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THE TREATMENT 
 
 Pelvic Inflammations 
 
 THROUGH THE VAGINA 
 
 BY 
 WILLIAM R. PRYOR, M.D. 
 
 'Professor of Gynecology, New York Polyclinic ; Consulting Surgeon, 
 City (Charity) Hospital ; Visiting Surgeon, St. EJlizabeth 
 Hospital, New York City. 
 
 WITH no ILLUSTRATIONS 
 
 PHILADELPHIA : 
 
 W. B. SAUNDERS 
 
 925 Walnut Street 
 
 1899 
 
Copyright, 1S99, dy W. B. Saunders 
 
 ^ V> 'A . j-v-t-<L/i,.t 
 
TO 
 
 FERNAND HENROTIN, M.D., 
 
 IN 
 
 ADMIRATION OF HIS SURGICAL ABILITY 
 
 AND AS A 
 
 TOKEN OF THE WARMTH OF MY AFFECTION 
 
 THIS WORK 
 
 IFs irnscribeO 
 
 BY 
 THE AUTHOR. 
 
PREFACE. 
 
 This little book has been written at the request of the 
 gentlemen who have attended my lectures in the New 
 York Polyclinic, and is but an elaboration of what I have 
 said and done before my audiences. 
 
 There exists the utmost confusion in the profession 
 regarding the most successful methods of treating pelvic 
 inflammations ; and inasmuch as inflammatory lesions 
 constitute the majority of all pelvic diseases, the subject 
 is an important one : Furthermore, these cases are, as a 
 rule, emergency cases. An attending physician cannot 
 waste time in studying up an operation to be performed, 
 nor can he transport his patient to a distant hospital. 
 
 I have gone into pathology only so far as will enable 
 the operator to identify the lesions. Some stress has 
 been laid upon the physical characteristics of the intra- 
 peritoneal lesions as revealed by vaginal section, for it is 
 upon such an inspection that the nature of further work 
 must be based. It has been my endeavor, having in 
 mind the object for which the book is written, to put 
 down every little detail, no matter how insignificant, 
 which might be of service. 
 
PREFACE. 
 
 The spirit predominant throughout this book is that 
 of an aggressive interference. Yet I have generally laid 
 down also a palliative method of treatment for each 
 disease, to be applied where operation cannot be done 
 I have told what I think and do. The views and meth- 
 ods of others can readily be procured from the medical 
 press. And as I write ex cathedra^ quotations and refer- 
 ences are unnecessary. Still, it must not be imagined 
 that all herein contained is claimed as original. The 
 contribution of any one of us must nowadays be small as 
 the science progresses, and I take pleasure in acknow- 
 ledging my indebtedness to Recamier, Pean, Segond, and 
 Pozzi in Europe, and to Gaillard Thomas, Byford, and 
 Henrotin in America. 
 
 I have had great assistance in the pathological work 
 from Dr. F. M. Jeffries, who has been as interested in the 
 work as I ; Mr. C. L. Remele has been most painstaking 
 in photographing the specimens ; and to ]\Iiss Fanny 
 Elkins is due all credit for the illustrations of the opera- 
 tions. I can only hope that I may succeed in directing 
 the attention of the general practitioner to a surgical 
 treatment of the infectious pelvic diseases of women ; and 
 if I do so, he will find in these pages some hints which 
 
 may be of service to him. 
 
 William Rice Prvor. 
 
CONTENTS. 
 
 PAGE 
 
 Endometritis 17 
 
 Acute and Chronic Septic Endocervicitis 20 
 
 Acute Gonorrheal Endocervicitis 25 
 
 Chronic and Latent Gonorrheal Endocervicitis 25 
 
 Septic Endometritis 26 
 
 Puerperal Infection 34 
 
 Acute Gonorrheal Endometritis 47 
 
 Chronic Gonorrheal Endometritis • 50 
 
 Tubercular Endometritis 52 
 
 Pelvic Inflammation 54 
 
 Salpingitis 63 
 
 Acute Gonorrheal Salpingitis 63 
 
 Acute Septic Salpingitis 69 
 
 Chronic Septic and Gonorrheal Salpingitis 72 
 
 Tubercular Salpingitis 89 
 
 Pelvic Peritonitis 90 
 
 Tubercular Peritonitis 104 
 
 Inflammatory Diseases of the Ovaries 106 
 
 Broad-Ligament Cyst 114 
 
 Adherent Retropositions 117 
 
CONTENTS. 
 
 PAGE 
 
 Broad-Ligament Abscess 121 
 
 Diffuse Pelvic Sui-pikation 123 
 
 Anesthetic • • • . . . . 125 
 
 Curettage 126 
 
 Exploratory Vaginal Section 136 
 
 Conservative Treatment 146 
 
 Conservative Operations upon the inflamed Adnexa Uteri 152 
 
 Preparation of Patient for A Vaginal Section .... 161 
 
 Vaginal Ablation 163 
 
 Ablation en Masse 180 
 
 Ablation by Hemisection .... 187 
 
 Morcellation 209 
 
 Vagino-Abdo.minal Hysterectomy in Puerperal State 215 
 After Treatment of Hysterectomy and Vaginal Sec- 
 tion 219 
 
 Accidents and Complications 223 
 
 Secondary Hemorrhage 227 
 
 Intravenous Injection of Nor.mal Salt Solution . . . 229 
 
 Instru.ments 231 
 
 FORMUL.E 237 
 
 Sterilization 238 
 
 Index 241 
 
ENDOMETRITIS. 
 
 General Considerations. — Believing that the phe- 
 nomena of inflammation in the female genitals have the 
 same general significance as when occurring in other 
 parts of the body, and that pus produced by such in- 
 flammation is caused by the same pyogenic cocci as 
 cause inflammation elsewhere, my conception of its treat- 
 ment is distinctly surgical. In view of the ravages which 
 these inflammations, when neglected, work in woman's 
 special organs, organs important to her no more than 
 to the community, organs so intimately associated with 
 her mental and social as well as her physical life, I am 
 an advocate of .energetic methods of treatment. Pyosal- 
 pinx, ovarian abscess, and peritonitis rarely occur except 
 through the medium of the uterus. The excepted cases 
 where the intestinal tract is to blame for the pelvic lesions 
 are so rare that they but emphasize the rule. Such 
 being the case, the importance of properly treating en- 
 dometritis is apparent. 
 
 But while we combat their diseases, the special func- 
 tions of the organs must be considered, and in our en- 
 deavors to check an invasion from without we must so 
 act as to do the least damage to that peculiar membrane, 
 the endometrium, whose function it is to produce the 
 decidual cell. Therefore I advocate the use of large 
 quantities of mild antiseptics as washes, agents which by 
 their bulk ensure cleanliness, and by their innocuous- 
 ness do not damage the tissues. Conversely, I am op- 
 posed to the use of small quantities of powerful escharotic 
 antiseptics, such as carbolic acid, zinc chlorid, etc. The 
 greater the degree of infection within a cavity, the less 
 the indication for strong antiseptics ; for these but de- 
 2 17 
 
i8 PELVIC INFLAMMATION. 
 
 stroy tissue in a locality whose vitality is already damaged 
 by inflammation, and by the slough caused they produce 
 the most propitious culture medium for the germs not 
 removed. Dead tissue must be cast off by suppuration. 
 If after curettage, for example, in chronic purulent (sep- 
 tic) endometritis, the raw surfaces be painted with car- 
 bolic acid or even iodin, the intra-uterine packing of 
 iodoform gauze will be followed by temperature. Why? 
 Because the superficial slough produced by the applica- 
 tion is not removed by the dressing, retention results, 
 and recovery is accompanied by fever. But if after a 
 clean curettage the uterus be irrigated with boric acid 
 solution, the gauze dressing protects the uterus while 
 the endometrium is in process of repair, and the conva- 
 lescence is afebrile. Sterility commonly follows one 
 method, conception can be expected after the other. 
 That is, the function of the uterus is partially destroyed 
 by one, while its return to a physiological state is pro- 
 moted by the other. 
 
 So far as the treatment of endometritis is involved, the 
 physician is concerned clinically with whether it is puru- 
 lent or no)i-puruIcnt. If purulent, applications to the 
 endometrium are contra-indicated : if non-purulent, appli- 
 cations may be used. But great care must be exercised 
 lest the innocent form be converted into the virulent 
 type. Whenever pus is discharged from the uterus, the 
 woman's position is just the same as that of any other 
 patient who has a purulent discharge from some other 
 part of the body; it is a surgical case. With our present 
 precise methods of examination, and in view of our ability 
 to do clean work under all circumstances, there no longer 
 exists any excuse for employing the opium, poultice, and 
 douche treatment of a spreading infection. The moment 
 a physician sees pus escape from the uterus his anxiety 
 must begin, and the instant an extension to the adnexa 
 or peritoneum sets in, his responsibility becomes great. 
 A woman who has once had tubal or peritoneal disease 
 occupies an unfortunate position in society; she has be- 
 fore her all her life a possibly dangerous operation. For 
 
ENDOMETRITIS. 
 
 19 
 
 a man to sit quietly by and see this condition brought 
 about without attempting to check the infection is to 
 assume a responsibility before his patient and the pro- 
 fession which I always refuse. Be careful lest you con- 
 vert the simple milky discharge of the nullipara into a 
 purulent one by caustics ; and be again careful lest you 
 promote an extension of a purulent disease ; finding the 
 one, let it alone ; detecting the other, check it instantly. 
 
