there is some malformation about the vaginal orifice (imperforate hymen, thick hymen, septum in vagina, organic stenosis of vagina), the ob- struction must be removed by the necessary operative measures. 2. If coitus is interfered with by tender areas about the vaginal entrance, or by ulcers or by hyperesthesia, the following measures may be employed : a. Abstinence from sexual intercourse for one to three weeks. b. Hot vaginal douches once or twice daily — medicated or unmedi- cated, depending upon the presence of discharge. g94 DISTURBANCES OF FUNCTION c. Laxatives as needed. Chronic constipation increases the conges- tion and irritability of the structures. d. Some sedative ointment — for example, chloretone ointment (10%), applied two or three times daily. e. Bromides, if there is much nervous irritability or apparent hyper- esthesia of reflex centers. f. "When intercourse is again attempted, the patient should coat all the sensitive surfaces with a sedative ointment. The chloretone ointment above mentioned may be used or, if that is not effect- ive, an ointment containing 2 to 5 per cent of cocaine. 3. If the vaginal opening is too small or there is the spasmodic condition known as vaginismus, stretching of the opening is to be employed in addition to the other measures just detailed. In some cases the tendency to spasm may be overcome by gradual stretching Avith a speculum every few days without anesthesia. In cases of organic narrowing it is advisable to pack the vagina in order to hold what has been gained and to aid in securing relaxation. If the gradual stretching without anesthesia fails, then the patient should be anesthetized and the vaginal opening thoroughly stretched. If the opening does not stretch well or the tendency to spasm is marked, it is well to divide the constricting structures and close the wound over them by sutures: The treatment of the other organic lesions mentioned under causes is. taken up in detail in the appropriate chapters. SEXUAL inPOTENCE. The absence of strong sexual feeling in the woman during coitus does not assume the serious aspect it does in the man, with whom erection is necessary to insemination leading to pregnancy. The strong sexual feeling, with its consequent orgasm, in the woman is not at all necessary to impregnation, though it increases the probability of impregnation. From the history of cases of sexual disturbance it is evident that many otherAvise normal Avomen have little or no sexual feeling until some months or years after marriage — sometimes not until after one or more children are born. The response to sexual excitement apparently groAvs AAdth the proper exercise of the sexual functions. Tliis fact is important and may be used to prevent discord and disruption in families Avhere cither the husband or the A\dfe is becoming dis- satisfied and despondent because it is felt that there is not the proper sexual response. Again, there are cases in Avhich the Avife is not in physical condition to re- spond. She lias some chronic trouble Avhich so saps her strength that she has not the A'itality for this function. This loss of strength may be due cither to some general condition or to some local condition, or to both. It is hardly necessary to name the A^arious conditions. They comprise the whole list of debilitating conditions, both general and local. STERILITY 895 The treatment of f3exiial impotence is directed toward removing any local disease, aud toward building up the general health to the higliest point — by a long course of tonics (including iron, strychnia, etc.), by change of environ- ment, and by rest from care and worry and overwork, and too frequent sexual intercourse. The rest indicated is very important, for the things mentioned tend to keep the patient dragged down below par and in no condition to re- spond buoyantly and vigorously to any of the mental or physical require- ments of daily life. STERILITY. Sterility is the absence of pregnancy under circumstances that normally lead to pregnancy. It is said that about 10 per cent of marriages are without offspring, and the popular impression is that this sterility is nearly always due to some defect or disorder in the genital organs of the woman. The woman receives almost altogether the blame for the inability to produce offspring. In many eases the defect is with the woman, but in many other cases this blame is placed upon her unjustly. If we exclude from the definition of sterility those cases in which the failure to produce offspring is due to early abortions, or to prevention of conception, then sterility is in a large proportion of the cases, if not in the majority of them, due primarily to the husband. In that large class of cases in which the immediate cause of the sterility is gonor- rhoea! inflammation involving the tubes and ovaries, the primary cause lies with the husband and on him must rest the blame for the childless home. Sterility is sometimes defined as the inability to bring. forth a living child, even though that the child were carried to full time. But I prefer to limit the term to the cases of absence of pregnancy. This is sometimes designated as "absolute sterility." Therefore, considering sterility from the gyneco- logical standpoint, let the definition be "the inability to become pregnant." The patient may have had children or abortions in former years, or she may not. At any rate, she does not become pregnant now, though she earnestly desires to be so. CAUSES. In order to assist in determining the exact cause of the sterility in the various cases, it is well to consider what is necessary that a normal pregnancy may take place. It is necessary ordinarily (a) that healthy spermatozoa be deposited in the vagina, (b) that the spermatozoa remain healthy and pen- etrate into the uterine cavity and into the Fallopian tubes, (c) that a healthy ovum be formed in the ovary, (d) that it find its way into the Fallopian tube, where it can be fertilized by a spermatozoon, (e) that the fertilized ovum pass into the uterus, and (f) that it find there an endometrium suit- able for its implantation and development. Some of these conditions are not always absolutely necessary. At least 896 DISTURBANCES OF FUNCTION five cases of conception, with labor at term, have taken place in patients where both Fallopian tubes and presumably both the ovaries were removed. Of course, some ovarian tissue was left. But the tubes may be removed and still the openings in some cases, without doubt, reopen and permit the ovum to pass. Fritsch ligated both Fallopian tubes in the middle with silk and still pregnancy followed three years later. Ashton reported the occurrence of pregnancy in the cervix following removal of the body of the uterus for fibromyomata, showing that even the body of the uterus was not absolutely essential to pregnancy. Again, pregnancy has occured in cases where pen- etration of the male organ into the vagina was impossible, showing that the spermatozoa may pass from the external genitals up to the uterus. But these are all very exceptional cases. Ordinarily each of the conditions men- tioned is each a bar to pregnancy. Assuming that the husband furnishes healthy spermatoza, the sterility may be due to the following causes : 1. Some Conditions Interfering- with Coitus. These conditions are con- sidered under ''dyspareunia'' (page 892). 2. Laceration of Pelvic Floor. When there has been a marked lacera- tion, the vagina may be so relaxed and patulous that the semen is not re- tained in contact with the cervix long enough for the spermatozoa to pass up into the uterine cavity. 3. Vaginitis or profuse discharge in the vagina may interefere chemically with the vitality of the spermatozoa or mechanically with their progress to, or entrance into, the cervix uteri. In either case the chance of pregnancy is diminished. 4. Some Obstruction in the Cervical Canal, a. Stenosis of external os. — This may be found in the form of the congenital "pin-hole" os or it may be due to scar-tissue resulting from former injuries. b. Stenosis at internal os. — This may be due to scar-tissue, but it is more frequently due to a sharp anteflexion of the cervix. It is often combined with a long pointed cervix and the ''pin-hole" os already mentioned. This com- bination is a frequent cause of sterility in women who have never been preg- nant, and it is usually accompanied with dysmenorrhoea. c. Discharge. — There may be in the cervical canal an excessive secretion or discharge which interferes chemically with the vitality of the spermatozoa or mechanically with their journey upward. 5. Some Displacement of the Uterus, a. Retrodisplaeement. — Retrodis- placement of the uterus may throw the cervix so far forward that the sper- matozoa do not readily enter it. b. Anteflexion. — Sharp anteflexion of tlie cervix may also throw the cer- vical opening too far forward. e. Decided Prolapse. — Prolapse of tlie uterus may interrere meclianically with coitus or with the passage of tlie spermatozoa to the interior o-f the uterus. 6. Some abnormal condition within the uterine cavity,' Avliich iuterferes STERILITY 897 with the passage of the spermatozoa to the tubes, or which fails to furnish a proper place for the implantation and nourishment of the fertilized ovum. a. Simple endometritis. b. Infected endometritis. e. Tuberculosis of the endometrium. d. Malignant disease (carcinoma or sarcoma). e. Fibromyoma. 7. Some affection of the Fallopian tubes which interferes with the entrance of the spermatozoa into the tube or with the entrance of the ovum into the tube, or with the passage of the fertilized ovum from the tube into the uterus. a. Inflammation. — Inflammation of the tube is the most frequent cause of sterility from tubal disturbance. This may be very slight — not enough to produce symptoms nor physical signs, but just enough to cause occlusion of one or both ends of the tube. It may vary all the way from this mild form to severe inflammation and disorganization of the tube, with extensive exu- date and adhesions and abscess formation. Salpingitis, coming on after the first childbirth, or miscarriage, because of inflammation during the puer- perium or because of gonorrhoea, infection brought by the husband, who was untrue to his wife during her confinement, is a prolific source of the so-called "one pregnancy sterility." b. Tuberculosis. — Tuberculosis of tubes and adjacent structures. c. Tumor. — A tumor of the tube or in the vicinity of the tubes, interfering with their functions. d. Malformation of the Tubes. — This may consist in atresia of one or both ends of the tubes, or in blind passages and diverticula into which the ovum may wander and lodge. Or there may be abnormal openings in the wall of the tube through which the ovum may pass out into the peritoneal cavity and be lost. 8. Some affection of the ovaries that interferes with their function to such an extent that healthy ova are not formed or are not discharged in such a way that they pass into the Fallopian tubes. a. Inflammation. — Inflammation of the ovary may be present in some of its various forms — infected oophoritis, simple oophoritis, cystic ovary, cir- rhotic ovary or an ovary covered with exudate and adhesions. b. Tuberculosis of ovaries and vicinity. c. Tumors of the ovary. d. Displacement of the ovary. — This may be so marked that the ova, in- stead of passing into a Fallopian tube, where they would be fertilized, pass into the peritoneal cavity and perish. 9. Certain operations — for example, removal of the uterus or of the Fallo- pian tubes, or of both ovaries. 10. Douches, which may interfere chemically or mechanically with the process of impregnation. 11. General Conditions. The general health may be so poor that all the or- 898 DISTURBANCES OF FUNCTION gans of the body are in too poor a condition to properly functionate, the genital organs among them. This is seen in some cases of marked anemia and emaciation, and general depression. On the other hand, it is present at times in patients who are inclined to stoutness. The effect of obesity in diminishing menstruation has been mentioned, and it sometimes has much the same effect on the capacity for impregnation. It has happened that sterility came on when a patient accumulated fat and disappeared promptly on reduction to her usual weight. DIAGNOSIS. A couple come to consult you because they have no children. Your prob- lem is to find the cause of the sterility in this particular case. If the husband is an intelligent man, he will speak of any genital disturbance which he has had that might have a bearing on the subject. If no explanation is made, it is to be assumed that the husband is healthy, though this assumption should be confirmed as soon as opportunity occurs of questioning him when the wife is not present. Gross found the male directly at fault in about 16 per cent of the cases of sterility and De Sinty found the trouble to lie with the male in 25 per cent of the cases. The chief causes in the male were im- potence, or absence of semen or absence of living spermatoza. If there is any question as to the ability of the husband to perform his part in the process of impregnation, a specimen of the semen should be submitted to microscopic examination, that the presence or absence of living spermatozoa may be posi- tively established. Assuming that the husband is healthy, the wife is questioned to secure the systematic gynecological history and to bring out any special facts that may have a bearing on the sterility. The history may point decidedly to some serious pelvic disorders, or there may be nothing in the history to indicate that the pelvic organs are other than normal. A thorough pelvic examina- tion is then made to determine if there is any pathological condition in the genital tract. The various conditions that may give rise to sterility, together with their diagnostic points, have just been detailed under "causes." TREATMENT. 1. If there is difficulty in coitus, treatment for that will be required. This is considered in detail under dyspareunia (page 893). 2. There may be. anteflexion of the cervix, with stenosis in the canal, a fre- quent cause of sterility in patients who have never been pregnant. Where sterility results from this condition, the treatment is dilatation of the canal, and for this there are three methods, as follows: a. Partial Dilatation without Anesthesia. — The details of this procedure as employed for sterility are the same as described under Dysmenorrhoea, except that the dilatation is made immediately after each menstrual flow STERILITY 899 instead of before the flow. Just after menstruation is supposed to be the most favorable time for impregnation, so the canal is dilated then and it re- mains somewhat dilated for a week or so. The patient is directed to take no douches unless there is a troublesome discharge. If there is a discharge necessitating douches, a saline douche (a tablespoonful of table salt to two quarts of warm water) should be used and the douche should be taken in the evening — not in the morning. No antiseptic douche is allowed because it interferes with impregnation. This treatment may be repeated after each menstrual flow for several months, until pregnancy takes place or until it is apparent that no result is to be accomplished by this method. In many cases more radical measures are necessary. In some cases, how- ever, the simple dilatation just described carried out a few times will put the parts in such condition . that pregnancy ensues, and it is worthy of trial in all cases where the canal dilates readily and there is not a profuse uterine discharge. In one of my patients, pregnancy followed a single such treat- ment made after several years of sterility. b. Thorough Dilatation Under Anesthesia. — The patient is anesthetized, the cervix widely dilated and the interior of the uterus cureted. The curet- ment is advisable in practically all such eases, for the endometrium is usually not entirely healthy. This thorough dilatation under anesthesia is employed in cases in which the previous method fails to produce results. It is advisable as the primary treatment in those cases where the cervix is small and sensitive. The dilata- tion thus secured is likely to persist in a measure over several months, and thus gives a good chance of pregnancy. c. The Dudley Operation. — This is explained and illustrated under Dysmen- orrhoea. It is employed for the purpose of permanently overcoming the ob- struction in cases where the stenosis tends to recur after wide dilatation un- der anesthesia. 3. There may be inflammation of the cervix, Avith discharge, which inter- feres with the vitality or upward progress of the spermatozoa. Such a con- dition requires the treatment for endocervicitis (see chapter VI). 4. Laceration of the Cervix, with consequent cystic degeneration and dis- charge, may be present and requires the usual measures to allay the inflamma- tion and lessen the discharge. If these palliative measures are not effective, the cervix should be put in better condition by an operation for repair — be- ing careful in the denudation to leave a wide cervical canal, so that there will be no resulting stenosis. This removes the chronically inflamed and dis- charging surfaces, and thus increases the chance of the spermatozoa being able to penetrate into the uterus. 5. If there is marked chronic endometritis, that must receive appropriate treatment — which will include usually a thorough curetment. 6. Retrodisplacement of the uterus may be present. If so, it requires the treatment detailed in chapter VII. 7. Tumors in the uterus, or elsewhere in the pelvis, must be removed when it is at all probable that they are a factor in the sterility. 900 DISTURBANCES OF FUNCTION 8. Pelvic Inflammation in one of its various forms may be found. If the inflammation is of recent origin and there are no serious symptoms, employ palliative measures. If the pelvic inflammation is improved thereby, these palliative measures may be kept up for several months in the hope that na- ture will repair the damaged organs sufficiently to restore their function. For the prognosis in regard to pregnancy alter pelvic inflammation see page 728. In chronic pelvic inflammation the chance of pregnancy may in some cases be decidedly increased by the removal of the disorganized portions of the Fallopian tubes and special treatment of the remaining part. The special treatment consists of splitting open the distal end of the stump of the tube for some little distance and sewing it open, and then establishing the patency of the tube, if practicable, from the distal end to the uterine cavity. 9. If no local lesion is found, improve the general health (by the use of ton- ics, and exercise and other appropriate measures) and make particular inves- tigation as to the husband's condition. In regard to the patient's general health, if she is too stout, her weight should be reduced. 10. If the patient has been taking douches for the treatment of any disorder or as a routine measure, stop them. In cases where a douche is really neces- sary, direct the patient to employ the saline douche, and to postpone its use for at least eighteen hours after sexual intercourse. LEUCORRHOEA. There is normally a slight mueo-epithelial discharge about the genitals, sufficient to keep the parts properly moist. Abnormal discharge may be only an increase in the normal muco-epithelial discharge, or the discharge may be muco-purulent in character, or watery or bloody, as explained on page 32. For convenience the various kinds and discharge may be grouped under the two terms, leucorrhoea and bloody discharge. These disturbances are not diseases, but, like the other disturbances of function, are only symptoms. Under the term ''leucorrhoea" I include all varieties of pathological dis- charge from the genitals, except discharge containing blood. CAUSES AND DIAGNOSIS. Leucorrhoea due to extra-genital disturbances only and without local change is hardly probable, for the leucorrhoea is in itself evidence of some local departure from the normal functional activity. Of course, there are in- stances, particularly in virgins, in which the functional disturbance evidenced by the leucorrhoea is dependent largely on malnutrition or on pelvic con- gestion from extra-genital causes. The mild leucorrhoea found in anemic or cachectic patients may disappear when the patient is put in good general health. Again, in pelvic congestion from heart disease, or from some general cause, there may be present a mild leucorrhoea, whicli disappears when the functional pelvic congestion is corrected. In this sense leucorrhoea may be said, in some cases, to be due to extra-genital causes and its relief to depend LEUCORRHOEA 901 upon treatment of same. In all but these exceptional cases, discharge from the genitals is due to oue of the following local conditions: Inflammation or Ulcer of Vulva. There is a history of discharge from the vulva, of burning or itching, and of frequent urination, with perhaps some pain. Examination of the external genitals shows redness, either general or localized to certain areas. There is tenderness and discharge, and also evidences of the cause of the intlammation or ulcer. If the trouble is an ulcer, it may be simple, chancroidal, syphilitic, tubercular or malignant.. Acute Vaginitis. There is a history of a free yellow discharge of short duration, irritation of vulva and frequent urination, with some burning. Ex- amination shows a yellowish discharge and redness of vulva. If gonorrhoeal, there is usually involvement of the vulvovaginal glands ; also the discharge shows gonococci. The vaginal walls are rough and hot and tender — ^too ten- der to admit of satisfactory bimanual examination. When exposed with the speculum, the vaginal walls are reddened and there is not enough discharge from the cervix to account for the leucorrhoea. Chronic Vaginitis. This occurs principally in children. There has been a yellow discharge for several weeks or months, with irritation of the vulva and some bladder irritability. Examination shows a yellow discharge and redness of the vulva, with more or less tenderness. The discharge should be examined for gonococci. If the patient is a child, no vaginal examination is made. If an adult, examination shows tenderness and chronic thickening and roughness of vaginal wall, usually most marked in the posterior fornix. Speculum examination shows redness of vaginal wall, either general or in patches, and there is not enough discharge from the cervix to account for the leucorrhoea. Adhesive Vaginitis. This occurs principally near or after the menopause. There is a history of chronic discharge, with irritation of the vulva, and some- times bladder irritability. On examination it is found in most cases that the discharge is slight and is sticky or "gluey" in character, though in exceptional cases it is free and purulent. In some cases there are scratch-marks, result- ing from the patient's attempts to overcome the pruritus. On vaginal examina- tion the vaginal walls are found adherent in spots, especially at the upper part of the vagina. If the adhesions are recent, they separate easily, with some bleeding. If the adhesions are old, they are firm, and in some cases the vagina is almost obliterated by the process. "When the walls are separat- ed with the speculum, in the less advanced cases, irregular spots may be seen which are raw and bleed slightly. Ulcer of Vagina. This may be simple, chancroidal, syphilitic, tubercular, or malignant. There is a history of an acute or chronic discharge and prob- ably also of other evidences of the disease causing the ulceration. Exam- ination shows a discharge about the vulva and more or less irritation of the surfaces. When making the vaginal examination, the indurated edges or base of the ulcer may be felt. The speculum exposes the ulcer to view, and further investigation shows it to be the sufficient cause of the discharge. 902 DISTURBANCES OF FUNCTION Acute Endocervicitis. There is a liistory of a tenacious, stringy discharge of recent origin. There may or not be irritation of the external genitals. Vaginal and bimanual examination shows nothing special. Speculum exam- ination shows a stringy, tenacious discharge coming from the external os. There is also congestion of the cervix and usually erosion about the external os, Chronic Endocervicitis. There has been a discharge for a long time. Vag- inal and bimanual examination shows no e^ddence of involvement of the cor- pus uteri or the adnexa. Specukun examination shows a very tenacious, stringy, mucopurulent dicharge from the external os, with more or less sur- rounding erosion. In many cases there has been also severe laceration of the cer^dx, the evidences of wliicli may be felt and seen. Laceration of Cervix. In these cases the discharge is not due so much to the tear itself as to the subsequent eversion, and irritation and chronic in- flammation. The various appearances presented by the lacerated cervix are shown in Figs. -iSl to 4i2. Ulcer of Cervix. Such an ulcer may be simple, chancroidal, sjT)hilitic, tu- bercular or malignant. There is a liistory of leueorrhoea. In the vaginal ex- amination the ulcer of the cervix may or may not be felt, depending on whether or not there is any indiu'ation in the edges or base. VThen the cer^dx is ex- posed with the speculum, the ulcer is seen, presenting a distinctly marked margin and a base of granulation tissue. Malignant Disease of Cervix. This may appear in the form of an ulcer, with indurated margins and base, or as a papillary growth from some spot on the cervix or within the cervix. For the various appearances of beginning ma- lignant disease of the cervix see Figs. 443 to 447. Polypi of Cervix. Polypi of the cervix of various kinds may give rise to considerable leueorrhoea, though usually a bloody discharge is the promi- nent feature in these cases (page 562). Acute endometritis, whether gonorrhoeal or due to pus infection following labor or miscarriage, gives rise to free discharge. There is a history of recent labor or miscarriage, or instrumentation or gonorrhoea, or a history of chronic endometritis due to one of these causes. Examination shows a free discharge, the character of which points to the cause of the trouble, as explained in chapter VI. Vaginal and bimanual examination show tenderness of the body of the uterus, but no tenderness around the uterus unless there is complicat- ing trouble. Speculum examination shows a free purulent discharge coming from tlie uterus. Chronic Endometritis. There is a history of chronic leueorrhoea. Exam- ination shows nothing in the vagina or cervix to account for the discharge. The body of the uterus may be somewhat enlarged or tender, though not nec- essarily so. Through the speculum it is seen that the discharge comes from the uterus and not from inflammation of the vaginal wall. The character of the discharge indicates that it comes largely from the endometrium and not from tlie cervical glands. Retrodisplacement of uterus causes leueorrhoea by causing chronic irrita- tion of the endometrium, resulting in a chronic endometritis. LEUCORRHOEA 903 Fibroid of uterus causes leucorrhoea by causing chronic irritation of the eudoiiK^triuin. ])()tli l)y direct pressure and by interference with its blood supply. Cancer of corpus uteri causes leucorrhoea by the breaking down of the can- cerous area and also hy the chronic irritation of the adjacent endometrium. Periuterine disease causes leucorrhoea by causing chronic congestion of the endometrium, with the resulting endometritis. Functional congestion of the uterus or pelvis causes leucorrhoea by the nu- tritive and so-ealh;Ml inflammatory changes in the endometrium and cervical mucosa resulting therefrom. TREATMENT. For the purpose of considering treatment, it is convenient to divide the cases of leucorrhoea into three classes. 1. In the Virgin. Leucorrhoea is not an infrequent complaint in the virgin. It may be due to local malnutrition and loss of tone from marked anemia (de- pendent on chlorosis or other cause), it may be due to pelvic congestion from obstruction to circulation by heart disease or liver disease, or other extra-gen- ital affection, or it may be due to functional pelvic congestion incident to the. occupation or other condition mentioned under Menorrhagia (page 864). In the virgin it is assumed that the leucorrhoea is due to one of these causes, un- less evidences of decided local disease are present, and treatment is given accordingly. The treatment consists of the following measures : a. The administration of iron and other tonics internally and the employ- ment of the other measures mentioned in the tonic regimen for the treatment of anemia accompanying amenorrheoa (page 854). b. The use of laxatives and other measures required to overcome any chron- ic constipation that may be present. c. The administration of some uterine astringent for the purpose of dim- inishing the congestion of the endometrium. The ergotin capsule (see Form- ulae) is a very good preparation for that purpose. The uterine astringent is specially indicated for those cases accompanied with excessive menstruation. d. Where the discharge persists after the patient has been put in good gen- eral health by the measures mentioned above, a vaginal douche may be order- ed to be taken once or twice daily. It is well to start with a mildly astringent solution, such as the alum douche (one teaspoonful of powdered alum to tAvo quarts of hot water) or the aluminum acetate douche (see Formulae), and ad- vance to the stronger astringents, such as the zinc sulphate and the alum douche (see Formulae), if necessary. e. Local examination, with such subsequent treatment as is necessary for the particular local lesion found. In the virgin this is reserved for those cases in Avhich the discharge per.sists after the employment of the measures above given or in which the evidences of local disease are so marked that an examination at once is necessary. 2. With Marked Local Lesion. In the married woman, who comes com- plaining of leucorrhoea, an examination is ordinarily made at once in order 904 DISTURBANCES OF FUNCTION to determine if any marked lesion is present. In these cases, and also in ex- ceptional cases of the previous class in which an examination is finally nec- essary, it may be found that there is a decided local lesion, or that, on the other hand, the parts show no decided lesion. When a marked lesion that constitutes sufficient cause for the leucorrhoea is present, it should, of course, receive the appropriate treatment. The va- rious lesions that may cause a discharge from the genitals have just been men- tioned in the preceding pages, and the treatment required for each lesion is detailed in the chapter dealing with such lesion. In many of these cases the leucorrhoea is a very subordinate feature, the treatment being principally for the relief of more serious symptoms. In the case of many patients with a chronic uterine discharge, in which there is a more serious disorder requiring some operative procedure, it is well to curet the interior of the uterus at the same time in order to check the discharge. 3. Without Marked Lesion. In some patients with troublesome leucorrhoea the examination shows no marked lesion. There is probably a mild chronic endometritis or hyperplasia of the endometrium, but there is nothing that gives rise to any symptoms other than the leucorrhoea, with perhaps a slight tendency to excessive menstrual flow. In such a case employ the measures just mentioned for treatment in the virgin. If these do not suffice, then a few astringent intra-uterine applica- tions (see page 321) may be made if the cervix dilates easily, or a few intra- uterine applications of electricity. If the leucorrhoea still persists to a troublesome extent, thorough curetment of the interior of the uterus under anesthesia should be employed. The curetment should be followed by a general and local tonic regimen, that the new endometrium may develop under bettered conditions. In suspicious cases of persistent uterine discharge, the material removed in the curetment should be submitted to microscopic examination, that the pres- ence or absence of malignant disease of the endometrium may be positively determined. BLOODY DISCHARGE. Bleeding not connected with menstruation may vary from a streak of blood, or a slight coloring of a muco-purulent discharge, to a free flow of blood. Occasionally there is a hemorrhage sufficiently free to threaten the patient's life. In most cases, however, the bloody discharge is slight and irregular, and is of serious import only because it may have a serious condition for its cause. CAUSES. Any of the following disorders may cause a bloody discharge from- the genitals, the character of the discharge varying from a muco-purulent dis- charge, only streaked with blood, to a profuse flow of blood and clots. All of BLOODY DISCHARGE 905 the eonditions mentioned in the first part of the list give rise, also, to leucor- rhoea and are mentioned under it. The other conditions occur with preg- nancy and must be thought of whenever a bloody discharge is complained of : Inflammation or Ulcer of Vulva. Acute Vaginitis, Chronic Vaginitis. Adhesive Vaginitis. Ulcer of Vagina. Acute Endocervicitis. Chronic Endocervicitis. Laceration of Cervix. Ulcer of Cervix. Cancer of Cervix. Polypi of Cervix. Acute Endometritis. Chronic Endometritis. Retrodisplacement of Uterus. Fibroid of Uterus. Cancer of Corpus Uteri. Periuterine Disease. Functional Congestion. Threatened Miscarriage. The patient may have missed the menses only a few days or may be several months pregnant. Threatened miscarriage is usually accompanied by considerable pelvic pain. In exceptional cases there may be a bloody discharge for several hours, or a day or two, before pains begin. In some cases, by questioning the patient, it will be found that, fail- ing to come unwell at the proper time, she has been taking medicine to pro- duce an abortion ("to bring on the flow"). Miscarriage. Here there are sharp, cramp-like pains, with the expulsion of blood-clots and pieces of membrane or a formed fetus, depending on the period of pregnancy at which the accident happens. Then the pain subsides and after a few days the bloody discharge ceases. Incomplete Miscarriage. The uterus is not entirely emptied and the retained remnants cause a persistent bloody discharge for one or two weeks after it should have stopped, and there is resulting subinvolution of the uterus. The blood may pass as a muco-sanguinous discharge or in clots. It may disappear when the patient stays in bed, to reappear when she gets up. This is perhaps the most frequent cause of persistent bleeding in women of the child-bearing age. There is usually little pain after the miscarriage has taken place. The principal symptom is the bleeding, with the resulting anemia and weakness. If infection takes place, the symptoms of sepsis are added. Placenta Praevia. Bleeding from this cause does not usually take place until the pregnancy lias advanced so far that the diagnosis is perfectly clear. Laceration of Cervix with Pregnancy. The cervix is lacerated, everted 906 DISTURBANCES OF FUNCTION and eroded, and there is added the softening and congestion from pregnancy. There are no pains such as accompany miscarriage. There may be some slight pain and uneasiness in pelvis, which is relieved by lying down. The bloody discharge persists, off and on, without apparent evidence of threat- ened miscarriage or other intra-uterine disturbance. Tubal Pregnancy. The rupture of a tubal pregnancy, or a tubal abor- tion, is nearly always followed in a few days by an irregular bloody dis- charge, which may persist for several days or several weeks. In some cases pieces of membrane are associated with the bloody discharge. There are also the other evidences of tubal pregnancy (page 773). Myopathica Hemorrhagica. This is a symptomatic term used to designate the condition in certain uteri that bleed persistently in spite of repeated curettage, without sufficient reason so far as any gross lesion is concerned. On microscopic examination of such uteri, practically all are found to have have marked disease of the vessel walls — in some instances local, in others general. TREATMENT. In considering the treatment of bloody discharge from the genital tract, it is well to divide the cases into two classes — those with an evident local lesion and those without evident lesion. 1. With Marked Local Lesion. In a certain proportion of the cases in which the patient comes complaining of a bloody discharge, the ordinary gynecologic examination will show a marked lesion of the external genitals, or the vagina or the uterus, of such nature as to account for the bloody discharge. The treatment required is the regular treatment for the particular lesion, the details of which are given in the appropriate chapter. When there is free hemorrhage from the uterus, a firm vaginal packing or tamponade may be used for temporary effect. This is best applied with the patient in the Sims posture and the perineum retracted with the Sims speculum. The gauze or cotton used for the packing should first be dipped in an antiseptic solution and then squeezed as dry as possible. Gauze or cotton thus prepared is much more effective for checking hemorrhage than when perfectly dry. No firm vaginal packing should be employed in a preg- nant patient as long as there is a chance of preserving the pregnancy, as such a packing might cause a miscarriage. 2. Without Marked Local Lesion. The ordinary gynecologic examination shows no decided lesion. It is evident that the bloody discharge comes from within the uterus, but the history and examination show no other sign of uterine disease, except perhaps some menstrual disturbance. What is to be done for such a patient? The following treatment should be employed : a. Tonics. It is important to overcome any marked anemia or general malnutrition by the administration of iron and other internal remedies as BLOODY DISCHARGE 907 indicated and the employment of the other measures of an effective tonic regimen. b. Laxatives. The careful regulation of the bowels is needed, both for the local effect in diminishing pelvic congestion and for the general effect in improving nutrition. c. Uterine Astringents. Ergotin or stypticin should be given regularly, three to four times daily, for a period of two or three weeks in order to secure the full hemostatic effect. This is to some extent a diagnostic meas- ure as well as a therapeutic measure. If the bloody discharge is due simply to subinvolution or a mild endometritis, it is likely to cease under these meas- ures and remain away permanently if the treatment is continued for some months — long enough to restore the general health and the local tone. If the bloody discharge persist in spite of above measures continued for a few weeks, it means that there is some decided change in the endometrium. This may be only chronic inflammation or it may, on the other hand, be beginning malignant disease. In such a case the interior of the uterus should be thor- oughly curetted under anesthesia and the curettings submitted to microscopic examination. If the trouble is inflammatory, this is the most effective thera- peutic measure. If the trouble is malignant, the diagnosis is thus made early, at a time when removal of the uterus will probably effect a cure. d. Vaginal Douches. Douches are usually given along with the three measures previously mentioned. If there is a purulent discharge, a strong antiseptic is used — for example, the bichloride douche. If there is no decided purulent discharge, an astringent is used, such as alum, or zinc sulphate and alum (see Formulae). e. Intra-uterine Applications. In some cases a few intra-uterine applica- tions may be made for therapeutic and diagnostic effect. Copper sulphate (10% solution) is the preferable astringent to use. In simple hyperplasia or mild inflammation it tends to stop the bleeding. In beginning malignant disease the bloody discharge persists. f. Curetment. When there is a bloody discharge that persists off and on, in spite of other measures employed for a few weeks, then thorough curet- ment under anesthesia is indicated as a diagnostic and therapeutic measure. In cases where the cervical canal is wide, or where it dilates easily without much pain, some scrapings from the endometrium may be obtained in the regular office examination by means of the small exploring curet (Fig. 101). If such scrapings show malignant disease, the diagnosis is thus established without anesthesia. If the scrapings do not show malignant disease, then curetment under anesthesia is indicated, for in such a case malignant disease cannot be excluded until a thorough curetment is made and all the scrapings examined. If no malignant disease is found, but the bleeding recurs, a second curetment with examination of the scrapings is indicated. If the bleeding recurs only at long intervals, repeated curettage may be employed with much benefit, provided malignancy can be positively excluded. g. Hysterectomy. If malignant disease is present, hysterectomy at once is, 908 DISTURBANCES OF FUNCTION of course, indicated. If no malignant disease is present, but still the bleeding recurs soon after curetment, and especially after repeated curetment, hyster- ectomy may be necessary. It is clearly indicated where the uterine wall is damaged permanently and to a serious extent, by scattered fibroid nodules, by chronic metritis (sclerosis) or by the condition designated as "myopathica hemorrhagica." 909 CHAPTER XV. INVASION OF THE PERITONEAL CAVITY For the Treatment of Gynecologic Diseases. In the treatment of certain gynecologic affections it is necessary to invade the peritoneal cavity. This invasion of the great peritoneal sac in the center of the body necessarily carries with it much risk to the patient. In the pre- antiseptic days the mortality was great — so great that the operation was but rarely resorted to. By modern antiseptic and aseptic methods, however, the mortality has been reduced to a very small per cent. But though the mortality of the operation is small, we must not forget that there is a mor- tality due directly to the operation. The danger varies much in different cases, depending on the particular form of disease present and on the condition of the patient at the time of operation — but there is some danger in every case. I call particular atten- tion to this because some physicians seem prone to overlook, or at least fail to give proper weight to, the fact that occasionally a patient, with everything apparently favorable, will die, and no one can promise any patient abso- lutely that she will survive. One may say, in a favorable case, that the risk is very slight and that in all probability the patient will go through the operation and convalescence without trouble. But though the risk is slight, it is nevertheless a risk, and the patient or her friends must so understand it. Such necessary explanation to the patient or her relatives is made with much better grace before operation than afterward. The peritoneal cavity may be readily entered in two ways — by incision through the anterior abdominal wall (abdominal section) or by incision through the vaginal wall (vaginal section). ABDOMINAL SECTION. Abdominal section is incision into the peritoneal cavity through the ab- dominal wall. This is known also as "celiotomy" and as "laparotomy," and as "suprapubic section." These terms all refer simply to the incision through the abdominal wall into the peritoneal cavity and not to the subse« quent operative manipulations carried out within the cavity. The incision may be located at any part of the wall — in the median lino or laterally. The direction of the incision may be longitudinal or transverse or oblique, or a combination of these directions. There is usually some additional operative procedure carried out after the peritoneal cavity is opened, and this additional procedure frequently gives 910 INVASION OF THE PERITONEAL CAVITY the name to the whole operation — for example, ovariotomy (abdominal sec- tion with removal of an ovary or an ovarian tumor), myomectomy (abdomi- nal section with removal of a fibromyoma of the uterus), abdominal hysterec- tomy (abdominal section with removal of the uterus). INDICATIONS For Abdominal Section. The most common indications for abdominal section in gynecologic work are as follows : 1. Ovarian tumors. 2. Broad ligament tumors. 3. Uterine fibromyomata with serious symptoms not yielding to minor measures. The abdominal operations in these cases are myomectomy, supravaginal hysterectomy, and total abdominal hysterectomy. 4. Cancer of the uterus (total abdominal hysterectomy). 5. Extra-uterine pregnancy. 6. Acute pelvic inflammation which spreads in spite of other meas- ures and threatens life. 7. Chronic pelvic inflammation with a collection of pus high in the pelvis, as in pyosalpinx. 8. Chronic pelvic inflammation with a large amount of exudate and persistent troublesome symptoms. 9. Chronic pelvic inflammation without decided exudate, if every- thing else fails to relieve the pelvic distress. 10. Pelvic tuberculosis, if other measures fail to produce decided im- provement. 11. Adherent retrodisplacement of uterus or persistent prolapse, causing troublesome symptoms and not yielding to less danger- ous measures. 12. Obscure or doubtful pelvic disease which, in spite of other meas- ures, threatens the patient with death or with chronic invalidism (exploratory abdominal section). CONTRA-INDICATIONS. The more common contra-indications to abdominal section are : 1. Marked nephritis, especially chronic interstitial nephritis. 2. Diabetes mellitus. 3. Inoperable cancer or advanced pulmonary tuberculosis. 4. Any chronic disease, general or local, causing marked weakness and lessening the patient's resistance. 5. Acute disease that may be aggravated by the operation. 6. Dermatitis within the operative field. All these contra-indications are of course only relative. There may arise ABDOMINAL SECTION 911 circumstances demanding the operation at once in spite of contra-indica- tions — that is, circumstances in which the danger of delay would be greater than the danger of immediate operation. But when the case is not one of extreme urgency, the operation should be postponed until the complicating condition can be corrected and the patient placed in better condition. Pregnancy increases the danger of abdominal section very decidedly, l)ut it is not often a contra-indication for the reason that the disease requiring operation (for example, a large tumor or an abscess) precludes the full de- velopment of the fetus or makes the dangers from advancing pregnancy greater than those from immediate operation. DANGERS Of Abdominal Section. The immediate dangers of an abdominal section are three : 1. Failure of the vital forces to stand the shock of the operation. This shock is due principally to (a) the loss of blood, (b) the handling of intra- peritoneal structures and (c) the anesthesia. 2. Failure of the vital organs (heart, lungs, kidneys and gastro-intestinal tract) to perform the extra work thrown on them in the first few days fol- lowing the operation. 3. The development of infection, causing general peritonitis or localized suppuration. PREPARATIONS For Abdominal Section. In order to reduce to a minimum the dangers of the operation, careful preparation is required. The operation should, when possible, be carried out in the clean, well- arranged operating room of a hospital, even though the patient has to be moved a considerable distance to obtain the requisite hospital facilities. Ab- dominal section is too serious an operation to be undertaken in the home if the patient's condition will permit her removal to a hospital. When the operation must be performed at the home of the patient, the room should be made as clean and free from dust as possible by the follow- ing steps : a. One or two days before operation remove the bric-a-brac and super- fluous furniture and sweep the walls, ceiling and floor thoroughly. b. The carpet may be removed, leaving the bare floor, or, after sweeping the carpet well, it may be covered completely with oilcloth well tacked down. c. All the wood-work should then be thoroughly scrubbed with soap and water and afterward with an antiseptic solution. The further preparations for the operation may be divided into three parts as follows: 912 INVASION OF THE^PERITONEAL CAVITY A. Preparation of the patient. B. Preparation of instruments and dressings. C. Preparation of operator and assistants. A. Preparation of the Patient. The patient, having been subjected to a careful general examination, including urine analysis, to exclude contra-indica- tions, is sent to the hospital one or two days before operation, that the proper preparation may be carried out. Of course there are cases of rapidly spread- ing pehdc inflammation, or of intra-abdominal hemorrhage or injury, in which the abdomen must be opened at the earliest possible moment. In such a case there is no time for preliminary preparation — careful immediate sterilization is carried out and the abdomen is then opened. But when the case is not an emergency one, the preliminary preparation should be made. It gives the patient a decidedly better chance of complete and uninterrupted recovery. The purposes of this preliminary ]3reparation are : a. To tone up the patient's nervous system so that she will be better able to stand the operation. b. To see that the kidneys are in good working order, and to prepare the urine for possible catheterization. c. To nourish the patient so as to limit intestinal decomposition, and to empty the intestine tract well just before operation. d. To prepare a sterile field for the operative work. These desired results are secured by a program ordinarily about as follows, supposing the time for operation to be an early morning hour : 1. Nervous System and General Measures. For two or three days before operation the patient is given strychnia sulphate 1-40 gr. by mouth every four to eight hours, depending upon the amount of stimulation needed. If the patient's stomach is much disturbed, tliis may be given hypo dermatic ally. Such other medicines should be given as are indicated by pain or nausea, or cough or other symptoms. If there is a vaginal discharge, give an antiseptic douche once or twice daily. 2. Kidneys and Urine. Determine whether the kidneys are doing their work well. ]\rake the regular analysis of the urine, and, when indicated, the special examinations. As the patient may have to be catheterized after opera- tion, it is well to give some urinary antiseptic for a day or two before — such, for example, as urotropin, 5 grains in glass of water every eight hours. Have the patient take water rather freely. Formerly I took particular pains to thoroughly saturate the patient with water before operation, for the purpose of aiding the kidney action after operation and diminishnig the thirst, but have discontinued tlie practice as a routine because I found certain drawbacks — the principal one being that it interfered with spontaneous urination after operation. The avoidance of catheterization is much to be desired and can usually be accomplished, pro- vided the bladder does not fill until the patient has well recovered from the anesthesia. In the watei* saturated patients the urine is secreted so rapidly that frequently the bladder becomes distended before the reflexes are suffi- PREPARATIONS FOR ABDOMINAL SECTION 913 ciently established to bring about spontaneous urination. In certain eases, however, wliere the kidneys are defective, I still employ it. 3. Diet and Laxatives. Light diet is to be given up to and including noon of the day before operation, then liquids only, but with water in abundance. After midnight, just preceding the operation, nothing is to be given by mouth but water — the water may be continued up to within an hour of the operation. A dose of castor oil (1 to 2 ounces) is to be given about 3 P. M. the day before operation, and the next morning an enema until the water returns clear. The idea is to have the intestinal tract in as near a normal condition as possible (hence no abnormal putrefaction), with simply a good clearing out by a non-irritating purgative just before the operation. Experience has shown that this simple method of preparation brings the patient to the operat- ing table in better condition and causes less disturbance after the operation than the prolonged dieting and purging formerly employed. The latter upset the functional routine of the intestine, disturbed the normal peristalsis, increased the intestinal irritation and putrefaction, and reduced the patient's strength. When there are complications that may necessitate resection of the intestine • or opening of the stomach, then, of course, the usual preoperative measures for approximate sterilization of the upper intestinal tract should be employed. 4. Sterilization of the Field. Five to fifteen hours before operation (most conveniently the afternoon or evening before) cover the whole abdomen with a poultice composed of absorbent cotton soaked in a solution of green soap in warm water. The cotton should be applied sufficiently wet so that the skill ■\^^11 be thoroughly soaked by the soapy water. This loosens all the dead epidermal scales and all extraneous particles on the skin and makes the sub- sequent shaving much more effective as a cleansing process. After the soap solution has been on half an hour to an hour, remove it and shave the abdomen. Then scrub the abdomen well with absorbent cotton or a very soft brush, using warm water and green soap or ethereal soap. At this point your hands should be again sterilized. Then wash off the soap solution vrith sterile water. Then wash the abdomen carefully and vigorously with alcohol (about 80%), using sterile cotton balls. Then wash with bichloride solution (1-2000), using sterile cotton balls. Then apply a compress of absorbent cotton moistened with bichloride solution (1-5000). This compress is to remain in place until after the patient is under the anesthetic, or, if preferred, the bichloride dress- ing may be removed a short time before anesthesia and the cleansing process repeated. In this process of sterilization special attention must be given to the umbilical depression and other irregularities in the surface. When the patient is on the operating table and under the anesthetic, the bichloride compress is removed and the field again washed with alcohol or ether, applied by means of cotton balls, then M^th sterile water applied in the same way. The abdomen is then dried with sterile gauze and is ready for incision. If the vagina also is to be invaded during the operation, it must be prepared as described later under vaginal section. 914 INVASION OF THE PERITONEAL CAVITY There are many minor variations from the above used in different hospitals, to some of vhich variations much importance is attached by those using them. I have been on the lookout for improvements, but so far have encountered nothing that, on critical analysis, surpasses this standard method in simplicity and effectiveness. In hurry cases, where the abdomen must be opened at the earliest possible moment, the preliminary softening and loosening of the epi- dermal scales by the soap poultice must be dispensed with, and consequently extra care must be exercised in the other steps of the preparation. Here Harrington's solution (corrosiv. sublimate, 0.8 gm. ; water, 300 c.c. ; hydro- chloric acid, 60 c.c: alcohol, 640 c.c.) is preferable to the plain bichloride solution. It is a much stronger disinfectant, but more irritating. The various "rapid" methods of abdominal disinfection should, it seems to me, be confined to emergency cases, in which there is not time for the regular and more reliable process of skin cleansing. B. Preparation of Instruments and Dressings. There are several ways of preparing instruments, sutures, dressings, etc. The usual method is as follows : 1. Instruments are boiled ten to fifteen minutes. They must be entirely immersed in the water and the water must boil (not simply simmer) for at least ten minutes. A 1% solution of sodium carbonate (washing soda) is pre- ferable to plain water, as it tends to prevent rusting of instruments. There are a few exceptions to the boiling rule. The knives and scissors are usually soaked in 95% carbolic acid for ten minutes or in 10% carbolic solution for half an hour, as boiling tends to dull them. However, if in a hurry, they may be boiled with the other instruments, in which case the cutting edge should be wrapped in cotton. 2. Gauze sponges and pads and dressings are sterilized in the steam sterilizer. The goAvns for operator and assistants, and the sterile cloths and sheets, and . instrument -trays and basins are put through the same process. In emergency work in the country, where no steam sterilizer is available, an ordinary wash boiler may be used. The various articles to be sterilized (gauze, sponges, towels, sheets, gowns, etc.) are wrapped in small packages, each package being wrapped in two thicknesses of cloth, and are then boiled for thirty minutes. In order to dry the gowns somewhat, they may be removed from the boiler, wrung as dry as pos.sible Avith clean hands, being careful to not disturb the double covering, and then dried in an oven. In regard to the form of sponges used, I would strongly recommend the gauze-strip sponges for abdominal work (page 925). The numerous detached sponges ordinarily used are dangerous and have led to many deplorable accidents. 3. As to suture and ligature materials, silk and silkworm gut are boiled along with the instruments. Reliable catgut may be purchased, sterilized and ready for use. 4. The rubber gloves are wrapped in a towel and boiled along with the instruments. After boiling they are placed in 1-5000 bichloride solution. PREPARATIONS FOR ABDOMINAL SECTION 915 They are much easier put on when partly filled with solution. The weak bichloride solution is used, so as to kill any bacteria that may work to the surface of the skin of the hands during the course of the operation. When the gloves are put on in simply sterile w^ater, the warm mixture of sterile water and macerated epithelium, which forms in the glove during the course of a long operation, becomes a culture-medium for the bacteria which w^ork to the surface from the deeper layers of the skin, and which may be liberated in the peritoneal cavity by a puncture of the glove. C. Preparation of Operator and Assistants. Everything that is to come in contact with the operative field must be sterilized. The hands and forearms of the operator and assistants must be disinfected as far as possible, and should then be covered, so that there is no chance of direct contact of the operative field with the skin of the hands or arms, for the skin can not be absolutely sterilized. Again, the operator and assistants must be so covered as to effect- ually protect the field of operation from contamination by the clothing or by particles from the hair or beard, or by particles carried in the breath. The accomplishment of this thorough protection of the operative wound has been the object of many decades of study and experimentation. The present effective technique for the preparation of the operator, as well as all the other antiseptic and aseptic preparations, w^as attained gradually by im- provements added year by year, but it is all the direct outgrowth of the epoch-making work of Pasteur and of Lister. The following are the steps in the preparation of the operator and assistants : 1. The sleeves are rolled w^ell up above the elbows and the finger-nails are trimmed short and cleaned thoroughly. 2. The hands and forearms are then scrubbed carefully and vigorously, for from three to five minutes, with warm water and some liquid preparation of green soap — using a stiff brush and giving particular attention to the irregularities about the nails and knuckles and to the spaces between the fingers at their junction with the hand. Where the brush causes undue irri- tation of the skin, gauze is preferable for scrubbing the arms, but not the hands. 3. Then the soap is washed off with sterile water, and the hands and fore- arms are scrubbed in 80 per cent, alcohol with gauze. 4. Then they are scrubbed in bichloride solution (1 to 2000), with a brush or gauze. 5. The sterile gown is then put on, the hair and mouth, and neck and greater part of the face are covered with gauze by the nurse, the rubber gloves and sterile muslin sleeves are adjusted and the operator is ready to begin. The gauntlet of the rubber glove is brought up over the lower end of the sterile sleeve to hold it in place, and the arm is thus securely covered and there is no chance for any skin surface to come in contact with the wound. The assistants must go through the same process. The process of hand disinfection given above is known as the "alcohol- 91g INVASION OF THE PERITONEAL CAVITY bichloride" method. It is also called, from its originator, the Fiirbringer method. There are three methods of hand-disinfection which are much used. The thorough scrubbing with green soap and warm water is common to all of them. The further steps differ as follows: a. The "alcohol-bichloride" method. The various steps in this method are given in detail above. b. The "permanganate and oxalic acid" method. The hands and forearms are next immersed in a hot saturated solution of potassium permanganate and kept there until the skin takes on a dark brown color, then they are immersed in a hot saturated solution of oxalic acid until the skin again has its natural color. The oxalic acid is washed off in sterile water or sterile lime water, and the hands and forearms are then washed in bichloride solu- tion (1-2000). c. The "chlorinated lime and sodium carbonate" method. After the pre- liminary scrubbing a tablespoonful of chlorinated lime is taken in the palm of the hand, moistened with enough water to make a thick paste, and then a piece of sodium carbonate (washing soda) about the size of the thumb is crushed in the hand and rubbed thoroughly into the lime paste. This mixture, containing nascent chlorine, is then rubbed vigorously into the skin of the hands and forearms for three to five minutes. The parts are then washed in sterile water, and later in weak ammonia water to remove the chlorine odor. As to the choice of method of hand-disinfection, that is largely a matter of personal preference. Any one of the above three methods, properly carried out, will give good practical hand-disinfection — i. e., from hands and arms so prepared, infection will rarely if ever take place. The important thing is not which method is chosen, but how thoroughly the chosen method is car- ried out. I have used all three methods, and very decidedly prefer the "alcohol-bichloride" method, though I have nothing serious to say against the others. Absolute disinfection of the hands and arms is impossible by any method, as the disinfection is necessarily confined to the superficial layers of the epider- mis. Bacteria situated in tlie deeper layers of the epidermis may work to the surface during the course of the operation; hence the importance of thoroughly covering the prepared hands and arms with rubber gloves and sterile sleeves. REGULAR STEPS In Abdominal Section. In order to present some idea of tlie main features of this important thera- peutic measure, I shall run hastily over tlie regular steps in this operation, and later consider briefly some of the special points that require attention. The regular steps incident to every case of abdominal section are as fol- lows: REGULAR STEPS IN ABDOMINAL SECTION 917 1. Anesthesia. 2. Incision. 3. Exploration. 4. Correction of pathological condition. 5. Toilet of peritoneum. 6. Closure of incision. 7. Dressing. I'lg. 713. The Sate Position of the Arms during Anesthesia. The elbows are brought to the patient's sides and the forearms rest comfortably against the chest, where they are held by the sleeves being pinned to the gown 1. Anesthesia. Ether is safer than chloroform, and is to be preferred in all cases except where there is some definite contra-indication. There is neither space nor occasion here for a general consideration of an- 918 INVASION OF THE PERITONEAL CAVITY esthesia. There is one point, however, that I think advisable to call attention to, and that is the position of the patient's arms during anesthesia. Many cases of paralysis of one or both arms following anesthesia have been re- ported — the paralysis lasting for many months and sometimes for a year. It is due largely to faulty position of the arms during anesthesia. This is a Fig. 714. A Dangerous Position of the .•Vrms during Anesthesia. Many cases of paralysis of one or both arms from this position have been reported. serious matter and attention should be called to it in every work dealing with anesthesia — and yet it is seldom mentioned. In 1905 I reported two cases of such brachial paralysis in detail to the St. Louis ]\Iedical Society, called attention to previous work and investigations on the subject, and demon- strated, directly on the cadaver, the compression of the brachial plexus by REGULAR STEPS IN ABDOMINAL SECTION 919 the clavicle when the arm is above the head.* As stated in the article, this has long been recognized as the cause of the paralysis, the attention of the profession generally having been first called to the subject by Budinger in 1894. Fig. 713 shows the safe position for the arms during anesthesia. No case of paralysis has ever occurred, as far as known, when the elbows were kept to the side as here indicated. Fig. 714 shows a dangerous position of the arms — the position the arms occupied in my two cases and in most of the reported cases of paralysis affecting the brachial plexus. Figs. 715 and Fig. 715. View of the Dissected Area ia a Cadaver, ia wliich the arm was brought above the head as shown in Fig. 714. C, cla\icle. R, first rib. T, transverse process of first dorsal vertebra. O, outer trunk of brachial plexus. S, stump of suprascapular nerve. G, compression groove made by cla\icle when arm was above the head. (Crossen — Journal of Missouri State Medical Association.) 716 serve to call attention to the anatomical features of the trouble. Fig. 717 shows another dangerous position of the arm during anesthesia — this posi- tion being liable to lead to peripheral paralysis from pressure by the edge of the table. 2. Incision. In abdominal section for pelvic disease the incision is made, almost invariably, in the median line. All parts of the pelvis may be reached * Brachial Paralysis Following Surgical Anesthesia; Report of Two Cases of Missouri State Medical Assocation, vol. 1,'No. 10, 1905, By H. S. Crossen, M. D.— Journal 920 INVASION OF THE PERITONEAL CAVITY from such an incision and, in practically every case, exploration of the whole pelvis should be made. Ordinarily the incision is begun about midway from the umbilicus to the symphysis and continued downward three or four inches. If there is no large solid tumor, the incision is made small at tirst, but large enough to admit the fingers or hand into the pelvis for exploration. As a rule the primary incision is about four inches long. If the abdominal walls are very thin, it may be shorter ; if they are very thick, it must be longer. The lower the incision is placed, the more easily the deeper portions of the Fig. 716. Diagram of Left Brachial Plexus from Gray's Anatomy. F, Probable field within which would occur the lesion producing the symptoms mentioned in the reported cases. G, Location of compression groove in this cadaver. (Crossen— /cmmaZ of Missouri Slate Medical Association.) pelvic cavity may be reached, but the incision must not be low enough to injure the bladder. When a tumor is present, the bladder may be drawn up considerably ; consequently in such a ease the incision must not be extended low until the peritoneal cavity has been opened and the bladder located. If it is thought that the bladder may be drawn so high as to interfere with the ordinary incision, a steel bougie may be introduced into the bladder and the height of its cavity determined before the incision is made. In cutting through the abdominal -wall it is not necessary to strike the REGULAR STEPS IN ABDOMINAL SECTION 921 tendinous tissue between the recti muscles. If the incision is made a little to one side of the tendinous center and passes through the rectus muscle of that side, it makes little difference. Consequently, no time should be lost trying to make a careful dissection exactly in the median line. The incision is continued through the skin and the subcutaneous fat and fascia, and the rectus muscle with its tendinous sheath, down to the loose subperitoneal fat. When the subperitoneal tissue is reached, all bleed- ing it stopped, and the subperitoneal fat and connective tissue are cut through between two dissecting forceps. The peritoneum is then picked up with the Fig. 717. Another Dangerous Position of the Arm during Anesthesia. dissecting forceps and a short cut is made in it, and this opening in the peritoneal cavity is enlarged by scissors or knife. 3. Exploration. When the proper opening has been made, the hand is in- troduced into the peritoneal cavity and the various pelvic organs are out- lined and the pathological condition determined as accurately as possible. 4. Correction of Pathological Condition. After the exploration of the pelvic ca^dty and the determination of the exact condition present, the particular measures to be employed will depend on the nature of the trouble — the various affections requiring very different methods of treatment. 5. Toilet of the Peritoneum. All blood and clots are sponged out of the pehds and, as far as practicable, the pedicle ends are turned under and all raw surfaces covered with peritoneum. All abdominal pads are then removed, the intestines are permitted to come back into the peMs (the patient having 922 INVASION OF THE PERITONEAL CAVITY been lowered from the Treudelenburg posture) and the omentum is spread out in its proper place. 6. Closure of Incision. There are two methods of closing the incision — (a) by "through and through sutures" of silkworm-gut and (b) by "tier sutures" of cat-gut or other absorbable material. Except in hurry cases, where it is exceptionally important to get the abdomen closed as quickly as possible, the preferable method is the latter — approximation by tier sutures of cat-gut, with or without two or three tension sutures of silkworm-gut. Fig. 718. The Abdominal Dressing. Gauze next to the wound. The Flat Fig. 719. Gauze. The Abdominal Dressing. The Rough 7. Dressing. The dressing of the abdominal wound consists of a large thick dressing of sterile gauze over the wound (Figs. 718, 719), next to that a layer of sterile absorbent cotton (Fig. 720) covering the anterior surface of the abdomen, and over that a medium-thick layer of sterile common cotton to turn any water that might be spilled on the dressing during con- valescence and to give even elastic pressure at all points — the whole held in place by a binder about the abdomen, with perineal straps to hold it well down (Fig. 721). SPECIAL POINTS IN ABDOMINAL SECTION 923 SPECIAL POINTS In Abdominal Section. There are a number of special items that must receive careful consideration by every one doing abdominal section work. Among these may be mentioned the following : 1. Drainage. 2. Shock. 3. Injury to adjacent organs. 4. Foreign bodies in abdomen. Fig. 720. The Abdominal Dressing. The layer of Absorbent Cotton. 1. Drainage. The rule in abdominal surgery is never to drain unless there is some special reason for it, and that special reason must be a very strong one. Experience has abundantly shown that in all but exceptional cases the best results are obtained by closing the peritoneal cavity completely and leaving nature to carry on the reparative process alone, undisturbed by tubes or gauze or other form of drainage. That small percentage of cases in which drainage is advisable includes the following classes- 924 INVASION OF THE PERITONEAL CAVITY a. Rapidly spreading inflammation of the peritoneum or acute general peritonitis. In such cases free drainage is indicated, and as a rule the freer the better. b. Rupture of abscess in pelvis. This accident happens not infrequently during the enucleation of an inflammatory mass containing pus. In some cases the pus is not confined in any removable sac, but has burrowed in Fig. 721. The Abdominal Dressing. The Binder applied. various directions among the adherent organs. In such a case as soon as the adhesions are separated the pus flows out into the peritoneal cavity. c. Persistent fr.ee oozing from surfaces left after the enucleation of an in- flammatory mass. Here the effect desired is pressure rather than drainage, but, as the end of the gauze used for pressure must be brought out through the abdominal wound or through the vagina, it is usually referred to as a drain or pack. 2. Shock. The principal factors in shock are (a) loss of blood, (b) ex- posure and handling of abdominal contents and (c) long anesthesia. To SPECIAL POINTS IN ABDOMINAL SECTION 925 avoid shock, therefore, particular atteutiou must be given to the following points : a. Careful hemostasis. All vessels that can be located are ligated or clamped before they are divided. In cutting through ligated tissues, forceps are in readiness to catch any vessel that may have escaped the ligature or upon which the ligature is not tight enough. b. Protection of the abdominal contents, as far as possible, from handling and exposure. The Trendelenburg posture accomplishes this to a large ex- tent. In this posture the intestines and omentum gravitate into the upper part of the abdominal cavity, away from the field of operation. Those parts that still tend to protrude into the pelvis are held out of the way by gauze, which, at the same time, serves to wall off the pelvis from the abdominal cavity. When the intestines are unavoidably permitted outside of the peritoneal cavity, they should be kept covered with large sterile towels soaked in hot saline solution. c. Minimum duration of anesthesia. To cut down the duration of the operation and consequently of the anesthesia, the operator should work rapidly — as rapidly as is consistent with safety and accuracy — but accuracy must not be sacrificed to haste. 3. Injury to Adjacent Organs. The ureter, the bladder and the intestines are the organs particularly liable to injury in difficult cases. Ordinarily an injury of any of these organs occurring in the course of an operation must be repaired at once or at the close of the operation, and any one doing pelvic surgery must be prepared to immediately take care of the injuries mentioned. 4. Foreign Bodies Left in the Abdomen. The absolute certainty of the removal of all articles carried into the peritoneal cavity is a subject that deserves most careful consideration. It is surprising how easily and quickly the intestinal coils will enfold an object and carry it out of sight and touch. Sponges. A sponge left in the peritoneal cavity following an operation con- stitutes one of the most deplorable accidents of abdominal surgery. This is not a new subject. Much has been written upon it and many cases have been reported, and many suggestions have been made as to preventive meas- ures. But all such measures hitherto proposed have broken down under the various circumstances and vicissitudes of surgical work, as evidenced by the records subsequently cited. In connection with this subject I wish to call at- tention to the following facts : 1. Sponges are lost in the peritoneal cavity much more frequently than is generally supposed. The accompanying table of reported cases (page 934) wnll indicate the importance of the subject. And it must be kept in mind that the reported cases represent only a small proportion of the recognized cases, for, naturally, the accident is not given publicity except where there in some special reason for doing so. In any large body of surgeons a little experience meeting, in w^hich testimonies are freely given, will bring to light a number of unreported cases of this accident. 926 INVASION OP THE PERITONEAL CAVITY Furthermore, many cases are not even recognized. The patient dies with evidence of peritonitis; there is no suspicion of any foreign body having been left in the abdomen, no post-mortem examination is made and the death is supposed to be due to ordinary peritonitis. The possibilities in this direction are indicated by the fact that in the series mentioned, in thirty-nine of the cases the accident was recognized only on post-mortem examination, when the sponge was found, but would have remained unknown had there been no autopsy. 2. It is a most serious accident. In the large series of cases collected more than one-fourth of the patients died, and of those who recovered many went through weeks and months of suffering. 3. To persons outside the profession the accident seems absolutely inex- cusable. They can understand how other complications may arise, such as hemorrhage or sepsis or kidney failure, in spite of every precaution, but they can imagine no reasonable excuse for allowing a sponge to be lost in the patient's interior. To those not familiar with surgical work it seems past belief that the surgeon would carry into the peritoneal cavity anything the removal of which was not provided for with absolute certainty. The growing cognizance of the public in regard to the occurrence of this accident and the feeling in regard to the responsibility for it are reflected in the increasing number of lawsuits connected therewith (see Chapter XVII). 4. There has hitherto been no sure preventive method which was appli- cable in all the circumstances of abdominal surgery. The list of preventive measures recorded later shows that much thought has been given to devising means for preventing this accident. Rules interminable have been proposed, and expensive and cumbersome racks and stands devised for the purpose. Not one of these devices, however, has proven absolutely safe, for the reason that in their use the certain removal of all sponges carried into the abdomen depends on the studied attention of the oi)erator or on a system of attentive co-operation among assistants or nurses. While such attentive co-operation is entirely feasible under ideal conditions and with ideal persons, the fact remains that it is not secured and is not likely to be secured under the variable circumstances of abdominal work. The many emergencies which arise in the course of abdominal operations, the changing assistants and nurses, the hurried operations at night in the hospital with short help, the operations in private homes where the patient cannot be gotten to the hospital at all — all these conditions play havoc with safety arrangements depending upon a nicely-balanced system of rules and co-operation or on the use of cumbersome racks or stands. There is not space here to take up in detail the various ways in which mis- takes have occurred; suffice it to say tliat a review of the eases where de- pendence was placed on counting shows an appalling list in which a sponge was left, because one was liastily torn in two and one-half forgotten, or an extra one was primarily included in the bundle and missed in the counting, THE SPONGES IN ABDOMINAL SECTION 927 or an extra one was secured for an emergency during the operation, or some loose piece of gauze, not intended for intraperitoneal use, slipped in while near the wound, or a mistake Avas made in the final count of the sponges re- moved. It is astonishing what a sliglit inattention may lead to a sponge being left, and the consequent death of the patient. The method of attaching a tape to each sponge and then fastening a forceps to the tape and at the same time to the abdominal sheet, is the method probably in most general use. It has a record of many accidents — the tape pulled off the sponge, or there was a failure to attach the forceps, or the for- ceps failed to hold well. In one case recorded the sponge, tape and forceps were all lost in the cavity. The difficulty of guarding absolutely against leaving a sponge in the abdo- men is such that entire security against this fatal accident is counted one of the unsolved problems of abdominal work. Practically all writers on the subject state that there is no guaranty against its occurrence, even in routine hospital work and wdth all the rules of co-operation and the special apparatus designed to prevent it. Neugebauer, in a most exhaustive consideration of the subject, comes to the conclusion that the accident is, to a certain extent, un^ avoidable. Schachner, in an excellent paper, states, "So long as surgery continues an art, just so long wall foreign bodies continue to be unintentionally left in the abdominal cavity." In an article published recently, Findley states, "In former years the abdominal surgeon was seriously disturbed by well-grounded fears of secondary hemorrhage and sepsis, but surgery has mastered these problems to a large degree and they are little feared and seldom experienced. Now it is the thoughts of the sponge that disturb the night's repose wdien the report comes that something has gone wrong with our patient. The operator never can rid himself of the feeling of uncertainty as to the possibility of leaving a sponge." This expresses very well the feeling of those who have given attention to this subject, and particularly of those who have personally experienced the accident and have thus been brought face to face with a concrete exemplification of the inadequacy of the usual methods. The continued occurrence of this fatal accident and the failure of the preventive methods in general use constitute sufficient reason for my calling attention to a method which I have used with much satisfaction for the past four years. This method gives entire security and at the same time is simple and inexpensive, and is effective in all conditions of abdominal work — in the emergency operation in the country with unfamiliar assistants, as well as in the routine hospital w^ork. The failure of the safety methods in general use is due to their dependence upon sustained attention concerning the sponges, which attention on the part of the surgeon cannot be given to the sponges, for it is required elsew^here. A method, to be effective under all circumstances, must be practically automatic, insuring the removal of all gauze without particular attention on the part of any one at the time of the operation. 928 INVASION OF THE PERITONEAL CAVITY The Method. The underlying principle of this method is the elimination of all detached pads and sponges. In place of them I use long strips of gauze, each strip packed into a small bag in such a way that it may be drawn out a little at a time as needed. I was led to a study of the subject and the adoption of this method by an unfortunate experience. Following the usual technique, I operated for years without accident, but five years ago I left a gauze pad in the abdomen. The case was one of diffuse pelvic suppuration, requiring extensive drainage, and, fortunately, the pad was discovered and extracted through the drainage opening about two weeks later. The patient recovered without serious result from the accident — but the lesson was not lost. I determined to find some method that would really prevent such an accident — a method which would be entirely under the control of the operator and first assistant (a greater division of responsibility increases the. danger) and one which would occasion no delay in the closing steps of the operation. There had to be taken into con- sideration the large pads for holding the intestines out of the way and the small pads and gauze pieces for sponging. In place of several large pads for packing back the intestines, I adopted the large roll of gauze, then in iise by a number of operators, and found it satisfactory. The matter of the small pads and sponges, however, was not so easily dis- posed of. I felt that it was imperative to find some method that would do away entirely with dependence on the counting of the sponges at the close of the operation. As long as there was dependence on counting of the numer- ous small pads and sponges there would be mistakes, and consequently sponges would occasionally be left in the cavity. To eliminate this hazardous dependence on counting, and to provide a method that Avould make the leaving of a sponge in the abdomen practically impossible, was not an easy task. I worked over the problem for the greater part of a year. I tried various methods in common use for keeping track of the small pads and sponges, such as clamping an artery forceps to a tape attached to each sponge, attach- ing a heavy ring to each tape before stei-ilization, clamping each tape or a corner of each sponge to the sterile sheet about the wound, and the like. But I did not find any such method that was practical under all circumstances and absolutely safe. It then became evident to me that if safety were to be secured, the detached pads and sponges must be eliminated entirely. In pursuance of that idea I devised the method here described. The principle of this method is that no detached piece of gauze shall enter the abdominal cavity. Each piece of gauze introduced for sponging is simply part of a very long piece, the greater part of which is always outside the cavity. To make assurance doubly sure, I have recently put the large roll of gauze above mentioned into a bag, similar to the bags for the narrow strips, except that it is open on the side. As now used, therefore, the set consists of the following : THE SPONGKS FOR ABDOMINAL SECTION 929 Gauze-strip Sponges for Abdominal Section. i'-our narrow strips— 10 yds. long, M in. wide— (J tliicknesses. One wide strip — 5 yds. long, 9 in. wide — 4 thicknesses. Have another set of strips (4 narrow and 1 wide) in reserve. For the Narrow Strips the yard-width of gauze is divided into two strips, and each of these, when folded to six thicknesses, is about three inches wide. For the Wide Strip the full yard-width of gauze is used — when folded to four thicknesses it is nine inches wide. Turn in all raw edges so that no raveling can be left in the abdominal cavity. Pack each Narrow Strip into a separate small cloth bag, 5 in. wide and 10 in. deep, (Fig. 722, a) and attach a large safety pin to the bottom of the bag. The safety pin is to pin the bottom of the bag to the abdominal sheet at operation. Make the bag of extra heavy muslin or drilling, and sew with French seams to avoid raveling on the inside. The end of the strip first introduced to bottom of the bag should be fastened there securely by stitching through and through. Then pack the strip firmly into the bag (Fig. 723) in such a way that it will come out easily, a little at a time as needed (Fig. 726). Four of these filled bags belong in each set (Fig. 725, a). For holding the Wide Strip use a bag 6 in. by 10 in., and open on the side instead of at the end (Fig. 722, b). Fold the strip back and forth, thus forming a narrow pile about three inches wide (see Fig. 724). Fasten one end of the strip securely to the bottom of the bag by sewing through and through. Then place the folded strip in the bag in such a way that, when pulled upon, it will come out, a little at a time, as a wide strip suitable for packing back the intestines. Fold over the open side of bag and pin with two large safety pins (Fig. 725, b). The safety pins are for fastening two corners of the bag to the abdominal sheet (Fig. 727). One wide strip and four narrow strips constitute one set and are to be wrapped together in a cloth for sterilization in the usual way. Have also an extra sterilized set in reserve. At the operation the bag containing the wide strip is to be placed in hot normal saline solution. The narrow strips are to be used dry. Fig 722. The Cloth Bags Empty. A. Bag for each Narrow Strip. It i.s five inclifs v.i.lf and ten inches deep, and is open at the top. It is made of extra heavy muslin and is sewed with French seanis, so that there is no chance for any raveUng to be pulled out with the gauze. B. Bag for the Wide Strip. It is six inche.s by ten inches, and is open at the side. This bag is the same as those for the narrow strips except that it is one inch wider and is open at the side instead of at the end. 930 INVASION OF THE PERITONEAL CAVITY Fig. 723. PackiiiK the Narrow Strip into the bag. The end of the strip is caught witli a forceps and car- ried to the bottom of the bag, where it is fastened securely by sewing through and through, and then successive portions are rapidly packed in with the forceps. When packed in thus, the gauze strip may be drawn out a little at a time as needed. liK. 724. Tlift Wide Strip folded and ready to put in the bag. One end of the strip is first introduced to the bottom of the bag and fastened there securely by sewing through and through. Then the whole strip, folded as shown, is placed in the bag. When the strip is folded in this way it will, when pulled upon, come out as a wide strip, suitable for packing back the intestines (see Fig. 727.) Fig. 72.3. A Sft of diin/Cc-Strip Siiongcs. .