 We may well ask the simple question, why do women 
 have peritonitis so much more often than men ? The 
 answer comes with the question. If then the open in- 
 fected uterus is to blame, why not attack its filth first ? 
 Here the infection began, and from this source the fire 
 is fed. Combat it here. To me it is as rational to incise 
 an axillary bubo and neglect the felon which causes it, 
 as to remove acutely inflamed tubes and ignore the 
 causative endometritis. This I can say to the man who 
 first sees these cases, that whereas we now do many 
 hysterectomies for pelvic inflammation, but few would 
 require it if the uterine inflammation were first energeti- 
 cally and properly treated. 
 
 It must not be understood from what I have said that 
 I believe all forms of endometritis are caused by patho- 
 genic germs. Undoubtedly simple endometritis may 
 be found frequently to be of purely hematogenous origin, 
 and such a type may have the characteristics com- 
 mon to those forms due to germs, except the production 
 of pus. Such an endometritis being purely local, never 
 inducing complications so long as it maintains its type, 
 never causing metastases, is amenable to non-surgical 
 measures. The leucorrhea of the young girl is relieved 
 by tonics and a change of climate; that of the gouty 
 woman is cured by agencies directed against the diathe- 
 sis, etc. Of these states of the endometrium, I will not 
 treat. The neglect to draw clearly the distinction be- 
 tween those changes in the uterus which are hematoge- 
 nous and those produced by germs has led to much 
 confusion among gynecologists regarding the various 
 methods of treatment. It is in the first class that appli- 
 
20 PELVIC INFLAMMATION. 
 
 cations to the endometrium arc permissible. I can but 
 repeat the caution I gave above, for it is exceedingly- 
 easy by means of a filthy sound or dilator to change one 
 type without complications into that other virulent form 
 which is the starting point of processes of the most de- 
 structive kind. 
 
 Forms of Endome'jritis. 
 
 ^^P^^^', , ] Of the Cervix; 
 
 (jionorrheal, > 
 
 Tubercular, J ^^ ^^'^ ^^''P"-^- 
 
 ACUTE AND CHRONIC SEPTIC ENDOCERViaTIS. 
 
 The dense, firm tissue of the cervix has normally great 
 resistant power against all the pyogenic cocci except 
 the gonococcus. Lined as it is by a membrane well 
 supplied with racemose glands, it presents the charac- 
 teristics of other structures so formed. In the mature 
 woman septic endocervicitis does not often exist alone, 
 but in young women it is very common (Fig. I.) Most 
 often it is found to be co-existent with a more or less 
 severe type of corporal endometritis. Where the gono- 
 coccus is the cause of the inflammation, endocervicitis 
 very frequently exists alone. 
 
 Symptoms. — In the acute stage, beyond a sense of 
 weight in the pelvis, little discomfort is felt. There is a 
 profuse purulent discharge from the cervix, tenacious 
 and hard to remove. But in some cases no discharge is 
 noticed other than one normal to the parts, the patho- 
 genic germs being quiescent. Upon examination we 
 find the cervix congested and in very acute stages, 
 bleeding upon the slightest touch. The follicles project 
 from the surface as red papillae and give to the cervix the 
 appearance of being " eroded " or " ulcerated." (Figs. 2, 3). 
 In more chronic cases the Nabothian follicles become af- 
 fected ; certain of the typical glandular follicles become 
 closed, and they too form cysts. This process of in- 
 flammation may be so general and extensive that the 
 
Fig. 2. — «, b, simple papillary erosion; c, follicular, slightly enlarged (Pozzi). 
 
ENDOMETRITIS. 
 
 2r 
 
 cervix becomes riddled with cysts, constituting cystic 
 degeneration. In such cases, in addition to a possible 
 folliculitis, we have presented the appearance of slight 
 rounded elevations projecting upon the vaginal face of 
 the cervix and covered by epithelium. Upon pricking 
 
 ■ Fic;. I. — Transverse section through the upper part of the cervix, showing 
 . the entire mucous membrane. The central cavity is the cervical canal : b, b, 
 internal surface of mucous membrane, presenting small folds, superficial 
 glandular depressions, and large incisions of the arbor vitse {d); ^,g, deep 
 glands ; a, a, ovules of Naboth ; m., in, musculartissue of the uterine wall 
 (Cornil). 
 
 one, either a clear, glairy fluid escapes, or else a drop of 
 pus is squeezed out, leaving a depression. The condi- 
 tion obtains not only upon the surface, but also through- 
 out the entire cervical structure. When the mouths of 
 the glands within the cervix become closed, they may 
 
22 
 
 PELVIC INFLAMMATIOM. 
 
 continue to secrete, and the enlargement becomes more or 
 less pedunculated, forming a polypus (Fig. 4). Even in 
 cases presenting no symptom other than enlargement, a 
 positive diagnosis of the cause can not be determined with- 
 out the microscope. In collecting the secretion, a curette 
 should be used and not a swab, as pressure upon the 
 glands is necessary to dislodge their contents. Where 
 
 Fk;. 3. — Simple follicular cysts of the cervix (Auvard). 
 
 cystic degeneration is present, emotional disturbances 
 are common. Tlie presence of any purulent discharge 
 calls for not only a digital exajiiination, but an ocular one 
 as zvell. 
 
 Diag-nosis. — Endocervicitis alone does not produce 
 the intense pain, fever, and the uterine tenderness which 
 accompany purulent endometritis. The erosions of en- 
 docervicitis can scarcely be mistaken for either the ulcera- 
 tive or nodular cancer of the cervix; but a badly cystic 
 cervix will sometimes closely resemble nodular cancer. 
 The patient's age may still further render the case sus- 
 picious. If cancer exist, a pair of blunt bullet forceps 
 made to grasp the questionable cervix will tear out easily 
 and produce profuse bleeding. In cystic degeneration 
 there is greater strength in the tissues, and pulling the 
 forceps through such a cervix is very difficult and will 
 
ENDOMETRITIS. 
 
 23 
 
 evacuate a number of cysts. It is commonly easy to 
 push a Simpson's sound into a cancer nodule. Cystic 
 degeneration is apt to be general throughout the cervix, 
 whereas nodular cancer is at first — the only period at 
 which it is possible to mistake it for any other condition 
 
 Fig, 4. — Mucous polypi from the interior of the cervix and upon the 
 surface (Pozzi). 
 
 — limited to one portion of the cervix, and even later on 
 in the disease one nodule is prominent over the others. 
 The nodules of cancer are larger than the cysts and have 
 more injected and more vascular edges. It must not be 
 forgotten that both cancer and cystic degeneration may 
 exist in the same subject. Should the diagnosis be still 
 further in doubt, a piece should be amputated and sub- 
 mitted to a pathologist for examination. 
 
24 
 
 PFXVIC INFLAMMATION. 
 
 Trcatinoiit. — Endocervicitis should be vigorously 
 treated. The best application is tincture of iodin, a 
 powerful diffusible antiseptic and astringent. A silver 
 applicator is wrapped with cotton and dipped in the 
 iodin. It is then passed to but not through the internal 
 OS. The cervical speculum should not be used. The 
 cervix, if markedly congested, should be punctured with 
 a scalpel in a half dozen places to produce bleeding, and 
 this should be promoted by hot vaginal douches of ^ ot 
 I per cent. lysol every four hours, continued for one day. 
 The iodin is to be applied every other day except in 
 gonorrhea, and then once each day. Usually, in a few 
 days this treatment will subdue all symptoms of inflam- 
 mation. If the cervix be the seat of polypi, or is hyper- 
 trophied or markedly cystic, it should be amputated after 
 all acute symptoms have subsided. During treatment 
 coition is prohibited. 
 
 The latency of gonorrlieal and septic endocervicitis and 
 the fact that either form of infection may exist witJwiit pro- 
 ducing patliological discharges must be constantly before 
 the physician zvhen he wishes to nse the sound, or to operate 
 upon the cervix. In any case giving the history of a pre- 
 vious purulent discharge or any form of pelvic inflamma- 
 tion, the introduction of the sound through the unster- 
 ilized cervical canal is positively contra-indicated. The 
 application of tincture of iodin to the cervix will super- 
 ficially sterilize it for the use of the sound. If cystic 
 degejieration is present the cysts should be pricked and 
 the pits touched with tr. of iodin. If cervical polypi are 
 present they may be removed without narcosis by using 
 cocain. An applicator wrapped with cotton is dipped in 
 lO per cent, cocain solution and passed into the cervix. 
 It is left there five minutes. The polypus is then seized 
 by Luer's forceps and twisted off The bleeding is usu- 
 ally trivial. If of moment, the cervix is steadied by 
 bullet forceps and iodin painted over the oozing surface, 
 after which the cervix and vagina are packed for twenty- 
 four hours with iodoform gauze. These polypi, although 
 not of cancerous nature, are apt to recur, and it is there- 
 
ENDOMETRITIS 
 
 25 
 
 fore advisable to amputate the cervix by Shrocder's 
 method if more than one polypus is present. 
 
 ACUTE GONORRHEAL ENDOCERViaTlS. 
 
 The gonococci lie upon the surface of the membrane 
 and deep in the glands. Of all acute forms of endocer- 
 vicitis, this is the most common. 
 