\. Four Niirrow Strips. Tlie safety-pin at the bottom of each bag is for fastening the bag to the abdominal sheet (see Fig. 727). B. Wide Strip. The two safety-pins closing the bag are u.sed later for fastening tlie comer.s of the bag to the abdominal sheet (see Fig. 727.) GAUZE-STRIP SPONGES FOR ABDOMINAL SECTION 931 -^rr^' — r--:-;:n-n Fig. 726. Method of Using the Gauze-Strip Sponges. Just before the incision is made, a bag containing a Narrow Strip is fastened at the side of the abdomen by pinning the bottom of the bag to the sterile sheet- If desired, the top of the bag may be pinned in Hke manner. The mouth of the bag lies conveniently near the wound, but not in the way. The end of the gauze strip is caught with the forceps or fingers and pulled out as needed for sponging, as here indicated. In a case where but little sponging is required, one bag will be sufficient. In a case where more sponging is likely to be required, it is well to fasten a bag on each side of the abdomen at the beginning of the operation. The bag on each side gives a sponge immediately at hand for both the operator and the first assistant. The convenience of this will be appreciated by those who have had to wait, in an emergency, for a sponge to be handed to them. [For photographing, the checked toweling was used instead of the usual white abdominal sheet, so as to show the white bag and strip better by contrast.] Fig. 727. Method of Using the Gauze-Strip Sponges. As fresh portions of the strip are drawn out for use, the soiled portions are not cut off, but simply dropped down beside the bag and off the table. It is the continuity of the strip that insures safety, hence the strip should not be cut during the course of an operation. Trouble.some accumulation of folds of the strip about the wound (with conse- quent tangling \\ith instruments) may be prevented by always dropping the soiled portion outside the field close to the bag, as here shown. This photo- graph shows also the Wide Strip in place, ready to be used for packing back the intestines or walling off a large area or any other purpose for which large pads are ordinarily used. The bag containing the wide strip is preferably wrung out of hot saline solution just before use. It is then laid on the abdomen, opened, two corners pinned to the abdominal sheet, as here sbcvn, and the strip drawn out as required. No detached pads or other pieces of gauze are allowed about the operative field, hence none can be carrierl into the abdominal cavity tobe left there. This method eliminates all chance of leaving a piece of gauze in the abdo- men, for a large part of the strip is always outside the cavity, and the end is fastened securely outside. An important point is that the sure removal of all gauze is practically automatic. It does not depend on the accuracy of a hur- 932 INVASION OF THE PERITONEAL CAVITY ried. counting of sponges at the close of the operation nor on catching each sponge or sponge-tape with a forceps as it is put into the cavity, nor on a studied "watching what sponges go in and what sponges come out of the cavity." Those methods that depend for safety on the observance of compli- cated rules or on the strict following of a regular routine, or on the constant attention of the operator, have all broken down under the difficulties and vicissitudes of abdominal surgery, as the reported cases clearly show. A method, to be safe and suitable for general use, must be practically automatic in the removal of all gauze carried into the cavity, must be comparatively inexpensive in materials and preparations, must be fairly simple and con- venient in use, and must be applicable in every environment, including emer- gency work in the country. These requirements are met by the method here described. The dangers from hemorrhage and sepsis in clean cases have been largely done away v^^itll through improvements in technique, and now this other serious menace in abdominal work should be eliminated. The patient has a right to demand, and is demanding as the many law suits show (see Chapter XVII), that real protection be afforded against leaving a sponge in the abdo- men. It seems only justice to those who intrust themselves to our care that we should provide absolute security against this fatal accident, so far as such security is practically attainable. It simplifies the preparations for abdominal section — all the many pads and sponges of various sizes being replaced by five strips of gauze. The gauze is simply folded and then tacked by a few stitches at each end to prevent unfold- ing. Nurses as a rule welcome the method, stating that it is much less trouble- some than the sewing of the numerous small pads and sponges. The bags may be used again and again after sterilization. Many questions have been asked me concerning this method by surgeons contemplating its use, but there is room here for only two. "Do not the methods in general use give practical safety?" — The facts previously mentioned and the table of cases subsequently given answer that question to a large extent. Hitherto there has not been a method, practically applicable in all the vicissitudes of abdominal surgery, which would entirely prevent this accident. Practically all autliorities state that it is to a certain extent unavoidable. Notwithstanding all the methods hitherto proposed, many lives are still being sacrificed to this accident. In spite of widespread interest in the subject in recent years and of much study and investigation of it and several excellent papers by different authorities, there has been no signal advance. Ten years ago operators were using the same preventive measures now commonly employed. The sponges were couiit(Hl, tapes were attached to the sponges tluil Avcre counted, forceps were attjiclied to Hie tapes tluit were attached to Hie sponges tli;it were eonnted, etc. Yet willi nil these complicated precautions, many sponges were left in the cavity, as the records show. LONG INSTRUMENTS FOR ABDOMINAL SECTION 933 ''Is not the strip of gauze exteucling i'roin the forceps to the bag inconveu- ient aud in the way Avheu sponging?" — Sometimes it is in tlie way to a slight extent, but not as much as woukl at first appear. Any new method seems somewhat awkward at first, and this is no exception to tlie ruU;. However, in my experience so far, I have not found any situation in which there was seri- ous interference with satisfactory sponging or Avith any other operative mani])- ulation. Like any other important step in technic, it should he studied until it is clearly understood before an attempt is made to use it. There are two particular points that may be mentioned. To prevent the accumulation of loose folds of gauze in the vicinity of the wound, the used portion of the strip should always be dropped outside the field, close to the bag. Again, w^lien taking hold of a fold, to sponge wdth, draw it out of the bag for some distance, so that it can be introduced into the abdomen as far as desired freely and wdthout tension. Forceps. In about one-fourth of the recorded cases of a foreign body left in the abdomen the article left w^as a forceps or piece of an instrument, or other small object used about the w^ound. This calls attention forcibly to the fact that small instruments should not be allowed about an open abdominal wound. Neugebauer long ago called attention to this danger of small instru- ments, and urged the use of long instruments exclusively in abdominal work. ]\Iany surgeons have adopted this safety measure, but there are many others who seem to give no thought to the matter, and continue to use numerous small instruments in this dangerous locality. It may not be possible at present to entirely prevent the accident of leaving some article of the surgical armamentarium in the abdomen, but it is possible to reduce the danger to a minimum by the use of long instruments exclusively, and it seems to me that all those wdio are engaged in abdominal surgery should be led by common prudence to adopt this simple expedient. The details, as carried out in my own work, are as follow^s : Every instrument used about the wound is long — so long that a portion of it is practically always outside the abdominal cavity. Again, if by accident such an instrument should slip entirely into the cavity, its length is such that it would almost certainly be felt when the hand is carried into the cavity for the final palpation before closing. All the artery- forceps, dissecting-foreeps, tenaculum-forceps, pedicle needles, scissors and other instruments for internal work are from six and a half to eight inches long, the shortest being the large dissecting scissors (six and one-half inches). The shortest instrument used anywhere about the wound is the scalpel (six inches), wdiich is laid aside as soon as the peritoneal cavity is open. The needles and Murphy buttons are not brought near the wound, except when held wnth a forceps or wnth a suture attached. No IMichel clamps (for hold- ing rubber tissue or gauze along the wound margin) or other small unattached objects are allow^ed near the wound as long as the peritoneal cavity is open. The following table wall serve to call attention to the importance of the subject of foreign bodies left in the abdominal cavity at operation. 934 REPORTED CASES OF A FOREIGN BODY LOST IN THE ABDOMINAL CAVITY Abdominal Section. Sponges Left. No. 1859 Operator* Character of Operation. Article Lost. When and How Removed. Result. 1 Fehr 7 Sea sponge. Details not given. Mentioned by 7 Fehr and quoted by Olshausen. 2 1877 ? 7 Sea sponge. Found at secondary operation by G. Braun. c. 7 3 1883 Lawson Tait. 7 Sponge. Sponge missed. Four hours later wound was reopened and sponge recovered, a. 7 4 1884 H. P. Wilson. Ovarian cyst and pregnancy. Pieces of sea sponge. Five months after operation, pieces passed through sinus in scar. a. Recovery 5 1884 T. G. Thomas. Carcinoma of spleen. Pieces of sea sponge. Found at autopsy. Patient died four days after operation. Car- cinoma inoperable, a. Death. 6 1884 Howltz. Uterine necrosis. Sponge. Found at autopsy. Details not given. aDed by Wilson, a. Death. 7 1884 London surgeon. 7 Sponge. Found at autopsy .t Cited by W.T. Howard and also by Wilson, a. Death 8 1889 Bridden. Myomectomy. Sea sponge, 7 cm . wide. Found at autopsy. Patient died sixth day of peritonitis, c. Death. 9 1892 Pilate. Hysterectomy. Compress, 8 inches long. Passed per rectum, nine months after operation, a. Recovery 10 1892 Salin. Ovarian tumor. Gauze napkin. One year later, gauze removed through an abscess sinus, with subsequent fecal fistula which healed, a. Recovery 11 1892 French surgeon. Salpingitis. Two strips of gauze. Eight months later, 35 cm. strip of gauze extracted per vaginam, still later intestine resected and 10 cm, strip found within, a. Recovery 12 1892 French surgeon. Uterine fibroid. Compress, 26 cm. long. Eight months later passed per rec- tum, without alarming symp- toms at any time. a. Recovery 13 1892 French surgeon. Myomectomy. Sponge. A few hours after operation ab- domen was reopened and sponge located and removed, a. Recovery 14 1892 Quinn. Pyosalpinx. Napkin. Found at autopsy. Was suspected. Death on third day with symp- toms of se\ere dysentery, a. Death. 15 1893 Terrier. 7 Sponge. Found at autopsy. Death on third day from peritonitis, a. Death. 16 1893 ? Hysterectomy. Compress. Secondary operation by Michaux for painful abdominal mass. Compress found within intestine. Death. 17 1895 Eisner. Fibroid and ova- rian cyst. Pad, 7x8 inches. Six months later, passed per rec- tum. Progress of mass noted along course of colon in last month, a. Recovery 18 1896 MacLaren Ovarian cyst and retroversion. Gauze sponge 6x6 inches. Ten days after operation, expelled from rectum. Secondary opera- tion three months later for ad- hesions, a. Recovery 19 1896 ? 7 Sea sponge. Details not given. Two cases were observed by MacLaren at autop- sy in New York Woman's Hos- pital. Death. 20 1896 ? 7 Sea sponge. See preceding note. Death. 21 1896 Severeano Ovarian sarcoma. Two compresses, each 130x30 cm. After some months, one compress was extracted from a persistent sinus, and three weeks later, the other, a. Recovery 22 1897 Tuholske. 7 Sponge. One hour after operation, sponge missed. Abdomen reopened and sponge found and removed. Recovery 23 1897 ? ? Sponge. Details not given. H. C. Coe states that in autopsy work he found a sponge in five cases. Death by sepsis in each. a. Death. 24 1897 ? 7 Sponge. See preceding note. a. Death. 25 1897 ? 7 Sponge. See preceding note. a. Death. 26 1897 ? 7 Sponge. See preceding note. a. Death. 27 1897 ? • 7 Sponge. See preceding note. a. Death. 28 1897 7 7 Sponge. Twelve years later, passed per rec- tum. Reported by Hefting, a. Recovery 29 1897 Linquist. Tubal pregnancy. Gauze compresf5. Two months later, passed per rec- tum, a. Sponge missed before patient re- 7 30 1897 McMurtry. Ovarian cyst. Flat sponge. Recovery covered from anesthetic. Su- tures clipped and sponge re- moved . Four hours later, sponge missed. 31 1897 R. B. Hall. Appendicitis. Sponge. Recovery Abdomen reopened and sponge 32 1898 Wiggin. Secondary opera- tion for silk ligature. Gauze strip. renio\'ed . Some weeks after operation, gauze strip was removed from a per- sistent sinus. Lawsuit, c. Recovery REPORTED CASES OF A FOREIGN BODY LOST IN THE ABDOMINAL CAVITY. 935 Abdominal Section. Sponges Left. "o t" Characfer of No. 1898 Operator* Operation. Article Lost. When :uid How Removed. Result. 33 Schramm. Hysterectomy. Compress. Four weeks later, operated for a'Recovery mass, which proved to be the compress, a. 34 1898 Leopold. ? Compress. Removed by seconrlary operation. Recovery Was near li\er. a. < 35 1898 ? Cesarean section. Compre.ss. Found at autop.sy by Olshausen.' Death. Caused fatal peritonitis, a. 36 1898 Brosin. Bicornuate Compress, 20 cm. Six months later, expelled from a Recovery nteru.s. long. persistent sinus, a. 37 1898 Roesger. Uterine fiijroid. Fragments of sea sponge. After six months, particles dis- Recovery charged through a persistent sinus, n. 38 1898 Bolt. Hysterectomy for Gauze sponge. Several months later, secondary Death. fibroid. operation. Sponge found in in- testine. Resection. Death from shock, a. 39 1898 Schroeder. Oophorectomy. Gauze sponge. Secondary operation some months' 7 later for an abdominal mass. Sponge in ma.ss. a. 40 1898 ? ? Sponge. Found at autopsy by Thiersch, a. Death. 41 1898 ? 7 Sponge. Boldt stated in 1898 that he knew, 7 of five unpublished cases (among colleagues) of foreign bodies left in abdomen, a. 42 1898 ? ? Sponge. See preceding note of five ca.ses 7 (count three sponges, and two forceps), a. 43 1898 ? ? Sponge. See preceding note. a. \ 7 44 1898 ? ? Sponge. Boldt states that pathologist in Death. New York Hospital found for- eign body at autopsy in two cases (1 sponge, 1 forceps.) a. 45 1898 ? 7 Sponge. Boldt cites two cases in which 7 abdomen was immediately opened, and forgotten article removed (1 sponge, 1 forceps.) a. 46 1898 Eckstein. Ovarian cyst, Sponge 20x40 Five weeks later extracted from Recovery twisted pedicle. cm. sinus in scar. Count of spongesi after operation, stated "correct." d. Two and one-half years later re- Recovery 47 1899 Buschbeck. Tubal pregnancy. Large compress. moved from .sinus in scar. a. 48 1899 Meinert. ? Mull compress. Three weeks later, secondary oper- Recovery ation for mass in right lower ab- domen. Proved to be com- press, a. 49 1899 Rehn. Pyosalpinx. Compress, 1 m. square. Four months later secondary Recovery operation. Compress found within intestine. Resection of 40 cm. a. 50 1899 Kader. Salpingitis. Compress, size of handkerchief. Sinus present for six months. Later Death. the compress passed per rectum. Death from peritonitis, c 51 1899 Busch. Uterine fibroid. Mull compress. Two months later, passed per rec- Recovery tum, after much trouble, a. 52 1899 Fritsch. ? Sponge. One year later removed by second- Recovery ary operation. Cited by Kay- ser. c. j 53 1899 Fritsch. ? Sponge. No details given. Cited by Kay-j ? ser. c. 1 Two years later removed by Recovery 54 1899 Fritsch. ? Sponge. secondary operation. Cited by Kayser. c. ' 55 1899 Gillette. Tubal pregnancy. Sponge. Eighteen months later, removed Recovery by secondary operation. Law- suit. 56 1900 Merttens. Pelvic suppura- tion. Compress. Five months later, operation for abdominal mass. Compress witliin intestine. Resection of intestine, a. Recovery 57 1900 Wunderlich. Ovarian cyst. Compress, 21x100 cm. Three months later, compress was pas.sed per rectum, c. Recovery 58 1900 Wunderlich. Cystectomy. Linen cloth. Found at autopsy. Death on third day. No evidence of peri- tonitis. '(/. Death. 59 1900 H. A. Kelly. Pehic suppura- tion. Marine sponge. Some davs later, wovmd was re-]Reco\ery opened because of disturbance.' Sponge found anrl removed, c. 60 1900 Kelly. Ovarian cyst. Large gauze pad. Two and a half months later, i Recovery operation for abdominal ma.ss. Mass contained sponge and ab- scess, t. 936 REPORTED CASES OF A FOREIGN BODY LOST IN THE ABDOMINAL CAVITY. Abdominal Sectiox. Sponges Left. No. Operator* Character of Operation. Article Lost. AViien and How Removed. Cca 61 1900 Kelly 62 63 87 1900! Assistant to Kelly. 1900 1900 ? 1900 Spencer Wells. 1900 Winkle. 1900! 1900 1900 1900 ? 1900 ? 1900 Krasowski. 1900 Frankenhauser. 1900 Bier. 1900 Bier. 1900 ? 1900 .\tlee. 1900 Borysowicz. 1900 Karl Braim. 1900 ? 1900 ? 1900 George J. Engle- mann. 1901 Beck. 1901 ? 1901 Everke. 1901 Everke. 1901 Le Conte. 1901 1901 1901 1901 M. D. .Mann. H. C. Coe. 1901 1901 Coe. 1901 [Coe. 19011 Roberts. Ovarian cyst and appendicitis. Fibroid of ab- dominal wall Myomectomy. Gauze pad. Gauze, 360 gm. weight. Sponge. Sponge. Sponge. Sponge. Wound of omen- Sponge, tum. Myomectomy. Tubal pregnancy. Pelvic tuberculo- sis. Two laparot- omies, pyosal- pinx. Ovariotomy. Gauze napkin. Gauze. Gauze. Gauze. Sponge. Sponge. Mull compre.ss, 1x13^ m. Gauze strip. Iodoform gauze, 52x44 cm. Sponge. Uterine fibroid. Gauze sponge. Sponge. Sponge. Ovarian cyst. Gauze napkin. Small sponge. Fibroid and pyo- Sponge, salpinx. Sponge. Pyosalpinx. Gauze compress. Cesarean section. I Napkin. Tubercular peri- tonitis. ? 7 Hy.sterectomy. Gauze strip, 1 yd. wide and 5 ft. long. Flat sponge. Gauze pad. iGauze pad. , Gauze pad. Large gauze pad. Gauze sponge. Gauze pad. Sponge. Result. Five days later, operation for fever and a mass. In mass was sponge and abscess, c. One month later, secondary opera- tion for mass in abdomen. Con- tained sponge and abscess, c. Reeves Jackson described two cases in which a sponge was found at autopsy, a. Set preceding note. a. Sponge missed. Abdomen re- opened next day and sponge found, a. Found at autopsy. Details not given, a. Two weeks later, sponge was ex- tracted from an abdominal sinus. a. Found at autopsy by Kijweski. Details not given, a. Przewoski found gauze in cavity at three autopsies following ab- dominal section, a. See preceding note. a. See preceding note. a. Prof. Krasowski was legally pro- ceeded against for leaving a; sponge in the abdomen, a. Removed by secondary operation. Details not stated, a. j Six months later, secondary opera- tion. Compress found witliin intestine, c. Long time afterward, gauze passed per rectum, c. Secondary operation for intestinal obstruction by Chaput. Gauze found within intestine. Intes- tine incised, c. Found at autopsy. At operation a sponge was torn in two by an assistant, a. Three weeks later, sponge was? passed per rectum. Lawsuit threatened, a. Found at autopsy, a. Found at autopsy. Reported by W. T. Bull. a. Found in a secondary laparotomy by Dmochosky. a. Sponge missed at operation. Searched for carefully but not found. Found at autopsy four days later, a. One month later, sponge was ex- tracted from an absce.ss in scar. Sponge finally passed per rectum. Cited by Beck, who was called to see patient by Leusman. Later recovered by seconriary oper- ation. Details not given.' Law- suit, c. Foimd at autopsy. Death on fifth day from splanchnic irritation. No sepsis, c. Year later, strip removed from a persistent fecal fistula. Sug- gestion made that accident was beneficial to iiatient. b. c. Removed next day. No harm re- sulted, b. c. Cited by M. D. Mann. /). c. Cited by M. D. Mann in his letter to ScliiU'hner. b. c. Some niontlis later, pad was dis- charged through sinus in scar. Cited by .M . 1). Mann. h. c. Four weeks later, pad was felt un- der scar, and remo\ed. b. c. Particulars not {.'i\pn. b. c. Particulars not given, b. c. One week lider, siK)ns.'e was ex- tracted froin an al)scess in the \\eration. Gauze roll within intestine. Re.<;ection. Recovery 938 REPORTED CASES OF A FOREIGN BODY LOST IN THE ABDOMINAL CAVITY. ABDOinNAL Section. Sponges Left. 1 No. Qtti 1903 Operator* Character of Operation. .Article Lost. When and How Removed. Result. 131 Beckmaun. ? Napkin. Beckman stated that he had three ? cases in which napkin was lost in abdominal ca\-ity. 132 1903 Beckmann. ? Napkin. See preceding note. No details given. See preceding note. No details given. Secondary operation for fecal fis- tula. Sponge found within in- ? 133 1903 Beckmaim. ? Napkin. ? 134 1903 Fick. Perityphilitis. Cotton compress. Recovery testine, c. 135 1903 Gruning. Uterine myoma. Marley tampon. Some weeks later, after pain in lower abdomen, tampon passed per rectum. Recovery 136 1903 Schaefer. Myomectomy. Gauze napkin. Found at autopsy, two years later. Accompanied by intestinal necrosis, c. Death. 137 1904 Ahfeld. ? Gauze sponge. Prof. Ahfeld was subjected to a lawsuit in 1903, because of a sponge left in the abdomen, c. ? 138 1904 Corson. Ectopic preg- nancy. Sponge, 18x36 in. Two and a half months later, sponge passed per rectum, d. Recovery 139 1904 ? Kidney opera- tion. Lapa- rotomy. Sponge, 1 meter long. Forty-six days later, secondary operation for painful mass and ileus. Sponge within intestine. Resection, d. Recovery 140 1904 Reise. Extrauterine pregnancy. Sponge. Ten months later, secondary opera- tion for ovarian cyst and in- flammation. Sponge found near sigmoid, d. Recovery 141 1904 Thorne. Abdominal tumor. Sponge. After several months, secondary operation. Sponge found. Law- suit, d Recovery 142 1904 Winter. Hysterectomy for fibroid. Sponge. Found at autopsy. Death three weeks after operation, of em- bolus, d. Death. 143 1906 Waldo. Hysterectomy for fibroid. Towel. Some weeks later was extracted through sinus in scar. Sponges counted and "correct." d. Recovery 144 1906 ? Salpingectomy. [odoform-gauze strip. Two years later, found at second- ary operation. Cited by Waldo. d. Later discharged per vaginam. ? 145 1906 Ward. ? Sponge. Recovery 146 1906 Brothers. Ectopic preg- nancy. Pad. Six weeks later, pad protruded from opening in lower part of scar. ? 147 1906 Grandin. ? Pad. Two and a half years later, found encysted in the omentum. Recovery 148 1906 Grandin. ? Towel, with hos- pital name on. Three weeks later, secondary operation for mass imder liver. Mass contained towel. Recovery 149 1906 ? Sponge. One and a half years later, opera- tion by .A.mann for supposed fibroid. Proved to be a sponge. d. Eighteen weeks later, secondary Recovery 150 1906 Landau. Ovariotomy. Napkin. Recovery operation for fecal a fistula. Sponge found, d. 151 1907 MacLaren. Hysterectomy. Sponge, 12 in. square Found at autopsy, up under the liver. Death on the fourth day. Death. 152 1907 Crossen. Pelvic suppura- tion. Gauze pad. Two weeks later, appeared in drainage tract and was ex- tracted. Recovery 153 1907 d'Antona. Carcinoma of liv- er. Gauze napkin 40x70 cm. Found at autopsy. Death in one month from carcinoma, peri- tonitis and adjacent pleuritis. Two lawsuits, d. Death. 154 1907 Dobrucki. Ovarian cy.st. Sponge. Three weeks later extracted through sinus in scar. d. Recovery 155 1907 Janczewski. Ovarian cyst and pyosalpinx. Gauze napkin. Twenty-one days later removed from abscess in wound. (Janc- zewski, assistant to Neuge- bauer.) d. Recovery 156 1907 Poten. Myomectomy. Sponge. Found at autopsy. Death after six weeks from bronchitis. No peritonitis, d. Death. 157 1907 Prochownick. 7 Sponge - Sponge missed. Wound imme- diately reopened and sponge found, d. Recovery 158 1907 Russian opera- tor. Gauze compre.s.s. No details. Reported by Neuge- bauer. Operator did not wish name given, d. ' ? 159 1907 Polish operator. 7 Gauze compress. Details not given. Reported by 7 1 Neugebaucr. d. ' REPORTED CASES OF A FOREIGN BODY LOST IN THE ABDOMINAL CAVITY. 939 Abdominal Section. Spo.nges Left. "o t, No. 1907 Operator* Operation. Article Lost. When and How Removed. Result. 160 Sippel. Broad ligament lodoform-gauze Six weeks later, the gauze strip Recovery tumor. pack. passed per rectum, d. 1(51 1907 Berlin operator. .A.dnexal mass. Gauze strip. Later extracted from the bladder by W. Stuckel. d. ? 162 1907 L. Meyer. Cesarean section. Mull napkin. Found at autopsy. Death on the Jourth day of peritonitis. Sponges counted and "correct." d. Some months later removed by Death. 163 1908 ? ? Five-foot roll of ? gauze. secondary operation, which was witnessed by J. C. Morfit. 164 1908 7 Appendicitis. Iodoform gauze, 1 sq. yd. Found at secondary operation in Mount Sinai Hospital. Wit- nessed by M. G. Seelig. Recovery 165 1908 ? Appendicitis. Piece of sea sponge. Extracted from sinus at Mt. Sinai Hospital, in 1900, by M. G. SeeUg. Details not stated. Patient Recovery 166 1908 Schooler. ? Pad, 16 in. sq. Recovery awarded 11500 damages by a 167 1908 Hageboeck. Appendicitis. Sponge. Abscess formation and death of patient. Three trials for $50,000 damages. Death. 168 1908 Fiiidley. ? Strip of gauze, 5 ft. long. Ten days later, found at second- ary operation. Sponges counted and stated "correct," but one roll had been cut in two. Recovery 169 1908 ? Ovarian cysts (bilateral.) Two gauze pads. Removed by secondary operation, six weeks later. Followed by fecal fistula, which finally healed. Recovery 170 1908 ? Pelvic tuberculo- sis. Small sponge. One year later, secondary opera- tion for persistent sinus. Sponge found. Death from operation. Death. 171 1908 ? Gallstone opera- tion. Small sponge. Found at autopsy. Death after four days from peritonitis. Death. 172 1908 Rieck. Extrauterine pregnancy. Compress, 15x20 cm. No symptoms. Four months after operation, compress passed per Recovery rectum. Abdominal Section. Forceps and Other Articles Left. 173 1880 174 1886 175 1892 176 1896 177 1896 178 1897 179 1898 180 1898 181 182 1898 1898 183 1898 184 1898 Mariani. Olshausen. French surgeon. MacLaren. ? Morestin. Herczel. ? Nussbaum. Ovariotomy. Ovariotomy. 9 ectomy. ? Salpingitis. Drainage tube. Forceps. Forceps. Artery forceps. Forceps. Artery forceps. Clamp. Forceps. Forceps. Forceps. Forceps. Drainage-tube. Drainage tube slipped inside and was overlooked. One week later it passed per rectum, a. Ten months later passed per rec- Recovery tum, after only two weeks dis- turbance, a. Immediately after the operation, the abdomen was reopened to recover a forceps, a. Two years later, secondary opera- Recovery tion. Found forceps perforating cecum, ileum, and appendix. Ferrier stated that one of his asso- ciates had recovered a forceps left in the abdomen. Three years later, forceps were Recovery passed per rectum, after per- sistent suffering, a. One and a half years later, re- moved by secondary operation. a. Boldt stated in 1898 that he knew of five cases among colleagues, in which a foreign body was left. (Count two forceps.) a. See preceding note. a. Boldt stated that a pathologist in Death, a N. Y. hospital had found a; foreign body at autopsy in two Death, cases. (Count 1 forceps, 1 sponge.) a. Boldt mentioned two cases in' ? which abdomen was reopened I to recover article left. (Count l! forceps, 1 sponge.) n. ! Two months later, patient herself Recovery drew it out of an abdominal si- nus, after a night of dancing, n. I 940 REPORTED CASES OF A FOREIGN BODY LOST IN THE ABDOMINAL CAVITY. Abdominal Section. Fobceps and Other Articles Left. No. 185 1898 186 1898 187 1899 Operator* Character of Operation. Article Lost. When and How Removed. Bode. American sur- geon. Lassallette. 188:1900 H. A. Kelly. 189 1900 G. Braun. 190 1900 Sepp. 191 1900!Cushing. 192 1 1900 Nussbaum. ! ! 193 i 1900 ? 194 1900 ? 195 1900 Spencer Well 196 1900 Spencer Well 197 1900 Terrier. 198 1900 Terillon. 199 1900 Winkle. 200 1900 ? 201 1900 Kosinski. 202 1900 Kosinski. 20.3 1900 ? 20-1 1901 M. D. Mann. Schnachner. 7 7 Nussbaum. Prochownick. 7 Large Obroid. Hysterectomy. OvArian cyst. Ovariotomy. ? ? ? Ovariotomy. Ovariotomy. Inoperable tu- mor. Uterine fibroid. Strangulated hernia. Myomectomy. Ovarian cyst. Ovariotomy. Drainage-tube. 'Diamond ring. Forceps. Forceps. Bulldog forceps. Xelaton catheter. Seal ring. .Artery forceps. Piece of glass irrigator. Forceps. .\rtery clamp. Artery clamp. Forceps. Forceps. Forceps. Richelot clamp. .\rtery forceps. 'Two artery forceps. Artery forceps. Hemostat. Forceps. i ; Forceps. Forceps. Seis.sors. Forceps. Pean forceps. Forceps Forceps. .\rtery forceps Tube slipped into wound and was forgotten. After a few days, wound was reopened and tube found, a. Remained six months in the ab- 1 domen. Other details not given. Found at autopsy. Criminal trial. Operator sent to prison. (See Legal Complications.) c. Found in drainage tract after a few days. In operation to extract it/ patient died from hemor- rhage, a. Forceps found at autopsy, a. Found in bladder \\\x\i some silk ligatures, several months later. Catheter had been used to ligate| pedicle, a. Some j-ears after the laparotomy! the ring was recovered by in- cision in vaginal vault, a. Nine months later, passed per rec- tum, a. Two weeks later lound at autopsy by Kyewski. Patient died ^ith symptoms of nephritis, a ReeVes Jackson mentions a case in which autopsy revealed a forceps left in the ca\ity. a. One month later, the clamp was found in the bladder, a. Clamp missed. Wound reopened next day and clamp found, a. Eight days later, forceps was dis- charged spontaneously from re- gion of umbilicus, a. Neugebauer states that Terillon forgot a forceps in the abdominal cavity, a. Later discharged spontaneously from an abscess, a. Details not given. Simply stated that clamp was left beliind. a. Four months later forceps ex- tracted from an abdominal ab- scess, a. Two secondary operations, in the second of which patient died of hemorrhage. Criminal trial. (See Legal Complic.) a. Found at secondary operation by another operator, who related the case to Neugebauer. a. Removed in one hour after opera- tion. No trouble resulted, h. c. Seven months later, secondary operation for ileus. Forceps found within intestine. Re- moved by incision. 6. c. Removed at autopsy, after a lap- arotomy. Witnes-sed by J. A. Wveth.' b. c. Eight and a half years later, part of forceps was extracted from an abdominal sinus. Cited by Ellison, d. Later, secondary operation. Scis- sors found. 'Cited by Senn in letter to Schachner, b. c. Six months later half of forceps extracted from sinus in scar. c. Six years later, secondary opera- tion for ileus. Forceps found. Patient died. Reported by Hedlund. (/. Seven years later, forceps felt through abdominal wall. Ex- tracted by \aginal incision by Gruzdews. d. Secondary operation later by Gruzdews, and forceps found, d. Ten anil a half years later, .second- ary ot)eration. Forceps per- forating bowel. Reported by Stewart, d. Result. 7 Death. Death. Death. Recovery Recovery ? Death. Death. Recovery ? ? ? Recovery Death. 7 Recovery Recovery Death. Recovery Recovery Recovery Recovery Recovery ? Recovery REPORTED CASES OF A FOREIGN BODY LOST IX THE ABDO.MIXAL CAVITY. 941 Abdominal Section. Sponges and Other Articles Left. No. 214 1906 215 1906 216 1906 217 1907 218 1907 219 1907 220 1907 221 1907 222 1907 Operator* Character of Operation. Article Lo.st. Dollinger. Kuestner. Paris surgeon. Sarcoma of ab- I dominal wall. Artery forceps. Forceps. -Artery forceps. Forceps. ICyst of pancreas. Forceps. Ovarian car- cinoma. Forceps. Forceps. Piece of an instru- ment . Pair of spec- tacles. When uri'! H'^ Result. Six years later, ileath from intes- tinal necrosis. Forceps found at autopsy within bowels. Re-i ported by LeGondre. d. ' Doyen did a secondary operation, and found forcep.; within in- testine. Resection, d. Four months I'.cer, secondary oper- ation by Ward for ileus. For- ceps found. I Nearly three years later (after two succe.ssful pregnancies) trouble from forceps, Operation. Death. Lawsuit, d. Six weeks later, forceps appeared at angle of scar and was ex- tracted, d. Found at autopsy. Death soon after operation, of shock, a Found at autopsy. Death after si.x days, of ileus and peritonitis. d. -Details not given, except that piece was left in abdomen at operation. Criminal trial, d. Three operations — in .\merica, Germany, France. Frenchmani found spectacles in abdomen. German was sued for damages d. Death. •> ? Death. Recovery Death. Death. Death. Recovery V.\Gix.\L Operation'3. Spoxges axd Other Articles Left. 223 224 225 1886 1886 1897 Veit. Veit. Friend of H. C. Coe. Vaginal hysterec- tomy. Vaginal hysterec- tomy. Vaginal hysterec- tomy. Rubber drain. Rubber drain. Gauze sponge. 226 1898 Eriach. Vag. operation for fibroid. lodoform-gauze pack. 227 228 1898 1898 Boldt. Rydygier. Vag. drainage after abdom. hysterectomy. Vaginal hysterec- tomy Gauze drain, in- serted third day. Sponge. 229 2.30 1899 1899 Meinert . Pel\ic tuberculo- sis. .\dnexal trouble. lodoform-gauze strip. Compress. 231 1899 Schramm. Pyosalpinx. Tampon. 232 1900 Hillmann. Pyosalpinx. Gauze sponge. 233 1901 ? Pelvic inflamma- tion. Sponge. 234 2.35 236 237 1901 1901 1901 1902 Pryor. Assistant to Pryor. .\ssistant to Pryor. Vaginal opera- tion. Vag. operation. Vag. operation. Uterine tumor. Gauze. Gauze. Gauze. Tampon. 238 239 1906 1907 Brothers. MacLaren.- Vaginal hysterec- tomy. Pelvic suppura- tion. Gauze drain. lodoform-gauze strip. 240 1908 Cal.nann. Vaginal hysterec- tomy. Sponge, slipped from holder. Four months later, drain passed [Recovery per rectum^, d. j Later expelled from the bladder. {Recovery Details not given, d. > Two days later, on removing ? clamps, one was found to be a sponge-holder minus the sponge. Laparotomy, found sponge un- der liver, a. 'Nine days later, strip found in'Recovery vaginal abscess. Nine months later, another strip removed from bladder, c. Drain forgotten. Two months Recovery later the gauze was passed per rectum, a. ! 'Seven weeks later, sponge was Death. discharged from vaginal sinus. Patient finally died of p.vemia. Five months later, extracted from Recovery vaginal sinus, a. One year later, extracted from a Recovery vaginal sinus. Cited by Mein-j ert. a. \ Ten weeks later, tampon came out Recovery while patient was dancing, c. Found later in bladder, accom- Recoverv panied by violent cystitis, c. Later secondary operation (ah- Recovery dominal section) and sponge found in pehis, by L. Frank. b.c. Cited by W. R. Cited by Pry- Cited by Pry- Details not given. Pr.vor. b. c. Details not given. or. b c. Details not given. or. b. c. Four months later, tampon wa.s{ Recovery extracted per vaginam. Re-! ported by Gudbrod. (/. Several months later, drain was Recovery extracted through vasinal sinus. Two months later, the patient ex- Recovery traded a twelve-inch strip of gauze from vasrina. \ Extensive palpation per vaginam, ? extending to liver and kidneys. | Not found. Remo\ed later by, laparotom.v. I a. Cited by Neugebauer, 1900. c. Cited by Neusebauer, 1904. b. ,A.dditional cases, cited by Schachner, 1901. d. Cited by Neugebauer. 1907. *Supposed to be the operator. In some cases the record is not entirely clear on this point. 942 INVASION OF THE PERITONEAL CAVITY References for all the cases cited, and also other items of importance in connection Avith this subject, are given in the original article.* In a few cases reports obtained from different sources were contradictory, making it difficult to determine positively certain details Avhere the original report was not accessible. Since making this list many other cases have been brought to my notice, but it is not necessary to include them. My object is not to make a complete list, but simply to present actual cases in such number and variety that operators will be led to pause and think on this subject. VAGINAL SECTION. Vaginal section is incision through the vaginal wall into the peritoneal cavity. If the entrance is made behind the cervix, it is known as "posterior" vaginal section. If the opening is made in front of the cervix, it is known as "anterior" vaginal section. In some cases of pelvic disease it is better to enter the peritoneal cavity from below — i. e., by vaginal section ; while in other cases it is better to enter from above — i. e,, by abdominal section. ADVANTAGES Of Vaginal Section. The advantages of Vaginal Section, in suitable cases, are as follows : 1. Less danger. There is less exposure and handling of the intestines and peritoneum. In vaginal section the manipulations are nearly all in the pelvic cavity, while in abdominal section the central portion of the great peritoneal sac is invaded; theerfore, in vaginal section there is less shock and less danger of general peritonitis. Again, if infection should develop after vaginal section, it is very likely to be "walled off" from the general peritoneal cavity and to cause simply local suppuration, whereas when infection appears after abdominal section it is very likely to take the form of an acute general peritonitis. 2. Evacuation of pus without contamination of peritoneal surfaces. This is one of the strongest points in favor of vaginal section in suitable cases. As a rule, when there is a large collection of pus that can be reached from below, it should be evacuated that way. This is particularly important if the pus be of recent origin. In such a case it is very important to prevent soiling of the peritoneal surfaces with this infectious fluid. This is accom- plished by opening from below. Again, in many eases of pelvic suppuration the pelvic cavity, containing the abscess, is entirely shut off from the general peritoneal cavity by a wall or roof of inflammatory exudate, which binds together the upper pelvic ♦Abdominal Surgery Without Detached Pads or Sponges; A Practical Method of using Gauze-strip.s so as to Eliminate the Possibility of Any Gauze Being Left in the Abdomen. By H. S. Crossen, M. D. — Ayncrican Journal of Obstetrics, vol. LIX, p. 58. VAGINAL SECTION 943 structiil'es. When operating from l)elo\v we work heneatli this roof, wliicli protects tlie general peritoneal cavity from contamination. 3. l^etter drainage. In vaginal section the opening is made at the lowest part of the pelvic cavity — the best place for drainage. 4. Quicker convalescence. There is less disturbance of the intra-a])dominal structures. Also, the wound is smaller, better protected and supported by surrounding parts, and is not so likely to be followed by hernia. 5. No visible scar. This is of some importance. A long scar marking the site of a former opening into one's interior is not particularly pleasant for the patient to contemplate. It is an ever-present reminder of the disease that Avas present and of the operation. ' It is well to avoid making such a scar in cases wliere other metliods are just as good. 6. Vaginal section combines easily with certain plastic operations, which are sometimes indicated at the same time. DISADVANTAGES. The disadvantages of vaginal section are : 1. Lack of room in the operative field. The manipulations are cramped and are carried out with less certainty of accomplishing the desired result. 2. Imperfect exploration of pelvis and lower abdomen. The pelvic struc- ■ ures are harder to reach and the lower abdominal structures (appendix, etc.) can not be satisfactorily reached at all. And of the structures reached, the determination of their condition must be usually made a^:-.ost altogether through the sense of touch, for the structures can be only imperfectly ex- posed to sight. 3. Remnants remain. Where the adhesions are extensive there is likely to be imperfect work unless the uterus is removed, and in many cases it is not advisable to remove the uterus. 4. There is not so good a chance to determine whether or not the conditions are favorable for conservative work on the ovaries or tubes, and the work itself, when indicated, can not as a rule be so satisfactorily executed. 5. Appendix affections can not be satisfactorily handled. The appendix is diseased and requires removal in a considerable proportion of patients with pelvic disease. Selection of Cases. The operative cases in which I consider the vaginal operation preferable to the abdominal are : 1. Acute infection in the pelvis that has not yet spread to the general peritoneum. This acute severe pelvic peritonitis is seen principally in cases of sepsis following labor or abortion. If general peritonitis is present, abdom- inal section is preferable. 2. A collection of pus low in the pelvis within easy reach of the fingers, 944 INVASION OF THE PERITONEAL CAVITY particularly if there is a probability that the general peritoneal cavity is well walled off above. 3. For exploration of the pelvis in certain doubtful cases when it is evident that all the information required can be determined from below. The operative cases in which I consider abdominal section preferable to vaginal section include : 1. Chronic inflammatory lesions, with or without a collection of pus. 2. Cases of adherent retrodisplacement of the uterus. 3. Cases in which conservative work on ovaries or tubes is probably re- quired. 4. Ovarian and broad ligament and uterine tumors (except certain fibroids that can be satisfactorily removed from below). 5. Extra uterine pregnancy (except where all that remains is a walled-off hematocele). 6. Cases complicated with, or probably complicated with, appendix trouble. 7. Obscure cases, requiring thorough examination of the pelvis and lower abdomen. PREPARATIONS For Vaginal Section. The preparations for vaginal section are practically the same as for ab- dominal section, except that, in the preparation of the operative iield, the ex- ternal genitals and the vagina are prepared instead of the abdomen. The patient receives an antiseptic douche one to three times daily, depend- ing upon the amount and character of the discharge. The afternoon or even- ing before the operation the external genitals and adjacent surfaces are shaved and then carefully scrubbed with green soap and warm water, using cotton-balls or a soft brush. The vagina also is cleansed with cotton-balls held in the forceps. This cleansing should be done gently, so as not to abrade the vaginal surface and thus invite infection at points in the operative field. No alcohol nor ether is used here, as it Avould cause too much irritation. After the careful cleansing with soap, the soap is cleared away with sterile water and the vagina and external genitals are cleansed with a bichloride solnlion (1-2000). After the cleansing the parts are covered with bichloride pack (cotton wrung out of 1-5000 bichloride solution). Some prefer to pack the vagina at tliis time with antiseptic gau/o, the packing to remain in place until llic ])Mli<'ii1 is anesthetized for the operation. If there is much discliarge, however, the packing liohls tlie discliarge in the vagina, where it decomposes more or less ; consefjuently, in sucli cases the packing is not advisal)le. Tn certain complicated cases and in doubtful cases tlie alidomen also should be prepared, as it may be necessary to employ abdomiiinl siH'tion in order to deal satisfactorily with the conditions found. After the patient is under the anesthetic the external genitals and vagina CONSERVATIVE SURGERY 945 are scrubbed thoronglily, first with the soap solution and later with tlie bichlo- ride solution. This cleausius" under anesthesia (Figs. 574, 575) is the most important step in the antiseptic preparation, for it can be made so much more thorough than before anesthesia Avhen there is likely to be pain and re- sistance. STEPS In Vaginal Section. The steps in the operation are essentially the same as for abdominal section, changing the field from the abdominal surface to the depths of the vagina. The steps are : 1. Anesthesia. 2. Exposure of operative field by suitable retractors. 3. Incision and entrance into the peritoneal cavity. 4. Exploration. 5. Correction of pathological condition. 6. Restoration of structures to approximately normal relations. 7. Closure of incision or drainage, as thought preferable in that particular case. 8. Dressing. CONSERVATIVE SURGERY of the Ovaries, Tubes, Uterus. By the term "conservative surgery" is meant the conserving or saving of undiseased portions of ovaries and tubes, or of portions that are somewhat affected, but not enough to threaten serious trouble should they be left. A "conservative operation, ",_ then, is an operation that saves an organ or part of an organ that would otherwise (by the regular radical operation) be wholly removed. Conservative surgery of the ovaries and tubes is of rather recent development, and in order to bring it before you in its proper relation I shall recall briefly the steps preceding it. Before the eighteenth century, operation for the removal of ovarian tumors had been suggested by a number of physicians, but it had never been put into practice. Later, the celebrated John Hunter and the equally celebrated John Bell both advocated the operation, but neither of them ventured to perform it. The first ovariotomy in the world was performed by Ephraim McDowell, a native of Virginia, practicing in Kentucky. McDowell had attended the lectures of John Bell in Edinburg in 1749 ; and was convinced of the correct- ness of his teacher's views in regard to the removal of ovarian tumors. He returned to Kentucky and practiced his profession without special incident until 1808, when he was confronted bj^ a case of ovarian tumor requiring oper- ation. After giving the matter careful consideration and making full ex- planation to the patient, he performed the operation, and the patient re- covered. From that time the practice gradually spread over the civilized 946 INVASION OF THE PERITONEAL CAVITY world, and after half a century ovariotomy became comparatively frequent. The ovaries were removed, not only for tumors, but for all sorts of ovarian diseases, from the most serious to the most trivial. In fact, it became quite common, later, to remove practically normal ovaries for various nervous dis- turbances which it was thought might be due to them (Battey's operation). After a time, however, it began to dawn upon the profession that the ovaries had another function than ovulation, and that when the ovaries were removed the patient was deprived, not only of ovulation, but also of some factor which has a marked influence on the general health. Gradually the trophic function of the ovary, explained when speaking of the physiology of the ovary, was worked out. From the facts thus far established we know that, aside from the consideration of ovulation or pregnancy, an ovary should Fig. 728. Conservative Surgery of Ovary and Tube. Excision of damaged portion of tube, showing how the end of the stump is spUt and sewed open. Excision of cyst from ovary, witli preservation of the unaffected portion of the organ. be preserved wherever possible on account of the influence it exerts over the patient's health, particularly over her nervous system. The objects for Avhich conservatism is thus practiced in pelvic surgery are three : 1. Preservation of the possibility of pregnancy. To make pregnancy possible, there must be one ovary, or a functionating piece of one ovary, and a patient tube. The patent tube may be on the same side as the ovary or on the oppo- site side. It may be a normal tube or it may be simply the stump of a tube, the remainder of the tube having been removed on account of some disease (Fig. 728). Under all these circumstances pregnancy is possible and has taken .place in a number of instances. Of course, it is not as likely to take place as in a normal individual, but still the patient has a chance of becoming pregnant. CONSERVATIVE SURGERY 947 Another point, sometimes overlooked, is that, even though no pregnancy- results from these efforts at conservatism, the simple fact that the patient may become pregnant — that pregnancy is still possible — conduces much to her peace of mind. 2. Anotlier effect sought by conservative pelvic surgery is continuation of menstruation. Even though the hope of pregnancy must be sacrificed on ac- count of disease necessitating the complete removal of both tubes, if an ovary or functionating piece of an ovary can be left in the pelvis with the uterus, menstruation continues, though pregnancy is impossible. 3. Still another effect sought by this conservative surgery is the continua- tion of the trophic influence of the ovary. When the uterus must be removed, pregnancy and menstruation are of course no longer possible. However, if an ovary or a functionating piece of an ovary can be saved, the trophic in- fluence of the ovary is preserved, provided that the retained portion of the ovary continues its function — i. e., continues to form ova and corpora lutea. This latter fact must be kept in mind. The mere leaving of a portion of the ovary does not insure a continuation of menstruation or of the trophic in- fluence. To produce the desired result, the portion of ovary left must con- tinue to functionate. If its nutrition is so interfered with that ovulation does not continue, it is just the same as though no ovarian tissue had been left. Some time ago there came to me a woman who had been operated on in a distant city. The operator had told her that she would menstruate, as part of one ovary had been left in place. Menstruation, however, ceased entirely after the operation, and when I saw the patient she was suffering from the symptoms of the artificial menopause. She was inclined to think that both ovaries had been completely removed and to blame the operator for "deceiv- ing" her. It was evidently, however, one of those cases in which the portion of ovary preserved had not survived in condition to continue its functions, and the patient's confidence in her former physician was restored by this explanation. 4. Another form of conservative work is the preservation of a part of the corpus uteri in certain fibroid cases ordinarily subjected to supravaginal hysterectomy. Instead of removing all of the uterus except the cervix, the amputation of the affected portion is made so as to preserve the lower part of the corpus. Again, the uterus may be split in the median line, the tumor and affected portion removed and the remaining lateral portions, with as much endometrium as possible, preserved and sutured together. In this way the preservation of menstruation, which is an important matter in young women, may be attained in certain cases. Conservative pelvic surgery in its various forms is still in the developmental stage. As more and more of this conservative work is done and remote re- sults recorded, we shall be able to determine more accurately its limitations, and to say in just what conditions it is advisable and in what conditions not advisable. 948 CHAPTER XVI. AFTER-TREATMENT IN OPERATIVE CASES. AFTER=TREATMENT IN ABDOMINAL SECTION. The details of the care of a patient after abdominal section may be divided into (A) the regular after-treatment and (B) the care in special conditions. (A.) REGULAR AFTER-TREATMENT. First Day. During the operation the bed which the patient is to occupy should be warmed with hot-water bottles placed under the blankets. When the patient is placed in bed the hot water bottles are distributed about her, to maintain the heat and diminish shock. Care should be taken that there is no leakage from any bottle, and that a thick blanket is everywhere between the hot bottles and the patient. Much discomfort and even serious injury may follow a burn from a hot-water bottle, caused by the bursting of a bot- tle or leakage from a bottle, or a too thin protective covering between the bot- tle and the patient. In several instances legal complications have resulted, involving the nurse or the hospital, or the physician. The patient's head should be low (no pillow under it) until ^he has re- covered from the anesthetic. Keep the patient quiet and let her sleep as long as she will from the anesthesia. If the patient vomits, she should be turned well over on the side to cause the vomited material to run out of the throat, that there may be no chance of its getting into the larynx and choking her. Death may occur from this cause. To diminish the thirst, swab the "interior of the mouth frequently (when the patient is awake) with cold water, either plain or acidulated with a few drops of vinegar or lemon juice. The orders for the first day are usually about as follows: If in much pain, give codeine phosphate Va gr. to % gr. hypod., and repeat after two hours as necessary to give rest. If vomiting, turn well on one side. May have water as soon as she wishes it— hot or cold, as best retained, half an ounce every fifteen minutes when desired, unless vomiting persistently. Catheterize only if ' necessary. When bladder fills, employ usual expedients to assist urination (propping up in bed, warm water to genitals, pressure on bladder, etc.). It is not necessary ordinarily for the patient to be kept strictly on her back. After a few hours, if very tired of the one position, she may be propped partly to one side or the other occasionally. But she must not be allowed to develop that restlessness that insists on constantly changing from one side REGULAR AFTER-TREATMENT 949 to the other in an endeavor to tind a comfortable position. No position is very comfortable under the circumstances and the too frequent changing in- creases the discomfort. The patient should be quieted as much as possible without medicine, in or- der that the administration of sedatives may be avoided or kept within small amount. The nurse can do much, by arranging the patient comfortably in bed and directing her frequently to keep the eyes closed and to nap as much as possible. If there is such severe pain that the codeine does not give rest, morphia, in 1-6 gr. doses, may be given, but that is rarely necessary. If preferred, the sedative may be given by suppositories, but its effect is not so prompt and cannot be so accurately graduated. As a rule I prefer to let the patient have Avater in small doses as soon as she wishes it. It diminishes the thirst and helps to supply the system Avith needed fluid. Occasional vomiting does no harm ; rather it is beneficial in that it helps to clear out the ether-saturated mucus, the retention of which increases stomach irritation and disturbance. If there is persistent vomiting, and especially if there is persistent epigastric pain, a stomach tube should be in- troduced and the stomach washed out with a quart of normal saline solution. This stomach w^ashing (lavage) has come to be recognized as a most important measure in post-operative treatment. It is the only effective treatment for the serious complication of acute dilatation of the stomach (page 961), and in any case of persistent stomach irritation it adds much to the patient's comfort by clearing out the irritating material. If the patient can not take water by mouth, the thirst may be diminished by saline solution per rectum by the drop method (proctoclysis). If the pa- tient is in shock, start the. proctoclysis and employ the other measures for that condition (page 959). Second Day. During the second day the orders previously given are con- tinued unless there is some special reason for modifying them. The patient may take water more freely, and the liquid nourishment is now begun and gradually increased as the stomach wall bear it. For this purpose peptonized milk may be used, or milk and lime-water (half and half), or albumen water or beef tea — one or two ounces about every two hours, hot or cold as best retained. If the patient has to be catheterized, it is well to give some reliable urinary antiseptic to diminish the danger of cystitis. If gas in the intestines is troublesome, a rectal tube may be introduced. If the operation was an emergency one, where there was no opportunity for preliminary preparation of the intestinal tract, it may be advisable to secure a bowel-movement within the second twenty-four hours, in which ease the calomel is now bc^- gun. Ordinarily, however, that is preferably postponed until the tliird day. Third Day. At the beginning of the third day start the patient on the purgative regimen, indicated below, that a bowel movement may be secured some time during this tAventy-four hours. If the quantity of urine is good, the frequency and duration of the proctoclysis (if it is being used) may be reduced. 950 AFTER-TREATMENT IN ABDOMINAL SECTION The orders for the third day are usually about as follows : Calomel % gr. every half hour till eight doses are taken. Four hours after last dose of calomel give a high enema of magnesium sulphate (1 oz.), glycerine (2 oz.) and water (4 oz.). This is to be retained twenty minutes if possible. If there is not a satisfactory bowel movement from this enema, give the patient a teaspoonful of Rochelle salt every two hours till three doses are taken, and four hours after the last dose repeat the magnesium sulphate enema. Continue the codeine if necessary to give rest. Urotropin 5 gr. in two ounces of water every eight hours. Fourth Day. Ordinarily by this time one or two good bowel movements have been secured, and the patient has become fairly comfortable. If the kidneys are secreting well, the proctoclysis may be stopped. All medicines may now be given by mouth. The patient may be propped up as necessary, to aid in urination if she is not already urinating. Some semi-solid and solid arti- cles of diet (custards, breakfast foods, toast, crackers, bread, etc.) may be allowed. As a rule, no sedative is now necessary, except an occasional dose of sodium bromide when the patient is particularly restless at night. It is well to start the patient on some good iron tonic, for these patients are usually anemic. Tincture of the chloride of iron, with care in giving, is ex- cellent. If preferred, some one of the numerous organic iron preparations may be used. If adhesive strips have been put on at the first dressing, re- move them now, so that the skin will be in good condition for the other strips to be put on when the sutures are removed. The orders given at this time may serve as standing orders, to be continued as long as the patient is in the hospital, except when modified for some special indications. They are about as follows : Strychnia sulphate, 1-40 gr. in a capsule, three times daily, after meals. Tincture ferri chloridi, 10 drops in a capsule, three times daily, after meals. Light diet, with extras. Push the nourishment. Give an abundance of water and of liquid nourishment. Articles from the regular diet may be added as desired. Urotropin, 5 gr. in half a glass of water, twice daily. Laxative pill (aloin, bella- donna, strychnia and cascara) one each night, unless bowel movements are too frequent. Give an enema when no bowel movement during day. Subsequent Orders. It is well to continue the urinary antiseptic for a week after the urine is passed spontaneously. The diet is gradually in- creased until the patient is taking regular diet with extras. She should con- tinue to take liquid nourishment between meals. If during convalescence the patient does not take and digest sufficient food, the digestive powers may be increased by massage, salt rubs, passive movements and resisted movements, judiciously administered by a com- petent nurse. The careful carrying out of the regular nursing given bed patients (including the daily morning bath and evening alcohol rub) is also an important factor in causing the patient to be comfortable and to rest well REMOVING THE SUTURES 951 at night, and to digest her food promptly. If there is any decided digestive disturbance, some remedy for that should of course be given. Removing the Sutures. Unless there is some indication of irritation in the wound, the dressing is not to be disturbed for ten days . Then it is taken off and the sutures removed. The Avound is now healed. The vicinity of the wound is dusted freely with boric acid powder, a smooth piece of gauze (sev- eral thicknesses) is laid over the scar (Fig. 718), and the abdomen is strapped with strij)s of two-inch adhesive plaster (Fig. 729) in such a way as to take the strain from tlie newly healed wound. Four to six strips are put on (Fig. Fig. 729. Strapping the Abdomen after removing the sutures. 730), so as to give firm support. Then a piece of cotton is placed over all and the binder reapplied. The adhesive strips are usually left undisturbed for about a week. If it is desired to look at the wound area, because of irritation along the suture tracts or for other reason, the adhesive plaster is cut along the edges of the gauze (Fig. 730) and the gauze removed so that the scar and vicinity are exposed (Fig. 731). After the required treatment, gauze is again applied and then new plaster put on, the ends of the new plaster adhering to the old plaster at each side. This permits inspection of the wound area as often 952 AFTER-TREATMENT IN ABDOMINAL SECTION as desired Avithout the discomfort of repeated removal of plaster from the skin. Ordinarily, however, the adhesive strips need not be disturbed for a week. In the meantime a strong, light-weight abdominal supporter is fitted to the patient. It is well to leave the adhesive strips on until the patient reaches home, as thev serve as an additional protection during the extra exertion of the trip. After the patient reaches home and the abdominal supporter has become comfortably adjusted, the adhesive strips are taken off. The supporter is to be worn for about three months, but only when the patient is up and about. It may be taken off at night. Some authorities recommend that no abdominal supporter or binder be worn. But while most patients Fig. 730. Cutting the Plaster, so as to inspect the wound and change the gauze without remo\ing the plaster from tlie skin. get along very well without it, I feel that it is a precaution which it is well to employ. It is of decided benefit in some cases (where the abdominal wall is lax and protuberant) ; it adds to the patient's comfort in most cases, it reminds the patient of- the necessity of avoiding over-exertion in all cases, and it does no harm in any case if waist constriction be avoided. Sitting" Up, Walking". T'nless there is some special reason for hurrying the patient to t]i(_' sitting posture, she should be allowed to remain quiet and in the recumbent posture for the first few days. After the bowels liave moved well, I encourage the patient to move about in the bed and to be propped up as much as she likes — more and more each day — so that by the SITTING UP— WALKING 953 end of the first week she is ready to sit out of bed and begin walking. The advantages of this early moving about in the bed and early getting up are better circulation (less "bed-weakness"), and consequently better repair of wounds, better digestion and quicker restoration to normal condition. It is not advisable, however, to get the patient up too early, while nature is still fully occupied with the acute repair work of the first few days. The feeling of the patient is, as a rule, the best guide as to w^hen to begin activity. I am convinced that the plan just described is decidedly preferal)le to the "hurry up" method of getting the patient out of bed in one or two days, which was recently so popular with some. In cases where I think the patient will be benefited by further rest, I do not hesitate to keep her in bed ten Fig. 731. Method of Exposing the Wound as often as necessary for change of dressing, without causing the patient the discomfort of repeated removal of plaster from the skin. The new plaster is put over the old. days or two weeks, or even longer. In many instances the patient is greatly debilitated and literally "worn out" by chronic sepsis or by months of suf- fering and ill-health, or by heroic work for her children in spite of failing strength. In all these cases the enforced rest in bed may be an important aid in restoring the patient's health. After the patient has returned to her home, the tonic medicines and regimen should be kept up for three to six months, as necessary, to put the patient in first-class general health. 954 AFTER-TREATMENT IN ABDOMINAL SECTION (B.) SPECIAL CONDITIONS. 1. Drainage Cases. When a glass tube is left extending into the pelvis for drainage, a large piece of sterile sheet-rubber is usually slipped over the end of the tube (Fig. 732), to keep the fluid that comes out of the tube Fig. 732. Dressing the Drainage Tube. The piece of sheet -rubber punctured and slipped over the end of the tube. Fig. 733. Dressing the Drainage Tube. The gauze wick and applicator for emptying the tube. After the tube is emptied, a gauze wick is left in it to assist drainage. Fig. 7?A. Dressing the Drainage Tube. Gauze pieces arranged about the end of the tube, to absorb the discharge. Fig. 735. Dressing the Drainage Tube. The sheet -rubber folded over, to inclose the gauze about the end of the tube and thus protect the general dressing. from soiling the gauze on the abdominal wound. A small wick of twisted gauze (Fig. 733) is then passed to the bottom of the wound to aid in the drainage. This twisted wick should be small enough to leave plenty of room around it inside the tube to permit the discharge to come out. Some pieces CARE OF DRAINAGE CASES 955 of gauze are now placed over the end of the tube (Fig. 734) and the piece of sheet-rubber is folded over the gauze from all sides (Fig. 735). The whole is then covered with a large piece of sterile cotton and the binder applied, taking care to avoid pressing on the tube. This is the technique ordinarily emploj^ed in the dressing at the time of the operation. The frequency with which the drainage tube must be dressed varies with the amount of drainage fluid. In chronic cases, where the pelvis is left fairly dry, the amount of fluid is usually small. It is well to dress the tube within three to six hours, or before if there is a probability of much oozing or secre- tion. The frequency of the subsequent dressing is regulated by the amount Fig. 736. Dressing the Drainage Tube. Articles required — applicator, scissors and pair of rubber gloves. of fluid found. The idea is to change the dressing before all the gauze con- fined in the rubber-dam becomes filled with absorbed fluid. Usually every eight to twelve hours is sufficient for the first two days and after that once daily. In cleansing and dressing the tube the strictest asepsis must be observed. The instruments needed are simply a long probe or applicator, for pushing the gauze wick to the bottom of the tube, and a scissors for cutting the gauze. These instruments should be boiled, and in addition to the ordinary disin- fection of the hands it is well to wear sterilized rubber gloves (Fig. 736). After the preparation of the instruments and of the physician's hands, the binder and outer part of the dressing is removed by the nurse, thus expos- 956 AFTER-TREATMENT IN ABDOMINAL SECTION ing the sterile sheet-rubber. The physician then unfolds the sheet-rubber and removes the gauze therein and also the saturated gauze wick in the tube. Another gauze wick is then twisted, taking care to remove all loose ravel- ings. The end of this sterile wick is then pushed to the bottom of the tube and left there for a minute to absorb the discharge. It is then removed and a Fig. 737. Syringe and part of a catheter, for removing large amount of fluid from drainage tube. fresh one introduced. This process is repeated until all the fluid in the tube is removed. A fresh wick is then introduced and gauze is placed about the end of the tube, and the sheet-rubber folded over as before. The inner sur- face of the rubber-sheeting should l)e cleansed with some reliable antiseptic solution (e. g., ])ichloride, 1-2000) and the interior of the tube may be cleansed with a gauze-wick wrung out of the same solution. Also, the 'tube should be raised slightly and rotated once daily, iu order to prevent in- CARE OF DRAINAGE CASES 957 jurious pressure on tlie rectum (which laiglit cause perforating ulceration) and to prevent stopping-up of the drainage holes by omentum or bowel, or exudate. The tube is removed "wheu the collection of tluid in the pelvis ceases — that is, in two to five days. In suppurative cases the secretion of course keeps up indeiinitely. In such a case the tube is left in until all acute threatening symptoms have disappeared and until a good wall has formed about the tube tract, shutting it off from the general peritoneal cavity. It may as a rule be removed in four to six days, and a small ru])V)er tul)e or piece of gauze in- Fig. 738. Elevation of the Upper Part of the Body, to aid Drainage toward the pel\is. This simple eleva- tion of the head of the bed is employed immediately after operation, and in other cases where the patient is too weak to be placed in the "half-sitting" or regular Fowler posture. The head of the bed is raised about twenty-four inches. serted into the tract to keep the outer end open until it closes from tlie l)ot- tom. The treatment of such a tract is to keep it clean by cleansing (daily or less frequently, as needed) with hydrogen peroxide, keeping the outer end open as mentioned, and protecting it from secondary infection by an antiseptic dressing. It is well to keep some antiseptic drying powder (e. g., boric acid) dusted freely on the wound about the drainage tube. In acute cases, where there is virulent infection and free secretion, the tube must be cleansed very frequently — as often as every t^vo or three hours at first. In these cases, where the fluid is abundant, the removal of it from the 958 ABDOMINAL SECTION tube is preferably aeeomplislied -vvitli a syringe. A very convenient arrange- ment for this purpose is the ordinary hard-rubber syringe with a soft-rubber catheter attached. It is more convenient to handle when only two-thirds of a catheter is used, as shown in Fig. 737. In the very acute cases, where drainage in various directions is required and it is necessary to leave the wound partly open, the whole dressing soon becomes soiled with the dis- charge and consequently must be changed frequently. In fact, in some of these cases it is advisable to employ warm moist dressings (wrung out of normal saline solution or boric acid solution, 3 per cent) all over the abdo- men and wound, the moist dressing to be changed every few hours, or as often as it absorbs a considerable amount of the septic discharge. Fig. 739. Elevation of the Upper Part of the Body, to aid Drainage toward the pelvis (Fowler posture). When rubber tubing is used for drainage, it may be used alone or with gauze around the tube or as the "split -tube with gauze." In the latter a piece of large rubber tubing . is split longitudinally and a small wick of twisted gauze laid inside, but the gauze wick must be small enough to per- mit the free escape of fluid through the tube. Rubber-tube drains are left in until the necessity for drainage has disappeared and the drainage tract is largely closed from the bottom. Where the rubber tube is of large size, it is removed after a few days and a smaller size introduced. When gauze is used for drainage, alone or with rubber tubing, it is re- moved usually in two to four days. TREATMENT OF SHOCK 959 In all drainage cases, except where the patient is in severe shock, the upper part of the body should be raised higher than the pelvis, so as to cause all septic fluid in the peritoneal cavity to gravitate to the pelvis, where it is removed through the drainage tube. Immediately after the operation raise the head of the bed about two feet, as shown in Fig. 738. After the patient has recovered from the anesthetic she may be propped up in the half- sitting posture (Fowler posture), as shown in Fig. 739. In acute septic cases normal saline solution should be used freely per rec- tum, as described on page 722. 2. Uterine Replacement Cases. The principal special points in the care of the patient after any operation for fastening the uterus and adnexa for- Fig. 740. Elevation of the Lower Part of the Body, for the treatment of Shock. The foot of the bed is raised about twenty-four inches. ward, is to see that the bladder is not allowed to fill sufficiently to force the uterus backward again in the first few days following operation. If the patient can not urinate, she should be catheterized often enough to prevent injurious distention. 3. Severe Shock. When the patient is in severe shock, the head should be lowered by the elevation of the foot of the bed about two feet, as shoAvn in Fig. 740, except in those eases where there is danger of spreading pus from the pehds to the upper part of the uncontaminated peritoneal cavity. Give the patient digitalin 1-50 gr. every two hours and strychnia sul- 950 AFTER-TREATMENT IN ABDOMINAL SECTION pliate 1-40 gr. every four hours until reaction comes on. Still more im- portant is the free use of normal saline solution by proctoclysis. If the shock is extreme, saline solution may be given also subcutaneously, one or two pints under the skin of the chest on one or both sides.' If a very large cpian- tity of blood has been lost and the pulse is thready and almost gone, a pint to a pint and a half of saline solution may be given intravenously. The use of oxygen is an additional measure of value in eases where respiration is defective. The hot water bottles must be renewed as necessary to keep the patient warm, and the proctoclysis and other treatment should be given in such a way as to avoid chilling of the surface. 4. Internal Hemorrhage. A serious internal hemorrhage is indicated by rapid weakening of the pulse, an increase of pain in the abdomen and sub- normal temperature. It is rare after the first twelve hoiu's, and usually comes within the first six hours. If there is a drain through the abdominal incision or into the vagina, there will be a free flow of bloody serum, or, if it is a tube drain, of blood itself. The treatment of a slight hemorrhage is (a) to elevate the pelvis by rais- ing the foot of the bed (Fig. 7-10), (b) to put an ice-bag on the pelvis out- side the dressing, (c) to keep the patient perfectly cpiiet on her back, and (d) to give a sedative (codeine) if necessary to secure rest. Discontinue the normal saline enemata, as the pelvic disturbance occasioned thereby may increase the hemorrhage or start it after it had once ceased. Do not give any stimulants or employ any measure that will increase the blood pressure. The hope is that, as the blood-pressure is low, the bleeding will cease for a few hours — long enough to permit effective clotting to take place in the oozing area. In twenty-four hours such clots become so firm that a renewal of the bleeding is not probable. "When the hemorrhage is severe, the abdomen should be promptly re- opened (if the patient is seen in time) and the bleeding vessel caught. 5. Persistent Vomiting. To make the nausea and vomiting as slight as possible, the patient's head should be low (no pillow) for several hours after anesthesia. For the first day the patient should be kept perfectly quiet, with the eyes closed most of the time, so as to nap as much as possible. The nausea is increased by talking or by even looking about. If a visitor is allowed, it should be for only a few minutes and there should be but little talking. When water is begun, it is preferable usually to give hot water, in tablespoonful doses and frequently, though some patients retain cold water very well from the first. When the nausea and vomiting is such that the patient can not rest, give codeine phosphate, i/o to % gr. hypodermically, and repeat after three hours, as necessary to give rest. The most effective measure for overcoming vomiting, persistent nausea, and stomach distress generally is washing out of tlie stomach with normal saline solution, as described on page 720. After the bowels are well opened the vomiting usually ceases unless there is some serious complication, such TREATMENT OF INTESTINAL PARALYSIS 961 as beginning peritonitis or intestinal obstruction, both of which are men- tioned later. 6. Acute Dilatation of Stomach. This is a serious complication that may- develop any time after operation, but especially within the first sixty hours. The patient complains of persistent pain in the epigastric region, and this region becomes more or less distended. The pulse becomes rapid and w^eak without apparent cause. There is usually nausea and vomiting, but the most constant and characteristic signs are the persistent epigastric pain and the failing pulse. The anatomical change is over-distention of the stomach with gas, due to different causes in different cases. In the majority of cases it is probably due to some displacement of the stomach, with kinking and o])struc- tion at the pylorus. As the gas can not escape, its continued accumulation becomes a serious matter, and in several instances death has resulted from over-distention of the stomach caused thereby. The treatment for this condition is prompt introduction of the stomach tube, to permit the gas to escape, and irrigation of the stomacli with normal saline solution to remove all decomposing material and prevent reaccumula- tion of the gas. This complication should be watched for and recognized, and the stomach tube used before it reaches a serious stage. If the trouble re- curs, several stomach-washings may be required. It is well also to vary the patient's position, so as to overcome displacement of the stomach aiid drag- ging on its supports. In some cases it has been thought that the Fowler posture was a factor in the development of this condition. 7. Kidney Insufficiency. This is easier prevented than treated after it once develops. The preventive measure is to make sure that the kidneys are doing their work well before operation. The treatment for kidne.y insuffi- ciency after operation consists in the free administration of normal saline solution by proctoclysis, in elimination by means of free bowel-movements, and sweat packs and such other measures as are used for the regular treat- ment of uremia. In urgent cases the normal saline solution may be given subcutaneously or even intravenously. 8. Constipation and Intestinal Paralysis. When the purgative measures given under the regular after-treatment (page 950) fail to cause bowel movement, the loss of function may be due simply to temporary paralysis of the bowel or to intestinal obstruction, or to beginning peritonitis. Unless there are decided evidences of intestinal obstruction or peritonitis, it is to be assumed that the trouble is temporary intestinal paralysis, and treatment for the same is begun. The treatment consists in giving strychnia, in giv- ing repeated doses of purgatives, such as compound cathartic pills or mag- nesium sulphate by mouth, and in administering enemata that tend to stimu- late the bowels to action. A tablespoonful of turpentine may be added to the magnesium-sulphate enema already mentioned. Or the patient may be given a high enema of half an ounce each of ox-gall and turpentine in a pint of water, to be retained as long as possible. Eserin salicylate has seemed to assist in stimulating intestinal peristalsis in some cases — 1-80 gr. hypod., and repeat after four hours if no effect. 962 AFTER-TREATMENT IN ABDOMINAL SECTION 9. Intestinal Obstruction. This is indicated by the combination of per- sistent vomiting, absence of bowel movement in spite of the use of the purga- tive measures already mentioned, severe cramp-like pains in the abdomen re- curring every few minutes, a serious rise in the pulse rate, and the absence of fever, such as would be caused by peritonitis of sufficient severity to give rise to the other symptoms. Later there is fecal vomiting. Such a combina- tion of symptoms calls for immediate reopening of the abdomen, and relief of the obstruction. Unless this is carried out promptly, there will develop a peritonitis which, in combination with the obstructive trouble, is very likely to prove fatal in spite of later operation. 10. Peritonitis. This is indicated by the combination of symptoms consist- ing of fever (beginning or increasing after the second day), persistent vomit- ing (extending into the fourth and fifth days), serious increase in the pulse rate, steady pain in the abdomen (without the cramp-like pains of intestinal obstruction), and an increasing tenderness in the lower abdomen, which gradually spreads to the upper abdomen. The intestinal tract is usually slug- gish (partial intestinal paralysis), but there is not the complete absence of bowel movement, such as is seen in intestinal obstruction. A rise of temperature within the first twenty-four hours after operation is not of serious significance. Not infrequently in extensive operations, involv- ing large peritoneal or connective-tissue surfaces, there is a sharp rise of tem- perature (up to 102° or 103°), coming on within twenty-four hours and sub- siding the second or third day without further disturbance. In the absence of a more definite explanation, this "aseptic rise of temperature" is said to be due to the "absorption of blood-ferment." But when there is a rising temperature after the second day, it is indicative of some unusual dis- turbance, and when the combination of symptoms above mentioned is present the diagnosis of peritonitis is clear. The treatment of peritonitis following operation is the same as for peri- tonitis without operation. This has already been described under Acute Pel- vic Inflammation (page 717). 