 Sjanptoms. — These are the same as those of septic 
 endocervicitis. With gonorrheal infection there is apt 
 to be more erosion and the production of pus is greater. 
 
 The diag-iiosis is based upon finding the gonococcus in 
 the discharges and upon the presence of symptoms of 
 gonorrhea in other parts of the genital tract or urethra. 
 
 Treatment. — Strong solutions of silver nitrate (5j to 
 fSj) may be applied daily so long as acute symptoms 
 exist, but the tincture of iodin and local blood-letting 
 have given me such excellent results that I usually 
 employ them. A slender applicator is wrapped with 
 cotton and dipped in the solution. It is then inserted 
 into the cervix up to the os internum. This application 
 is made every day or two until the discharge of pus 
 ceases. The vagina should be douched with bichlorid, 
 1 : 10,000, every three hours. The complications result- 
 ing from an extension of the infection are gonorrheal 
 endometritis and salpingitis. The cervix infected by the 
 gonococcus should never be irrigated lest the cocci be 
 washed higher into the more important uterine cavity. 
 
 CHRONIC AND LATENT GONORRHEAL 
 ENDOCERVICITIS. 
 
 This condition is more common. A woman may have 
 the gonococcus infect her cervix and pass through a mild 
 attack of " yellow leucorrhea " without disagreeable sub- 
 jective symptoms. Absolutely all discharge may cease, 
 and yet she be" in a condition to infect others and to 
 become acutely inflamed if the cervix be subjected to 
 traumatism. I examined one hundred clinic cases show- 
 
26 
 
 PELVIC INFLAMMATION. 
 
 ing no discharge of pus from the cervix. The gonococ- 
 cus was found in the cervix in twenty-two. This fact of 
 latency explains those accidents which follow the rough 
 use of the sound or operations upon the cervix. The 
 cervix must be scraped with a small curette in securing 
 its discharge, for the cocci lie deep in the glands. 
 
 The symptoms and treatment are the same as for 
 
 septic endocervicitis. In fact 
 the clinical picture of both con- 
 ditions is much the same and 
 bacteriological examination 
 will alone differentiate them. 
 
 After repeated attacks of 
 cervical inflammation the tis- 
 sues about the cervix become 
 infiltrated by connective tissue 
 elements, and as a result the 
 cervix becomes more or less 
 fixed at the vaginal vault. This 
 pericervical thickening and 
 contraction is more marked 
 in the condition described as genital sclerosis (Fig. 5). 
 
 Fig. 5. — Gonococci in the secre- 
 tion from the urethra in fresh gon- 
 orrhea: a, mucus with separate 
 cocci and diplococci; b, pus cells 
 with diplococci ; c, pus cells without 
 diplococci ; X 7°° diam. 
 
 SEPTIC ENDOMETRITIS. 
 
 Acute Septic Endometritis. 
 
 Septic inflammation of the lining membrane of the 
 body of the uterus is not often found to exist in cases 
 which have not recently been pregnant or which do not 
 have neoplasms, as polypi, within the uterus ; but the 
 condition existing as a chronic state may at any time be 
 converted into an acute one by any traumatism inflicted 
 upon the uterus. The causative germs are staphylococci 
 and streptococci (Figs. 6, 7 and 8). 
 
 Symptoms. — There may be a chill, but this is not 
 usual. From twelve hours to three days after the infec- 
 tion the patient begins to have a sense of fulness in the 
 pelvis. In a {q\^ hours this increases to a positive pain, 
 
ENDOMETRITIS. 
 
 27 
 
 and in aggravated cases spasmodic contractions of the 
 uterine muscle follow (" womb cramps "). With the first 
 
 ■%'^^^i&i& mm 
 
 
 Fig. 6. — Normal mucous membrane of the uterus during menstruation. A 
 preparation of the layer removed by curette during menstruation. The figure 
 reproduces the upper third of the membrane. There are small extravasations 
 here and there ; in the deeper parts is almost normal interglanduiar tissue, the 
 glands being somewhat more sinuous than usual. The blood-vessels are full ; 
 the upper layers are partly normal, partly infiltrated with blood cells ; the epi- 
 thelium, for the most part preserved, is here and there raised from its seat and 
 covered with altered blood cells ; hemorrhage into the glands in places ; no 
 appearance anywhere of the fatty degeneration described by certain authors 
 (Williams, Kundrat, Engelmann). It is very likely that sometimes during 
 menstruation part of the mucous membrane is destroyed (Leopold, Wyder), 
 and that there is no such desquamation at other times (Moericke). This 
 figure shows that the different changes may be simultaneous, and that there 
 is great diversity m the process : a, Normal uterine tissue formed of numerous 
 rounded embryonal cells ; i, same, infiltrated with blood corpuscles to a con- 
 siderable depth; c, dilated vessels, full of blood; d, intact uterine mucosa; e, 
 place where it has become detached ; /, longitudinal section of a gland ; the 
 epithelium near its mouth has disappeared ; £-, dilated glands ; k, gland whose 
 lining epithelium has become detached ; i, normal deep glands ; j, mucous 
 membrane raised by infiltration of blood (Pozzi). 
 
 symptom there takes place a slight rise in the tempera- 
 ture, and the evening temperature is usually one degree 
 
28 
 
 PELVIC INFLAMMATION. 
 
 higher than the morning. Or, there may be no fever. 
 The subjective symptoms rapidly increase until within a 
 few hours the discharge begins. At first this is muco- 
 purulent, but generally by the end of the first day it has 
 become distinctly purulent and may be tinged with blood. 
 The woman takes to bed, so great is the suffering, and 
 
 Fig. 7. — Acute endometritis. Slightly enlarged view of entire mucosa : a, 
 Superficial layer formed of more or less altered tissue, infiltrated with coagu- 
 lated blood ; b, round-celled embryonal tissue ; c, zone in which these cells are 
 especially numerous ; d, large dilated and varicose vessels gorged with blood ; e, 
 lymph spaces ; /, transverse sections of glands ; g, glandular cul-dc-sac (PozziJ. 
 
 soon after the onset the pain has become general over 
 the pelvis. If the infection occurs at the menstrual time, 
 the flow is increased considerably and the blood is apt 
 to clot. 
 
 Upon examination the suprapubic region is sensitive. 
 The finger introduced into the vagina passes without 
 evidence of suffering until the cervix is touched, when 
 the patient will jump and utter an exclamation. If 
 
ENDOMETRITIS. 
 
 29 
 
 bimanual examination is possible, the entire uterus will 
 be found exceedingly sensitive and more or less fixed in 
 the pelvis. This fixity is not due to peritonitis or tubal 
 disease in all cases, but to a tonic contraction in the liga- 
 ments supporting the organ. Examining with the specu- 
 lum, a rope of mucopus is seen hanging from the cervix. 
 
 Wi 
 
 
 V 
 
 Fl(5. 8. — Microscopic section of tlie normal endometrinm, sliowing the 
 utricular glands extending into the muscular tissue (Beyea). 
 
 The cervix is deeply congested, and in cases due to infec- 
 ting plastic operations upon the cervix the tissues may 
 be in a sloughing condition. Wherever there has been 
 a break in the cervical or vaginal tissues there will be 
 found a patch of gray false membrane. This is only 
 occasionally the case in staphylococcus infection, but 
 almost invariably in streptococcus inoculation. The 
 cervix may bleed upon the slightest touch ; it is soft and 
 the OS more open than normal. After existing for a few 
 days, the case either presents the symptoms of some 
 complication or the acute symptoms subside. In the 
 latter event, after three days the woman feels better, the 
 
3° 
 
 PELVIC INFLAMMATION. 
 
 discharge diminishes, and within a week she is able to be 
 up. TJiis happy result is not often seen in untreated 
 cases, and in those cases which do recover without com- 
 plication, the inflammation usually persists as a chronic 
 process. 
 
 Differeiitial Diag-nosis. — There is usually a history 
 of traumatism, such as an operation or invasion of the 
 inside of the uterus or of abortion or labor. This is 
 lacking in gonorrhea. Again, in gonorrhea there is to be 
 found usually some other manifestation of that disease, 
 as urethritis or Bartholinitis, or vulvitis. Endoccrvicitis 
 does not present the grave symptoms which are due to 
 endometritis. Acute tubal and ovarian inflammation and 
 peritonitis give signs in the peri -uterine tissues which are 
 not found with uncomplicated endometritis. 
 
 Sequelee. — The most common sequela of a neglected 
 septic endometritis in a nuUiparous uterus is salpingitis. 
 The peritoneum may become involved, and from this 
 point the infection may spread so as to implicate the 
 ovaries and general pelvic peritoneum. The uterus may 
 be retroposed or become so, and will become adherent 
 in its displaced position. 
 
 Treatment. — Non-operative. — If the condition fol- 
 lows a septic plastic operation, all sutures should at once 
 be removed and the wound painted with tincture of iodin. 
 No vaginal dressing should be applied, but the freest 
 possible exit to the pus afforded. Warm vaginal douches 
 of one-half of one per cent, lysol or three per cent, boric 
 acid are to be used every three hours. Attempts should 
 always be made to wash out the uterus. The ease with 
 which this may be done is dependent upon the state of 
 the cervical canal. The patient is placed in Sims' posi- 
 tion and the perineum drawn back. The operator and 
 his material are sterilized (see sterilization). The cervix 
 is sterilized by means of an application of iodin (see endo- 
 ccrvicitis), steadied by a pair of blunt bullet forceps, and 
 the direction of the uterine canal found by a sound. A 
 Fritsch-Bozeman catheter to suit the size of the cervical 
 canal is then introduced up to the fundus (Fig. 9). No vio- 
 

 
 J' 
 
 \\ I 
 
 \\ * 
 
 Fig. 9. — Irrigating the uterus through a double-current catheter. 
 