11. Local Suppuration. This is indicated by fever, coming on after the sixth day, and a moderate increase in the pulse rate and localized pain. If the suppuration is deep in the pelvis, the patient complains of deep-seated pain and usually of backache or of pain extending down one thigh. If the inflammatory focus is situated in the back part of the pelvis, bowel movement ()r the giving or an enema causes pain. Vaginal examination shows a boggy mass, which is very tender. The treatment for such local inflammation deep in the pelvis is to secure good bowel movement, to make the patient com- fortable, to i::crease tissue resistance, and to await resolution or al)scess fonuation. Yvhou fluctuation can be detected by vaginal examination, open and dr;iin tlio al)scess per vaginnm. Exceptionally, it may be advisal)lo to open into fi solid mass Cinflanniintory focns witlioi;! fluctuation) or to open into the ciil-de-sae for general pelvic draiiiagc. When the suppuration is in the abdominal incision, there is increasing TREATMENT OF PHLEBITIS 963 pain along the course of the incision. This calls for removal of the dressing and inspection of the wound. Inflaniniation there is indicated by the cardinal signs (pain, heat, redness and swelling), localized at some part of the incis- ion, or extending all along it. If the disturbance is slight, a hot moist anti- septic dressing, changed every twenty-four hours, may ])e sufficient. If there is a pronounced cellulitis at some point, that portion of the wound should be opened superficially and a gauze or tube drain put in and the hot moist dres.sing applied. If drainage of the infected area can be satisfactorily ef- fected without removing the tension sutures, that is preferable. In some in- stances the inflammation is confined to the subcutaneous tissue and no dis- turbance of the deep buried sutures is necessary. The important point, how- ever, is to secure free drainage of the infected area and prevent serious ab- sorption. If the whole wound is infected, it must all be drained. In such a case the whole Avound (except the peritoneum) is likely to open. As soon as serious absorption has ceased, the sides of the wound are brought together by strapping with adhesive strips, the wound being exposed and cleansed every day or two (depending on the amount of discharge) with hydrogen peroxide. Later, if thought preferable, the granulating surfaces may be freshened by curetting and then brought together by sutures, with the idea of securing secondary union. 12. Phlebitis. This seldom occurs now% since patients are gotten out of bed early. When it does appear, it is usually in about the third week, when the patient has passed the time for the ordinary operative complications and is congratulating herself that she will soon be entirely well. She complains of pain in the groin and upper part of the thigh on one side, and the temperature gradually rises to 102° or 103°. There may or may not be swelling of the foot and leg, but there is always tenderness on pressure over the femoral vessels just below Poupart's ligament. This ten- derness may, in some cases, be traced a considerable distance down the thigh, and also up along the iliac vessels. The treatment of phlebitis is immediate bandaging of the leg and thigh (from toes up), elevation of the leg in a comfortable position on pillows, and the maintenance of this position and of the dorsal posture for several days. In mild cases the measures mentioned usually relieve tlie sponlaneous pain, but in the severe cases sedatives may be necessary for a time to give rest. It Avill be necessary to maintain this position most of the time for a week or more, depending on the severity of the trouble and the rapidity of the im- provement. When the above treatment is carried out promptly and persist- ently, serious trouble seldom results. If the patient is permitted to use tlie leg, the suffering is increased and the disability prolonged, and there is dan- ger of serious embolism by particles detached from the thrombosed area in the vein and carried to the brain or heart or lungs. On account of the danger of detaching emboli, no massage or rubbing of the involved area is. permissi- ble until sometime after all acute symptoms have subsided. Getting patients out of bed early (at the end of a week) has almost elimi- 964 AFTER-TREATMENT IN ABDOMINAL SECTION nated this complieation. I have not had a case now for two years, while under the old regimen of keeping the patients in bed three weeks it was rather frequent, occurring in about two per cent, of the abdominal operative cases. 13. Pain During Convalescence. Aside from the conditions already men- tioned and the natural soreness of the recently disturbed structures, pain during convalescence is usually due to gastric or intestinal indigestion, with gas formation and resulting painful intestinal peristalsis. The treatment for this condition is to remove the irritating material from the intestinal tract by an enema and laxatives, and, if necessary, administer some remedy for the gastric or intestinal indigestion. Of course, operated patients are subject to neuralgic and neurasthenic pains the same as other individuals, and these are likely to be more pronounced at the menstrual time. An abdominal operation often causes the menstrual flow to appear ahead of time. Not infrequently there is also a slight bloody flow from the uterus, without any relation to menstruation, within a few days after the operation. Such need occasion no alarm, as it disappears in a short time. 14. Subsequent Disturbances. As the patient begins to walk about, there may be more or less soreness in the pelvis for some time, until the hyperemia of the healing tissues has disappeared and the new connective tissue is firm. In drainage cases a sinus sometimes persists. The persistence of such a sinus may be due to sloughing tissue or to a ligature. In the case of a cat- gut ligature or sloughing tissue, the troul-lesome material will usually dis- integrate and come away in the course of some Aveeks. The sinus-track, in the meantime, should be kept clean by freciuent cleansing with hydrogen peroxide — every day or two, depending on the amount of discharge. The patient can care for the fistula at home after being shown how to apply the peroxide and the dressing. If a silk ligature is at the bottom of the sinus, it may come out itself after some weeks or months, or it may have to be taken out. Sometimes it may be caught up by "fishing" with a silkworm-gut loop or other contrivance. Otherwise, it must be removed by operation. A rare cause of persistent fistula is a sponge or forceps left in the cavity. Occasionally a fistula connected with the bowel follows abdominal sec- tion. Ordinarily such a fistula should be treated by a simple cleansing for some time, for in a considerable portion of the cases it will heal spontaneously Avithin a few weeks. If it persists indetinitely, it requires operative treatment. Such an operation should not be undertalani lightly, for it may prove very diffi- cult and dangerous. A hernia in the scar indicates defective healing of the Avound. This is usually due to the necessity for drainage, which prevents perfect approximation of the sides of the wound. If the hernia is small, it may in some cases be held l)ack satisfactorily by an abdominal supporter. If large, or if persistently troublesome even though small, it requires operative treatment. AFTER-TREATMENT IN VAGINAL OPERATIONS 965 AFTER=TREATMENT IN VAGINAL OPERATIONS. The general after-treatment of vaginal operations is practically the same as for abdominal operations. Gauze extending from the vagina into the peritoneal cavity is removed usually in three or four days. After removing gauze, if there is much of a cavity, it is advisable to replace the gauze in the vaginal incision, to keep it open until the cavity is nearly closed by granulation. In the case of an a1)- scess cavity, a rubber tube, arranged as previously explained (Fig. 687), is / ^ m Fig. 741. Cleansing the External Genitals. The use of the "Pitcher-douche." preferable. After the gauze is left out of the vagina, a cleansing douche of normal saline solution or an antiseptic solution is given once or twice daily, depending on the amount of discharge. After a vaginal or perineal operation the vulva and adjacent surfaces must be kept covered with an antiseptic dressing, the same as any other wound region. Here, however, on account of the necessity of evacuation of the bowel and bladder, the problem of wound protection is more complicated. The dressing must be changed several times daily and with each change of dressing there is danger of contamination. 966 AFTER-TREATMENT IN VAGINAL OPERATIONS When it is necessary to change the dressing, the nurse should disinfect her hands and then cleanse the operative field with an antiseptic solution (e. g., bichloride 1-5000). The cleansing may be conveniently accomplished by means of the ''pitcher douche" (Fig. 741). After the cleansing a fresh dressing is put on and the T-bandage again applied (Fig. 742). If the patient can pass the urine, she should ordinarily be permitted to do Fig. 742. The Vulvar Dressing Applied. This dressing should be large enough to co\er all the adjacent surfaces, including the pubic hairy region, and should be kept spread out by a wde T-bandagei so, whatever the character of the vaginal work. Catheterization is more like- ly to do harm than urination, especially as the urine remaining on the gen- itals is at once removed by the cleansing solution. To aid spontaneous urina- tion, patient may be propped up, hot packs on the vulva may be used, and also firm pressure over the bladder as the patient is trying to urinate. Hot douches also aid some, and may be used if there is no contraindication. , In many cases, however, the patient cannot urinate at first, and must be cathetorized for two or three, or more, days. Catheterization must be carried out under strict antiseptic precautions. The catheter is boiled, the nurse's CATHETERIZATION 967 Fig. 743. Catheterization. After the nurse cleanses the vestibule as here indicated, the labia must be kept spread apart until the catheter is introduced. When the labia are allowed to drop back over the meatus after cleansing, the meatus must be again cleansed with the antiseptic solution before the catheter is introduced. Fig. 744. Catheterization. After the catheter is boiled, do not touch the point with the fingers. The catheter is grasped well back from the point, as here .shown, and the point is introduced into the urethra without touching the labia or the finger.s. A glass catheter or a soft rubber catheter may be used, as preferrei. 968 AFTER-TREATMENT IN VAGINAL OPERATIONS hands are disinfected, and the vestibule and meatus of the patient are care- fully cleansed with an antiseptic solution. After the labia are once separat- ed and the vestibule cleansed, the labia must be kept separated, so that there is no recontamination of the vicinity of the meatus, until the catheter is in- troduced (Figs. 743, 744). Care should be taken to avoid touching the part of the catheter which enters the bladder. The catheter should be grasped well back from the point, as shown in Fig. 744. In order to prevent cystitis, it is well to give the patient some reliable internal urinary antiseptic while she has to be catheterized and for several days after the urine' is passed spontaneously. An additional precaution is to have the bladder irrigated with 3 per cent, boric acid solution once or twice daily while catheterization is necessary. For the After-treatment of Pelvic Abscess, see page 713. For the After-treatment of Perineorrhaphy, see page 493. For the After-treatment of Trachelorrhaphy, see page 556. For the After-treatment of Curetment, see page 582. The After-treatment of Extraperitoneal Shortening of Round Ligaments is practically the same as for Abdominal Section with the special points for Retrodisplacement cases, except that there are two wounds and they are situated laterally and do not require particular support after they are healed. 9C9 CHAPTER XVII. MEDICO-LEGAL POINTS IN GYNECOLOGY. There are various conditions connected with the genital organs concerning whicli the physician may be called to testify in court or to give a written opinion. Such testimony is, generally speaking, simply the recitation of facts in anatomy, pliysiology, pathology, symptomatology, diagnosis, treatment and prognosis, with which the physician is necessarily more or less familiar because of his daily work. But there are certain things, of little or no value in the ordinary diagnosis and treatment of diseases, which assume much importance when the case comes into court. So, when called to attend a case in -svhich there is any probability of court proceedings, the facts that are of medico- legal importance should be given considerable attention. I shall point out some of these facts in connection with certain subjects that frequently find their way into court. RAPE. Rape is defined as "the unlawful carnal knowledge of a woman without her consent," and again, more in detail, as "sexual intercourse Avitli a woman effected by violence, or with a young girl by abuse of her ignorance." Medical evidence is ordinarily required to confirm or disprove the state- ment that rape has taken place. False accusations of rape are very fre- quent. Taylor states that for one real rape tried in the courts there were, on the average, twelve pretended cases. Some of these cases of false accusa- tion are founded on a mistake, as may happen with infants, children and per- sons mentally defective. In other cases the accusations are made willfully and designedly for the purpose of extortion or revenge, or from other ulterior motive. In some instances the false accusation may be at once disproved by medical evidence, though it has happened that the medical man has been deceived and duped by designing persons. In many cases in adults the medical evidence is not decisive, and the truth or falsity of the charge must rest almost wholly on the statements of the prosecutrix herself along with the corroborating circumstances. The question for the physician to decide as far as possible, from his exam- ination, is whether or not sexual intercourse took place, or was attempted, at approximately the time indicated. Subsidiary information may be re- quired — e. g., as to whether there were evidences of violence elsewhere on tl>e body, or as to whether intercourse has ever taken place or has freciuently '970 MEDICO-LEGAL POINTS IN GYNECOLOGY taken place, or as to whether death was caused by the injuries inflicted, or as to whether disease was communicated at the time, and, if so, what is the nature and probable outcome of such disease. On all such points the physi- cian is supposed to be informed, and he is also supposed to keep such record of his cases as Avill enable him to testify with certainty, some years after- ward, concerning his findings in any particular case. For the consideration of the medical evidence of rape it is convenient to divide the case^ into three classes, the first including infants and children, the second including young unmarried women and the third including married women. There are, however, certain points that should be kept in mind in all cases. "When called to examine or treat a person on whom rape is alleged to have been committed, notice and record, as soon as you can conveniently, the fol- lowing points, for you are likely to be questioned in court concerning them. 1. The precise time at which you were summoned, the exact hour and date of the examination and the place of the examination. It is important in some cases to know whether or not the female, alleged assaulted, took the earliest opportunity to complain. Also, the exact time elapsing between the alleged assault and the examination has an important bearing on the signs found. The place of the examination at a certain time may be important as showing the truth or falsity of some statement of the defense or prosecution regarding the movements of the female shortly after the time of the alleged assault. 2. Marks of violence about the genitals. 3. Marks of violence on the body elsewhere or on the clothing of the com- plainant. 4. Presence of stains of spermatic fluid or of blood on the clothing. When the character of the stain is not clear, make a microscopic examination of the contaminating material. 5. The existence of disease probably conveyed in the alleged assault (gon- orrhoea, syphilis, chancroid). The evidences of rape will vary with the age of the patient and other cir- cumstances. It may be stated that, to establish the fact of rape, it is not necessary to prove penetration into the vagina by the male organ. It has been decided that if the evidence shows penetration of the vulva or to the vulvar cleft, that is sufficient — the legal establishment of the crime requiring only the fact of the penetration, the degree of penetration being quite immaterial. Conse- quently, the hymen is not necessarily ruptured, even in cases where entrance of the male organ into the vagina would be absolutely impossible without such rupture. "]\ledical men sometimes have fallen into error on this point, considering that, when the hymen was entire, rape could not have been com- mitted, but the statute law says nothing about the rupture of the hymen as a necessary part of the medical evidence ; it requires from the medical witness merely proof of vulvar penetration — this may occur and the hymen remain RAPE 971 intact.'"* However, laws diflfer, and in any case it would be well to look up the wording and interpretation of the law in the state or country where the alleged assault occurred. Infants and Children. In the case of infants and children there are usually decided evidences of injury about the genital organs. Of course, such injury does not necessarily exist, but Avhen it does not exist the proof of rape must rest largely on evi- dence other than medical. xVgain, where there are evidences of injury about the genitals in a child alleged to have been assaulted, it does not necessarily follow that the injuries are due to rape. The abnormal appearance may be due to some disease or to some accidental injury, or to some injury inflicted by a designing person with the object of deceiving the physician. All these things must be kept in mind. In this as in other situations, the physician's diagnosis of the conditions present and the interpretation of the meaning of those conditions must be founded on incontrovertible physical evidence that will stand attack from all sides. The evidences of rape will, of course, vary much with the time that elapses after the occurrence before the child is seen. 1. If the child is seen within a few hours, the following conditions may be present : a. More or less abrasion of the vulva and vaginal opening, with probably some bleeding or clots. If penetration into the vagina has taken place, there may be extensive injuries — tearing of the hymen, perineum, and vaginal walls into the rectum or even into the peritoneal cavity (Figs. 236. 237). b. Evidences of violence elsewhere on the body or about the clothing — scratches or bruises on the body, tears of clothing, or blood on same or disar- rangement of same. In some cases the child has been rendered insensible by a blow on the head or by some drug administered. c. Presence of semen in the vicinity of the genitaL of the child or on the clothing. The contaminating material should be submitted to microscopic examination, that the presence or absence of spermatozoa (as a positive evi- dence of semen) may be determined. d. Presence of gonorrhoeal pus on the genitals. The presence of pus about the genitals of the child does not necessarily indicate rape. The pus may have been put there, with blood and scratches, for purposes of deception. If micro- scopic examination of the pus shows gonococci, it has come, directly or indirectly, from gonorrhoeal inflammation in a male of female. Gonorrhoeal ophthalmia is a not infrequent form of gonorrhoeal inflammation, and the pus from such a condition in the mother or attendant may be responsible for the gonorrheal vulvitis in the child. 2. If the child is seen after a few days or a week or so, the following con- ditions may be found: • Taylor's Medical Jurisprudence: American edition by Clark Bell. 972 MEDICO-LEGAL POINTS IN GYNECOLOGY a. Acute inflammation, apparently due to violence. The fact that inflamma- tion is present is established by the presence of a mucopurulent discharge, yellowish in color and staining the linen. This may not be present the first day or two, but after that it is ordinarily present if there has been much injury of the vulva or vagina. The inflammation is further indicated by the redness of the parts, the tenderness and the pain on urination. The acuteness or recent onset of the inflammation is shown by the severity of the process compared with its extent, the marked painfulness of the affected areas, the presence of recent abrasions and tears about the hymen and vulva, and possibly swelling from edema. The parts may be so painful that the child strongly resists any attempt to make an examination — even the separation of the thighs. This is of no diagnostic significance, as children with inflammation from other causes, or even with no inflammation, may do the same. If this obstacle to examination is extreme, it may be necessary to anesthetize the child in order to make the examination. If extensive inflammation is present, there may be fever, and in the very extreme injuries the most serious acute symptoms may develop. Several deaths from this cause, with consequent con- victions for murder, have been recorded. The fact that the inflammation was immediately preceded by violence or mechanical injury is shown by the evidences of recent tears or abrasions, or by ecchymoses due to bruises from some cause, and also by the extent and severity of the inflammation in such a short time and without other apparent cause. Gangrene with sloughing of the external genitals and vagina and adja- cent tissues has occurred from these causes, usually with fatal effect, though some have recovered after considerable sloughing. Care should be taken to exclude similarly appearing conditions due to other causes. The very severe inflammation of the genitals called "noma" has more than once led to a mistaken supposition of rape. It is seen principally in debilitated children with severe acute diseases, such as scarlet fever, diph- theria, typhoid fever, etc. Occasionally, however, it occurs in apparently healthy children where the genitals are neglected and dirty, permitting some severe infection. It may follow marked bruising or injuries of the parts from any cause. It may follow even a comparatively slight injury in an otherwise healthy child. Taylor relates a rapidly fatal case in a child 5 years old who accidentally fell on some thorns, from which she sustained slight injuries, fol- lowed l)y a severe infection and noma and death. The condition of the parts, witli tlie evidence of mechanical injury, were such that it might easily have led to a charge of rape, had the real cause not been known. b. Gonorrlioeal inflammation in the acute state. Conorrhoeal inflammation is likely to extend into the uretlira, tliough the vagina may escape. The diag- nosis of gonorrhoeal inflammation is established by finding gonococci in the discharge. The significance of the presence of acute gonorrhoeal inflamma- tion depends on circumstances, as already explained. c. Evidences of chancroidal infection (page 421). d. There may be present some of the other conditions mentioned under the earlier examination. RAPE 973 The disturbance of the parts may be very slight, as shown in cases where other cireimistanees proved the rape. For example, an adult was convicted of rape on an infant only seven months old. According to the medical evi- dence the vulva was somewhat swollen, there was slight excoriation about Nthe lalbia minora and a small amount of blood. The hymen was not lacerated, and there Avas no evidence of penetration past it. Seminal fluid was found on the person of the child. The evidences of rape, when not severe, may very quickly disappear. Casper relates a case of a girl of 8 years upon whom rape was committed by a mau in a drunken condition. The girl was examined the next day. The labia were then reddened, and there was congestion about the vaginal entrance, which was very tender. Examination ten days later showed the genitals to be in their natural state, and there was nothing at that time to indicate that the girl had been subjected to violence. 3. An examination after some weeks or months may show no evidence of the disturbance, or may show one or more of the following conditions : a. Chronic muco-purulent discharge from the vulva or vagina. This is present in many infants and young girls from simple causes, such as want of cleanliness, scalding from frequent irritating bowel movements, seat worms, irritating urine, adherent prepuce over clitoris, skin diseases of the vulva, pediculi and various other sources of irritation about the genitals. b. Chronic gonorrhoeal discharge from the external genitals or vagina. The fact that the discharge is gonorriioeal is established by finding gonoeocci. If the beginning of this discharge can be fixed as about the time of the alleged assault, it is strong corroborative proof. Gonorrhoeal vulvitis and vaginitis occur, however, not infrequently from wholly different causes, as previously stated. c. Evidences of syphilis or chancroid. d. Laceration or destruction of hymen. The presence of the intact hymen does not preclude rape, as previously explained, neither does the absence of the hymen or apparent laceration of the hymen necessarily imply injury of the membrane by rape or otherwise, though the condition of the hymen might be strong corroborative proof in a particular case, especially if it could be established by the mother or the nurse, or a physician who had made an inspection, that there was, prior to the time of the alleged assault, a well- formed and apparently intact hymen. The hymen is very different in shape and appearance in different individuals (Fig. 209). Occasionally it is prac- tically absent in a child otherwise normal. e. Abnormal size of vagina, as though it had been at one time dilated. Permanent marked dilation is not very likely to follow a single distention by coitus or otherwise. This condition, which is found occasionally in older girls where the question arises, is due usually to repeated distention of the vagina, by coitus or otherwise, extending over a considerable period of time. In such cases the parts may soften and relax to a remarkable extent, even leading to the suspicion that child-birth may have taken place. 974 MEDICO-LEGAL POINTS IN GYNECOLOGY f. Scars from injury of the genitals. The genitals are exceptionally well protected, and are not often injured, except by some disease process or in attempts at coitus. Occasionally a child will fall astride of some object and inflict an injury. Again, injury may come from attempts of the child to intro- duce some foreign body into the vagina, though such injuries are more likely to be found in girls somewhat older. Scars about the genitals may, of course result from any severe inflammation or destructive process, and also from chronic inflammation of milder grade when it is accompanied by persistent scratching, with resulting ulceration. Older Girls and Unmarried Women. In this class the severity and certainty of the signs decrease and the difii- culties of arriving at a definite conclusion increase. The, mechanical injuries following coitus, or attempted coitus, are less marked and sooner disappear, and there remain fewer deviations from the normal. Again, in the case of older girls and adult women the medical man is likely to be subjected to two lines of questioning — (A) as to whether or not coitus or attempted coitus took place at about the time of the alleged assault, and (B) whether or not coitus has ever taken place before, and, if so, whether several times or over a considerable period. A. Evidences of Recent Coitus or attempted coitus. The evidences found will, of course, depend to a considerable extent on the period of time which intervenes between the assault and the examination. If the examination is made within a few hours after the assault, one or more of the conditions men- tioned on page 971 may be found. The mechanical injury to the genitals is likely to be less because the parts are larger, and the epidermis less delicate and less easily abraded. The evidence of injury on other parts of the body are likely to be more marked because of the greater resistance which the victim . is able to make. If the examination is made after a few days or a week, the additional points mentioned on page 972 must be investigated. As the local injuries are less than in younger females, they will subside more quickly. If the examination is made after several weeks or months, the problem for the physician resolves itself into determining whether or not sexual inter- course Jias ever taken place. The determination of the time when the coitus took place is ordinarily impossible after several weeks have elapsed. In cer- tain cases the medical testimony may be strongly corroborative of other testi- mony in establishing the time of the assault, even after several months. For example, if it should ]re establislied l)y other testimony (a) that up to the time of the assault tlie young woman was perfectly well and had never had coitus, and (b) that immediately afterward she liad a discharge and had been sick more or loss ever since, and (c) that there had been no subsequent (;oitus — th(^n the finding of a chronic pyosalpinx with chronic endometi'itis, in an examirifition some months later, Avould be strong corroborative proof that the infecting coitus took place about the time of the alleged assault. RAPE 975 Ordinarih', however, after a few weeks all the acute and sul)acute evi- dences Jiave subsided, leaving only those that, so far as any distinctive char- acteristics are concerned, might have been there some months or some years. So the question here is essentially whether or not coitus has ever taken place in the case of the individual concerned. B. Evidences of Remote Coitus. Ordinarily, it is easy to tell, by a compara- tively superficial examination, whether or not a girl or woman has probably had coitus. The diflfereuces in appearance of the external genitals and vagina when coitus has taken place (especially if it has taken place several times) are usually so marked that the physician has little difficulty in distinguish- ing them. This is the general rule. There are, however, exceptional cases which present many of the ordinary evidences of coitus when iu fact none has taken place. On the other hand, there are persons who present signs which are considered almost pathognomonic of virginity when in fact sexual intercourse has occurred, and not only sexual intercourse, but pregnancy and labor at full term. So, in exceptional cases it may be very difficult to decide certainly whether or not sexual intercourse has occurred, and in such a case it is particularly difficult to legally prove the same, for the anomalies must then be considered. The evidences of remote coitus or attempted coitus can be summed up as follows : 1. Evidences of previous child-birth at or near term. a. Destruction of the hymen, leaving only irregular tags here and there about the vaginal opening, with scar tissue between. This condition is very strong evidence of childbirth at or near term. It means that there has passed through the vaginal opening some body large enough not only to stretch and lacerate the hymen, but to stretch out the vaginal ring enormously, and to so stretch and compress and bruise the hymen that the subsequent slough- ing and scar-contraction has practically destroyed it. There is really no hymen that can be traced as a circular ring of tissue with simply laceration from intercourse. The hymen, as such, is gone, and there remain only irregular projecting particles of tissue (carunculae myrtiformes) here and there to mark the place where the hymen used to be. Of course a large tumor — e. g., a fibroid — delivered through the vagina might do the same. Also, some destruc- tive inflammatory process or serious injury during childhood or later miglit produce practically the same results, but such conditions are rare and show also other evidences. There are cases of congenital deformity in wliich the hy- men may be present simply as irregular tags of tissue, or it may, as recorded in some cases, be absent altogether. In such cases we would not expect the scar tissue about the vaginal opening nor the marked enlargement of the opening. So the destruction of the hymen as described, when present, is strong pre- sumptive evidence of preA'ious childbirth. Suppose the hymen is not destroyed — does that prove that no cliildl)irt]i lias taken place? Not necessarily. Occasionally during labor the liymen is sim- ply torn and then the ring beyond it is stretched and torn. After labor the 976 MEDICO-LEGAL POINTS IN GYNECOLOGY portions may heal in such a "way that the hymen appears practically intact. Still rarer cases have been recorded in which the hymen softened and dilated sufficiently to permit the child to pass and then underwent involution to about its former size. Such a hymen is likely to stretch also during coitus instead of tearing. The examination of such a patient would show an "intacli hymen," or, as some, laying too much stress on the condition of the hymen, are wont to write, "virgo intacta. " The absurdity of such a designation based only on the condition of the hymen is well expressed by Taylor when he re- marks, ''Such 'virgines intactae' have frequently required the assistance of accoucheurs and have in due time been delivered of children." b. Evidences of laceration or great stretching of the perineum, vagina and pelvic floor. These evidences are a large vaginal opening, close approach of the opening to the anus (partial destruction of perineal body), scars about the opening or on the perineum, lax vaginal walls and lax pelvic floor. These have about the same significance as the destruction of the hymen above mentioned — that is, their presence is strong evidence of previous childbirth but their absence is not of much legal significance. c. Laceration of the cervix. The establishment of a distinct laceration of the cervix is very strong evidence of a previous parturition or operation involv- ing division of the cervical wall. There are conditions that simulate a slight laceration, but a deep laceration Avould hardly be simulated by anything short of some congenital deformity, and in such a case there would be likely to be other deformities. Also, there would be no scar tissue, such as is ordinarily found about a laceration of the cervix. d. Evidences of previous lactation. It may be possible to press some fluid from the breasts, or the breasts may show the enlarged veins and the white striae (lineae albicantes) of a previous distention. e. Evidences of a previous distention of the abdominal wall . There may be present the striae (lineae albicantes) indicative of previous stretching of the skin from distention from pregnancy or other causes. When other causes (obesity, tumor, ascites) can be eliminated by the history, such striae indi- cate previous pregnancy. Also, marked relaxation of the abdominal wall may be due to previous distention by pregnancy. 2. Evidences of previous abortion. The evidences are exceedingly uncer- tain in many cases after a short time. There may be some slight lacerations, with resulting scars, that may be corroborative evidence, especially partial laceration of cervix. Their presence may help some, but their a])sence is of no particular significance. 3. Laceration of hymen and some dilatation and laxity of vaginal opening and vaginal canal. These are the ordinary evidences of coitus and are nearly ahvays present, especially if repeated coitus has taken place. Usually the opening in a virgin hymen is so small that the introduction of one finger is effected with some difficulty and causes pain. Ordinarily, after repeated coitus has taken place, the vaginal opening admits two fingers easily for examination, and without pain, providing the perineal edge of the opening is carefully depressed. RAPE 977 In exceptional cases the hymen may remain intact after coitus, particularly in those cases where the opening is large and a little stretching will accom- modate the male organ. Occasionally, however, a hymen with a small open- ing will remain intact. In such cases the hymen is usually elastic and un- usually tough, and consequently it stretches and dilates under a force that would rupture an ordinary hymen. So that, though it may be said that there are many exceptions to the rule that "coitus ruptures the hymen," there are \ery few cases in which a hymen presenting the normal rupture capacity (of normal size, normally tense and having the normal consistency, elasti- city, and strength) does not rupture on first coitus. In doubtful cases, then, the physician should take care to ascertain accurately, not only the presence of the hymen, but also its character. The apparent laceration of the hymen or even the absence of the hymen, while presumptive evidence of coitus, is not positive evidence of the same. It may be absent wholly or partially from congenital deformity. It may have been destroyed or dilated by disease or injury in infancy, childhood or later life. It may have been lacerated by an operation or an examination. Its apparent laceration is, however, strong corroborative evidence of coitus when taken in connection with the history of the case, and especially when there is reliable testimony establishing that it was formerly intact. 4. Evidences of a disease usually communicated in sexual intercourse, such as gonorrhoea, syphilis, chancroid, pediculosis pubis. 5. Evidences of uterine or tubal inflammation, presumably due to infection following labor or abortion, or coitus. Married Women. In married women normal sexual intercourse has, of course, already taken place, so that the establishment of the fact of coitus is of no help in estab- lishing rape. The medical evidence, if any is required, must bear upon the question of coitus by some one other than the patient's livisband and against her resistance. The following points should be investigated : 1, Evidences of injury about the genitals, indicative of forced and hurried coitus. There may be abrasions, tears, bruises or bleeding. 2, Evidences, elsewhere on the body or clothing, of injury in resistance. There may be bruises and scratches, or an excited or hysterical state, such as might be caused by a harrowing experience. The clothing may show tears or blood-stains, or contamination with dirt of the road or disarrangement. Of course none of these evidences of violence establish the crime of rape. They only go to show that something was attempted that excited the woman's resistance. They might have been due to attempted robbery or to a quarrel. Again, they may have been placed there intentionally. The woman may be trying to deceive for the purpose of extorting money or for other reasons. 3, Stains of spermatic fluid may be present on the clothing or person of 978 MEDICO-LEGAL POINTS IN GYNECOLOGY ■the -woniau. If there is any suspicious stain, some of the contaminating ma- terial should be submitted to microscopic examination, that the presence or absence of spermatoza may be determined. Any discharge in the vagina may also be examined microscopically, but the presence of spermatoza in the vaginal discharge is not of much significance unless it can be established that no coitus with the husband has taken place for three or four days. 4. Disease ''gonorrhoea, syphilis, chancroid') not present in the husband. The Question of Consent. The question of consent is often the crucial point on the legal side of these cases of alleged rape in adult women, whether married or unmarried. This question is, as a rule, decided largely or wholly by testimony other than medical. In some cases, however, the medical man may be required to give testimony concerning corroborative facts. An adult woman of ordinary health and strength is supposed to make strong resistance. In such a ease, if there are no ob^dous e^ddences of resistance, the legal assumption is that consent was given and the case is not one of rape. It has been claimed that a scrong woman can make effective resistance, and therefore that an accusa- tion of rape by such a woman is an absui^lity. "Some medical jurists have argued that a rape can not be perpetrated on an adult woman of good health and vigor, and they have treated all accusations made under these circum- stances as false."' This view is too extreme, for there are circum.stances and conditions that would make effective resistance impossible even by, a woman of unusual strength, as when two or more are combined in the attack or when the woman is rendered powerless by terror or by exhaustion from long strug- gling with her assailant. The physician may be required to state his opinion regarding the possibility or probability that sexual intercourse could take place A^thout the consent of the woman under various circufstances ; for example, the following : 1. When a woman is weak from age, sickness or other bodily infirmity. That coitus could be forced under such circumstances is evident. 2. "Where there is imbecility or other form of mental irresponsil)ilit3'. In sucli a case consent in the legal sense is impossible. 3. "Wlum the woman is attacked by several persons or by one person of superior strength. Rape is unquestionably possible under such circumstances. 4. When there is unconsciousness or partial unconsciousness from narcotics or intoxicating liquors. Coitusmay take place under such circumstances with- out the consent, and in some cases even witliout the knowledge, of tlie woman. Many young women are ruined in this way in I he "wine-rooms'" of our cities. Tliis fact is recognized in tlic law Avliich makes it a crime to give a woman intoxicants with the intention of stupefying licr. so that coitr.s may take place without her consent. 5. When there is unconseiousness or partial unconsciousness from a gen- eral anesthetic, such as chloroform or ether or laughing gas. The fact that FOREIGN BODIES LEFT IN ABDOMEN 979 rape may, and occasionally has l)een, committed under these circumstances is sometimes taken advantage of by designing persons to extort blackmail from dentists and others who must, in their work, anesthetize or partially anesthetize patients without a third party present. Anesthesia or partial anesthesia of a girl or woman without a third party present is hazardous for another reason. The patient, while going under the anesthetic or recovering from the same, may experience certain feelings or hallucinations that cause her to really believe and firmly proclaim that sexual intercourse took place. Many such cases of false accusations, honestly made, are on record. In one instance "a young lady Avas accompanied to a dentist by her affianced lover, who never left her while the anesthetic was adminis- tered and a tooth extracted; yet she could scarcely be convinced subse- quently that the dentist had not attempted to ravish her." 6. "When there is unconsciousness or partial unconsciousness from hypnotic sleep. Convictions have occurred of undoubted rape under this condition. Also, false accusations may be honestly made from sensations experienced in this condition. This comes under partial or complete anesthesia. Another source of false accusations, honestly made, is mental aberration of various kinds — from well-marked insanity to the various functional nervous dis- turbances. 7. When there is unconsciousness or partial unconsciousness from fainting, syncope, an epileptic seizure, a fall or a blow. 8. "When the woman is temporarily helpless from terror or from an over- powering feeling of horror at her situation. 