ENDOMETRITIS. 
 
 33 
 
 lence is to be used. The irrigator (see sterilization) should 
 be five feet above the patient. At first a quart of Thiersch 
 solution is allowed to flow through the catheter, to be 
 followed by at least four quarts of a three per cent, solu- 
 tion of boric acid crystals. The treatment varies accord- 
 ing to the progress of the case. Often one such washing 
 will suffice to subdue acute symptoms ; but, if after wait- 
 ing twelve hours, the patient is not markedly better, the 
 washing is to be repeated. The irrigations are to be made 
 once or twice daily, the physician being governed by the 
 amount of discharge and the symptoms. An ice-bag 
 should be worn over the pubes continuously until con- 
 valescence begins. The sense of weight and even the 
 inflammation are materially lessened by local blood- 
 letting. This is done by superficial stabs into the cervix 
 with a bistoury. 
 
 After the acute symptoms subside, the case is to be 
 treated as are cases of chronic endometritis. The pain 
 is sometimes unbearable. In vigorous individuals phena- 
 cetin, grs. v, with codein, gr. ss., may be administered 
 and repeated in two hours if needed. Or a rectal sup- 
 pository of extract of opium and ext. belladonna, each 
 gr. ss., may be given. But in administering these drugs 
 the sympt ms are so masked that the extension of the 
 disease may not be appreciated, and it is therefore advis- 
 able to avoid them. It is not necessary to purge these 
 patients; merely normal stools are all that are required. 
 The rectum must be kept empty. 
 
 If after two days' treatment the local and general symp- 
 toms do not improve, an extension to theadnexa or peri- 
 toneum is to be suspected. During the treatment, light 
 vaginal tampons of iodoform gauze may be used instead of 
 the douches, where the uterus is subjected to jarring by 
 vomiting. 
 
 Surgical Treatment. — In view of the possible exten- 
 sion of the infection to the peritoneum and adnexa, it is 
 important to check the disease at once. This -can be 
 done with certainty by a properly performed curettage 
 (see curettage). The responsibility resting upon the at- 
 
 3 
 
34 
 
 TELVIC INFLAMMATION, 
 
 tendant is so great that he should in all cases place him- 
 self clearly on record with his patient and compel her to 
 assume responsibility for any complication which may 
 follow a neglect to clean out an infected uterus. If the 
 curettage has been improperly performed or done too 
 late to check an extension to the tubes and peritoneum, 
 it will be necessary to open the cul-de-sac and treat the 
 adnexa (see cul-de-sac operation). 
 
 PUERPERAL INFECTION. 
 
 This is an infection occurring during the first four 
 weeks after delivery. Infection ensuing after that time 
 is not puerperal infection, but is merely endometritis in 
 a large uterus ; and treatment applied to an infected 
 uterus after the puerperal month is not the treatment of 
 a puerperal uterus, although the lesions may be the re- 
 sult of a puerperal infection. Therefore, curettage or 
 hysterectomy done some six weeks after delivery is not 
 to be considered as having been applied for puerperal 
 fever. The condition of the tissues one week and six 
 weeks after labor are so different that the lesions pro- 
 duced are different, and the dangers from a hysterectomy 
 at the two intervals are about as fifty per cent, to five per 
 cent. Infection after abortioji is similar to that after labor. 
 But the smaller uterus with its less active lymphatics and 
 vessels, when infected, produces less septicaemia. The 
 gravity of the symptoms is Usually in direct ratio to the 
 period of gestation. The infections after early abor- 
 tions, as at the fourth week, take on the type of endo- 
 metritis. The later abortions assume the characteristics 
 of infection at full term. The line cannot be sharply 
 drawn between those cases to be classed purely as abor- 
 tions and those which shall be called puerperal. 
 
 It is eminently proper that I describe in a separate 
 chapter the forms of infection occurring during the puer- 
 perium. More especially am I prompted to do this be- 
 cause the method of treatment I employ is somewhat 
 different from that of most sureeons and because these 
 
ENDOMETRITIS. 
 
 35 
 
 cases commonly fall into the hands of the general prac- 
 titioner. 
 
 The puerperal uterus may be the seat of an invasion by 
 any one of the pyogenic cocci and various bacilli. The 
 lesser degrees of infection are caused by staphylococci 
 and the more virulent by streptococci. These produce 
 septic endometritis. Certain saprophytes when intro- 
 duced into the puerperal uterus produce /?//77'ir/ endome- 
 tritis. 
 
 The activity of these microbes results in the produc- 
 tion of toxins which alter the chemical processes in the 
 body and may cause death. 
 
 The infection starts in the endometrium and may be 
 general over the whole inside of the organ or limited to 
 the placental site. 
 
 If putrid infection occurs there will be found over a 
 certain area of the endometrium a patch of slough in 
 which the saprophytes are situated, more or less mixed 
 with other germs. Beneath this patch there is arranged 
 in the endometrium an aggregation of white blood cor- 
 puscles whose presence tends to prevent an extension of 
 the saprophytes into the deeper parts of the organ. 
 
 In septic infection the cocci lie either upon the surface 
 of the endometrium, within it, or may even penetrate into 
 the peri uterine structures. 
 
 Putrid infection results in a sapraemia, while septic 
 infection causes a septicaemia. 
 
 Putrid infection, pure and unmixed with septic germs, 
 is a superficial affection and does not destroy life. But 
 inasmuch as the necrotic area is so likely to become the 
 point of entry of septic germs, the appearance of sap- 
 rsemia is often the forerunner of a septic process. 
 
 Septic Puerperal Endometritis.- — The cocci enter the 
 walls of the uterus through the lymphatics or the vein's. 
 As they proceed we have perhaps the veins filled with 
 infected blood clots, tlirombo-pldebitis; or there may be a 
 pelvic, then a general, lymphangitis (Fig. lo). The perito- 
 neum lying near the infected spots throws out a quantity 
 of serum and lymph and a peritonitis results. Immediately 
 
PELVIC INFLAMMATION. 
 
 Fig. io. — Lymphatics of the pelvic visccra^and^abdomen : A, Aorta; B, 15, 
 iliac arteries; C, C, the bifurcation and two branches of the iliac arteries; D, 
 vena cava; E, left renal vein; F, right renal vein; G, iliac veins; H, H, ure- 
 ters, I, rectum; K, uterus; L, cervix; M, M, vaginal walls; N, N, Fallopian 
 tubes ; P, P, ovaries ; Q, Q, round ligaments ; i, Deep lymphatic vessels of the 
 right kidney, and ganglia into which they empty; 2, 2, 2, 2, superficial lym- 
 phatic vessels; 3, 3. 3, 3, the same ; 4, two gangha that receive these superfi- 
 cial vessels; 7, 7, subovarian plexus of lymphatics; 8, 8, ducts leading from 
 this plexus; 9, g, the same; 10, 10, 11, 11, glands receiving these ducts; 12, 
 12, 12, 12, lymphatic ducts, originating m the fundus uteri, and terminating in 
 the same glands as the ovarian ducts ; 13, 13, ducts from the anterior surface 
 and sides of the uterus; 14, 14, glands into which they empty; 15, 15, ducts 
 originating in cervix and upper part of vagina ; 16, 16, glands into which they 
 e.npty; 17, 17, efferent vessels of these glands; 18, 18, lymphatic ducts from 
 posterior surface of the uterus and glands into which they empty ; 19, lumbar 
 gland (exceptional); 20, gland into which occasionally a duct from lower uter- 
 ine segment empties (Sappey). 
 
ENDOMETRITIS. 
 
 37 
 
 adjacent to the infected vessels suppuration may occur, 
 and this may take place primarily in the folds of the 
 broad ligament or in the ovary, and subsequently the 
 fallopian tube and pelvic peritoneum may be the seat ot 
 a suppurative process (Fig. ii). 
 
 In some cases the gross lesions are all local, but occa- 
 sionally as in cases reported by the author as early as 
 1886, and again in 1895, spe- 
 cimens have been shown in 
 fatal cases where there were 
 no gross lesions observable in 
 the pelvis, but only at some 
 distant point, such as the dia- 
 phragmatic peritoneum, the 
 pleura or the heart membranes. 
 
 The more virulent and rapid 
 the infection the less are the 
 local manifestations of the dis- 
 which die. 
 
 ease m 
 
 Fig. II. — Streptococcus pyogenes 
 
 in pus (X 1000) (Frankel and 
 
 Pfeiffer). 
 
 cases 
 There is in some instances 
 produced a stasis in the in- 
 fected uterus, and before it is possible for masses of 
 lymph to be effused or pus to be produced the patient is 
 dead. A fatal result of course more speedily ensues in 
 the thrombo-phlebitic type. If the patient recovers 
 through the action ofnatural processes only, it will be with 
 damaged pelvic organs. The pelvic lymphangitis results 
 in the production of connective tissue in the broad liga- 
 ments, which bind and fix the uterus. The effusion of 
 lymph upon the pelvic peritoneum results in the occlu- 
 sion of the tubes and all the various forms of adhesions 
 to be found in the pelvis. There may also be found pus 
 foci in the broad ligament, the ovary, or even, as a 
 secondary complication, in the tube. The organs higher 
 in the abdomen may be bound to each other, and there 
 may be adhesions in the diaphragmatic pleura. As a 
 result of endocarditis the valves become distorted and 
 permanent heart lesions are found. Throughout the 
 body, along the lymphatics of the supra-clavicular 
 
^S PELVIC INFLAMMATION. 
 
 spaces, in those of the groins and at other points buboes 
 may form and result in disfiguring scars. A thrombo- 
 phlebitis in a leg may permanently interfere with its cir- 
 culation, and articular inflammations result in stiff joints. 
 Finally, any one or all of the results of a profound 
 degree of general septiccEmia may be noted. The 
 graver sequelae are endocarditis, pneumonitis and nephri- 
 tis. Naturally women who have suffered from septicae- 
 mia are particularly prone to contract phthisis. 
 
 It is not the province of this book to enter more 
 elaborately into a description of the methods of con- 
 tagion, etc., for these points are elaborated in many works 
 on obstetrics. I have stated enough to show the im- 
 portance of early treatment, not only that life may be 
 saved — we have passed beyond that — but that the rav- 
 ages of sepsis in the system may be prevented. We 
 have ceased to be guided solely by the mortality, and 
 are attacking the morbidity statistics (Fig. 12). 
 
 Post partum women may have a rise in temperature 
 from general causes as well as from intra-uterine infec- 
 tion. Before proceeding to treat the uterus, the respon- 
 sibility for the rise in temperature must be placed there. 
 It is taken for granted that so soon as the pyrexia has 
 been noticed, the attending physician has eliminated the 
 element of intestinal toxicosis by washing out the colon 
 with normal salt solution, and likewise has proven the 
 case non-malarial by the administration of a large dose 
 of quinin. It is an undoubted fact that seventy-five out 
 of every hundred women who have a rise in temperature 
 after labor, will reach a normal state in a few days, if left 
 alone. But among the other twenty- five will be found a 
 few who will perish in a few days if not treated, and the 
 others of that number will be invalids for life. It is 
 most desirable that every physician in America have the 
 ability to make cultures from the inside of the uterus, 
 and in this way be able to differentiate the various 
 causes of puerperal fever. Still, few of the expert 
 bacteriologists agree upon one plan of collecting these 
 discharges, and they are still debating about it. The 
 
Fig. 12. — Specimen from a patient who died septic, showing the material 
 that would be found to be removed by the curette or the finger on the 
 " roughened placental site." " Clots in the uterine sinuses" (Army Medical 
 Museum, Washington, D. C, No. 10,619). ("An American Text-Book ol 
 Obstetrics.") 
 
ENDOMETRITIS. 
 
 4T 
 
 fact remains, anyway, that the great body of the profes- 
 sion prefers to be governed by clinical symptoms rather 
 than bacteriological examinations when made by any 
 except the most skilled. Therefore, the family physi- 
 cian who attends most of these cases of puerperal fever 
 must either waste important time while determining that 
 a given case is virulent streptococcus infection or not, or 
 else he must apply that method of treatment which will 
 do good in all cases and harm in none: At least; any 
 sensible man will, though a theorist may not. 
 
 Having flushed' out the bowel, cinchonized the patient 
 and having excluded all other causes for the fever, if the 
 patient evidently suffers from an infection starting from 
 the uterus, I proceed as follows : 
 
 Treatment. — The patient's vagina should be thor- 
 oughly cleansed by a prolonged douching with bichloride 
 of mercury solution, i : io,000. The operator prepares 
 his hands and material as described in the article upon 
 sterilization. All of this is done before an examination 
 is made. Inasmuch as putrid infection remains superfi- 
 cial and sepsis at one stage is also only upon the surface 
 of the endometrium, I advocate intra-uterine douches. 
 The time element is important. If seen within twelve 
 hours of the onset of the first evidences of infection, 
 before the germs have penetrated the deeper layers of 
 the decidua, intra-uterine irrigations will cure. But if 
 the patient is seen after the germs have passed into the 
 decidua, some antiseptic must be employed which will 
 be more rapidly absorbed than they can proceed, as 
 iodin in the form of iodoform. If they have passed still 
 deeper, curettage is needed. 
 
 Should the invasion have passed outside the uterus, 
 curettage and the cul-de-sac incision with proper dress- 
 ings applied to the pelvis will cure nearly every case. 
 The excepted cases are those in which purulent perito- 
 nitis has set in, cases of thrombo-phlebitis, and those 
 with some mortal complication, as endocarditis. Rarely 
 will hysterectomy be indicated, so rarely in fact that I ad- 
 vise against it except under the circumstances which 
 surround one in a perfectly appointed hospital. 
 
42 
 
 PELVIC INFLAMMATION. 
 
 Puerperal infection is wound infection and should be 
 treated as such. 
 
 Irrigation of the Uterus. — The vulva should be 
 shaved and the patient placed in the lithotomy posture 
 on the table, with a suitable arrangement made for 
 catching the irrigating fluids. A sheet tightly rolled 
 and shaped like a horseshoe may be laid under the 
 buttocks, and a piece of rubber cloth over this will pro- 
 tect the clothing and floor. The vagina is irrigated 
 with four quarts of bichloride solution i : 10,000. The 
 perineum is drawn down by either a speculum or the 
 fingers and the anterior lip of the cervix is seized with 
 my blunt bullet forceps (see Fig. 42) and drawn down. 
 The largest return-flow irrigating tube (see No. 4, Fig. 
 49) is then passed to the fundus. In doing this the in- 
 strument is not allowed to touch any part of the patient 
 until the cervix is reached, and the utmost gentleness is 
 employed to avoid bruising the endometrium. The 
 tube of the fountain syringe is then attached and the 
 current turned on. I first allow one quart of Thiersch 
 solution to pass into the uterus, to be followed by six or 
 eight quarts of boric acid or salt solution (see Fig. 9). 
 
 Frequently this one washing will suffice to control all 
 symptoms. The operator remains in the house for an 
 hour and repeats the procedure. The rectal temperature 
 is taken every half hour. If in four hours the tempera- 
 ture is not normal, the uterus is again irrigated, and is 
 packed full of iodoform gauze, 10 per cent, strength. 
 This packing is made in the following manner: The 
 strips of gauze are four inches wide. While steadying 
 the uterus with the heavy forceps, the operator seizes 
 the end of the gauze in Hunter's forceps, and passes it 
 to the fundus. He continues to insert the strip until the 
 uterus is filled, the end of the gauze extending into the 
 vagina. The vagina is then packed with iodoform 
 gauze. The iodoform becomes rapidly disintegrated in 
 the presence of the uterine discharges and free iodin is 
 detected in the urine in three hours. 
 
 If in twenty-four hours after this, the temperature is 
 
ENDOMETRITIS. 
 
 43 
 
 not normal, the operator proceeds to curette the uterus 
 and open the cul-de-sac; for the infection being no 
 longer superficial, it is impossible to say how far it has 
 extended; presumably it has passed to the peri-uterine 
 lymphatics, and it will be necessary to treat these by 
 sterilizing dressings. 
 
 But if the temperature is normal in a day, the packing 
 is allowed to remain in the uterus for forty-eight hours 
 and is then withdrawn. It is not renewed. It is almost 
 needless to say that the presence of retained membranes 
 or placenta requires their careful renewal before institut- 
 ing this treatment. I must advise against digital explora- 
 tion of the uterine cavity, unless it is followed by irriga- 
 tion and gauze packing. It is most difficult to disinfect 
 the finger, whereas instruments are easily cleansed by 
 boiling. Whenever I suspect the presence of placental 
 tufts or membranes their removal is to be made under 
 chloroform by Luer's forceps or Munde's curette. 
 
 And if retained placenta is accompanied by symptoms 
 of sepsis, its removal is to be accompanied by curettage 
 of the uterus; for it is presumed that under the circum- 
 stances the infection also invades portions of the endome- 
 trium other than the placental site. 
 
 Curettage. — The uterus is drawn down as before and 
 washed out with several quarts of bichloride i : 1 0,000. 
 The antiseptic is not contraindicated here, for it is in- 
 tended to remove the decidua and no slough will follow 
 its use. Taking the largest sized curette, the operator 
 introduces it into the uterus and systematically curettes 
 the entire surface. It will not be necessary to use force 
 as the tissue is soft. The bleeding is pretty free, but is 
 to be ignored. After curetting the organ, it is again 
 washed out with the large irrigator, which has been 
 resterilized while the curettage was proceeding. At this 
 second washing I employ boiled salt solution at a temper- 
 ature of about 115° F. The uterus is then packed full 
 of iodoform gauze, 10 per cent, strength. The size of 
 the cervical canal will largely govern the width of 
 the strip to be used. As the patient is under chloro- 
 
44 
 
 PELVIC INFLAMMATION. 
 
 form a large strip can be inserted, usually nine inches 
 in width. The organ is to be tightly packed, and the 
 vagina also filled. In two days these dressings are re- 
 moved, and a second packing made, but not so firmly. 
 The cervix will be found widely open. This second 
 dressing is taken out in two days more and the patient 
 is put on ergot and quinia. 
 