9. A woman may cease her resistance under threats of death or duress. FOREIGN BODIES LEFT IN ABDOMEN. This is a subject the importance of which is frequently not appreciated by the physician until he is involved in a lawsuit concerning the same. Conse- quently, I think it well to call attention to the subject by detailing some illustrative cases, that the danger may be recognized and avoided. Lawsuit. Small Gauze Strip Extracted from Abdominal Sinus. — In a case of retro- flexion, Wiggin did a vaginal fixation and also removed the left ovary. Suppuration followed presumably from the stump. Later, laparotomy was performed for the removal of the ligatures. This was followed by an abscess in the abdominal wall and a persistent sinus. The patient then went to another institution, and later a small gauze strip was taken from the sinus. Suit was entered for $10,000. Dr. Wiggin contended that the gauze was not the kind he used in sponging, and that the small strip had probably been left in the sinus while the patient was being dressed at the other institution. Verdict for the defendant. Lawsuit. Small Gauze Sponge Removed by Secondary Operation. — The patient was operated on for appendicitis by Gillette. After the abdomen was open it was found that the trouble was tubal pregnancy. The appendix incision was closed and a median incis- ion made, and through that the operation was completed. About four days after the operation the appendix incision began to discharge pus. Gillette treated this sinus persistently under the impression that it was kept up by unabsorbed kangaroo tendon, 980 MEDICO-LEGAL POINTS IN GYNECOLOGY which might at any time be wholly absorbed and thus permit healing. After twelve months of this treatment the patient went to another physician, who, eighteen months after the first operation, did a secondary operation and found a small gauze sponge, after which the patient recovered. Suit was entered for $5,000. In the trial court the verdict was for the defendant on the ground that the cause of action, if any arose, was barred by the statute of limitation. The Circuit Court held that the trial court was in error and reversed the decision. The Supreme Court was divided equally on the subject, hence the decision of the Circuit Court was allowed to stand — verdict for the plaintiff. Lawsuit. Sponge Left in Abdomen. — Baldwin was made defendant in a suit, and a question that assumed much importance in the case was as to whether the responsi- bility for the count of the sponges lay with the surgeon or with the nurse. The suit against the surgeon was finally withdrawn, and legal action was begun against the hospital where the operation occurred. Lawsuit. Sponge Removed at Secondary Operation. — The patient was operated on for an abdominal tumor by Thorne. Several months later a secondary operation was per- formed by another surgeon and a sponge was found in the abdominal cavity. The patient recovered. Legal proceedings were begun against the first operator (Miss May Thorne) on the ground that she was guilty of negligence in not personally counting the sponges used in the course of the operation before the wound was closed. The defendant denied negligence and held that the leaving of a sponge was an acci- dent that could not always be avoided. She further said that, like a large number of other operating surgeons, she left the counting of the sponges to a responsible nurse — considering that it was the duty of the surgeon to keep his or her eyes continually upon the patient until the wound had been closed. The judge, in summing up the case, said there was no doubt that the defendant was a skillful surgeon, but the question in this case was not as to her skill, but whether she had been guilty of want of reasonable care. The points for the jury were: (1) whether the defendant was guilty of want of reasonable care in counting or superintending the counting of the sponges; (2) whether the nurse was employed by the defendant and under her control during the operation; (3) whether the nurse was guilty of negligence in counting the sponges; and (4) whether the counting of the sponges was a vital part of the operation which the defendant undertook to see properly performed. After lengthy consideration the jury returned a verdict for the plaintiff. Criminal Trial. Sponge Found at Autopsy. The patient was subjected to explora- tory laparotomy by d'Antona. A carcinoma of the liver was found, and an unfavorable prognosis given. The patient recovered from the immediate effects of the operation, but died after a month. At the autopsy a gauze pad, 70 by 40 cm., was found and also two liters of pus. The physicians who made the post-mortem examination gave out a statement to the effect that the death was due to the presence of the sponge and the peritonitis and secondary pleuritis resulting therefrom. The public prosecutor then had d'Antona indicted and placed on trial for criminal negligence. The verdict was that the patient would have died from the other causes present. The prosecutor then claimed that the hospital records had been falsified, hence a new trial was granted. In the second trial ten experts were called and they all testified that there was sufficient cause for death outside of any influence which the sponge within the abdomen might have had. The trial was then discontinued because of the absence of prosecuting evidence. This case was reported by Prof. Pio Foa, who stated that, if the autopsy had been conducted by competent pathologists, such an erroneous report would not have been made, and the unfortunate trials would not have occurred. Lawsuit. Sponge Left in Abdomen. The patient was subjected to abdominal section by Schooler. Later developments indicated that a sponge, sixteen inches square, had been left in the abdomen. Suit was entered for $1,500. Verdict for the plaintiff. FOREIGN BODIES LEFT IN ABDOMEN 9gl Lawsuit. Sponge Left in Abdomen. The husband of the plaintiff was operated on for appendicitis by Hageboeck. It was charged that a surgeon's sponge had been left in the abdomen and that this caused an abscess which resulted in death. Suit was entered for $50,000. In two trials the jury disagreed. It was reported that in each trial the jurors stood 11 to 1 in favor of the plaintiff. The case was to come up for a third trial the latter part of the year. Criminal Trial. Forceps Found in Abdominal Cavity at Autopsy. A patient with a large fibroid was operated on by Lassallette. Death occurred a few hours after the operation. Autopsy disclosed a forceps in the peritoneal cavity. At the trial the operator was condemned to two months in prison for homicide through negligence. The sentence was served. After serving the sentence, Lassallette put in a plea that the patient's death had not been caused by the retention of the instrument, but by nux vomica. The death occurred too soon to have been due to the presence of the instrument. It was proven that a midwife of bad reputation had a bottle of nux vomica in her hand at the house on the day of the death. This was an entirely new phase. The body was exhumed. Lassallette was acquitted. Criminal Trial. Two Artery Forceps Found in Abdomen at Secondary Operation. The patient was operated on for ovarian cyst, Dec. 22, 1897, by Prof. Kosinski and Dr. Solman, in the latter's private hospital. After a few days there appeared fever and a mass, which continued. In the meantime two artery forceps had been missed, and it was thought they might be in the abdomen. The disturbance persisted, and six weeks after the operation the abdomen was reopened and the mass of exudate in- vestigated, but neither forceps nor pus was found. The patient was better after- ward and went home, but did not get well. Later a hard mass developed near the umbilicus. Kosinski still thought the forceps might be in the abdomen, and insisted on another operation and offered to perform it gratis. But the sons would not hear to this, and the patient was taken to several other physicians, one after another hoping to be cured without operation. Finally, six months after the primary opera- tion, the symptoms became acute and threatening, and the physician who was called in insisted that the patient be taken to Kosinski at once, that he might perform the operation, which had then become imperative. This the family refused to do and called in another physician, who operated. On opening into the mass at the pelvic brim he found a cavity in which lay the two artery forceps. Both forceps had forced an entrance into the external iliac artery. The removal of the forceps was attended with a furious hemorrhage, from which the patient died on the table. Legal action was entered against Kosinski and there was an extensive trial, with an imposing array of legal and medical talent. Six experts were appointed to testify in the case — Przewoski and Troichij to consider the pathologico-anatomical features, Krajewski to describe a modern laparotomy, Maksimow to criticise the operation as performed in this case, Pawlow to consider the various complications and mis- takes that may occur in a laparotomy, and Neugebauer to supply the statistics which might be required in the trial. It was for use in this trial that Neugebauer compiled the list of cases that he published the following year (1900), which publication has done so much to enlighten the profession on this subject. The trial resulted in the acquittal of the accused as far as causing the death of the patient was concerned — it having been shown that he strongly insisted on a line of treatment which would probably have prevented the patient's death had the treat- ment not been peremptorily rejected by the family. A curious clinical feature of this case was that, during the patient's illness, a number of radiographs of the suspicious area were made, but not one of them showed the forceps — the failure being due doubtless to defective technique. Lawsuit. Artery Forceps Extracted From a Sinus. The patient was subjected to 982 MEDICO-LEGAL POINTS IN GYNECOLOGY operation for a sarcomatous growth in the abdominal v/all by Bollinger. The patient was three months pregnant at the time of the operation. She recovered from the operation and was delivered at term without any special disturbance. She became pregnant again. Her health was excellent and she was able to do all her housework. In the latter part of the pregnancy there appeared in the operative scar a swelling, which opened and discharged much offensive pus. The abscess v/as still further opened by the family physician. Within a lew days she was delivered. A few days after the delivery an artery forceps Vv'as discovered in the abscess wall. The patient was sent to the hospital and the forceps removed by operation. The patient died two days later. The husband of the patient demanded money of Bollinger, which demand was refused. He then went to the public prosecutor and endeavored to have a criminal prosecution brought against the surgeon. The prosecutor asked Bollinger for a written statement of the case, which was given. The prosecutor saw no evidence to warrant criminal proceedings, and dropped the matter. The husband then brought civil suit, and for thirteen months Bollinger spent all his time defending himself. Sensational reports appeared in the public press, and it is said that the comic papers made capital of it and pamphlets on the subject were sold at the cigar stands. Though acquitted, Bollinger suffered irreparable damage from the sensational newspaper reports and the consequent notoriety. He urges strongly that some means should be provided by which reputable physicians may protect themselves from this species of blackmail and newspaper persecution. Criminal Trial. Piece of an Instrument Left in Abdomen. A Paris surgeon lost part of a broken instrument in the abdominal cavity. The patient died. The surgeon was put on trial for manslaughter due to negligence. Result of trial not stated. Lawsuit. Pair of Spectacles Found in Abdominsl Cavity. The patient had three operations — the first in America, the second in Germany and the third in France. The French surgeon found a pair of spectacles in the abdomen. The patient sought redress in the courts. The outcome of the trial is not given, neither is it stated definitely who was sued. Neugebauer, who cites the case, blames the German surgeon — noting that he either left the spectacles himself or missed finding them if left by the previous operator. Lawsuit Threatened. Gauze Compress Discharged Per Rectum. The patient had jected to vaginal section, for pelvic suppuration, by :\IacLaren. It v.'as a very severe case. There was persistent bleeding requiring packing, and there were two secondary hemorrhages requiring repeated packing. The patient recovered. Two months after- ward a very offensive discharge appeared and the patient extracted a twelve-inch strip of iodoform gauze from the vagina. Suit was threatened and. on the advice of his attorney, JMacLaren paid the patient a considerable sum to avoid further proceedings. Lawsuit Threatened. Gauze Compress Discharged Per Rectum. The patient had uterine fibroids, which Borysowicz removed by abdominal operation. Three weeks later a gauze compress was passed per rectum. Evidently the compress had 'been left in the peritoneal cavity at the time of the operation. The patient recovered and thanked the operator most gratefully for his services and left him her photograph. Six years later he received a number of letters from the patient's husband, threatening prosecution for malpractice if he did not at once pay a certain sum. The husband had no doubt heard of a lawsuit (Kosinski's?) then on at Warsaw, and thought it an easy way to obtain some money from Borysowicz. Apparently nothing came of the elTort. Lawsuit Threatened. Forceps Alleged to Have Been Passed Per Rectum. . Tiie patient was operated on for a suppurating ovarian cyst by Tuholske. It was an extremely severe case, but the patient recovered and regained her health rapidly. Twenty months later she wrote that she had given birth to a fine baby and felt well. FOREIGN BODIES LEFT IN ABDOMEN 983 Labor had been uncomplicated. The account continues: "Some five or six months after that (more than two years after the operation) the husband called on me and stated that for two or three months his wife had had some rectal trouble, supposed to be piles, and that a week ago, under considerable suffering, she had passed a forceps at stool. He brought it to me; it was a forceps such as is usually carried as dressing forceps in a pocket case — not a hemostat. I did not claim ownership. At any rate, if that forcep had been in the pelvis for two and a half years, during pregnancy and labor, without giving rise to a symptom or modifying labor, it was a remarkable occurrence. Three months after this episode the patient was reported well." In a later reference to the case, Tuholske stated that several demands were made for money, accompanied by threats of a suit. No attention was paid to the demands and finally they ceased. He expressed the opinion that it was an attempt to obtain money by blackmail. The Question of Deception, Intentional or Otherwise. The repeated occurrence of this accident in the past and the possibility of its occurrence at any time gives an opportunity for designing persons to obtain money under false pretenses. Neuge- bauer calls attention to this fact, and remarks that, following the newspaper publicity given the Kosinski trial, a number of damage suits, alleging the accident, were filed, and that in most instances they were cases of blackmail or extortion. A case has been reported of a patient who, following convalescence from an abdom- inal operation, expelled pieces of gauze or thin cloth from the mouth. The patient claimed that the expelled pieces were vomited sponges, which had worked their way into the stomach from the peritoneal cavity. Suit was threatened. The matter was dropped, however, when the practical impossi'bility of the occurrence, as detailed, was explained to the patient. When discussing the subject of foreign bodies left in the abdominal cavity, a physician related to me some of the details of a case in which he had been involved. He performed an abdominal operation, and, some time following the convalescence, the patient came to him and exhibited a surgical needle and stated that the needle had been passed per rectum. The patient's statement was confirmed b}' a physician who claimed to have treated him at the time the needle was passed. Suit was threatened. On examination of the needle the operator found it was not the kind he used at the operation, and he became convinced that the alleged occurrence was an attempt at blackmail. The matter dragged along for some time. The operator accumulated all the infor- mation he could concerning the subject and concerning the parties involved, and finally confronted them in such a way that they were forced to make a written statement, acknowledging that the needle had not been passed per rectum, as alleged. The needle exhibited had been obtained elsewhere for the purpose of threatening suit and extorting money. Porter gives an account of a peculiar case bearing on this subject. The operation was for a parovarian cyst and hydrosalpinx and chronic appendicitis. The con- valescence was normal and the patient left the hospital twenty-two days after the operation, feeling well. Eight days later. Porter received a telephone message from the patient's family physician, stating that he had removed several pieces of gauze from her vagina. Quoting from the report, "On inquiry from him I learned that the pieces did not tear off, but came away, or rather were removed with forceps, in the shape of rolls about the length and size of a lead-pencil, and after all presenting were removed others would present in a few hours, requiring that he visit her two or three times a day to take them away. The doctor thought that the pieces came from the pelvic cavity through an openmg in the right side of the vagina about the size of a lead-pencil. "On the next day but one after learning of the matter. I visited the patient at her home with her doctor, and found the patient on a cot apparently suffering some pain. 984 MEDICO-LEGAL POINTS IN GYNECOLOGY which she said was due to more pieces 'coming down.' She did not look sick. In reply to my question she said she felt well until she got a jolt on the car on her way home and that since then she had been having pain, which was worse at times, and had not been so severe since the pieces began to come away. The first knowledge the doctor had of the nature of the trouble came through the patient's husband, who told him that there was a piece of gauze protruding from the vagina. I asked to see what had been removed and was shown a large number of pieces of different texture, whereupon I remarked that the goods were not such as I had used as sponges, that there were more pieces than had been used all told in the operation, and that conse- quently they had not been left in the woman's belly by me. It was averred that they could get into her belly only through the wound made by me and at the time it was made, because it had been closed, healed by first intention, and was still closed. The patient facetiously remarked that she 'supposed she swallowed 'em.' 'No,' I. replied, 'had you swallowed them they would not come out through the vagina.' "Dr. F. now asked the patient if she thought more 'pieces were down.' Being answered in the affirmative, he introduced a speculum and found that she was right. I removed the speculum, and, introducing my finger, came upon a small wad of some- thing which, upon removal, proved to be a piece of ordinary white muslin about three inches wide by seven inches long, twisted into a rope and doubled upon itself so as to make a small ball or wad. It was perfectly clean, and was so saturated with what looked and smelled like urine, that on squeezing between the fingers several drops were squeezed out. I examined the vagina with my finger, assuring myself that there were no more 'pieces' there, that there was no hole leading into the pelvic cavity and that, in fact, it was a perfectly healthy vagina and in nowise unusual except its cleanliness, for which, of course, the frequent wipings it received were accountable. "In the presence of the patient, her mother-in-law and the doctor I said, pointing my finger at the patient, 'Doctor, I don't know where those rags came from, but that woman knows very well, and could tell if she would.' The mother-in-law objected to my statement rather forcibly, but the patient said nothing. I then took the doctor outside, told him that the woman was a malingerer and that we would give her a chance to put some more rags in for removal. We received one more piece before we left. Before leaving I insisted upon both the doctor and myself making a thorough inspection of the vagina with the eye and the finger as well. This was done, but no abnormality was found. It should be stated that some of the 'pieces' were tinged with blood, but none of those removed during my visit were so tinged." Dr. Porter exhibited ten pieces of different size, shape and texture, and continued: "Eight days after my visit, Dr. Fisher reported 'no more exhibits.' So far as I know, no threat was made of a suit for damages, nor did the patient or her mother seem out of humor with me. The husband was at work and not present during my visit, although he presumably knew the day before that I was to be there, as I had sent word that I was coming." In regard to the possible cause for the deception, Dr. Porter mentioned: 1, desire for money; 2, desire for sympathy; .3, desire to avoid work; 4, sexual perversity. He stated that during the patient's stay in the hospital nothing pointing to a neurotic con- dition was noted. Indeed, she was regarded as an unusually nice and agreeable patient. Schaefer gives the details of a case which emphasizes the fact that when a piece of gauze is found in. the abdominal cavity it does not necessarily follow that it was left there in a previous operation. The case occurred in the practice of Pryce .Jones. Jones was called to see a woman with an abdominal swelling. This proved to be an abscess, which was opened and discharged a piece of cloth. There had been no previous operation. The woman was insane, and had been in the habit of tearing up pieces of cloth and swallowing them. The swallowed cloth had evidently caused ulceration of the stomach wall, with subsequent perforation into the peritoneal cavity. OTHER CONDITIONS 985 The noted intestinal "hair-balls," requiring operation, constitute another class of foreign bodies in the abdomen which were not left there by the surgeon. Again, the professional "knife swallowers" and "glass eaters" and their amateur imitators must be kept in mind. Fortunately the menu of these persons is limited, as a rule, to household articles. However, some such "actor," who has been relieved of his accumulated load by surgical art, might, from the intimate acquaintance, acquire a taste for surgical forceps instead of the usual nails and pocket-knives. In that case a condition might easily develop that would make it very uncomfortable for the previous operator, though wholly without fault on his part. To make absolutely certain tliat no sponge or other foreign body is left in the peritoneal cavity at operation is a hard problem. The solution of this problem is considered on pages 928-933. OTHER CONDITIONS Presenting Medico-Legal Points. 1. The various medico-legal questions concerned with the state of preg- nancy, abortion, labor and the puerperium belong more strictly to obstetrics, and need not be considered here. 2. The question of the character of a disease present — particularly gonor- rhoea, syphilis, or chancroid — and the source from which it could have come, and whether or not it is still transmissible, are all questions that may assume medico-legal importance under various circumstances ; for example, in suits for divorce, suits for possession of children, suits for alimony, suits for dam- ages against individuals or corporations, etc. Of injuries, also, of the genital organs you may be called to give the nature, extent, possible cause and prob- able outcome. All these are simple clinical questions, and the information regarding them may be obtained from the clinical portions of this work. 3. Various questions in regard to sterility may come up in legal inquiries. The required information on this subject is given in Chapter XIY. 4. In the case of the death of a woman or girl under suspicious circum- stances, the physician may be called upon to make a post-mortem examination and then to answer, as far as possible, various questions, among which may be the following: What pelvic lesions were present? What was the probable cause of these lesions? What was the cause of death? 5. In coroner's cases, and much more so in malpractice suits (before or after death), the following questions may be asked concerning almost any gynecological disease : What disease is present? What are the principal points upon which your diagnosis is based? In your opinion did the attending physician use reasonable care and skill in the diagnosis? What is the established treatment for the disease? In your opinion did the attending physician use reasonable care and skill in the treatment? 986 MEDICO-LEGAL POINTS IN GYNECOLOGY 6. In criminal eases and in damage suits the physician testifying as an expert may be required, particularly in the cross-examination, to explain in detail various points in the etiology, pathology, symptomatology, diagnosis, treatment and prognosis of the affection under consideration. To answer such questions, the physician must be well grounded in all the important facts and theories of the disease, and must be able to give the required explanations in a few words and in ordinary language, avoiding the little-understood tech- nical terms. On important contested points it is Avell to be fortified with the names of two or three recognized authorities on that particular subject, with their exact statements. This information is, of course, held in reserve, to be given only if requested. 987 APPP^.NDIX, FORMULA. The formulae may be classed in two groups- those for local use. -those for internal use and FOR INTERNAL USE. The various classes of remedies commonly used internally (by mouth or hypodermatically) in gynecological cases are cathartics, emmenagogues, sedatives, stimulants, styptics and tonics. CATHARTICS. Gm. ^ Sodii et Potas. Tartrat., 60. (gij.) (Rochelle Salt) Sig. One to three teaspoonfuls in a glass of water, each morning an hour before breakfast. [Used ' especially in acute inflammatory conditions in the pelvis.] ^ Fl. Ext. Rhamni Pursh. Aromat., 60. (gij.) Sig. Fifteen to thirty drops each night at bedtime. [Used as a tonic laxative in cases compli- cated by chronic constipation. Increase the daily dose to a teaspoonful if necessary.] Gm. ^ Pil. AJoin. Belladonna. Strychnia, and Cascara. (P. D. & Co.) Sig. One pill each night, or each night an I morning if necessary. [Used as a tonic laxative in chronic con- stipation. Each pill contains aloin 1/5 gr., strychnia 1/60 gr., extract of belladonna i gr.. and extract of cascara sagrada ^ gr.) ^ Sodii Phosphat. Gran: Effervesc, 120. (,3iv.) Sig. Teaspoonful in a glass of water, one to two hours after each meal. [A mild laxative, especially useful in cases complicated by liver disease or chronic gastrcK duodenitis. ] EMMENAQOQUES. ^ Manganes. Dioxid., 4. (5i.) Div. Pil. No. XXX. Sig One pill three times daily. [May increase the dose to two and three and even four pills, if no disturbance is noticed.] ^ Apiolini, 6. (,5iss.) Div. Caps. No. xxx. Sig. One capsule three times daily, after meals. ^ Quin. Sulphat. 4.00 (3i ) Ext. Nucis Vomic, 0.50 (gr viii.) Olei Sabinae, 1.00 (gr. XV.) Aloes Socotrin., 030 (gr V.) Cantharidis. 1.00 (gr XV.) Div. Pil. No. xxx. Sig. One pill three times daily. SEDATIVES. Dy.smenorrhoea Mixture. Gm. Potas. Bromid., 5. (5i.) Elixir of Guarana and Celery, 120. (,5iv.) Sig. Two teaspoonfuls every 4 hours when in pain. Fl. Ext. Viburn Prunifol., 120. (.3iv.) Sig. Teaspoonful every four to six hours. P^ ^ 120. (.5iv.) I^ Liquor Sedans, (P. D. & Co.) Sig. Teaspoonful every four to six hours. [The Liquor Sedans is more agreeable than the plain viburnum and also more effective. Each ounce contains viburnum prunifol. 30 gr., hydra.stis 60 gr., Jamaica dogwood 30 gr., and cascara sagrada, 40 gr.] 988 FORMULAE Gm. or c.c. ^ Sod. Bromid., 15. (5iv.) Ess. Pepsin., 30. (5!.) Aquae, q. s. ad 60. (,3ii ) Sig. Teaspoonful in sarsaparilla soda- water, when sleepless, and repeat after three hours as necessary. ^ Sulphonal., 4. (5i.) Div. Chart. Xo. i\'. Sig. One powder in a glass of hot lemonade at 10 p. m.; when sleepless. Bt- Phenacetin , 2. (5ss ) Codein. Phosphat., 0.18 (gr. iii.) Caffein. Citrat., 0.18 (gr. ui.) Div. Caps. Xo. vii. Sig. One capsule when pain is severe, and repeat after three hours as necessary. Gm. or c.c ^ Fl. Ext. Hyoscyami, 6. (3iss.) Potas. Citrat., 10. (jiiss ) Fl. Ext. Zeae, 60. (gii.) Aquae, q, s, ad 120 (oiv.) Sig. Teaspoonful in sarsaparilla soda- water, every three to six hours as ordered. [Used to relieve vesical tenesmus.] ^ Acid. Benzoic, 6. (3iss ) Sodii Borat., 8. (5ii.) Aquae, 240. (gviii.) Sig. Tablespoonful in water three times daily. In four days reduce the dose to a teaspoonful. [Used when there is a tendency to phos- phatic deposits from the urine, especially in cases of vesico- vaginal fistvila.] STIMULANTS. STRTCHXL-i. ScLPHATE, 1 .30 gT. hypoder- matically or by mouth, every four to eight hours. DiGiTAiix, 1/.50 gr. hypodermatically or by mouth, every two hours when pulse is rapid and weak. XoRiLiL Saline Solution (8/10%), given intravenously orsubcutaneously or in the open abdomen or per rectum. This is useful in all conditions of shock. It is especially effective in shock due to loss of blood (after the bleeding is stoppedj. If the patient is nearly pulseless, the empty vessels may be at once filled by intravenous injection, using a pint to a pint and a half (not more at one time), at a temperature of 100^ F. When the case is not so urgent but still a quick effect is desired, the saline solution is given subcutaneously, one to two pints under the skin on each side of the chest. If the abdomen is open, the peritoneal cavity may be filled with hot saline solution, provided there is no contra-indication such as a focus of pus which might be thus dissem- inated. For less urgent shock and for stimulating kidney action, the warm saline solution is used as high enemata, one pint or more every four to twelve hours. In acute septic cases, continuous rectal absorption is secured by allowing the tepid saline solution to flow into the rectum very slowly — drop by drop, as explained on p. 697. Oxygen is a useful stimulant when respira- tion is shallow or when there are lung compli- cations. It is administered by attaching a tube, with a face-piece and water filter, to the iron jar containing the oxygen. STYPTICS. ^ Ergotm. (Merck), 2. (jss.) Ext. XucLs Vomic, 0.36 (gr. vi.) Div. Caps. Xo. xxx. Sig. One capsule every six hours. [Used in hemorrhagic conditions not con- nected with pregnancy.] ^ Ergotin., 2. (3ss.) Ext. Xucis Vomic, 0.36 (gr. vi.) Ext. Cannab. Indie, . 0.60 (gr. x.) Div. Caps. Xo. xxx. Sig. One capsule every six hours. [Used when tnere is associated pain, par- ticularly of neuralgic character.] ^ Stypticin., 4. (5i.) Div. Caps. Xo. xxx. Sig. One cap.sule every six hours, when bleeding is present. [This is an excellent anti-hemorrhagic remedy, but it is so expensive that some patients object to it. In cases where it is desired to give a styptic for some months, the ergotin capsules may be given continuously and the stypticin capsules added during men- struation.] ^ Ergotin., 2. (3ss.) Stypticin., 2. (3ss.) Hydrastinin, 2. (3ss.) Div. Caps. Xo. xxx. Sig. One capsule every six hours , when bleeding is present. ^ Fl. Ext. Ergot., 60. (.51!.) Sig. Half teaspoonful every four to twelve hours, when bleeding is present. ^ Desic. Thyroid., 6. (3iss.) Div. Caps. Xo. xxx. Sig. One capsule three times daily. FOIiMLL.B 989 (jm. ^ Calcii Clilorid., 20. (5 v.) ElLx. Sinipl., 30. (51.) Aquae, q. s. ad 120. (oi^'O Sig. Teaspoonful in water three times iliily. [Used in hemorrhagic conditions, to increa.sc the coagulability of the blood.] Gm. ^ Adrenalin, 1-1000 .solution, 1.5. (.^ss.) Sig. Fifteen drops in water every three hours till bleeding ceases. TONICS. ^ Tinct. Ferri Chlorid., 30. (gi.) Sig. Ten drops in a capsule, followed by half a glass of water, three times daily. ^ Elix. Iron., Quinin., and Strychnin., 120. (o^v.) Sig. Teaspoonful in half a glass of water tliree times daily, before meals. ^ Strychnin. Nitrat., 0.06 (gr. i.) Massae Ferri Carbonat., 6.00 (3iss.) Quinin. Sulphat., 4.00 (3i.) Div. Caps. No. xxx. Sig. One capsule three times daily, after meals. ^ Liq. Potas. Arsenitis, 10. (Jiiss ) Syr. Ferri lodid., 60. (.^ii.) Sig. Ten drops in water three times daily Increase to twenty drops, as directed. ^ Hydrarg. Biclilorid., Tr. Ferii Chlorid., Liq. Acid; Arseniosi, Acid. Hydrochlor. dil., Syrup. Sim pi. , Sig Teaspoonful in water three times daily, after meals. [This mixture is known as the " Four Chlorides " and is a very effective tonic in cases complicated by anemia and neuroses. 0.09 (gr. iss.) 10.00 (5iiss.) 10.00 (oiiss.) 20.00 (5v.) 120.00 (,5iv.) FOR LOCAL USE. The various preparations used locally in gynecological cases are ointments, powders, solutions, suppositories and tablets. OINTMENTS. Antiseptic Ointments. Carbolized Vaseline, 1% Carbolized Zinc Oxide Ointment, 1%. Unguentuh Crede. ^ Hydrarg. Bichlorid., 0.15 (gr. iiss.) Lanolin., 15.00 (5iv.) Ungt. Aq. Rosae, 30.00 (,3!.) Sig. Apply locally, but not to mucous membranes. Anti=parasitic Ointments. R Sulphur. Precip., 4.00 (Ji.) Vaselini, 30.00 (gi.) Olei Rosae, q. s. Sig. Apply as directed twice daily. IvAPOZi's Petroleum Salve. 19^ Petrolati, 25. (5vi.) Olei Olivae, 10. (Jiiss.) Balsam. Peru., 5. (3i-) Sig. Apply as directed twice daily. Sedative Ointments. (Protective, Anti-pruritic, Anesthet^). Zinc Oxide Ointment. Vaseline. Ungt. Aquae Rosae. I^ ^ ^ R ^ Zinci Oxidi, g. (5ii.) Acidi Carbolici, 1. (TIXxv.) Lanolin., 30. ( = i.) Ungt Aq. Rosae, q. s. ad 60. (gii.) Sig. Apply several times daily. Zinci Oxidi, Bismuth, subcarbonat. Acidi Carbolici Vaselini, Sig. Apply as directed. 2. (3ss.) 2. (3ss.) 0.60 (TTLx.) 30. (51.) Mentholis, 4. (Ji.) Olei Olivae, 8. (3ii.) Chloroform., 2. (3ss.) Lanolin , 30. (gi.) Sig. Apply two or three times daily. Acid. Salicylici, 1.00(gr. xv.) Creosoti, 1.30 (TTl xx.) Glycerit. Amyli., 45.00 (.^iss.) Lanolin., 1.5. 00 (3iv.) Sig. Apply two or three times daily. Acid. Carbolici, 1 .00 (ITl. xv.) Hydrarg. Sulphid. Rubri., 0.50 (gr. ix.) Sulphur Sublimat, 45 00 (^iss.) Olei Bergam., 1.00 (ITL xv.) Sig. Apply as directed. 990 FORMULA ^ Gm. or C.C. Acidi Carbolici, 0.30 (triv.) Bismuth. Subnitrat. 2.00 (3ss.) Ungt. Hydrarg. Ammoniat., 8.00 (5ii) Ungt. Aq. Rosae, 15.00 (gss ) Sig. Apply as directed. ^ Lassar's Paste. Sulphur. Sublim., Zinci Oxidi, Amyli, Acid. Salicylic , Vaselini, Sig. Apply as directed. 4.00 (5i.) 4.00 (5i.) 4.00 (3i.) 0.60 (gr. X.) 30.00 (5i.) ^ Chloreton., Ungt- Aq. Rosae, Sig. Apply as directed. ^ Orthoform., Ungt. Aq. Rosae, Sig. Apply as directed. ^ Cocaine Hydrochlor., Ungt. Aq. Rosae, Sig. Apply as directed. 4.00 (5i.) 30.00 (gi) 4.00 (5i.) 30.00 (gi.) 1.00 (gr. XV.) 15.00 (5S3 ) ^ Gm. Stimulating Ointments. Ungt. Picis Liq., 4.00 (5i.) Zinci Oxidi, 4.00(51.) Ungt Aq. Rosae, 8 00 (3ii.) Lanolin., 15.00 (gss.) Sig. Apply on strips of muslin as directed. Wilkinson's Ointment. ^ Sulphur. Precip., Picis Liquid., Saponis Virid., Terrae Albae, Adepis, Sig. Apply as directed. ^ Resorcin., Acid. Salicylic, Vaselini Flav., Sig. Apply as directed. ^ Ungt. Hydrargyri, 10.00 (5iiss.) Ungt. Belladonnae, 10.00 (Siiss.) Ungt. lodi Comp., . 10.00 (Siiss.) Sig. Apply under pressure bandage. 10.00 (5iiss.) 10.00 (5iiss.) 10.00 (Siiss.) 6.00 (3iss.) 15.00 (gi.) 2.00 (5ss.) 0.36 (gr vi.) 30.00 (gi.) POWDERS. Antiseptic and Drying Powders. PxjLV. Boric Acid, dusted on freely directed. Aristol, dusted on as directed. ^ w "^ ^ Xeroform,, Acid. Boric, Sig. Apply as directed. Acid. Tannic, Xeroform., Acid. Boric, Sig Apply as directed. [Astringent and antiseptic] Zinci Oxidi, Magnes. Carbonat., Salolis, Amyli, Sig. Apply as directed. 6.00 (3iss.) 30.00 (gi.) 4.00 (3i.) 6.00 (3iss.) 30.00 (gi.) 15.00 (gss.) 15.00 (gss.) 15.00 (gss.) 15.00 (gss.) Comp. Stearat. of Zinc with Balsam Peru., 30. (gi.) (McK. & R.) Sig. Use as a dusting powder. • [A pleasant and effective drying powder which will turn water to some extent.] ^ Acid. Salicylic, 0.24 (gr. iv.) Acid. Boric, 30.00 (gi.) Iodoform., 8.00 (3ii.) Ess. Eucalyp., q. s. Sig. Apply freely on the affected surface several times daily. [Used to check the odor of sloughing tissue, as in malignant disease.] Sedative Powders. ^ Anesthesin., Acid. Boric, Sig. Apply as directed. I^ Chloreton., Acid. Boric, Sig. Apply as diiccdv'.. ^ Orthoform., Acid. Boric, Sig. Apply as directed. ^ Morphia. Sulphat., 2.00 (3ss.) Cretae Prep., 4.00 (3i.) Sig. Apply twice daily as directed. 4.00 (5i.) 30.00 (gi.) 4.00 (3i.) .30.00 (gi.) 4.00 (3i.) 30.00 (gi.) SOLUTIONS. Douche Solutions. ^ Hydrarg. P>ichlorid., Amnion. Chlorid., Methylene Blue., Aquae, q- s. ad Sig. For External Use. Tablcspoonful to two quarts of hot water. Use as directed. 6.00 (3iss.) 6.00 (3iss.) 0.001 (gr. -„\0 240.00 (gviii.) ^ Acidi Carbolici, 120.00 (giv.) Glyccrini, q. s. ad 240.00 (gviii.) Sig. For I'vXternal ITsc Tablespoonful to two quarts of hot water. Use as directed. ^ Lysol., Sig. For External Use. two quarts of hot water. 240.00 (gviii.) Tablcspoonful to FORMUL.E 991 I Gm. or c.c. ^ Potas. Permanganat. , 10.00 (oiiss.) Aquae, 240.00 (,5viii.) Sig. For External Use. Tablespoonful to two quarts of hot water. ^ Pulv. Aluminum. Acetat., 60.00 (5ii.) Sig. Teaspoonful of the powder dissolved in two quarts of hot water. Use as directed. ^ Formol., 30.00 (,31.) Sig. Poison. For External Use. Five drops to two quarts of hot water. Use as directed. I^ Zinci Sulphat., 1.5.00 (Bss.) Alum., . 60.00 (5ii.) Div. Chart. No. xv. Sig. One powder dissolved in one quart of water. [A strong astringent douche.] ^ Acidi Tanniei, 30.00 (gi.) Glycerini, 240.00 (sviii.) Sig For External Use. Tablespoonful in one quart of water. [A strong astringent douche.] Sedative Solutions. Lead axd Opium Wash. ^ Liq. Plumbi Subacetat., 30.00 (gi ) Tinct. Opii., 60.00 (Sii.) Aquae, q. s. ad 240.00 (,3viii ) Sig. For External Use. Apply as a lotion as directed. Alum and Lead Lotion. ^ Pulv. Alum., 2. r.oss.) Sol. Plumbi Subacetat., 2. (5ss.) Aquae, q. s. ad 24U. (gviii.) Sig. Apply on compresses under pressure bandage. Zinci Sulphat.. 0.24 (gr. iv.) Fl. Ext. Hydrastis, .30.00 (gi ) Aquae, q. s. ad 120.00 (,5iv.) Sig. For External Use. Calamine Lotion. Zinci Oxidi, 15.00 (gss.) Pulv. Calamin. Prep., 6.00 (3iss.) Glycerini, 30.00 (51-) Liq. Calcis, q. s. ad 240.00 (.gviii.) Sig. For External Use. ^ "^ Gm. or c.c. Anesthetic Solutions. Cocaine Hydhochlorate, 4% to 20% solutions for local application.?, and )i% to 4% for subcutaneous injection. Eucaixe Hydrochlor. B., same as cocaine for subcutaneous use. It is less toxic than cocaine, and, furthermore, the solution can be sterilized by boiling. ^ Eucain. Hydrochlor. B., 0.10 (gr. i.ss.) Morphia. Hydrochlor., 0.02.5 (gr. .ss.) Sodii Chlorid., 0.20 (gr. iii.) Aquae Distil., 100.00 (giiiss.) Sig. Schleich Solution, No. 2. [For producing local anesthesia by the in- filtration method. Sterilize the solution by boiling immediately before use.] ^ Miscellaneous Solutions. 0.60 (gr. x.) 1.30 (gr. XX.) 1..30 (lUxx.) 1.30 (TTL XX.) .30.00 (gi.) Apply as directed Ext. Cannabis Indie, Acidi Salicylic, Alcohol., Ether., Collodion., q. s. ad Sig. For External Use. twice daily. [For use on dry warts (not the ordinary condylomata) occurring about the external genitals]. Ivaiserling Solution.s. The preservation of specimens by the Kaiserling method, so that they retain the natural colors, consists of the following three steps. Step 1. Fix for one to five days (according to the size of the specimen) in the dark, in the following solution : — • Potassium Nitrate, 15.00 Potassium Acetate, 30.00 Formol (40% sol. of formaldehyde gas), 200.00 Aquae, 1000.00 Step 2. Then place the specimen in 80% Alcohol for one to six hours and then in 95% Alcohol for one or two hours. This treatment with Alcohol brings back the original colors to the specimen. Step 3. Then preserve the specimen in the dark, in the following solution: Potassium Acetate, 200.00 (gviss.) Glycerine, 400.00 (.gxiiis-s) Aquae, 2000.00 (glxviss) (.5ss.) (Si-) (gviss.) (gxxxiiiss.) SUPPOSITORIES. ^ Cocain. Hydrochlor., O.lS (gr. iii.) Olei Theobrom., q. s. Div. Suppositor. No. vi. Sig. For External Use. Use as directed. [To be used within the vagina.] Also, various manufacturing firms put up glycerin-gelatin suppositories with different medicines incorporated, such as protargol, hydra.stis, ichthyol and various combinations- TABLETS. Different manufacturing houses put on the market compressed tablets for vagioal use, containing a great variety of drugs and combinations. By looking over the lists one can find almost any formula desired. INDEX. DIAGNOSTIC, THERAPEUTIC AND GENERAL INDEX. Note. — Under "Examination, gynecologic" (page 1004), the references are arranged sys- tematically as in the text, instead of alphabetically. Following this, under "Examination" (page 1005), the references are arranged also alphabetically. Abdomen, 14, 119 auscultation of, 29 contour of, 14, 120 discoloration of, 16, 134 disinfection of, 913 distention of, 126 dullness in, 28, 156 from appendiceal mass, 162 from ascites, 157 from bladder, 156 from kidney tumor, 167 from liver, 156 from ovarian tumor, 163 from perirenal tumor, 169 from pregnant uterus, 156 from retroperitoneal tumor, 165 from spleen, 156 from tubal mass, 162 from uterine fibroid, 163 examination of, 14, 119 exploration of, 675 foreign bodies in, 925, 979 in ascites, 126, 156 in gynecologic diagnosis, 119 (see Diag- nosis) in obesity, 25, 27, 121 in pregnancy, 129 in tumors, 131, 148 in tympanites, 126 inspection of, 16, 119 mass in, 26, 148, 256 in right lower, 149, 269, 270 in left lower, 149, 281 in central lower, 150, 281, 284 in right upper, 152 in left upper, 154 in central upper, 155 mensuration of, 30 movements of, 134 palpation of, 17, 135 percussion of, 28, 156 prominence of, 17, 120, 160 regions of, 20, 135 right lower, 21, 138, 149 shape of. 15, 120 in ascites, 126 sterilization of, 913 tenderness in, 17, 137 tension of, 17, 135 tumor of, 132 Abdominal adhesions, 731 antisepsis, 913 applications, 307 (see Applications) bandage, 952 diagnosis, 119, 269, 287 drainage, 716, 923 dressing, 922 drainage cases, 954 ordinary cases, 922, 951 septic cases, 957 sterilization, 914 examination, 14, 119 (see Examination) gynecologic examination, 14, 119 (see Ex- amination) hernia, 124 hysterectomy, 641, 677 incision, 919 (see Incision) closure of, 922 myomectomy, 641, 657 operation, 909, 944 palpation, 15, 137 section, 909 after-care in, 948 after-treatment of, 948 bandage, 952 bladder, 948 bowels, 949 by days, 948 constipation, 961 diet, 949 dilatation of stomach, 961 drainage, 954 dressings, 951 drink, 949 exercise, 952 first day, 948 fistula, 964 fourth day, 950 Fowler posture, 722, 959 hemorrhage, 960 hernia, 964 intestinal obstruction, 962 intestinal paralysis, 961 kidney insufficiency, 961 laxatives, 949, 961 local suppuration, 962 nausea, 960 orders, 948 pain, 948, 964 peritonitis, 962 phlebitis, 963 993 994 INDEX Abdominal section — Cont'd after-treatment of position, 948, 957 pulse, 960 regular, 948 restlessness, 948 second day, 949 sedatives, 948 shock, 959 sinus, 964 sitting up, 952 stimulants, 959 strapping, 951 strychnia, 959 subsequent orders, 950 sutures, 951 temperature, 962 third day, 949 thirst, 949 tympany, 961 uterine replacement cases, 959 visitors, 960 vomiting, 949, 960 walking, 952 wound, 951 anesthesia in, 917 bandage in, 922 contraindications for, 910 dangers in, 911 drainage in, 954 dressings after, 922, 951 exploratory, 910 indications for, 910 position of arms during, 918 preparations for, 911 assistants, 915 diet, 913 disinfection, 913 dressings, 914 examination, 912 face mask, 915 general, 912 gowns, 915 hand disinfection, 915 in home, 911 instruments, 914 kidneys, 912 laxatives, 913 nervous system, 912 operative field, 915 patient, 912 rubber gloves, 914 sleeves, 915 sponges, 914, 925 sterilization, 913 surface of abdomen, 913 sutures, 914 take to hospital, 911 regular steps in, 916 anesthesia, 917 closure of incision, 922 dressing, 922 exploration, 921 incision, 919 toilet of peritoneum, 921 rubber gloves in, 916 Abdominal section — Cont'd special points in, 923 drainage, 923 injuries, 925 instruments left, 932 shock, 924 sponges left, 925 sponges, 929 supporter, 952 surface, sterilization of, 913 touch, 17 wall, 16, 120 abscess, 121 fat, 120 relaxation, 124 separation of recti, 124 skin, 16 tumor, 121 wound, 919 infection of, 962 strapping of, 952 suppuration of, 962 sutures in, 922, 952 Abdomino-rectal examination, 73 Abdomino-vaginal examination, 52 Abnormal pregnancy, 242, 251, 254 Abortion, 179 criminal, 8, 985 incomplete, 8 metrorrhagia from, 8, 905 tubal, 769 Abscess, 705, 729 appendiceal, 271 broad ligament, 257, 259, 712, 737 ischio-rectal, 257 of abdominal wall, 121 (see Abdominal wall) of Bartholin's glands, 33, 200, 441 of vulvo-vaginal gland, 33, 200, 441 ovarian, 277, 699, 730 pelvic, 257, 705, 725 acute, 705, 712 after-treatment, 713 appendiceal, 138, 271 bacteria, 698, 745, 751 broad ligament, 257, 712 chronic, 729 diagnosis, 702, 733 diffuse, 264, 699, 729 drainage, 705 drainage tubes, 710 gonococcal. 746 opening, 708 ovarian, 699, 730 prognosis, 712 streptococcal, 751 treatment, 705, 743 tubal, 699, 729 tubo-ovarian, 699, 730 pericaecal, 291 puerperal, bacteria in, 751 stitch-hole, 963 ■suburethral. 211, 438 tubal, 699, 729 urethral, 33. 211, 399 vulvo-vaginal, 33, 200, 441 INDEX 995 Absence of hymen, 975 of uterus, 854 of vagina, 185, 842 Accessory Fallopian tubes, 765 ovary, 841 Acid, oxalic, 916 Action of pessaries, 329 Acute dilatation of stomach, 961 endocervicitis, 542 endometritis, 562 metritis, 562 pelvic inflammation, 698 cellulitis. 699 oophoritis, 699 ovaritis, 699 peritonitis, 699 salpingitis, 969 urethritis, 33, 397 vaginitis, 386, 413 vulvitis, 402 Adenitis, inguinal, 425 Adenocarcinoma of cervix uteri, 294, 659 of corpus uteri, 244, 686 Adenomyoma of uterus, 627 Adherent labia minora, 184, 466 prepuce, 185, 466 retrodisplacement, 606 Adhesions, 731 abdominal, 731 of clitoris, 185 of external genitals, 446 of Fallopian tubes, 731 of intestines, 731, 736 of labia, 185, 446 of ovaries, 731 of prepuce, 185 of uterus, 606 of vaginal walls, 417, 842 post-operative, 962 tubercular, 761, 763 Adhesive plaster, 951 vaginitis, 417 Adjustable foot-rests, 99 leg-holders, 99 Adult, endometrium of, 526 After-care in abdominal section, 948 (see Abdominal section) After-treatment, 948 for repair of cervix, 556 for repair of pelvic floor, 493 in abdominal section, 948 (see Abdominal section) in curetment, 582 in pelvic abscess, 713 (see Abscess) in pelvic drainage, 722 954 in perineorrhaphy, 493 in trachelorrhaphy, 556 in vaginal section, 965 Agents, antiseptic, 100 Albicans, corpus, 803 Alchohol, 107 Alexander's operation, 609 Amenorrhoea, 851 causes of, 852, 857 classes of, 851 diagnosis of, 851 Amenorrhoea — Cont'd in the virgin, 852 symptoms of, 851 treatment of, 854, 861 Ampullar pregnancy, 766 Amputation of Fallopian tubes, 946 of cervix uteri, 561 of corpus uteri, 947 partial, of cervix uteri, 557 supravaginal, 641, 947 Amyloid degeneration of fibroid, 628 Anal fissure, 48 Anatomy of Bartholin's glands, 35, 379 of endometrium, 527 of external genitals, 32, 170, 375 of Fallopian tubes, 609 of hymen, 380 of ovary, 799 of parovarium, 808 of pelvic floor, 467 of peritoneum, 535 of round ligament, 535 of urethra, 378 of uterus, 520 of vagina, 381 of vulva, 170, 375 of vulvo-vaginal gland, 35, 379 pelvic, 1, 520, 691 Anemia, 112 Anesthesia, 917 ether in, 917 for diagnosis, 91 for examination, 91 for operation, 917 general, 91 gynecologic examination under, 91 in abdominal section, 917 (see Abdominal section) local, 73, 322 paralysis from, 918 position of arms in, 918 preparation for, 912 scopolamin in, 793 Animal extracts, 371 Ani muscle, levator, 470 sphincter, 493 Anodynes, 73 Anomalies, 836 of bladder, 132, 840 of Fallopian tubes, 765, 841 of hymen, 171, 841 of ovaries, 841 of urethra, 840 of uterus, 844 of vagina, 186, 842 of vulva, 185, 841 Anus, 49 Anteflexion, congenital, 232, 624 of cervix, operation for, 885 Anterior colporrhaphy, 504 vaginal section, 942 Antero-posterior section of pelvis, 1, 3 Anteversion, 624 Antisepsis, abdominal, 913 in examinations, 100 vaginal, 575 996 INDEX Antiseptic agents, 100 preparations for examination, 100 Aphthae of vagina, 415 Apostoli method, 638 Appendiceal abscess, 138 Appendicitis, 138 Appendix, diseases of, 272 vermiform, 272 Applications, 304 abdominal, 307 cervical, 321 cold, 309 counter-irritant, 310 dry heat 308 for endometritis, 565, 571 hot, 307 intrauterine, 346 moist heat, 307 rectal, 358 vaginal, 311 concentrated solutions, 319 douches, 311 powders, 323 suppositories, 324 tablets, 324 tampon-capsules, 327 tampons. 325 vulvar, 311. 321 Apron, Hottentot, 203 Arms, position of, during abdominal section, 918 (see Abdominal section) position of, in anesthesia, 918 Arrangements, office, 99 Artery forceps. 481 Ascites, 126, 157 abdomen in, 126, 156 diagnosis of, 126, 157 from fat, 120 from tumor, 121 dullness in, 157 percussion of abdomen in, 157 shape of abdomen in, 126 signs of, 157 wave in, 25, 27 Asepsis in intrauterine examination, 100 in operations, 913 abdominal, 913 vaginal, 944 in vaginal examination, 100 Aseptic fever, 962 technique, 913 Assault, indecent, 969 Assistant in office, 99 in operations, 915 Astringents, 321, 371 Atmocausis of Pincus, 353 Atresia, congenital, of cervix, 255 congenital, of vagina, 185 of cerv'ix, 255, 261 of hymen, 184, 185 of uterus, 255 of vagina, 185 of vulva, 184 Atrophic endometritis, 585 metritis, 585 Atrophy of uterine fibroids, 625 Atrophy — Cont'd of uterus, 589 Auscultation, 29 in pregnancy, 29 of abdomen, 29 B Bacillus, Ducrey, 421 Backache in gynecologic diagnosis, 302 (see Diagnosis) Bacteria, 389, 563 in cellulitis, 752 in endometritis, 562 in pelvic abscess, 698, 745, 751 (see Ab- scess) in peritonitis, 715, 746 in puerperal abscess, 751 in pyaemia, 751 in pyosalpinx, 746 in salpingitis, 746 in thrombo-phlebitis, 700 in urethritis. 33 in uterus, 562 in vagina, 384, 413 in vaginitis, 413 Bacteriologic examination, 35 for gonococci, 388 gynecologic, 34 securing discharge for, 34 Bag, hot water, 308 ice, 310 Bags for sponges, 929 Bandage. 581, 924, 951 abdominal. 924, 951 in abdominal section, 924, 951 (see Ab- dominal section) T, 325 Bartholin's glands, 35, 379 abscess of, 201, 441 anatomy of, 35, 379 examination of, 35 palpation of, 37 Bathing in gynecologic treatment, 365 Bed, examination in, 106 Bed-pan, 316 Bicornuate uterus, 844 Bimanual examination, 52, 238 gj-necologic, 53 of uterus, 53 palpation, 52, 238 replacement, 603 Bivalve speculum, 78 Bladder, anomalies of, 132, 840 carcinoma of. 132 care of, 494. 948. 966 catheterization of, 966 diseases of, 266 displacements of. 634 distended. 130 percussion of abdomen in, 154 drainage of, 519 exstrophy of, 132 injuries of, 925 malformation of, 132 prolapse of, 191, 217 INDEX 997 Bladder— Cont'd rupture of, 130 Bleeding in menopause, 851 senile, 673 Blood, 112 examination of. 111 retention of. 185 supply of vulva, 380 vessels of external genitals, 379, 380 of ovary, 539 of pelvic floor, 469 of tubes, 693 of uterus, 531 of vagina, 383 of vulva, 381 Bloody discharge, 904 causes of, 904 treatment of, 906 Body, Wolffian, 836 Boiling, 101 gloves, 104, 914 instruments, 101, 914 towels, 914 Bowels after operation. 495 before operation, 913 obstruction of, 962 in pelvic affections, 743, 913 Broad ligament, 138, 535 abscess, 257, 259, 712, 737 cyst of, 260, 832 haematoma of, 260 thrombosis, 700 tumor of, 276 varicose veins of, 270 Brushes, 103 hand, 103 in examination, 103 Bubo, 422, 425 Bulbs of vestibule, 279 Buried sutures, 497, 502 Byrne's cauterization method, 686 Cachexia, 672 Caecum, diseases of, 273 Caesarean section, 659 Calcareous degeneration of fetus, 283 Calcification, 628 Calculi of ureters, 259 of veins, 797 Calculus, ureteral, 259 Canal of cervix, 521 of Gartner. 808, 838 of Nuck, 452 Cancer cases, classification of, 659 curetment in, 684 metrorrhagia from, 667 of cervix uteri, 659 of corpus uteri, 686 of ovary, 832 of uterus, 245. 294, 659 of uterus, operation for, 677 of uterus, radical treatment for, 673 x-ray in, 345, 686 Capillary drainage, 954 Carcinoma, cervical, 659 of bladder, 132 of cervix uteri, 659 diagnosis, 667 duration, 666 etiology, 659 extension, 663 hemorrhage, 672 metastases, 666 operation, 677 palliative treatment, 683 pathology, 659 recurrence, 682 symptoms, 667 treatment, 673 varieties, 661 x-ray treatment, 686 of clitoris, 183 of corpus uteri, 686 diagnosis, 689 symptoms, 689 treatment, 689 of endometrium, 686 of Fallopian tube, 796 of ovary, 832 of rectum, 604 of urethra, 434 of uterus, 659 of vagina, 435 of vulva, 183, 434 of vulvo-vaginal gland, 206 Cards, history, 12 Care of bladder, 494, 948, 966 of pessaries, 336 Caruncle of external genitals, 440 urethral, 440 diagnosis of, 440 treatment of, 441 Case record, 11 Catarrh, cervical, 544 Cat-gut sutures, 481, 490, 555 Cathartics, formulae for, 987 Catneterization, 966 Catheters, sterilization of, 966 Cauliflower excrescence, 297 Causes of amenorrhoea, 852, 857 of bloody discharge, 904 of cystocele, 504 of dysmenorrhoea, 871, 889 of endocervicitis, 543 of endometritis, 562, 584 of eversion of cervical mucosa, 550 of extra-uterine pregnancy, 764 of fibromyoma, 625 of gonorrhoea, 384 of kraurosis vulvae, 458 of leucorrhoea, 176 of menorrhagia, 863 of metrorrhagia, 904 of papillary cysts, 818 of peritonitis, 715 of pruritis vulvae, 460 of retrodisplacement, 597 of salpingitis, 698 of shock, 924 of sterility, 895 998 INDEX Causes — Cont'd of tubal pregnancy, 764 of vaginitis, 384, 413 of vulvitis, 384, 402 Cauterization, 345, 684 metliod, Byrne's, 686 Cautery, Paquelin, 345 Cellulitis, bacteria in, 752 pelvic, 699, 736 vulvar, 406 Cervical applications, 321 canal, disinfection of, 248 carcinoma, 659 catarrh, 544 cyst, 588 incision, closure of, 554 mucosa, epithelium of, 529 eversion of, 550 myoma, 628 polypi, 562 hemorrhage in, 562 wound, infection of, 557 Cervix uteri, adenocarcinoma of, 659 amputation of, 557, 561 atresia of, 255, 261 canal of, 521 cancer of, 659 carcinoma of, 659 (see Carcinoma) congenital atresia of, 255 cystic degeneration of, 545, 558 depleting, 344 dilatation of, 49, 90, 231, 574 divulsion of, 577 ectropion of, 234 elongation of, 560 Emmet's operation for lacerated, 551 epithelioma of, 294, 661 erosion of, 539 eversion of, 233, 548 examination of, 49, 231 follicular degeneration of, 558 glands of, 529 hypertrophy of, 560 in gynecologic diagnosis, 231, 291 (see Diagnosis) infection of, 542 injuries of, 547 inspection of, 82, 291 lacerations of, 547 (see Lacerations) malformation of, 255 malignant disease of, 659 nodule in, 236 occlusion of, 255 operations, denudation in, 554 for anteflexion, 885 technique of, 551', 557, 561 (see Technique) partial amputation of, 557 polypi of, 562 repair of, incision for, 553 (see Incision) instruments for, 552 . Schroeder's operation on, 557 stenosis of, 544 sutures in, 352, 555 trachelorrhaphy, 551 ulcer of, 541 Chafing, 410 Chancre, 249 soft, 421 Chancroid, 421 of external genitals, 421 of vulva, 181 phagedenic, 425 Chancroidal virus, 421 Change of life, 850 Chapter on gynecologic diagnosis, 118 (see Diagnosis) on gynecologic examination, 1 Child-bearing, 7 Children, gonorrhoea in, 401 leucorrhoea in, 415 rape of, 971 vaginitis in, 415 Chorio-epithelioma, 688 Chronic endocervicitis, 544 endometritis, 567 gonorrhoea, 398 metritis, 567 pelvic inflammation, 728 cellulitis, 734 oophoritis, 738 ovaritis, 738 peritonitis, 729 salpingitis, 729 urethritis, 399 vaginitis, 398, 415 vulvitis, 405 Cirrhosis of ovary, 739 of uterus, 589 Classes of amenorrhoea, 851 Classification of cancer cases, 659 of causes of displacement, 597 of diagnostic signs, 287 of endometritis, 538 of examination methods, 13 of fibroid cases, 627 of fibromyoma, 627 of fistulae, 506 of operations for displacement, 609 of retrodisplacement cases, 614 of therapeutic measures, 304 of vulvar diseases, 384 Cleansing soap, 103 Climacteric, 850 Clitoris. 377 adhesions of, 184 carcinoma of, 183 cyst of, 209 hypertrophy of, 204 malformation of, 184, 204 Closure of abdominal incision, 922 of cervical incision, 554 of perineal incision, 490 Cocaine, 322 Coccygodynia. 76, 301 Coccyx, examination of, 77 palpation of, 77 Codeine, 494 Coeliotomy, 909 Coitus, difficult, 892 obstruction to, 892 pain in, 892 INDEX 999 Coitus — Cont'd violence in, 189 Cold in gynecologic treatment, 309 Collodion, 100 Colloid degeneration, 628 Colpeurynter, 364 Colpocele, 189 Colporrhaphy, 482 anterior, 504 Complications, 550 of operation, 954 Compresses, 307, 310 Conception, 895 Condylomata, 198, 444 excision of, 446 multiple, 444 of external genitals, 444 of vulva, 198, 444 Confinement, 7 Congenital anteflexion, 232 atresia of cervix, 255 atresia of vagina, 185 malformations, 184, 836 Congestion of pelvis, 864 of uterus, 566 of vagina, 81 Conjoined examination, 52 Conservative operation in salpingitis, 946 on Fallopian tubes, 946 surgery, contraindications for, 757 definition for, 945 indications for, 946 of Fallopian tubes, 946 of ovaries, 946 of uterus, 947 reasons for, 946 Constipation, 961 Constitutional treatment, 758, 854 Constriction, waist, 366 Continuous sutures, 488, 491 Contour of abdomen, 15 Contraction of levator ani, 42 Contraindications for abdominal section, 910 (see Abdominal section) for conservative surgery, 757 for curetment, 91 for operation, 910 to marriage, 385 Contusion of vulva, 457 Convalescence, 493 Corona of resonance, 157 Corpus albicans, 803 luteum, 803 luteum, cyst of, 811 uteri, 568 adenocarcinoma of, 686 amputation of, 947 cancer of, 686 carcinoma of, 686 (see Carcinoma) infection of, 562 in gynecologic diagnosis (see Diagnosis) malignant disease of, 686 Corrections, dress, 366 Corset, 366 Counter-irritation in gynecologic treatment, 310 Crab-louse, 412 Crede's ointment, 349 Criminal abortion, 8, 985 trials, 985 Crossen's gauze-strip sponges, 929 puncturing tenaculum-forceps, 615 retrodisplacement operation, 615 Crown suture, 489, 491 Cul-de-sac of Douglas, 3, 4 Cup and belt pessaries, 342 Curet, 88, 578 examination with. 90, 95 uterine, 88, 572 Curetment, 95, 571 after-treatment in, 582 contraindications for, 91 dangers of, 91 diagnostic, 90, 95 effects of, 581 exploratory, 90, 95 for endometritis, 571 in cancer, 684 in doubtful cases, 96 in endometritis, 571 in fibromyoma, 639 in tuberculosis, 592 indications for, 96 instruments for, 572 preparation for, 571 steps in, 572 technique of, 572 therapeutic, 571 Curettage (see Curetment) Curetting, microscopic examination of, 96, 670 Cylindrical speculum, 83 Cyst, cervical, 588 dermoid, 821 follicular, 810 hydatid, 593 intraligamentary, 260 mesenteric, 133 multilocular ovarian, 820 of broad ligament, 260, 832 of clitoris, 209 of corpus luteum, 811 of external genitals, 446 of Morgagni, 809 of vulvo-vaginal gland, 443 omental, 129 ovarian, 810 pancreatic, 133 papillary, 816 causes of, 818 description of, 819 diagnosis of, 819 pathology of, 818 prognosis of, 818 symptoms of, 821 treatment of, 831 parovarian, 832 proliferating, 812 pseudomucinous, 813 retention, 558 serous, of ovary, 816 vaginal, 223 1000 INDEX Cyst—Cont'd vulvo-vaginal, 443 Cystadenoma of ovary, 812 Cystic degeneration, 545 of cervix nteri, 558 of fibroid, 628, 651 Cystocele, 189, 504 causes of, 504 diagnosis of, 192, 504 operation, technique of, 505 pessaries for, 342 treatment of, 504 Cystoma, 812 D Dam, rubber, 954 Dangers in abdominal section, 911 (see Ab- dominal section) of curetment, 91 Debility, general", 111 Decidual remnants, 97 Deciduoma malignum, 688 Deep percussion of abdomen, 30 Definition of conservative surgery, 945 of menopause, 850 of menstruation, 847 of metrorrhagia, 867, 904 of retrodisplacement, 597 Degeneration, calcareous, of fetus, 283 colloid, 628 cystic, of cervix, 545 of fibroid, 628, 651 of ovary, 810 fatty, 628 follicular, of cervix, 558 malignant, 633 myxomatous, 628 of fibroids, 628, 633 Delayed menstruation, 9, 851, 857 Denudation for repair of cervix, 554 for repair of pelvic floor, 484 in cervix operations, 554 in fistula, 514 in pelvic floor operations, 484, 496, 501 Depleting cervix, 344 Dermatitis, 402 Dermoid cyst of ovary, 821 Description of knee-chest posture, 367 of papillary cysts, 816 Detached sponges, 929 Development of Fallopian tubes, 836, 840 of hymen, 837 of ovaries, 840 of uterus, 595, 597 of vagina, 840 Diabetes mellitus. 111 Diagnosis, abdominal, 119, 269, 287 anesthesia for, 91 gynecologic, 118 abdomen in, 119 discoloration, 134 dullness, 156 mass, 148 movement, 134 prominence, 120 Diagnosis, abdominal — Cont'd abdomen in tenderness, 137 tension, 135 backache in, 302 cervix uteri in, 231, 291 discharge, 33, 291 displacement, 51, 231 distortion, 231 enlargement, 231 erosion, 294 eversion of mucosa, 548 flxation, 237 hardening, 236 laceration, 292, 294 mass in canal, 237 softening, 234 tenderness, 236 chapter on, 118 corpus uteri in, 54, 238 displacement, 57, 239 enlargement, 58, 240 fixation, 59, 256 hard nodules, 59, 255 softening, 59, 255 tenderness, 59, 256 methods of, 118 pain in pelvis in, 297 pelvic mass in, 256 mass low in pelvis, 256 to right of cervix, firm, 256 to right of cervix, fluid, 259 to left of cervix, firm, 263 to left of cervix, fiuid, 263 behind cervix, firm, 263 behind cervix, fluid, 264 in front of cervix, firm, 266 in front of cervix, fluid, 266 filling pelvis, firm, 267 filling pelvis, fluid, 268 mass high in pelvis, 269 in right side, flrm, 269 in right side, fiuid, 276 in left side, firm, 281 in left side, fluid, 281 in center, firm, 281 in center, fiuid, 284 table for, 287 vaginal, 224 bleeding area, 290 congestion, 289 mass, 225 roughening, 224 tenderness, 224 ulcer, 290 vulvar, 224 discharge. 176 inflammation, 180 laceration, 186 malformation, 184 swelling, 189 ulcer, 181 judgment in, 117 leucocytosis in, 114 method of, 118 (see Diagnosis) of amenorrhoea, 851 INDEX 1001 Diagnosis, abdominal — Cont'd of ascites, 12() (see Ascites) of cystocele. 189 of endometritis, 564, 570 of extra-uterine pregnancy, 772 of fibromyoma, 634 of gonorrhoea, 387 of imperforate hymen, 185, 842 of Ivraurosis vulvae, 181, 458 of menopause, 850 of menorrhagia, 863 of menstruation, 849 of metrorrhagia. 867, 904 of papillary cysts, 819 of peritonitis, 702 of pregnancy, 240 of pruritis vulvae, 460 of retrodisplacement, 601 of salpingitis. 702. 732 of suppuration of abdominal wound, 962 of tubal pregnancy, 772 of urethral caruncle, 210, 440 of vaginitis, 387, 413 of vulvitis, ISO, 403 Diagnostic curetment, 90, 95 signs, classification of, 287 table of questions, 287 Diagrams in records, 11 Diet. 950 Difficult coitus, 892 Diffuse fibromyoma, 628 Digital examination, 39, 224 rectal, 73 uterine. 96 vaginal, 39, 224 palpation. 39, 224 Dilatation, 39, 224 acute, of stomach, 961 of cervix uteri, 49, 90, 231, 574 of vaginal orifice, 31, 465 Dilating forceps, 88, 572 tents, 90 Dilators, uterine, 88, 572 Diphtheritic vaginitis, 416 Diplococcus of gonorrhoea, 389 Directions for giving nutritive enemata, 725 Discharge, 32, 176 bloody, 904 causes of. 904 treatment of, 906 from vulvo-vaginal gland, 36 purulent, 32 securing, for bacteriologic examination, 34 urethral, 34 Discoloration of abdomen, 134 Disease, echinococcus, of uterus, 593 of pelvis, 798 gynecologic, relation of insanity to, 759 hydatid, 593 insanity from, 759 malignant, of uterus, 659 marriage as cause of, 385 vesical, 266 Diseases, general, 110 of appendix, 272 of bladder, 266 Diseases — Cont'd of broad ligaments, 734, 832 cysts of Kobel's tubules, 832 parovarian cysts, 832 varicocele, 797 of caecum, 273 of external genitals, 170, 384 abscess of vulvo-vaginal gland, 441 adhesions, 446 chancroid, 421 condylomata, 444 cyst of vulvo-vaginal gland, 441 cysts, 446 eczema, 176, 408 erysipelas, 405 follicular vulvitis, 405 gangrene, 407 gonorrhoea, 384 hematoma, 454 hernia, 452 herpes, 411 hydrocele, 454 intertrigo, 410 kraurosis vulvae, 458 lacerations, 186 malformations, 184 malignant disease, 434 pediculosis, 412 periurethral abscess, 438 prolapsus of urethral mucosa, 439 prurigo, 411 pruritis vulvae, 460 scabies, 413 stasis hypertrophy, 448 syphilis, 427 tuberculosis, 431 tumors, 434, 448 ulcers, 37, 181, 419 ulcus rodens vulvae, 436 urethral caruncle. 440 urethritis, 387, 397, 399 varicose veins, 456 vulvitis, 402 of Fallopian tubes, 698, 729, 762, 765, 796 catarrhal salpingitis, 699 displacements, 699 neoplasms, 796 salpingitis, 699, 729 of intestines, 281 of kidneys, 280 of labia, 182, 384 of liver, 156 of ovaries, 699, 729, 799 acute ovaritis, 699 carcinoma, 832 chronic ovaritis. 730 cystic tumors, 810 cysts of corpus luteum, 811 dermoid cysts, 821 fibroma, 831 follicular cysts, 810 glandular cysts. 813 hemorrhage, 786 inflammation, 699, 730 oophoritis, 699, 738 ovaritis, 699, 738 1002 INDEX Diseases — Cont'd of ovaries papillary cysts, 817 papillomata, 817 paroophoritic cysts, 832 prolapse, 740 sarcoma, 832 solid tumors, 831 of peritoneum, 283 of spleen, 156 of ureters, 259 of urethra, 438 caruncle, 440 polypi, 440 prolapse, 439 .suburethral abscess, 438 urethritis, 438 urethrocele, 439 of uterus, 539, 595, 625, 659 anteflexion, 624 cancer of body, 686 cancer of cervix, 659 cervical polypi, 562 displacements, 595 endocervicitis, 542 endometritis, 562 eversion of intracervical mucosa, 550 fibromata, 625 gonorrhoeal endometritis, 562 hypertrophy of cervix, 560 inflammation, 542 infravaginal hypertrophy of cervix, 219 inversion, 624 lacerations of cervix, 547 posterior versions and flexions, 597 prolapse, 619 sarcoma, 689 senile endometritis, 563 septic endometritis, 562 subinvolution, 587 superinvolution, 589 supravaginal hypertrophy of cervix, 219 of vagina, 384 acquired atresia, 842 acquired stenosis, 842 adhesive vaginitis, 417 cancer, 435 cystocele, 504 cysts, 446 emphysematous vaginitis, 417 fibromata, 448 gonorrhoeal vaginitis, 387 hernia, 452 prolapse anterior wall, 504 prolapse posterior wall, 504 rectocele, 504 sarcoma, 436 senile vaginitis, 417 simple vaginitis, 413 vaginal flatus, 477 vaginitis, 384, 413, 417 of vulva, 384 acne, 405 adhesions of clitoris, 184, 466 adhesions of labia, 184, 466 anterior hernia, 452 Diseases — Cont'd of vulvar* • benign tumors, 448 cancer, 434 chaflng, 410 chancre, 427 chancroids, 421 cysts, 446 cysts of vulvo-vaginal glands, 443 diabetic vulvitis, 408 diphtheria, 408 eczema, 408 edema, 196 elephantiasis, 196, 448 erysipelas, 405 fibroma, 207 follicular vulvitis, 180, 405 gangrene, 407 gonorrhoeal vulvitis, 384 hematoma, 190 herpes, 411 hypertrophy of clitoris, 204 inflammation of ducts of vulvo-vaginal glands, 441 inflammation of vulvo-vaginal glands, 441 inguino-labial hernia, 452 intertrigo, 410 kraurosis vulvae, 458 lipoma, 448 myoma, 448 myxoma, 448 prurigo, 411 pruritus vulvae, 460 sarcoma, 434 simple catarrhal vulvitis, 402 syphilides, 430 thrush, 412 tumors of clitoris, 204, 209 vaginismus, 892 varicose veins, 197, 456 venereal ulcers. 419 verrucae, 444 urethral, 35 uterine, 176 vaginal, 176 varieties of, 32, 176 venereal, 324, 421 vulvar, 176 Disinfection, hand, 916 methods of, 916 in examination. 100 of abdomen, 913 of cervical canal, 248 of hands, 100, 916 of vagina, 480, 575 of vulva, 480 Disorders of menstruation, 851 (see Men- struation) Displacement, classification of causes of, 597 of bladder, 634 of Fallopian tubes, 731, 736 of kidneys, 274 of ovaries, 736, 740 of uterus, 239, 595 INDEX 1003 Displacement — Cont'd of uterus anteflexion, 624 as a whole, 595 classification, 597 inversion, 624 normal position of uterus, 596 of primary importance, 597 of secondary importance, 624 posterior flexions, 597 posterior versions, 597 prolapse, 616 supports of uterus, 596 of vagina, 217 posterior, 597 Dissecting forceps, 481 Distended bladder, 130 percussion of abdomen in, 154, 156 Distention, intestinal, 126 of abdomen, 126 Disturbances, functional, 847 sexual, 892 Diverticulum of urethra, 213 Divulsion of cervix, 577 Dorsal posture, 31 Double uterus, 844 vagina, 185 Doubtful cases, curetment in, 96 Douche, hot vaginal, 316 intrauterine, 351 pitcher, 494, 965 vaginal, 311 Douglas, cul-de-sac of, 3, 4 Drainage, abdominal, 923 after-treatment in, 954 capillary, 954 dressings in, 954 gauze in, 958 glass tube in, 954 in abdominal section, 954 (see Abdom- inal section) in pelvic abscess, 710 in peritonitis, 721 of bladder, 519 peritoneal, 721 rubber tube, 710, 958 split-tube, 958 vaginal, 716 Drains, rubber, 710, 958 Dress corrections, 366 in gynecologic treatment, 366 Dressings, abdominal, 922, 951 (see Abdom- inal dressings) in drainage, 954 vulvar, 580 Dry heat in gynecologic treatment, 308 Ducrey bacillus, 421 Duct of Gartner, 808, 838 of Miiller. 836 oviducts, 4, 521, 691 vulvo-vaginal gland, 35 Wolffian, 691 Dudley's operation for dysmenorrhoea, 885 Dullness in abdomen, 28, 156 (see Ab- domen) in ascites, 157 Duration of menopause, 850 of menstruation, 849 Dysmenorrhoea, 857 causes of, 871, 889 Dudley's operation for, 885 in the married, 889 in the virgin, 870 membranous, 870, 873 treatment of, 876, 889 varieties of, 868, 870 Dyspareunia, 892 E Echinococcus disease of pelvis, 798 of uterus, 593 Ectopic gestation, 764 (see Extra-uterine pregnancy) Ectropion of cervix, 234 Eczema of external genitals, 176, 408 Edebohl's speculum, 572 Educated touch, 67 Effects of curetment, 581 Electricity, 353 in fibromyoma, 638 Electro-cautery, 345 Elephantiasis of labia, 196, 449 of vulva, 196 Elongation of cervix uteri, 560 Emmenagogues, formulae for, 987 Emmet's operation for lacerated cervix, 551 for lacerated pelvic floor, 482 Emphysematous vaginitis, 417 Encysted fluid, 128 Endocervicitis, 542, 544 acute, 542 chronic, 544 diagnosis of, 543 gonorrhoeal, 543 Endometritis, 562, 567 acute, 562 applications for, 565, 571 atrophic, 585 bacteria in, 562 causes of, 562, 584 chronic, 567 classification of, 538 curetment for, 571 curetment in, 571 diagnosis of, 564, 570 exfoliative, 873 fungous, 569 glandular, 690 gonorrhoea of, 562 hemorrhagic, 569 hypertrophic, 584 infected, 562, 567 interstitial, 568 pathology of, 562, 567 polypoid, 569 prophylaxis of, 563 senile, 563 septic, 562 simple, 566, 583 symptoms of, 564, 569 treatment of, 565, 570 1004 INDEX Endometritis — Cont'd tubercular, 592 varieties of, 538 Endometrium, anatomy of, 527 at menstruation, 528 carcinoma of, 686 epitlielium of, 527 glands of, 528 gonorrhoeal, 562 hyperplasia of, 583 inflammation of, 562 - of adult, 526 of infant, 525 regeneration of, 581 senile, 526, 528 tuberculosis of, 592 Endothelioma, 663 Enemata, 495 laxative, 961 nutritive, 725 directions for giving, 725 indications for, 725 materials for, 725 post-operative, 725, 961 pre-operative, 913 Enlarged liver, percussion of abdomen in, 156 spleen, percussion of abdomen in, 156 uterus, percussion of abdomen in, 154 Enterocele, vulvar, 452 Enteroclysis, 722 Epigastric region, 150, 155 Epithelioma of cervix, 294, 661 of vagina, 289, 435 of vulva, 183, 205, 434 Epithelium of cervical mucosa, 529 of endometrium, 527 of vagina, 383 of vulva, 377 Epoophoron, 808 Erect posture, 1, 2 Ergot in fibromyoma, 637 Erosion, follicular, 540 of cervix uteri, 539 papillary, 539 Erysipelas of external genitals, 405 Ether for examination, 91 for operation, 917 Eversion of cervical mucosa, 233, 548 causes of, 548 diagnosis of, 548 treatment of, 551 Examination, gynecologic, 13 (see note un- der Index) abdominal, 14, 119 anatomy, 16, 18 auscultation, 30 inspection, 15 palpation, 15 regions, 21, 23 special points of tenderness, 24, 26 mass, 27 fluid wave, 25, 27 fat wave, 27, 28 percussion, 15 mensuration, 30 Examination, gynecologic — Cont'd abdominal prominence, 15, 120 obesity, 120 mass in wall, 121 ventral hernia, 124 relaxation of wall, 124 separation of recti, 124 tympanites, 126 fecal impaction, 126 ascites, 126 encysted fluid, 128 pregnant uterus, 129 distended bladder, 129 pelvic tumor, 131 abdominal tumor, 132 movement of wall, 184 discoloration of wall, 15, 134 tension of abdomen, 15, 135 tenderness, 15, 137 in right lower abdomen, 138 in left lower abdomen, 140 in central lower abdomen, 140 in lumbar region, 142 in right upper abdomen, 143 in left upper abdomen, 144 in central upper abdomen, 146 in umbilical region, 1-47 diffuse, 147 mass felt, 22, 148 in right lower abdomen, 149 in left lower abdomen, 149 in central lower abdomen, 150 in right upper abdomen, 152 in left upper abdomen, 154 in central upper abdomen, 155 dullness, 28, 156 from liver, 156 from spleen, 156 from pregnant uterus, 154 from distended bladder, 154 from ascites, 157 from encysted fluid, 162 from pelvic tumor, 163 from abdominal tumor, 165 from kidney tumor, 165 from perirenal lipoma, 169 of external genitals, 31, 170 anatomy, 32, 170 discharge, 32, 176 inflammation, 37, 180 ulcer, 37, 181 swelling, 38. 189 new growth, 38, 205 malformation, 184 hymen, 38 perineum, 39 laceration. 39, 186 vaginal (digital), 39, 224 method, 39 vaginal walls, 42, 225 base of bladder, 43 urethra, 44 vulvo-vaginal glands, 44, 202 pelvic floor, 44, 186, 189 rectum, 48 INDEX 1005 Examination, gynecologic — Cont'd vaginal cervix uteri, 49, 231, 237 pericervical tissues, 52 vagino-abdominal (bimanual), 52, 239 uterus, 53, 238 position, 53, 239 size, 56, 240, 244 shape, 56 consistency, 56, 255 tenderness. 56, 256 mobility, 56, 256 attachments, 57, 256 displacement, 239 enlargement, 240, 244 softening, 255 hard nodules, 255 lateral regions, 58 tube, 60 ovary, 60 ureter, 65 mass or induration, 256 in right lower, firm, 256 in right lower, fluid, 259 in left lower, 263 behind, firm, 263 behind, fluid, 264 in front lower, firm, 266 in front lower, fluid, 266 filling lower pelvis, firm, 267 filling lower pelvis, fiuid, 268 in right side, high, firm, 269 in right side, high, fluid, 276 in left side, high, 281 in median, high, firm, 281 in median, high, fluid, 284 table of diagnostic points, 287 educated touch, 67 train one hand, 69 use two fingers, 70 deep examination, 70 drawing down uterus, 70 position of examiner, 71 varying conditions, 71 intestines in way, 72 diminish tenderness, 73 recto-abdominal palpation in, 73 disadvantage, 73 when useful, 74 of virgin, 74 recto-vagino-abdominal, 75 palpation of coccyx in, 77 instrumental, 77 by speculum, 77 instruments, 77 steps, 80 Information to obtain, 81 difficulties, 82 cylindrical speculum, 83 Sims' speculum, 83 by excision of tissue, 86 by sounding uterus, 87 steps, 87 indications, 88 contraindications, 89 information to obtain, 88 Examination, gynecologic — Cont'd instrumental by curetting, 90 of vaginal walls, 289 congestion, 289 bleeding, 290 ulcer, 290 of cervix, 291 normal, 291 discharge, 291 lacerated, 294 eroded, 294 malignant disease, 294 under anesthesia, 91 preparations, 91 vagino-abdominal palpation, 91 recto-abdominal palpation, 92 recto-vagino-abdominal palpation, 94 recto-vesical palpation, 92 curetment, 95 collecting curettings, 96 exploration of interior of uterus with finger, 96 excision of tissue, 97 preparations for, 98 office arrangements, 99 directions to patient, 99 antiseptic preparations, 100 soap, 103 brushes, 103 lubricant, 104: rubber gloves, 104 specimens, 107 non-gynecologic examination methods, 110 urine. 111 blood. 111 sputum, 115 nervous system, 116 Examination, abdominal, 14, 119, 287 (see note under Index) abdomino-rectal, 73 abdomino-vaginal, 52 anesthesia for, 91 antisepsis in, 100 antiseptic preparations for, 100 bacteriologic, 35 for gonococci, 388 securing discharge for, 33 bimanual, 52. 238 of uterus, 53 brush in, 103 by lamp, 82 chapter on, 1 conjoined, 52 digital, of vagina, 39 disinfection in, 100 ether for, 91 gloves in, 40 gynecologic, 13 (see note under Index) history in, 1 ■ in bed, 106 in standing posture, 50 instrumental, 77 by curet, 90, 95 by excision, 86, 97 by Sims' speculum, 84 1006 INDEX Examination — Cont'd instrumental by sound, 87 by speculum, 77 intrauterine, asepsis in, 101 judgment in, 13 knee-cbest posture in, 72 left band in, 69 metbods of, 13 metbods, classification of, 13 non-gynecologic, 110 microscopic, of curetting, 96, 670 of excised tissue, 97, 670 of pus, 35, 388 of abdomen, 1-4, 119 of Bartbolin's glands, 35 of blood, 111 of cervix uteri, 49, 231 of coccyx, 77 of external genitals, 31, 70, 171 of Fallopian tubes, 60 of kidney, 274 of nervous system, 116 of ovary, 60 of pelvic floor, 44 of rectum, 48 of sputum, 115 of ureter, 68 of uretbra, 44 of urine. 111 of uterus, 53 of vagina, 39, 79 of virgin, 74 of vulva, 31 of vulvo-vaginal glands, 44 office arrangements for, 99 order of, 13 pelvic, 52, 91 physical, 13 preparations for, 98 record of, 11 rectal, 48, 73 recto-abdominal, 73 recto-vagino-abdominal, 75 rubber gloves in, 104 soap in, 103 specimens from, 107 two fingers in, 70 tympanites in, 126 under anestbesia, 91 curetment, 95 digital of uterine cavity, 96 excision of tissue. 97 recto-abdominal, 92 recto-vagino-abdominal, 94 recto-vesical, 95 vagino-abdominal, 91 uterine digital, 96 vaginal, 39, 224 asepsis in, 100 vagino-abdominal, 52 Fallopian tubes, 60 general observations, 66 lateral regions, 58 other regions, 63 ovaries, 66 Examination — Cont'd vagino-abdominal uterus, 53 wben required, 13 Examining fingers, 40 band, 40 table, 98 Excised tissue, microscopic examination of, 97, 670 Excision, examination by, 86 of condylomata, 446 of vulva, 451 technique of, 451 of warts, 445 Excrescence, cauliflower, 297 Exercise, 369 Exfoliative endometritis, 873 Explanation, judgment in, to patients, 758 Exploration, intrauterine, 96 of abdomen, 96 Exploratory abdominal section, 675, 944 (see Abdominal section) curetment, 90, 95 vaginal section. 944 Exstrophy of bladder, 132 External genitals, 375 adhesions of, 446 anatomy of, 32, 170, 375 blood vessels of, 379, 380 caruncle of, 440 chancroid of, 421 condylomata of, 444 cysts of, 446 diseases of, 384 (see Diseases) eczema of, 176, 408 erysipelas of, 405 examination of, 31, 170, 171 gonorrhoea of, 384 hematoma of, 454 hernia of, 452 herpes of, 411 hydrocele of. 454 hyperesthesia of. 464 inliammation of, 36, 180 injuries of, 457 inspection of, 31, 170 intertrigo of, 410 lacerations of, 184 malformations of, 184 malignant disease of, 434 pediculosis of, 412 periurethral abscess of, 438 swelling of, 38, 189 syphilis of, 427 tumors of. 434. 448 ulcers of, 37. 181, 419 ulcus rodens of, 436 urethritis of. 387. 397. 399 varicose veins of, 456 Extirpation of vulva, 451 Extracts, animal, 371 of ovary, 807 Extra-uterine fetus, 283 gestation, 764 pregnancy, causes of, 764 ampullar, 766 INDEX 1007 Extra-uterine pregnancy — Cont'd diagnosis of, 772 hemorrhage in, 766 interstitial, 251 pain in, 773 treatment of, 790 shoclv from, 776 symptoms of, 772 signs of, 778 Exudates, 257 pelvic, 699, 729 F Face mask for operator, 915 Fallopian tubes, 691 accessory, 765 adhesions of, 731, 736 amputation of, 946 anatomy of, 691 anomalies of, 765, 840 carcinoma of, 796 conservative operations on, 946 conservative surgery of, 945 development of, 837 diseases of, 698, 729, 762, 765, 796 (see Dis- eases) displacement of, 731, 736 examination of, 60 gonorrhoea of, 681 hemorrhage from, 786, 793 infection of, 699 inflammation of, 699 malformation of, 840 malignant disease of, 796 neoplasms of, 796 occlusion of, 699, 729 palpation of, 61 papilloma of, 796 resection of, 946 rudimentary, 765 rupture of, 766 tuberculosis of, 762 tumors of, 796 Fat in abdominal wall, 120 (see Abdominal wall) Fatty degeneration, 628 Fecal fistula, 506 Female form, 2 Fermentation fever, 962 Fetal heart sounds, 29 membranes, 96 movements, 27 uterus, 522 Fetus, calcareous degeneration of, 283 extra-uterine, 283 Fever, 112 aseptic, 962 fermentation, 962 in leucocytosis, 113 Fibroid, amyloid degeneration of, 628 cases, classification of, 627 questions for, 636 cystic degeneration of, 628, 651 degeneration of, 628 hemorrhage in, 631 Fibroid — Cont'd interstitial, 626 intrallgamentary, 627 metrorrhagia from, 631 of round ligament, 448 of uterus, radical treatment for, 641 pediculated, 626 submucous, 627 subperitoneal, 625 tumor, infection of, 629 uterine, atrophy of, 625 sarcoma of, 628, 632 wandering, 627 (see Fibromyoma) Fibroma of labia, 207 of ovary, 207 Fibromyoma, causes of, 625 classification of, 627 curetment in, 639 degeneration of, 628 diagnosis of, 634 diffuse, 628 electricity in, 638 ergot in, 637 gangrene of, 629 infection of, 629 interstitial, 625 intrallgamentary, 627 intramural, 625 of uterus, 625 operation for, 641 palliative treatment of, 637 retroperitoneal, 627 submucous, 627 subperitoneal, 626 subserous, 626 suppuration of, 629 symptoms of, 631 treatment of, 637 Fibromyomata, multiple, 626 Finger-cots, 100 Fingers, examining, 40 Fissure, anal, 48 Fistula, 506 classification of, 506 denudation in, 514 fecal, 506 recto-perineal, 506 recto-vaginal, 506 uretero-vaginal, 510 vagino-rectal, 506 vagino-vesical, 510 vesico-vaginal, 510 Fixation of uterus, 606, 675 ventral, 610 Fixing specimens, 107 Flap-splitting operation, 499 Flatus vaginalis, 477 Flexion of uterus, 599 Floor, pelvic, 468 Fluid, encysted, 128 Follicles, Graafian, 802 Follicular cysts, 810 degeneration of cervix, 558 erosions, 540 vulvitis, 180, 405 1008 INDEX Folliculi, hydrops, 810 Foot-rests, adjustable, 98 Forceps, artery, 481 Crossen's puncturing tenaculum, 615 dilating, 88, 572 dissecting, 481 hemostatic, 481 sponge, 481 tenaculum, 552 tissue, 481 uterine, 572 vaginal, 572 Foreign bodies in abdomen, 925, 979 in vagina, 336 in uterus, 882 Form, female, 2 Formal, 107 Formulae, 987 for cathartics, 987 for emmenagogues, 987 for internal use, 987 for local use, 989 for ointments, 989 for powders, 990 for purgatives, 987 for sedatives, 987 for solutions, 990 for stimulants, 988 for suppositories, 991 for styptics, 988 for tablets, 991 for tonics, 989 gynecologic, 987 Fourchette, 376 Function, testing, of kidney, 912 Functional disturbances, 847 Fungous endometritis, 569 Furbringer's method, 916 G Gall-bladder, 130, 146 Gangrene of fibromyoma, 629 of vulva, 407 Gangrenous vulvitis, 407 Garrulty of vulva, 477 Gartner, canal of, 838 duct of, 838 Gas in intestines, 126 Gauze drainage, 958 in drainage, 958 iodoform, 716 packing, 325 strip sponges, 929 tampons, 325 Gehrung pessary, 343 General anesthesia, 91, 917 debility, 111 diseases, 110 investigation, 11 peritonitis, 717 Genitalia, 375 Genitals, external, 375 blood vessels of, 379, 380 diseases of, 384 (see Diseases) Genitals, external — Cont'd examination of, 31, 170 (see Examina- tion) Gestation, ectopic, 764 (see Extra-uterine pregnancy) extra-uterine, 764 in septate uterus, 844 in uterine horn, 271 normal, 241, 250 tubal, 764 Gilliam-Crossen operation, 612 Gilliam-Ferguson operation, 611 Gilliam operation, 611 Gland duct, vulvo-vaginal, 35 Glands, Bartholin's, abscess of, 201, 441 anatomy of, 35, 379 examination of, 35 palpation of, 37 lymphatic, 534 of cervix, 529 of endometrium, 528 Skene's, 378, 399 infection of, 37, 399 of urethra, 378 vulvo-vaginal, 35, 379 abscess of, 441 anatomy of, 35, 379 carcinoma of, 206 cysts of, 443 discharge from, 36 examination of, 44 gonorrhoea of, 398 infection of, 35, 441 inflammation of, 441 palpation of, 37 Glandular endometritis, 583 Glass drainage tube, 954 tube in drainage, 954 Gloves, boiling, 105, 914 in examination, 40 rubber, 40 (see Rubber gloves) Glycerine, 104 Gonococci, bacteriologic examination for, 388 Gonococcus, 389 Gonorrhoea, 384 cause of, 384 chronic, 398 diagnosis of, 387 diplococcus of, 389 in children, 401 latent, 385 of external genitals, 384 of Fallopian tubes, 681 of vulvo-vaginal gland, 398 of uterus, 562, 567 symptoms of, 386 treatment of, 393 Gonorrhoeal endocervicitis, 543 endometritis, 502 maculae, 55 salpingitis, 746, 749 urethritis, 384 vaginitis, 384 vulvitis, 384 Graafian follicles, 800 Gram's method, 391 INDEX 1009 Graves' speculum, 78 Gynecologic diagnosis, 118 (see Diagnosis) abdomen iu, 119 baci--='che in, 302 chapter on, 118 cervix uteri in, 231, 291 corpus uteri in, 238 methods of, 118 pain in pelvis in, 297 pelvic mass in, 256 table for, 287 vaginal, 234 vulvar, 170 disease, relation of insanity to, 759 examination, 13 abdominal, 14 (see Examination) bacteriologic, 384, 387 bimanual, 52, 238 chapter on, 1 digital, 39, 224 history in, 1 instrumental, 77 of external genitals, 31 (see Examina- tion) of virgin, 74 order of, 14 palpation of coccyx in, 77 pelvic, 53 physical, 14 preparations for, 98 record of, 11 recto-vagino-abdominal, 75 under anesthesia, 91 vaginal, 40 (see Examination) vagino-abdominal, 52 (see Examination) when required, 13 formulae, 987 postures, 367 pressure treatment, 364 records, 11 therapy, 304 treatment, internal, 370 intrauterine, 346 (see Treatment) Gynecology, x-ray in, 345 H Hand brushes, 103 sterilization of, 103 disinfection, 915 methods of, 916 examining, 40 Hands, disinfection of, 100, 915 sterilization of, 100, 915 Hard-rubber disk pessaries, 340 Harrington's solution, 914 Head mirror, 82 Heart sounds, fetal, 29 Heat, 100, 307 Hegar's operation, 496 Hematocele, pelvic, 766 Hematocolpos, 185 Hematoma, intraligamentary, 260 of broad ligament, 260 of external genitals, 454 pelvic, 260 Hematoma — Cont'd pudendal, 454 > subperitoneal, 769 vulvar, 190 Hematometra, 255 Hematosalpinx, 786 Hemoglobin, 112 Hemorrhage from Fallopian tube, 786, 794 from ovary, 794 in cervical polypi, 562 in extra-uterine pregnancy, 766 in fibroids, 631 in tubal pregnancy, 766 intraperitoneal, 766 pelvic, 793 post-operative, 960 shock from, 776 subcutaneous, 454 tampon for, 325 treatment for, 791 uterine, 179 vulvar, 454, 457 Hemorrhagic endometritis, 569 Hemostatic forceps, 481 Hermaphroditism, 