 If this treatment has not subdued the symptoms in 
 forty-eight hours, the cul-de-sac must be opened. 
 
 The Cul-de-Sac Operation. — Whenever I curette the 
 uterus for se/^si's I immediately open the cul-de-sac. In 
 cases of putrid infection and where retained placenta is 
 sought curetting alone will suffice. But in the presence 
 of sepsis which has not yielded to the non-operative pro- 
 cedures, I have never been able to determine how deeply 
 in the tissues the infection has extended. And as the 
 cul-de-sac operation is devoid of danger, and my anx- 
 iety is great lest the infection run away from my reach, 
 I always open the cul-de-sac whenever I curette for 
 sepsis, z. e., when milder procedures have failed. 
 
 The patient is under chloroform. The vagina is pre- 
 pared as described elsewhere ; and if there could be 
 degrees in cleanliness I would urge the highest here. 
 
 After curetting the uterus it is packed with gauze. 
 Selecting the fold just behind the cervix, it is picked up 
 with forceps and cut through for a space of a half-inch. 
 The cut extends through the mucous meriibrane only. 
 The finger is then shoved into the pelvis. About two 
 minutes are consumed in this. Upon withdrawing the 
 finger quite a quantity of serum escapes. The operator 
 carefully notices the character of the fluid which escapes. 
 He passes his finger back and forward behind the broad 
 ligament and gently palpates the adnexa. If the organs 
 are found matted together by lymph, they are liberated 
 with the finger. I seek to make this digital exploration 
 and separation of adhesions of the broadest kind, my 
 object being to open the lymph spaces not only that 
 they may discharge into the dressing which I am about 
 to apply, but that the antiseptic may be readily absorbed. 
 
ENDOMETRITIS. 45 
 
 Wherever there is an effusion of lymph there is a con- 
 test between germs and the tissues. Into this combat I 
 wish to enter. 
 
 Having- examined the pelvis and separated all adherent 
 organs, I insert two fingers into the cul-de-sac and stretch 
 the opening to a level with the sides of the cervix. The 
 pelvis is then filled with strips of iodoform gauze (see 
 Fig. 38). These pieces are made by taking a strip of 
 gauze a yard long and four inches wide, and folding it 
 until the shape represented. The strips extend up to 
 the level of the fallopian tubes. They are inserted as 
 described in the article on hysterectomy. The vagina 
 is packed. If the patient's pulse runs under the ether to 
 140, I deem it the indication of a profound degree of 
 septicaemia. It is then my duty to increase the action 
 of the kidneys as well as stimulate the heart. I there- 
 fore introduce into a vein from one to two quarts of salt 
 solution (see salt solution). This I also do whenever I 
 find that the lymph in the pelvis is breaking down into 
 pus, and whenever there are grave complications as pneu- 
 monia and nephritis. It is a question in my mind 
 whether it be not advisable to employ this in all cases 
 of streptococcus infection and at present such is my 
 practice, but I am not prepared to advise its general use. 
 
 Within a day after this operation the bed will be found 
 soaked with the muddy, toxin-laden serum from the 
 pelvis. The amount must be pints in quantity in some 
 cases, and the patient will feel the loss of so much fluid 
 unless provision be made to supply it. I therefore in- 
 ject into the bowel eight ounces of tepid salt solution 
 every three hours for several days. The patient is stimu- 
 lated by hypodermics of strychnia, but I do not believe- 
 in excessive doses. I usually give gr. i : 50, q. 4. h. A 
 few hours after the operation I begin giving fluids by 
 the mouth. If stimulants are needed I give either an 
 ounce of champagne every hour or a teaspoonful of 
 brandy in an ounce of water. If alcoholics are not neces- 
 sary, I give hourly an ounce of cold water to which has 
 been added five drops of lemon juice. The urine is 
 
46 
 
 PELVIC INFLAMMATION. 
 
 drawn- every three hours and is measured. It is tested 
 for albumen and iodin. I begin to adminster hquid food 
 after eighteen hours, beginning with a little hot chicken- 
 broth or squeezed juice of broiled steak. In three days 
 I remove the vaginal packing and the uterine gauze. 
 The vaginal packing is renewed, but the uterine is not 
 unless the septic symptoms persist. The cul-de-sac 
 dressing is taken out in a week and is replaced by fresh 
 gauze of 5 per cent, strength. 
 
 These dressing are repeated every four to seven days 
 until the opening closes. After that I apply ichthyol 
 tampons to promote involution. In conjunction with Dr. 
 Jeffries, bacteriologist to the Polyclinic, I have instituted 
 a series of experiments in the influence of these dressings 
 upon the streptococci usually found in these cases. I 
 have in fifteen cases placed the uterine scrapings in a 
 sterile tube and the fluid from the cul-de sac m another. 
 Whenever streptococci have been found, even though 
 pus was free in the peritoneal cavity in one case, and 
 sacculated in several others, we have never failed to find 
 that the dressings absolutely sterilized the operation field. 
 This is usually accomplished by the third dressing, but 
 in one case not before the fifth had been used. And in 
 many cases where no bacteriologic examinations were 
 made the treatment was equally successful. 
 
 So far as results are concerned, I have not lost a pa- 
 tient so treated. The success of this operation in a class 
 of cases formerly thought worthy of hysterectomy con- 
 vinces me that the latter operation is unnecessary. And 
 inasmuch as the operation is exceedingly simple and 
 requires no elaborate equipment of nurses, assistants, 
 and material, I shall expect it to become of general adop- 
 tion by those who have the surgical conception of the 
 treatment of this dreadful disease. 
 
 The importance of the proper treatment of this form 
 of infection is well shown by the report of the Registrar 
 General for England and Wales for the year 1895. Out 
 of every thousand deliveries two women died from some 
 form of infection. The morbidity in those that recovered 
 must have been appalling. 
 
ENDOMETRITIS. 47 
 
 ACUTE GONORRHEAL ENDOMETRITIS. 
 
 The sole caustive germ is the gonococcus, but the 
 infection is often a mixed one, other cocci besides the 
 gonococcus being present. Occasionally a woman will 
 have gonorrheal vulvitis, vaginitis, or endocervicitis for 
 some time without an extension to the endometrium ; 
 but prolonged exposure, menstruation, overindulgence in 
 coition, and any operation upon the uterus, or even the 
 passage of the sound, will cause a sudden attack of gon- 
 orrheal endometritis. 
 
 Symptoms. — These cannot be better brought out than 
 by describing a case. A girl of twenty-two married two 
 weeks before an expected period, a man with gleet. 
 Five days afterward she began to have painful and fre- 
 quent urination, and in a few days more a vulvovaginal 
 swelling appeared upon the right side. She thought 
 these symptoms due to frequent connections, and bore 
 her distress with good grace. There was a profuse puru- 
 lent discharge from the vulva, and she was compelled to 
 bathe frequently. The menstruation appeared on time, 
 and was normal up to the third day. She then had sharp, 
 lancinating pains in the uterus accompanied by the most 
 severe cramps. The menstrual flow increased in amount, 
 and three days after the onset of the severe symptoms 
 she had a most irritating and profuse yellow discharge. 
 She took to bed. The entire pelvis became so tender 
 that she could not bear to be touched. The pus was 
 mixed with blood. The rectal temperature when I saw 
 her on the tenth day was lOi.8° F., and the pulse was 
 106. Upon examination, I found a vulvovaginal abscess 
 discharging. The uterus was exquisitely sensitive, and 
 the uterine spasms continued after the menstrual flow 
 ceased. The cervix was livid in hue, sind markedly 
 eroded. It seemed to be entirely devoid of epithelial 
 covering, and from the os hung a rope of tenacious yel- 
 low discharge. The microscope showed the gonococcus. 
 
 Such is a picture of an average case. The uterine 
 
48 
 
 PELVIC INFLAMMATION. 
 
 infection may take place at any time, but it is most apt 
 to occur during menstruation, when the uterine epithe- 
 lium is exfoliated. Several days elapse, as a rule, between 
 the onset and the appearance of pus. The pus is produced 
 in great quantities, as much as several ounces in twenty- 
 four hours. It is tinged with blood in nearly all cases, 
 so deep is the congestion. The body temperature is ele- 
 vated^ but rarely goes to 103° F. The pulse is accelerated 
 up to 1 10 in the worst cases. The symptoms subside 
 slowly, but the purulent discharge continues for some 
 time, and, as a rule, the case becomes chronic. Rarely 
 does a cure occur without treatment, and complications 
 are very common. The uterus in the acute stage is en- 
 larged ; but after repeated attacks it may become little 
 more than a mass of fibrous tissue, being hard and small. 
 Such uteri we find in old prostitutes. Women with acute 
 gonorrheal endometritis take to bed. The suffering is 
 continuous, and the pain is marked by sharp exacerba- 
 tions — " uterine colic." The course of an attack persists 
 through one or two weeks and results in either a chronic 
 condition or some grave coriiplication. 
 
 Diag-nosis. — There will usually be found other evi- 
 dences of gonorrhea, such as urethritis or vulvitis. A 
 woman previously well suddenly attacked with acute 
 endometritis a few days after connection probably has 
 gonorrhea. By far the greater number of such cases 
 of acute endometritis which do not occur after abortion 
 or labor are due to gonorrhea. Indeed, I am warranted 
 in saying that gonorrhea is a disease of the non-pregnant 
 uterus, while sepsis is most frequently found to follow 
 conception. 
 