845 Hernia, 452 abdominal, 124 inguinal, 452 inguino-labial, 452 of external genitals, 452 pudendal, 452 umbilical, 122 vaginal, 452 ventral, 123 vulvar, 452 Herpes of external genitals, 411 of vulva, 411 Herpetic vesicles, 411 History cards, 12 in examination, 1 marriage in the, 6 taking, 1 judgment in, 11 Hodge pessary, 328 Holder, leg, 573 Home, operation in, 911 Horizontal posture, 15 Hospital, operation in, 911 Hot rectal irrigation, 359 vaginal douche, 316 water bag, 308 Hottentot apron, 203 Hydatid cyst, 593 disease, 593 mole, 594 Hydatidiform mole, 594 Hydrocele of external genitals, 454 Hydronephrosis, 262 Hydrops folliculi, 810 Hydrosalpinx, 278, 730, 735 Hydrotherapy, 365 Hydro-ureter, 262 Hymen, 38, 171 absence of, 977 anatomy of, 170 anomalies of, 171 1010 INDEX Hymen — Cont'd atresia of, 184, 185 development of, 840 imperforate, 185 malformation of, 184 rudimentary, 977 Hyperesthesia of external genitals, 464 Hyperplasia of endometrium, 583 Hypertrophic endometritis, 584 Hypertrophy of cervix uteri, 560 of clitoris, 204 of labia, 203, 448 stasis, 191, 448 operation for, 451 supravaginal, 220 Hypodermoclysis, 960 Hypogastric region, 21 Hypospadias, 840 Hysterectomy, abdominal, 641, 677 partial, 947 supravaginal, 641 total, 641 vaginal, 641 varieties of, 641 Hysteria, 116 Hysterorrhaphy, 610 Ice bag, 310 Ichthyol, 322 Ileus, 962 Iliac thrombosis, 963 Illumination, 82 Imperforate hymen, 185 diagnosis of, 185, 842 illustration of, 184 symptoms of, 842, 853 treatment of, 842 Impotency, 894 Incision, 919 abdominal, 919 care, 922 closure, 922 dressing, 922 removing sutures, 951 strapping, 951 suturing, 922 cervical, closure of, 554 for cervix repair, 553 for pelvic floor repair, 483, 496, 500 Emmet's, 489 Hegar's, 497 Tait's, 301 perineal, closure of, 490 suprapubic, 919 Incomplete abortion, 8 Incontinence of urine, 519 Indecent assault, 969 Indications for abdominal section, 752, 910 (see Abdominal section) for conservative surgery, 946 for knee-chest posture, 369 for nutritive enemata, 725 for operation, 910 for repair of cervix, 551 Indications — Cont'd for repair of pelvic floor, 479 Induration, vesical, 266 Infant, endometrium of^ 525 Infantile uterus, 521 Infected endometritis, 562, 567 Infection, 698, 717 localized, 705 of abdominal wound, 962 of cervical wound, 557 of cervix uteri, 542 of corpus uteri, 562 of Fallopian tubes, 699 of fibromyoma, 629 of lymphatics, 664 of ovarian tumor, 830 of ovaries, 699, 730, 734 of peritoneum, 715 of Skene's glands, 37, 399 of urethra, 397 of uterus, 562 of vagina, 387, 413 of veins, 700 of vulva, 402 of vulvo-vaginal glands, 441 puerperal, 715 Inflammation, 384, 698 acute pelvic, 698 (see Acute pelvic in- flammation) chronic pelvic, 728 (see Chronic pelvic in- flammation) leucocytosis in, 115 of endometrium, 562 of external genitals, 36, 180 of Fallopian tubes, 699 of ovary, 730 of pelvic connective tissue, 699, 734 of urethra, 397, 438 of uterus, 562 of vagina, 413, 417 of vulva, 402 of vulvo-vaginal gland, 441 opiates in, 704 pelvic, 141 prophylaxis of, 698 purgatives in, 704 rest in, 306, 704 retrodisplacement with acute, 606 with chronic, 607 Inflated ring pessaries, 340 Infusion, intravenous, 960 Inguinal adenitis, 425 hernia, 452 Inguino-labial hernia, 452 Injections, intrauterine, 562 intravenous, 960 rectal, 48, 73, 358 vaginal, 311 subcutaneous, 960 submucous paraflSn, 344 Injuries from labor, 473, 547 of bladder, 925 of cervix, 547 of external genitals, 457 of intestines, 925 of ureter, 925 < INDEX 1011 Injuries — Cont'd of uterus, 547 of vulva, 457 Insanity from disease, 759 post-operative, 759 relation of, to gynecologic disease, 759 Inspection of abdomen, 15, 119 of cervix uteri, 82, 291 of external genitals, 31, 170 of pelvic cavity, 921 of vaginal walls, 81 of vulva, 31, 170 Instrument sterilizer, 101 Instrumental examination, 77 (see Exami- nation) by curet, 90, 95 by excision, 86 by Sims' speculum, 84 by sound, 87 by speculum, 77 Instrumentation, intrauterine, 87 Instruments, boiling, 100 for curetment, 572 for repair of cervix, 552 for repair of pelvic floor, 481 sterilization of, 101 Internal use, formulae for, 987 Interstitial endometritis, 568 extra-uterine pregnancy, 251 fibroids, 626 fibromyoma, 625 pregnancy, 251, 770 Intertrigo, 410 of external genitals, 410 Intestinal distention, 126 movement, 134 obstruction, 962 paralysis, 961 tenderness, 139 tympany, 126 Intestines, adhesions of, 731, 736 diseases of, 281 gas in, 126 injuries of, 925 Intraligamentary cyst, 260 fibroid, 627 fibromyoma, 627 hematoma, 260 Intramural fibromyoma, 625 Intraperitoneal hemorrhage, 766 Intrauterine applications, 346 douche, 351 examination, asepsis in, 100 exploration, 87 injections, 349 instrumentation, 87 treatment, 346 (see Treatment) Intravenous infusion, 960 injections, 960 Introduction of pessary, 333 Inversion of uterus, 228 Investigation, general, 11 Iodoform gauze, 716 Irrigation, hot rectal, 359 of uterine cavity, 351 of vagina, 311 Irritable uterus, 589 Ischio-rectal abscess, 257 Ischuria, 961 Isthmic pregnancy, 765 Judgment in diagnosis, 118 in examination, 117 in explanation to patients, 758 in history taking, 11 in operations, 909 in palliative treatment, 714 in prognosis, 758 K Kelly's pad, substitute for, 98 Kidney, 139 diseases of, 280 displacement of, 274 examination of, 274 movable, 139 pain in, 10 palpation of, 274 tenderness of, 25 testing function of, 912 tumor of, 167 percussion of abdomen in, 166 wandering, 274 Knee-chest posture, 367 description of, 367 in examination, 72 in gynecologic treatment, 367 in pelvic tumor, 369 in prolapse, 369 in puerperium, 369 in retrodisplacement, 604 indications for, 369 Kobelt's tubules, 809 Kraurosis vulvae, 458 causes of, 458 diagnosis of, 458 pathology of, 458 prognosis of, 460 symptoms of, 458 treatment of, 459 x-ray in, 459 Labia, 170, 375 adhesions of, 185 diseases of, 182, 384 elephantiasis of, 196, 449 fibroma of, 207 hypertrophy of, 203 majora, 375 malformation of, 184, 466 minora, 376 adherent, 184, 466 stasis hypertrophy of, 448 structure of, 375 Labor, injuries from, 473, 547 Lacerated cervix, Emmet's operation for, 551 1012 INDEX Lacerated — Cont'd pelvic floor, Emmet's operation for, 482 Lacerations, 186, 473 of cervix, 292, 547 causes, 547 complications, 549 diagnosis, 549 examination, 550 operation, 551 pathologic changes, 547 prognosis, 557 symptoms, 549 treatment, 551 varieties, 547 of external genitals, 186 of pelvic floor, 186, 473 causes, 473 diagnosis, 44, 186 Emmet's operation, 482 Hegar's operation, 496 pathology, 474 symptoms, 476 Tait's operation, 499 treatment, 478 of perineum, 186 of vulva, 186 Lamp, examination by, 82 Laparotomy, 909 (see Abdominal section) Lassar's paste, 990 Latent gonorrhoea, 385 Lateral regions, palpation of, 58 Lavage, 720 Laxative enemata, 961 Left hand in examination, 69 lateral posture, 85 Leg holders, 573 Leucocytosis, 113 in diagnosis, 114 in fever, 113 in inflammation, 114 in pain, 113 Leucorrhoea, 32 causes of, 176 in children, 415 significance of, 176 treatment of, 903 varieties of, 32 Levator ani, contraction of, 42 muscle, 470 suturing of, 487 Life, chaiige of, 850 Ligament, broad, 535 tumor of, 276 varicose veins of, 797 round, 535 anatomy, 535 fibroids of, 448 • myoma of, 276 operations on, 609 transplantation of, 611 tumor of, 276 sacro-uterine, 533 vesico-uterine, 533 Ligatures, 481, 552 Lipoma of uterus, 658 of vulva, 448 Liquid soap, 103 Lithopedion, 283 Liver, 130 diseases of, 156 enlarged, percussion of abdomen in, 156 Local anesthesia, 73, 322 Local use, formulae for, 989 Localized infection, 962 pain, 5 tenderness, 24 Louse, pubic, 412 Lubricants, 103 Lungs, 111 Lupus vulvae, 431 x-ray in, 433 Lymphadenitis, 425 Lymphangitis, 406 Lymphatic glands, 534 Lymphatics, infection of, 699, 752 of uterus, 533 of vagina, 383 of vulva, 381 Lysol, 990 M Maculae, gonorrhoeal, 387 Malaria, 113 Malformations, 836 congenital, 184, 836 of bladder, 132 of cervix, 255 of clitoris, 184, 204 of external genitals, 184 of Fallopian tubes, 765, 841 of hymen, 184 of labia, 184, 466 of ovary, 841 of urethra, 840 of uterus, 844 absence, 854 bicornis, 838, 844 didelphys, 841 double, 841 duplex, 841 fetal, 872 infantile, 872 rudimentary, 844 septate, 840 unicornis, 841 of vagina, 186, 843 of vulva, 184, 434 Malignant degeneration, 633 disease of cervix uteri, 659 of corpus uteri, 686 of external genitals, 434 of Fallopian tubes, 796 of ovaries, 832 of uterus, 659 of vagina, 435 of vulva, 434 Malposition of uterus, 239 Marriage as cause of disease, 385 • contraindications to, 385 in the history, 6 sterility in, 895 INDEX 1013 Married, dysmenorrhoea in the, 889 Mass in abdomen, 2(), 148 (see Abdomen) Massage in gynecologic treatment, 359 pelvic, 359 Masturbation, 376 Materials for nutritive enemata, 725 Measurements, 30 Melancholia, 116 Membranes, fetal, 96 Membranous dysmenorrhoea, 873 Menge pessary, 341 Menopause, 528 bleeding in, 851 definition of, 850 diagnosis of, 850 duration of, 850 metrorrhagia in, 851 physical changes in, 528 symptoms of, 850 synonyms of, 850 time for, 850 treatment of, 851 Menorrhagia, 863 causes of, 863 diagnosis of, 863 pathologic significance of, 863 symptoms of, 863 treatment of, 865 Menses, suppression of, 862 Menstruation, 528, 672 definition of, 847 delayed, 890 diagnosis of, 849 disorders of, 847 amenorrhoea, 851 delayed menstruation, 890 dysmenorrhoea, 867 menorrhagia, 863 precocious menstruation, 891 retarded menstruation, 890 vicarious menstruation, 891 duration of, 849 endometrium at, 528 physical changes in, 528 physiologic significance of, 850 precocious, 891 relation of puberty to, 848 retarded, 890 symptoms in, 849 synonyms of, 849 time for, 848 treatment of, 850 vicarious, 891 Mensuration of abdomen, 30 Mesenteric cyst, 133 Metastasis, 666 Method, Apostoli, 638 Fiirbringer's, 916 Gram's. 391 Methods in gynecologic treatment, 304 non-gynecologic examination, 110 of diagnosis, 118 (see Diagnosis) of examination, 13 of hand disinfection, 916 of replacement, 603 Metritis, 589 Metritis — Cont'd acute, 566 atrophic, 585 chronic, 567 Metrorrhagia, 179 causes of, 904 definition of, 869 diagnosis of, 904 from abortion, 90, 905 from cancer, 670 from fibroid, 631 from polyp, 562 from tubal pregnancy, 773 in menopause, 851 symptoms of, 867, 904 treatment of, 906 Microscopic examination of curetting, 96, 670 of excised tissue, 97 ■ of pus, 35, 388 Microcysts, 810 Mirror, head, 82 Moist heat in gynecologic treatment, 307 warts, 444 Mole, hydatid, 594 Morgagni. cyst of, 809 Movable kidney, 139 retrodisplacement, 63 Movement, intestinal, 134 fetal, 27 of abdomen, 134 of wall, 134 Mucosa, cervical, epithelium of, 529 eversion of, .548 urethral, prolapse of, 211, 439 Muller, duct of, 836 Multilocular ovarian cyst, 820 Multiple condylomata, 444 fibromyomata, 626 Muscle, levator ani, 470 Muscles, recti, 124 separation of, 124 transverse perineal, 469 Mycotic vaginitis, 415 Myoma, cervical, 628 of round ligament, 276 of uterus, 625 Myomectomy, 641 abdominal, 641 Myometrium, 525 Myxomatous degeneration, 628 N Nausea, 960 Necrobiosis, 628 Necrosis. 629 Needle holder, 481, 552 Sims', 481 Needles, 481, 552 Neoplasms of Fallopian tubes, 796 of ovaries, 799 of uterus, 226, 244, 626 of vagina, 435, 448 of vulva. 434, 448 Nephritis, 111 1014 INDEX Nephroptosis, 273 Nerve trunks, 69 Nerves, pelvic, 69 Nervous system, examination of, 116 Neuralgia, 69 Neurasthenia, 116 Neuromata of vulva, 464 Neuroses, 116, 139 Nodule in cervix, 236 Noma of vulva, 407 Non-gynecologic examination methods, 110 Normal gestation, 241, 250 Nuck, canal of, 452 Nurse, 99 Nutritive enemata, 725 directions for giving, 725 indications for, 725 materials for, 725 Nymphae, 170, 376 Nymphomania, 464 O Obesity, 120 abdomen in, 25, 27, 121 Obstruction, intestinal, 962 of bowels, 962 to coitus, 892 Occlusion of cervix, 255 of Fallopian tubes, 729 of vagina, 842 Office arrangements, 99 assistant in, 99 Oidium albicans, 415 Ointment, Crede's, 349 Ointments, formulae for, 989 Omental cysts, 129 Oophorectomy, 757, 831 Oophoritis, 699, 738 suppurative, 699, 730 Operation, abdominal, 909 Alexander's, 609 anesthesia for, 917 asepsis in, 913 (see Asepsis) assistant in, 915 bowels after, 495 before, 913 cervix, denudation in, 554 technique of, 553 (see Technique) complications of, 954 conservative, in salpingitis, 945 on Fallopian tubes, 945 contraindications for, 910 Crossen's, retrodisplacement, 615 cystocele, technique of, 505 Dudley's, for dysmenorrhoea, 885 - Emmet's, for lacerated cervix, 551 for lacerated pelvic floor, 482 ether for, 917 flap-splitting, 499 for anteflexion of cervix, 885 for cancer of uterus, 677 for displacement, classification of, 609 for fibromyoma, 641 for prolapse, 623 for retrodisplacement, 609 Operation — Cont'd for stasis hypertrophy, 451 Gilliam, 611 Gilliam-Ferguson, 611 Hegar's, 496 in gynecologic treatment, 373 in home, 911 in hospital, 911 indications for, 910 in salpingitis, 714, 744 judgment in, 745 on round ligament, 609 opiates after, 948 pelvic floor, denudation in, 484 technique of, 482, 496, 499 (see Tech- nique) plastic, 480, 551 Porro, 657 preparation for, 911 prognosis in, 958 purgatives after, 950, 961 before, 913 rest after, 952 Schroeder's, on cervix uteri, 557 vaginal, 942 vomiting after, 960 water after, 949 before, 912 Wertheim's, 678 Operator, face mask for, 915 Opiates after operation, 948 in inflammation, 704 Order of examination, 13 Organs, pelvic, 1, 3 Orgasm, sexual, 894 Os, pin-hole, 896 Outlet, vaginal, 470 Ovariotomy, 831 Ovarian abscess, 699, 730 cysts, 810 multilocular, 820 thrombosis, 700 tumors, 799 infection of, 830 percussion of abdomen in, 157, 165 Ovaries, 799 accessory, 841 adhesions of, 736 anatomy of, 799 anomalies of, 841 blood vessels of, 539 cancer of, 832 carcinoma of, 832 cirrhosis of, 739 conservative surgery of, 945 cystadenoma of, 812 cystic degeneration of, 810 cystoma of, 812 dermoid of, 821 development of, 801 diseases of, 679, 718, 730, 799 (see Dis- eases) displacement of, 736, 740 examination of, 60 extract of, 807 fibroma of, 207 INDEX 1015 Ovaries — Cont'd hemorrhage from, 786 infection of, 699, 730 inflammation of, 699 malformation of, 841 malignant disease of, 832 neoplasms of. 810, 832 palpation of, 60 papilloma of, 819 prolapse of, 740 removal of, 888 resection of, 946 rudimentary, 841 sarcoma of, 832 serous cyst of, 816 solid tumor of, 832- supernumerary, 841 tuberculosis of, 760 tumor of, 810 vessels of, 532 Ovaritis, 699 Oviducts, 4, 521, 691 Ovulation, 803 Ovum, 805 Oxalic acid, 916 Oxygen, 988 Packing, 325 gauze, 325 vaginal, 325 Pad, Kelly's, substitute for, 98 Pads and sponges, 914, 929 Pain, 297 in coitus, 892 in extra-uterine pregnancy, 773 in kidney, 10 in pelvis in gynecologic diagnosis, (see Diagnosis) leucocytosis in, 113 localized, 24 Palliative treatment, judgment in, 714 treatment of fibromyoma, 637 Palpation, abdominal, 15, 137 bimanual, 52, 238 digital, 39, 224 of abdomen, 15, 135 of Bartholin's glands, 37 of coccyx, 77 of Fallopian tubes, 61 of kidneys, 274 of lateral regions, 58 of ovaries, 60 of ureters, 68 of uterus, 53, 238 of vulvo-vaginal gland, 37 recto-abdominal, 73 recto-vagino-abdominal, 75 vaginal, 39 vagino-abdominal, 52, 238 Pancreatic cysts, 133 Panhysterectomy, 641 Papillary cyst, 816 causes of, 818 description of, 817 297 Papillary cyst — Cont'd diagnosis of, 819 pathology of, 818 prognosis of, 821 symptoms of, 821 treatment of, 823 erosion, 539 Papilloma of Fallopian tube, 796 of ovary, 821 Paquelin cautery, 345 Paraffin injection, submucous. 344 Paralysis from anesthesia, 918 intestinal, 961 Parametrium, 677 Parasites, vulvar, 412 Paroophoron, 809 Parovarian cyst, 832 Parovarium, 809 anatomy of, 809 Partial amputation of cervix uteri, 557 hysterectomy, 947 Parturition, 473, 547 Paste, Lassar's, 990 Pathologic significance of menorrhagia, 863 Pathology of endometritis, 562, 567 of kraurosis vulvae, 458 of papillary cysts, 818 of peritonitis, 715 of pruritis vulvae, 460 of salpingitis, 699, 729 of tubal pregnancy, 765 (see Tubal preg- nancy) Patients, judgment in explanation to, 758 Pediculated fibroid, 626 Pediculosis of external genitals, 412 Pediculus pubis, 412 Pelvic abscess, 260, 691, 706 (see Abscess) after-treatment in, 713 bacteria in, 746 drainage in, 710 affections, bowels in. 743 anatomy, 1, 520, 691 cavity, inspection of, 921 cellulitis, 699, 734 connective tissue, inflammation of. 699, 734 examination, 52, 91 exudates, 699, 730 floor, 44, 468 anatomy of, 467 blood vessels of, 469 examination of, 44 Emmet's operation for lacerated, 482 incision for repair of, 489, 501 (see In- cision) instruments for, 481 lacerations of. 473 (see Lacerations) operation, technique of, 482, 496, 499 (see Technique) operations, denudations in, 484 repair, incision for, 489, 501 (see In- cision) repair of, 482. 499 (see Repair) suturing of, 489, 497 tears of, 473 1016 INDEX Pelvic — Cont'd gynecologic examination, 14 hematocele, 766 hematom-, 260 hemorrhage, 793 inflammation, 141 acute, 698 (see Acute pelvic inflamma- tion) chronic, 728 (see Chronic pelvic inflam- mation) prophylaxis of, 698 mass in gynecologic diagnosis, 148 (see Diagnosis) massage, 359 nerves, 69 organs, 1, 3 peritonitis, 715 suppuration, 705 tumor, 625, 659 knee-chest posture in, 369 Pelvis, antero-posterior section of, 1, 3 congestion of, 864 echinococcus disease of, 798 pain in, in gynecologic diagnosis, 297 pus in, 699, 730 tenderness in, 63 tuberculosis of, 760 Percussion of abdomen, 28, 156 deep, 30 in ascites, 157 in distended bladder, 154 in kidney tumor, 166 in enlarged liver, 156 in enlarged spleen, 156 in enlarged uterus, 154 in ovarian tumor, 157, 165 in retroperitoneal tumor, 166 in uterine tumor, 165 superficial, 30 Pericaecal abscess, 291 Perineal incision, closure of, 490 Perineorrhaphy, 482, 501 (see Pelvic floor) after-treatment in, 493 preparations for, 480 Perineum, 39, 467 lacerations of, 186 (see Lacerations) suturing of, 489, 502 Perirenal tumor, 169 Peritoneal drainage, 716, 954 Peritoneum, 535 anatomy of, 535 diseases of, 283 infection of, 715 inflammation of, 716 toilet of, 921 tuberculosis of, 764 Peritonitis, 715 bacteria in, 698 causes of, 698 diagnosis of, 702 drainage in, 716 general, 717 pathology of, 717 pelvic, 715 -symptoms of, 717 treatment of, 717 Peritonitis — Cont'd tubercnlar, 761 Perityphlitis, 271 Periurethral abscess^ 438 Pessaries, 328 action of, 329 care of, 336 cup and belt, 342 for cystocele, 342 --' for prolapse, 340 for retrodisplacement, 328 hard-rubber disk, 340 Hodge, 328 Gehrung, 343 in gynecologic treatment, 328 inflated ring, 340 introduction of, 333 Menge, 341 Skene, 343 Smith, 328 Thomas, 328 varieties of, 328 Phagedenic chancroid, 425 Phlebitis, 700, 763 Phlegmasia dolens, 763 Phlegmonous vulvae, 406 Physical change in menopause, 528 in menstruation, 528 examination, 13 Physiologic significance of menstruation, 850 Pincus, atmocausis of, 353 Pin-hole os, 896 Pitcher douche, 494, 965 Placental remnants, 97 Plaster, adhesive, 951 Plastic operation, 480, 551 Points, special, in abdominal section, 923 (see Abdominal section) Polyp, metrorrhagia from, 562 Polypi, 237, 562 cervical, 562 hemorrhage in, 562 of cervix uteri, 562 Polypoid endometritis, 569 Porro operation, 657 Portio vaginalis, 525 Position of arms during anesthesia, 917 of uterus, 595 Posterior displacements, 597 Post-operative adhesions, 962 enemata, 961 hemorrhage, 960 insanity, 759 vomiting, 960 tympanites, 961 Posture, dorsal, 31 erect, 1, 2 gynecologic, 367 horizontal, 15 knee-chest, 367 description of, 367 in examination, 72 in gynecologic treatmeBt, 367 in pelvic tumor, 3€9 in prolapse, 369 in puerperium, 369 INDEX 1017 Posture — Cont'd knee-chest in retrodisplacement, 604 indications for, 369 left lateral, 85 semi-prone, 83 Sims. 83, 85 Trendelenburg, 570 Powders, formulae for, 990 Precocious menstruation, 891 Pregnancy, 130, 241, 249 abdomen in, 130, 242, 251, 254 ampullar, 766 auscultation in, 29 diagnosis of, 240 extra-uterine, 704, 764 (see Extra-uterine pregnancy) in uterine horn, 271 interstitial, 251, 766 isthmic, 766 tubal, 764 hemorrhage in, 766 pathology of, 765 (see Tubal pregnancy) wandering, 771 Pre-operative enemata, 913 Preparations for abdominal section, 753, 911 (see Abdominal section) for anesthesia, 111 for curetment, 571 for examination, 98 for operation, 911 for perineorrhaphy, 480 for repair of cervix, 551 for repair of pelvic floor, 480 for trachelorrhaphy, 551 for vaginal section, 944 of operator, 915 Prepuce, adherent, 184, 185, 466 Preservation of specimens, 10, 107 Proctoclysis, 722 Prognosis in operation, 758 judgment in, 758 of kraurosis vulvae, 460 of papillary cysts, 821 of salpingitis, 727, 758 Prolapse, knee-chest posture in, 369 of bladder, 191, 217 of ovary, 740 of urethral mucosa, 211, 439 of uterus, 211 causes, 619 diagnosis, 621 pathology, 619 radical treatment, 623 symptoms, 620 treatment, 622 of vagina, 189 operation for, 623 pessaries for, 340 vaginal, 217, 504 Proliferating cysts, 812 Prominence of abdomen, 120, 180 Prophylaxis of endometritis, 563 of pelvic inflammation, 698 of retrodisplacement, 597 of shock, 92l of subinvolution, 588 Prurigo of vulva, 411 Pruritus vulvae, 460 causes of, 460 diagnosis of, 461 pathology of, 460 symptoms of, 461 treatment of, 461 x-ray in, 464 Pseudo-hermaphroditism, 845 Pseudomucinous cysts, 813 Psychoses, 116 Puberty, 848 relation of, to menstruation, 848 Pubic louse, 412 Pudendal hematoma, 454 hernia, 452 hydrocele, 454 tumor, 448 Puerperal abscess, bacteria in, 751 infection, 562, 698 Puerperium, knee-chest posture in, 369 Purgatives after operation, 950, 961 before operation, 915 formulae for, 987 in inflammation, 704, 743 Purulent discharge, 32 Pus in pelvis, 705, 744 microscopic examination of, 35, 388 Putting on rubber gloves, 104 Pyaemia, bacteria in, 746 Pyometra, 255 Pyosalpinx, 276, 277, 691 bacteria in, 748 Q Quadrants, 20 Questions, diagnostic table of, 287 in fibroid cases, 636 R Radical treatment for cancer of uterus, 673 for fibroid of uterus, 641 for prolapse of uterus, 623 for salpingitis, 714, 744 Rape, 969 of children, 971 Reasons for conservative surgery, 946 Rectal applications, 358 digital examination, 73 examination, 48, 73 injections, 48, 73, 358 irrigation, hot, 359 touch, 73 treatment, 306 Recti muscles, 124 separation of, 124 Records, 11 diagrams in, 11 gynecologic, 11 of examination, 11 Recto-abdominal examination, 73 Recto-abdominal palpation, 73 Rectocele. 189, 193, 504 Recto-perineal fistula, 506 1018 INDEX Recto-vaginal fistula, 506 Recto-vaglno-abdominal examination, 75 Rectum, 48 carcinoma of, 664 examination of, 48 Regeneration of endometrium, 581 Region, epigastric, 21 hypogastric, 21 umbilical, 23 Regions of abdomen, 18, 23, 135 Regular steps in abdominal section, 760, 916 (see Abdominal section) Relaxed abdominal wall, 124 (see Abdomi- nal V'cill) vaginal outlet, 44 Remnants, decidual, 97 placental, 97 Removal of ovary, 888, 946 of sutures, 951 Renal tumor, 167 Repair of cervix, 551 after-treatment for, 556 denudation for, 554 incisions for, 553 indications for, 551 instruments for, 552 preparations for^ 551 steps in, 553 sutures in, 554 of pelvic floor, 482, 489 after-treatment for, 493 denudation for, 484, 497, 502 flap-splitting operation for, 409 incisions for, 484, 496, 500 indications for, 479 instruments for, 481 preparations for, 480 steps in, 483 Emmet's operation, 482 Hegar's operation, 496 other operations, 504 Tait's operation, 499 sutures in, 490, 497, 502 Replacement, bimanual, 603 methods of, 603 of uterus, 603 of Fallopian tubes, 946 Resection of vaginal outlet, 482 of ovaries, 946 Resonance, corona of, 157 Rest, 306 after operation, 952 in gynecologic treatment, 306 in inflammation, 306 Retarded menstruation, 851 Retention cysts, 558 of blood, 185 of urine, 130 Retractors, vaginal, 481 Retrodisplacement, adherent, 606 cases, classification of, 614 causes of, 597 definition of, 597 diagno^s of, 601 knee-chest posture in, 604 movable, 603 Retrodisplacement — Cont'd of uterus, 597 operation for, 609 pessaries for, 328 prophylaxis of, 597 replacement of, 603 retroversion, 599 symptoms of, 600 treatment of, 603 with acute infiammation, 606 with chronic inflammation, 607 Retroflexion, 599 Retroperitoneal fibromyoma, 627 tumor, 166 percussion of abdomen in, 166 Retroposition of uterus, 239 Retroversion, 599 Retroversio-flexion, 597 Retroverted uterus, 239 Right lower abdomen, 23, 135 Rodent ulcer, 436 Round ligament, 535 anatomy of, 535 fibroids of, 448 myoma of, 276 operations on, 609 transplantation of, 611 tumor of, 276 Routine use of rubber gloves, 104 Rubber dam, 954 drains, 710, 958 gloves, 102, 104 in abdominal section, 755, 916 (see Ab- dominal section) in examination, 104 putting on, 104 routine use of, 104 sterilization of, 104 tube drainage, 710, 958 Rudimentary Fallopian tubes, 765 hymen, 977 ovaries, 841 uterus, 844 vagina, 843 vulva, 840 Rupture of bladder, 130 of Fallopian tubes, 766 Sacro-uterine ligaments, 533 Sactosalpinx, 276 Saline solution, 722 Salpingectomy, 744 Salpingitis. 699, 729 acute, 699 bacteria in, 698 causes of, 698 chronic, 729 conservative operation in, 945 diagnosis of, 701, 732 gonorrhoeal, 746 operation in, 744 pathology of, 699, 729 prognosis of, 727, 757 radical treatment for, 744 INDEX lOliJ Salpingitis — Cont'd suppurative, (lOO, 729 symptoms of, 701, 732 treatment of, 704, 743 tubercular, 7G2 varieties of, 099, 729 Salpingo-oophorectomy, 744 Sarcoma of ovary, 832 of uterine fibroids, 628 of uterus, 689 of vagina, 436 of vulva, 434 Scabies, 413 Schroeder's operation on cervix uteri, 557 Scopolamin in anesthesia, 793 Section, 1, 3 abdominal, 909 after-treatment of, 948 (see Abdominal section) bandage in, 763, 951 contraindications for, 752, 910 dressings after, 771, 951, 954 dressings in, 761, 922 drainage in, 764, 954 exploratory, 675, 944 indications for. 752, 910 position of arms during, 917 preparations for, 752, 753, 911 (see Ab- dominal section) regular steps in, 760, 916 (see Abdom- inal section) rubber gloves in, 755, 916 special steps in, 760, 923 (see Abdominal section) antero-postsrior, of pelvis, 1, 3 Caesarean, 659 exploratory vaginal, 943 vaginal, 942 after-treatment in, 965 preparations for, 944 Sedatives, formulae for, 987 Semi-prone posture, 83 Senile bleeding, 851 endometrium, 526, 528, 563 vaginitis, 417 vulvitis, 417, 460 Separation of recti muscles, 124 (see Ab- dominal wall) Sepsis, 715 Septate utei-us, 840 gestation in, 844 Septic endometritis, 562 Serous cyst of ovary, 816 Sexual disturbances, 892 orgasm, 894 Shape of abdomen, 15, 120 of abdomen in ascites, 126, 128 Shock, 924, 959 causes of, 924 from extra-uterine pregnancy, 776 from hemorrhage, 776 prophylaxis of, 924 symptoms of, 776 treatment of, 959 Significance of leucorrhoea, 176 of menorrhagia, 863 Significance — Cont'd of menstruation, 850 Signs of ascites, 126 of extra-uterine pregnancy, 773 Silkworm-gut, 481 Silver wire, 514 Simple endometritis, 566, 583 ulcer, 419 vaginitis, 413 vulvitis, 402 Sims' needle-holder, 481 posture, 83, 85 speculum, 83, 84 Sinus, 964 Sitz-bath, 308 Skene pessary, 343 Skene's glands, 378, 399 infection of, 399 of urethra, 378 Smith pessary, 328 Soap, 103 in examination, 103 liquid, 103 Soft chancre, 421 Solid tumor of ovary, 832 of vulva, 434, 448 of uterus, 626, 659 Solution, Harrington's, 914 saline, 722, 988 Solutions, formulae for, 990 Sound, instrumental examination by, 87 uterine, 88 Special points in abdominal section, 760, 923 (see Abdominal section) Specimens, fixing, 107 from examination, 107 preservation of, 10, 107 Speculum, 83 bivalve, 78 cylindrical, 83 Edebohl's, 572 examination by, 77, 84 Graves', 78 Sims', 84 Sphincter ani, 493 suturing of, 493 Spleen, 130 diseases of, 156 enlarged, percussion of abdomen in, 156 Split-tube drainage, 958 Sponge forceps, 481 Sponges, 929 abdominal, 929 (see Abdominal section) Crossen's gauze-strip, 929 detached, 934 Sputum, examination of, 115 Standing posture, examination in, 50 Stasis hypertrophy, 191, 448 of vulva, 448 operation for, 451 Stenosis of cervix, 544 of vagina, 842 Steps in curetment, 572 in repair of cervix, 553 in repair of pelvic floor, 482, 496, 499 (see Repair) 1020 INDEX Sterility, 895 causes of, 895 treatment of, 898 Sterilization of abdomen, 913 of abdominal dressing, 914 of abdominal surface, 754, 913 (see Ab- dominal section) of catheters, 966 of hand brushes, 103 of hands, 100, 915 of rubber gloves, 104 of sutures, 914 of instruments, 101 of vulva, 480 Sterilizer, instrument, 101 Stimulants, 959 formulae for, 988 Stitch-hole abscess, 962 Stomach, acute dilatation of, 961 Structure of labia, 375 Stupes, turpentine, 307 Styptics, formulae for, 988 Subcutaneous hemorrhage, 454 injections, 960 Subinvolution of uterus, 587 prophylaxis of, 588 Submucous fibromyoma, 627 paraffin injection, 344 Subperitoneal fibroid, 625, 626 hematoma, 769 Subserous fibromyoma, 626 Substitute for Kelly's pad, 98 Suburethral abscess, 212 Superficial percussion of abdomen, 30 Superinvolution of uterus, 589 Supernumerary ovary, 841 Supporter, abdominal, 733, 951 (see Ab- dominal section) uterine, 342 Supports of uterus, 596 Suppositories, formulae for, 991 Suppression of menses, 862 Suppuration of abdominal wound, 962 diagnosis of, 962 symptoms of, 962 treatment of, 962 of fibromyoma, 629 pelvic, 706 Suppurative oophoritis, 699, 730 salpingitis, 699, 730 Suprapubic incision, 919 Supravaginal amputation, 641 hypertrophy, 220 hysterectomy, 641 Surface, abdominal, sterilization of, 913 (see Abdominal section) Surgery, conservative, 757 (see Conservative surgery) Suspension, ventral, 610 Sutures, buried, 497, 502 catgut, 481 continuous, 488, 491 crown, 489, 491 in abdominal wound, 922, 951 in cervix, 352, 555 in perineum, 489, 502 Sutures — Cont'd in repair of cervix, 554 in repair of pelvic floor, 490, 498, 502 removal of, 951 sterilization of, 914 Suturing of levator ani, 487 of pelvic floor, 489, 497, 502 of sphincter ani, 493 of uterus forward, 609 of vulva, 451 Swelling of external genitals, 38, 189 of vulva, 189 Symptoms in menstruation, 849 of amenorrhoea, 851 of endometritis, 564, 569 of extra-uterine pregnancy, 773 of flbromyoma, 631 of gonorrhoea, 386 of imperforate hymen, 842 of kraurosis vulvae, 458 of menopause, 850 of menorrhagia, 863 of metrorrhagia, 867, 904 of papillary cysts, 819 of peritonitis, 715 of pruritis vulvae, 461 of retrodisplacement, 600 of salpingitis, 701, 732 of shock, 776 of suppuration of abdominal wound, 962 of tubal pregnancy, 773 of vulvitis, 403 Synonyms of menstruation, 849 of tubal pregnancy, 764 Syncytioma malignum, 688 Syphilides of vulva, 199, 430 Syphilis, 427 of external genitals, 427 Table, diagnostic, of questions, 287 examining, 98 for gynecologic diagnosis, 287 Tablets, formulae for, 991 vaginal, 991 Taking history, 1 Tampons, 325 for hemorrhage, 325 gauze, 325 vaginal, 325 T-bandage, 325 Tears of pelvic floor, 473 Technique, aseptic, 915 of cervix operations, 553 partial amputation, 557 regular amputation, 561 of curetment, 572 of cystocele operation, 505 of excision of vulva, 451 of pelvic floor operation, 482, 496, 499 Emmet's, 483, 492 Hegar's, 496 Talt's, 499 Tenaculum-forceps, 552 Crossen's puncturing, 615 INDEX 1021 Tenderness in abdomen, 24, 137 in pelvis, 73 intestinal, 139 localized, 24 of kidney, 25 urethral, 397 I vesical, 63 Tension of abdomen, 15, 135 Tents for dilating, 90 Testing function of kidney, 912 Therapeutic curetment, 571 measures, classification of, 304 Therapy, gynecologic, 304 Thomas pessary, 328 Thrombophlebitis, 700 bacteria in, 701 Thrombosis, broad ligament, 700 iliac, 701, 963 ovarian, 701 uterine, 701 Thrush of vagina, 415 Time for menopause, 850 for menstruation, 848 Tissue forceps, 481 Toilet of peritoneum, 921 Tonics, formulae for, 989 Total hysterectomy, 641 Touch, abdominal, 15 (see Abdominal sec- tion) educated, 67 rectal, 73 vaginal, 39 Towels, boiling, 914 Trachelorrhaphy, 551 after-treatment in, 556 preparations for, 551 Transplantation of round ligament, 611 Transverse perineal muscles, 469 Traumatism of vulva, 457 Treatment, constitutional, 852 for hemorrhage, 960 for menopause, 851 gynecologic, 304 bathing in, 365 cold in, 309 counter-irritation in, 310 dress in, 366 dry heat in, 308 intrauterine, 346 applications, 319, 346 cauterization, 352 curetment, 352 dilatation, 358 electricity, 353 irrigation, 351 vacuum, 358 knee-chest posture in, 367 massage in, 359 methods in, 304 moist heat in, 307 operations in, 373 pessaries in, 328 pressure treatment in, 364 rest in, 306 vaginal applications in, 319 vaginal douches in, 311 Treatment — Cont'd internal, 370 methods of, 304 of amenorrhoea, 854, 861 of bloody discharge, 906 of cystocele, 504 of dysmenorrhoea, 876, 889 of endometritis, 565, 570 of eversion of cervical mucosa^ 551 of extra-uterine pregnancy, 790 of fibromyoma, 637 of gonorrhoea, 393 of imperforate hymen, 842 of kraurosis vulvae, 459 of leucorrhoea, 903 of menorrhagia, 854 of menstruation, 850 of papillary cysts, 831 of peritonitis, 717 of pruritis vulvae, 460 of retrodisplacement, 603 of salpingitis, 704, 743 of shock, 959 of sterility, 898 of suppuration of abdominal wound, 962 of tubal pregnancy, 790 (see Tubal preg- nancy) of urethral caruncle, 441 of vulvitis, 402 palliative, judgment in, 744 of fibromyoma, 637 rectal gynecologic, 306 vaginal, 319 Trendelenburg posture, 570 Trials, criminal, 986 Trunks, nerve, 69 Tubal abortion, 768 abscess, 277, 699, 730 gestation, 764 pregnancy, 764 causes of, 764 diagnosis of, 772 hemorrhage in, 766 metrorrhagia from, 773 pathology of. 765 carried to term, 772 free intraperitoneal hemorrhage. 767 hematocele, 766 hematoma, 769 mass from repeated hemorrhage, 766 tubal abortion, 768 symptoms of, 772 treatment of, 790 advanced cases, 793 before rupture, 790 moderate hemorrhage, 791 pelvic hematocele, 790 pelvic hematoma, 793 profuse hemorrhage, 791 varieties of, 766 Tubercular adhesions, 762 endometritis, 592 peritonitis, 761 salpingitis, 762 vaginitis, 433 Tuberculosis, curetment in, 592 1022 INDEX Tuberculosis — Cont'd of endometrium, 592 of Fallopian tubes, 761 of ovaries, 761 of pelvis, 761 of peritoneum, 761 of uterus, 592 of vagina, 433 of vulva, 431 x-ray in, 433 Tubes, blood vessels of, 693 Fallopian, 691 glass drainage, 954 Tubules, Kobelt's, 809 Tumor, abdomen in, 131, 148 fibroid, infection of, 628 kidney, percussion of abdomen in, 166 of abdomen, 132 of abdominal wall, 121 (see Abdominal wall) of broad ligament, 276 of external genitals, 434, 448 of Fallopian tube, 796 of kidney, 167 of ovary, 810 of round ligament, 276 of uterus, 626, 659 of vagina, 435, 448 of vulva, 434, 448 ovarian, 810 infection of, 830 percussion of abdomen in, 157, 165 pelvic, 625, 659 knee-chest posture in, 369 perineal, 169 pudendal, 448 renal, 167 retroperitoneal, 166 percussion of abdomen in, 166 solid, of ovary, 832 of uterus, 626, 659 of vulva, 434, 448 uterine, 625, 659 percussion of abdomen in, 165 vesical, 132 Turpentine stupes, 307 Two fingers in examination, 70 Tympanites, 126 abdomen in, 126 in examination, 28, 126 post-operative, 961 Tympany, intestinal, 126 U Ulcers, 37, 181, 419 of cervix uteri, 541 of external genitals, 37, 181, 419 of vagina, 419 of vulva, 181, 419 rodent, 436 simple, 419 Ulcus rodens, 436 x-ray in, 438 Umbilical hernia, 122 region, 23, 152 Unicornuate uterus, 841 Ureter, 139 calculi of, 259 diseases of, 259 examination of, 68 injuries of, 929 palpation of, 68 Uretero-vaginal fistula, 510 Urethra, 378 anatomy of, 378 anomalies of, 840 carcinoma of, 434 caruncle of, 440 diverticulum of, 213 diseases of, 384 (see Diseases) examination of, 44 infection of, 438 infiammation of, 438 malformation of, 841 Skene's glands of, 378 Urethral abscess, 438 caruncle, 440 discharge, 33 diseases, 35 mucosa, prolapse of, 211, 439 tenderness, 41 Urethritis, 35, 384, 399 acute, 397 bacteria in, 33 chronic, 399 gonorrhoeal, 397, 399 Urethrocele, 212 Urinalysis, 111 Urine, examination of. 111 incontinence of, 519 retention of, 130 Uteri, corpus, 568 Uterine cavity, 521 irrigation of, 351 curet, 88, 572 digital examination, 96 dilators, 88, 572 diseases, 176 fibroids, atrophy of, 625 sarcoma of, 628 forceps, 572 hemorrhage, 179 horn, gestation in, 271 pregnancy in, 271 sound, 88 supporter, 342 thrombosis, 700 tumors, 625, 659 percussion of abdomen in, 154, 157, 165 Uterus, absence of, 854 adhesions of, 606 anatomy of, 520 anomalies of, 844 atresia of, 255 atrophy of, 589 bacteria in, 562 bicornuate, 841 bimanual examination of, 53 blood vessels of, 531 cancer of, 245, 294, 659 radical treatment for, 673 INDEX 1023 Uterus — Cont'd carcinoma of, 659 cirrhosis of, 589 congestion of, 566 conservative surgery of, 947 development of, 838 diseases of, 238, 537 (see Diseases) displacement of, 239, 595 double, 840 echinococcus disease of, 593 enlarged, percussion of abdomen in, 154 examination of, 53 fetal, 522 fibroid of, radical treatment for, 641 fibromyoma of, 625 (see Fibromyoma) fixation of, 606, 675 flexion of, 599 foreign bodies in, 882 forward, suturing of, 609 gonorrhoea of, 562, 567 infantile, 521, 522 infection of, 562 inflammation of, 562 injuries of, 547 inversion of, 228 irritable, 589 lipoma of, 658 lymphatics of, 533 malformation of, 844 (see Malformation) malignant disease of, 659 (see Malignant disease) malposition of, 239 myoma of, 625, 626 neoplasms of, 226, 244, 626 operation for cancer of, 677 palpation of, 53, 238 position of, 595 prolapse of, 211 (see Prolapse of uterus) radical treatment for, 623 replacement of, 603 retrodisplacement of, 597 retroposition of, 239 retroverted, 239 rudimentary, 844 sarcoma of, 689 septate, 840 gestation in, 844 solid tumor of, 626, 659 subinvolution of, 587 superinvolution of, 589 supports of, 596 tuberculosis of, 592 (see Tuberculosis) tumor of, 626, 659 unicornuate, 841 Vagina, 1, 3 absence of, 185 anatomy of, 381 anomalies of, 840 aphthae of, 415 atresia of, 185 bacteria in, 388, 413 Vagina — Cont'd blood vessels of, 383 carcinoma of, 435 congenital atresia of, 185 congestion of, 81 development of, 837 digital examination of, 39 diseases of, 224, 384 (see Diseases) disinfection of, 480, 575 displacements of, 217 double, 185 epithelioma of, 289, 435 epithelium of, 383 examination of, 39, 79 foreign bodies in, 336 infection of, 384, 413 inflammation of, 384, 413 irrigation of, 311 lymphatics of, 383 malignant disease of, 435 malformation of, 186, 840 neoplasms of, 435, 448 occlusion of, 842 prolapse of, 189 rudimentary, 840 sarcoma of, 436 stenosis of, 842 thrush of, 415 tuberculosis of, 433 tumors of, 435, 448 ulcers of, 419 Vaginal antisepsis, 575 applications, 311 (see Applications) cyst, 223 diagnosis, 244, 289 digital examination, 39, 224 diseases, 176 douche, hot, 316 in gynecologic treatment, 311 drainage, 710, 716 examination, 39, 224 (see Examination) asepsis in, 100 flatus, 477 forceps, 572 hernia, 452 hysterectomy, 641 injections, 311 operation, 942 orifice, dilatation of, 31, 465 outlet, 470 relaxed, 44 resection of, 482 packing, 325 palpation, 39 prolapse, 217, 504 retractors, 481 section, 942 after-treatment in, 965 anterior, 942 exploratory, 766, 943 preparations for, 944 tablets, 991 tampons, 325 touch, 39 treatment, 318 1024 INDEX Vaginal — Cont'd walls, 42 adhesions of, 417 inspection of, 80 Vaginalis, portio, 525 Vaginismus, 464 Vaginitis, acute, 413, 417 adhesive, 417 bacteria in, 385, 413 causes of, 385, 413 chronic, 398, 417 diagnosis of, 387, 414 diphtheritic, 416 emphysematous, 417 gonorrhoeal, 384 in children, 415 mycotic, 415 senile, 417 simple, 413 tubercular, 433 varieties of, 384 Vagino-abdominal examination, 52 (see Ex- amination) hysterectomy, 641 Vagino-rectal fistula, 506 Vagino-vesical fistula, 510 Varicose veins, 197, 456 of broad ligament, 270 of external genitals, 456 of vulva, 197, 456 Varieties of diseases, 32, 176 of dysmenorrhoea, 868, 871 of endometritis, 538 of hysterectomy, 641 of leucorrhoea, 32 of pessaries, 328 of salpingitis, 699, 729 of tubal pregnancy, 766 of vaginitis, 384 of vulvitis, 384 Varix of vulva, 197, 456 Vegetations of vulva, 198, 444 Veins, calculi of, 797 infection of, 700 varicose, 197, 456 Venereal diseases, 384, 421, 427 Ventral fixation, 610 hernia, 123 suspension, 610 Vermiform appendix, 272 Verruca, 444 Vesical induration, 266 tenderness, 41 tumor, 266 Vesicles, herpetic, 411 Vesico-uterine ligament, 533 Vesico-vaginal fistulae, 510 Vessels of ovary, 532 Vestibule, 75, 170, 377 bulbs of, 279 Vicarious menstruation, 891 Violence in coitus, 189 Virgin, amenorrhoea in the, 852 dysmenorrhoea in the, 870 examination of, 74 Virgin — Cont'd gynecologic examination of, 13 Virus, chancroidal, 421 Vomiting, 960 after operation, 960 Vulva, 32, 170 anatomy of, 170, 375 atresia of, 184 blood supply of, 380 vessels of, 381 carcinoma of, 183, 434 chancroid of, 181 condylomata of, 198, 444 contusion of, 457 diseases of, 170 (see Diseases) disinfection of, 480 epithelioma of, 183, 205, 434 epithelium of, 377 erysipelas of, 405 examination of, 31 excision of, 451 extirpation of, 451 gangrene of, 407 garrulty of, 477 herpes of, 411 infection of, 384, 402 inflammation of, 384, 402 injuries of, 457 inspection of, 31, 170 lacerations of, 186 (see Lacerations) lipoma of, 448 lymphatics of, 381 malformations of, 184, 434 malignant disease of, 434 neoplasms of, 434, 448 neuromata of, 464 noma of, 407 phlegmon of, 406 prurigo of, 411 rudimentary, 840 sarcoma of, 434 solid tumor of, 434, 448 stasis hypertrophy of, 448 sterilization of, 480 suturing of, 451 swelling of, 189 syphilides of, 199, 430 technique of excision of, 451 traumatism of, 457 tuberculosis of, 431 tumor of, 434, 448 ulcer of, 181, 419 varicose veins of, 456 varix of, 197, 456 vegetations of, 198, 444 wounds of, 457 kraurosis of, 458 x-ray in, 459 lupus of, 431 pruritis of, 460 x-ray in, 464 ulcus rodens of, 436 Vulvar applications, 321 cellulitis, 406 dermatitis, 402 INDKX 1025 Vulvar — Cont'd diagnosis, 31, 170 (see Diagnosis) diseases, 176, 402 (see Diseases) classification of, 384 dressings, 580 eczema, 408 enterocele, 452 hernia, 452 hematoma. 190 hemorrhage, 454, 457 itching, 460 jiarasites. 412 Vulvitis, 402 acute, 384, 402 causes of, 384, 402 chronic, 401, 405 diagnosis of, 403 follicular, ISO, 405 gangrenous, 407 gonorrhoea!, 384 senile, 417, 460 simple, 402 symptoms of, 403 treatment of, 403 varieties of, 384 Vulvo-vaginal abscess, 441 cvst, 443 gland, 35, 379 abscess of, 441 anatomy of, 35, 379 carcinoma of, 206 cysts of, 443 discharge from, 36 duct, 35 examination of, 44 infection of, 37, 441 inflammation of, 441 gonorrhoea of, 398 palpation of, 37 W Waist constriction, SCO Wall, abdominal, 16, 120 (see Abdominal wall) movement of, 134 vaginal, 42 Wandering fibroid, G27 kidney, 274 pregnancy, 771 Warm applications, 307 Warts, 44 excision of, 445 moist, 444 Water after operation, 949 bag, hot, 308 before operation, 912 Wave in ascites, 27 Wertheim's operation, 678 Wire, silver, 514 Wolffian body, 809, 836 duct, 836 Wound, abdominal, 919 (see Abdominal wound) infection of, 962 suppuration of, 962 sutures in, 922, 951 cervical, infection of, 557 of vulva, 457 X X-ray in cancer, 345, 685 in gynecology, 345 in Ivraurosis vulvae, 459 in lupus vulvae, 433 in pruritis vulvae, 464 in tuberculosis, 433 In ulcus rodens, 438