 The temperature, the great pain in the uterus, the 
 profuse purulent discharge, the excoriations produced 
 in the cervix and vagina by the pus, the presence of 
 other evidences of clap will render the diagnosis clear. 
 In all cases the gonococcus is found. 
 
 Treatment — ]Sr<ni -Operative. — The vulva and vagina, 
 if infected, should be painted with silver nitrate solution, 
 gr. XX to oz. j. With a sharp bistoury the cervix is 
 
ENDOMETRITIS. 
 
 49 
 
 bled. If the cervix is open enough the uterus should 
 be washed out with either bichlorid solution, i : lo,ooo, 
 or else with a saturated solution of boric acid. (See 
 Septic Endometritis.) I prefer to use both solutions at 
 the same sitting, the latter following the other. This 
 treatment I repeat in twelve or twenty-four hours. In 
 the interim I order douches of % per cent, lysol at a 
 temperature of iio°F. every two hours. If the case is 
 seen early such treatment will often result in subduing 
 acute symptoms after four days. But if the patient is 
 not seen before the cocci have penetrated into the deeper 
 portions of the endometrium, or if the cervix be markedly 
 stenosed, the uterine washings are useless or can not be 
 applied. The local blood-letting should be employed 
 but once or twice, and the co-existing vulvitis and vag- 
 initis will not require applications of silver solutions 
 more than once a day. It is wise to pack the vagina 
 with iodoform gauze wet in bichlorid, 1:4,000. This 
 dressing not only supports the uterus against painful 
 jarring, but it also sterilizes the vagina as well as the 
 discharge from the uterus. But it is not to be used in 
 cases where intra-uterine washings are impossible, for 
 there it will but dam up the discharges. Opiates will 
 usually be found necessary for the relief of pain. 
 
 Operative Treatment. — Whether seen early or late 
 after infection, I prefer to curette these cases. (See 
 Curettage.) Certain teachers consider complications 
 almost sure to result from such treatment, but the reason 
 for these ill results will be found in the method of oper- 
 ating. I can see no reason for discriminating in favor 
 of the gonococcus as against other pyogenic cocci. Cer- 
 tainly the worst that can result from operating is a com- 
 plication, and this follows the let-alone treatment in 
 nearly all instances. Indeed, it is doubtful if a general 
 gonorrheal endometritis ever runs its course without 
 producing some inflammatory process in either the tubes, 
 ovaries, or pelvic peritoneum. 
 
 Sequelae. — Gonorrhea of the uterus extends not 
 through the lymph streams, but through the tubes — 
 4 
 
so 
 
 PELVIC INFLAMMATION, 
 
 extension by continuity of tissue. As a result we have 
 salpingitis, ovaritis, and peritonitis the complications, 
 and never see primary broad ligament abscess result. 
 In view of the ravages which unchecked gonorrhea 
 works in a woman's pelvis, the very first symptom must 
 be vigorously met. The joint complications sometimes 
 seen in men, I have never seen in women, but they do 
 occasionally occur. Women who have had true gonor- 
 rheal endometritis and in whom it is not radically cured 
 are always sterile. Those cases which do not produce 
 some complication result in a chronic condition. My 
 belief is that gonorrhea of the endometrium is never cured 
 except by surgical means. 
 
 CHRONIC GONORRHEAL ENDOMETRITIS. 
 
 Symptoms. — Chronic gonorrheal endometritis is about 
 the happiest result to be expected from an acute attack. 
 I do not find the chronic state other than as a result of 
 the acute. There is slight enlargement of the uterus in 
 some cases ; but old cases who have had repeated attacks, 
 have usually small, hard uteri. The cervix in all is 
 usually the seat of folliculitis with erosions. There is 
 always a purulent discharge. The condition may exist 
 without pelvic complications, but I have neve}' seen jt. 
 Uterine pain is not present, but where the uterus is per- 
 sistently enlarged there is a sense of weight in the pelvis. 
 Whenever in such cases there is marked pelvic pain, it 
 is an absolute indication that the causative acute attack 
 has resulted in damage to the periuterine tissues. As a 
 result of the aggressiveness of pelvic surgery a good 
 many supposed conditions have been properly eliminated 
 from our pathology, and many apparently innocent states 
 of the uterus have been found to be accompanied by pro- 
 nounced disease in the adnexa. As I said above, I do not 
 find chronic corporal gonorrheal endometritis without 
 complications. It is these complications so difficult to 
 detect which produce the distressing symptoms and not 
 the chronic inflammation in the uterus. These women 
 are generally sterile. 
 
ENDOMETRITIS. 
 
 51 
 
 Diagnosis. — For clinical purposes chronic inflamma- 
 tions of the uterus are characterized by one prominent 
 symptom — a purulent discharge. There being no evi- 
 dence of adnexal disease, we may put the case down as 
 not due to gonorrhea. But far more difficult is it to 
 determine whether the cervix alone or the entire endo- 
 metrium is involved. To settle this the endocervicitis 
 must first be cured. If this is easily accomplished, the 
 flow of pus checked, and relapses without apparent cause 
 do not occur, we can be sure that the pus did not come 
 from above the os internum. But where the cervix re- 
 mains inflamed under persistent treatment, or where the 
 purulent discharge continues after the cervix is brought 
 to a normal condition, we may know that the endome- 
 trium is involved. The persistence of the discharge 
 despite energetic measures applied to the cervix con- 
 vinces us that the corporal endometrium is inflamed. 
 The patient's word cannot be relied upon in determining 
 this, for she probably douches and washes away dis- 
 charges. A piece of cotton large enough to fill the 
 vaginal vault is wrung out in Thiersch solution and ap- 
 plied over the cervix. It is kept there by vaginal tam- 
 pons. In twelve hours it is removed and the amount of 
 pus discharged in that time can be determined. 
 
 Treatment. — The presence of adnexal disease is no 
 bar to the methods of treatment. If the cervix be suffi- 
 ciently open for the, purpose, the uterus may be washed 
 out (see Septic Endometritis). But as all the cases of 
 chronic general gonorrheal endometritis which I have 
 met have some degree of adnexal disease, I advocate 
 curettage and the cul-de-sac operation (see Cul-de-Sac 
 Operation). A curettage alone undoubtedly checks the 
 source of infection, and, following it, some repair ensues 
 in the inflamed adnexa. But we must consider both in- 
 tra-uterine washings and curettage as merely palliative. 
 If a radical cure is to be effected, the adnexa must be 
 directly treated through the cul-de-sac. For a long time 
 it has been my behef that chronic gonorrheal endome- 
 tritis is never found except' as a result of an acute pro- 
 
5 2 PELVIC INFLAMMATION. 
 
 cess, and in this respect gonorrhea of the uterus differs 
 from septic endometritis which may from the first be 
 devoid of acute symptoms. 
 
 In no form of purulent endometritis do I ever make 
 applications. These, while destroying pyogenic cocci, 
 also kill the superficial cells of the endometrium and 
 furnish no means for the escape of the destroyed tissue. 
 The history-books of all of us bear many cases where 
 acute pelvic inflammations have resulted from intra- 
 uterine applications. 
 
 TUBERCULAR ENDOMETRITIS. 
 
 Tubercular disease of the cervix is exceedingly rare, 
 the disease being usually limited to the body of the 
 organ. But it is occasionally met with, and then is 
 secondary to vaginal tuberculosis. Occurring in the 
 cervix the disease is either miliary or ulcerative, and is 
 not often diagnosticated without the aid of the micro- 
 scope ; the miliary tubercles being mistaken for small 
 cervical cysts and the ulcers for carcinoma. 
 
 It is rare to find the cervix and corpus uteri involved 
 in the same individual ; the uterus being affected second- 
 arily, the cervix from the vagina, the endometrium from 
 the peritoneal face of the uterus. 
 
 Syuiptoms. — Tubercular endometritis produces pro- 
 fuse leucorrhea which may contain caseous masses. The 
 uterus is enlarged. Where menstruation occurs it is 
 irregular or profuse, but the concomitant cachexia gen- 
 erally produces amenorrhea in the later stages. Other- 
 wise the symptoms are those of chronic endometritis, 
 plus the general symptoms of general tuberculosis where 
 that exists. 
 
 Diag-iiosis. — Without finding the tubercle bacillus, a 
 positive diagnosis is impossible. It is not necessary to 
 excise portions of ulcerating tissue ; the discharge will 
 show the bacillus. 
 
 Treatment. — Whenever a diagnosis can be made, ex- 
 section of the affected portion is indicated if it possibly 
 
ENDOMETRITIS. e^ 
 
 Can be done. Tlie cervix without a tendency for the 
 disease to extend upwards, may be amputated. But 
 paihative treatment can not be applied to the corpus 
 uteri, and curettage alone will not check the disease. 
 Total vaginal extirpation of the uterus and adnexa is in- 
 dicated, both because the uterine disease is commonly 
 secondary to adnexal tubercular disease, and because 
 extirpation of the tubercular uterus works such mar- 
 vellous changes in the metabolism of the blood as to 
 hold in abeyance for years tubercular lung disease. Be- 
 cause of local and general reasons, if I may so term 
 them, hysterectomy is indicated in corporal tuberculosis. 
 Any other operative procedure but plays with the dis- 
 ease, opening new channels for its extension. Local 
 treatment is useless. Excision is the treatment for 
 tubercular disease of the genitals. I have seen a phthisi- 
 cal woman gain thirty pounds in two months after this 
 operation. No one who has not estimated the quantity, 
 often ounces a day, of discharge coming from these 
 women can have any idea of the drain upon their 
 systems. 
 
 The failure of agents lauded as corrective of tubercu- 
 losis to even modify the disease when the organ is within 
 easy access and the treatment applied under the eye, is 
 a commentary upon the methods of reasoning of those 
 who advocate them. 
 
 Sequelae. — When occurring as a primary disease, 
 uterine tuberculosis will surely extend to the peritoneum 
 and adnexa, to be followed by general tuberculosis. 
 
54 
 
 PELVIC INFLAMMATION. 
 
 PELVIC INFLAMMATION. 
 
 Up to a few years ago it was undoubtedly the practice 
 with most surgeons to remove through the abdomen all 
 ovaries and tubes which presented evidences of inflamma- 
 tion, whether these were diseased primarily, or as the 
 result of a lymphatic infection in the pelvis. So long 
 as this remained the established rule of procedure in 
 dealing with tubo-ovarian disease, precise differentia- 
 tion of the various lesions was not necessary. But a 
 more careful study of the manner in which the gross 
 lesions were produced, together with the application of 
 those general surgical principles which govern the treat- 
 ment of inflammatory lesions elsewhere, has taught us 
 the necessity for carefully separating those lesions which 
 necessitate the removal of the diseased organs from those 
 which are relieved by conservative measures. It there- 
 fore becomes our duty to enter into a thorough analysis 
 of each case. To do this it is not essential to a proper 
 conclusion that a bacteriological examination be made, 
 but the correct treatment can be reached by studying 
 the clinical history of each case. Although the ovaries 
 and tubes, as well as the pelvic peritoneum, will probably 
 suffer in most cases where the infection passes outside 
 the uterus, yet all the structures will not be equally 
 damaged. The manner in which the infection reaches 
 the pelvic structures as well as its nature will indicate 
 somewhat the organ we will find most affected. In all 
 infections, for instance, occurring in the uterus pregnant 
 after the third month, those lesions which result from 
 pelvic peritonitis are to be expected, for in such a uterus 
 the lymph streams and not the tubes are the chief car- 
 riers of the infecting agents. And inasmuch as the 
 poison of gonorrhea travels not through the lymphatics, 
 but through direct continuity of tissue along the uterus 
 
PELVIC INFLAMMATION. 
 
 55 
 
 and Fallopian tubes, this may usually be eliminated as a 
 cause of the trouble, and the case be set down as due to 
 sepsis. As a result we have produced the effusion of 
 lymph on the peritoneum, suppuration in the folds of the 
 broad ligaments, or ovarian abscess, one or all. (Second- 
 arily salpingitis may result.) Conversely, in a uterus 
 with undeveloped lymphatics, that is in the unimpreg- 
 nated uterus, the invasion is usually through the tubes, 
 and may be either gonorrheal or septic. The resulting 
 lesions are salpingitis with secondary involvement of the 
 periton.eum and perhaps of the ovary. Furthermore 
 the results of these various kinds of infection may be of 
 a purulent, a cystic, or even a connective-tissue type. To 
 characterize all these lesions as merely "tubo-ovarian 
 disease " is to subject them all to one method of treat- 
 ment, removal. 
 
 The diffuse peritonitis due to abortion is cured in the 
 same way as the pleurisy due to rib necrosis, by scrap- 
 ing away the infected focus ; cysts of retention, as cystic 
 ovary and hydrosalpinx, are to be treated as similar 
 accumulations elsewhere, that is by evacuation. Puru- 
 lent accumulations here behave exactly as elsewhere in 
 the body. If found in preformed sacs, as the tubes, they 
 are cured by removal or by evacuation and obliteration. 
 If seated in the continuity of tissue, as in the ovary or 
 broad ligament, evacuation will cure. But the situation 
 of the diseased focus, whether high up or low down, will 
 influence the method of operating; for the element of 
 drainage bears a most important part in all such work, 
 I mention these facts briefly to emphasize the importance 
 of carefully considering each case upon its merits, and to 
 show the utter folly of laying down hard and fast rules 
 for dealing with the several lesions. We formerly heard 
 much about "cellulitis." Cellulitis does not occur in 
 the tubes, that is, suppuration is not found in the tubal 
 walls except as consecutive upon more marked suppura- 
 tion in their cavities. Suppuration between the folds of 
 the broad ligament is not cellulitis. The pus is not pro- 
 duced in the thin cellular layer of the ligament, but in its 
 
56 
 
 PELVIC INFLAMMATION. 
 
 lymphatics. Broad ligament "cellulitis" is broad liga- 
 ment lymphangitis. The only true cellulitis found in 
 the pelvis is that which is seen in the ovarian stroma. 
 There may be effused about the broad ligament a large 
 mass of lymph as a result of lymphangitis between the 
 folds of the ligament, and suppuration in such an accu- 
 mulation may simulate " cellulitis." Even when applied 
 to ovarian suppuration, the term is misleading. It should 
 have no place in our nomenclature of pelvic lesions, and 
 I do not accept it as descriptive of any lesions I have 
 ever seen in the woman's pelvis. Migration of cells 
 takes place in the pelvic structures because of invasions 
 from without. If the cells die, pus is produced. The 
 generalization " cellulitis " is meaningless. Pyosalpinx, 
 ovarian abscess, pelvic peritonitis, are precise statements 
 of gross lesions, and gross lesions, not microscopic 
 changes, are the basis for our operations. 
 
 The great advance made in the treatment of pelvic in- 
 flammatory lesions is due to our knowledge that they 
 are produced by exactly the same agents as cause inflam- 
 mations elsewhere. Cold feet, fright, menstruation, etc., 
 have ceased to be causes for pus in the pelvis, although 
 used as excuses for unclean surgical operations and infi- 
 delity. 
 
 Certain germs produce certain lesions under certain 
 conditions. The pathology of pelvic inflammations is as 
 accurate as any other, and upon an accurate knowledge 
 of the causative germs, the conditions under which they 
 exist, and their paths of extension, will depend the 
 proper treatment of the results of their activity. 
 
 This precise differentiation of the conditions under 
 discussion cannot always be made upon examination, but 
 the cul-de-sac exploration will clearly show them. 
 
 Starting, then, with the history of the case and the 
 data furnished by carefully kept clinical notes and re- 
 peated examinations, we are in a position to determine 
 the propriety of operative interference. And the sur- 
 geon will decide whether his attention should be limited 
 to the uterus alone or whether the adnexa should be at- 
 
TELVIC INFLAMMATION. 
 
 57 
 
 tacked. In the latter event the exploratory part of the 
 operation can be made as satisfactorily through the va- 
 gina as through the belly and with far less risk to the 
 patient. Meeting with certain conditions, the vaginal 
 section can be made a curative operation without removal 
 of any organs and without risk. This much cannot be 
 said of laparotomy. 
 
 All these questions are brought under discussion in 
 the proper places. 
 
 Diag-iiosis. — Before attempting to proceed with any 
 method of treatment, it is essential to determine that the 
 case is one of inflammation of the generative organs. 
 The diseases with which pelvic inflammation is most com- 
 monly confounded are : appendicitis, ureteral inflamma- 
 tion, acute cystitis, general peritonitis and suppurating 
 ovarian cyst. 
 
 Appendicitis. — This cannot be mistaken for pelvic in- 
 flammation of course, except where the disease is on the 
 right side. The pain of appendicitis is usually situated 
 somewhere about a line drawn from the umbilicus to the 
 anterior superior spine of the ilium. Pain due to tube 
 ovarian disease is commonly much below this. The sen- 
 sitiveness to touch in appendicitis is greatest when pres- 
 sure is made upon the belly over the caecum, while 
 greatest pain in adnexal disease is developed by vaginal 
 examination. The pain due to appendicitis radiates up- 
 ward toward the hypogastric region, while that due to 
 tubo-ovarian disease extends downward toward the pu- 
 bic region of the pelvic cavity. In appendicitis disturbed 
 bowel function frequently precedes the attack, while it 
 follows salpingitis, if it occurs at all. Symptoms of col- 
 itis often accompany appendicitis, while they are absent 
 with tubal disease. Tympanites is usual in appendicitis, 
 the distention being general, while in pelvic inflammation 
 it is usually limited to the colon. In appendicitis there 
 is absence of signs of genito-urinary inflammation, such 
 as endometritis, urethritis, etc. ; while some one of these 
 is present with salpingitis. Very often tubo-ovarian dis- 
 ease coexists with appendicitis, and the inflamed organs 
 
58 
 
 PELVIC INFLAMMATION. 
 
 may be matted together in one indistinguishable mass. 
 In such cases the operator must consider the lesions as 
 abdominal rather than pelvic. Appendicitis does not 
 cause fixity of the uterus, and digital search in the vagina 
 does not increase the pain of appendicitis. The con- 
 trary is true where pelvic inflammation exists. But ap- 
 pendicitis may coexist with pelvic inflammation. As 
 the abdominal symptoms will predominate over the pel- 
 vic a suspicion of the appendicitis must be held. Such 
 cases are to be viewed from the abdominal side if the 
 cul-de-sac exploration fails to clear up the 'diagnosis. 
 
 Cystitis. — Ardor urinje, blood or pus in the urine, pain 
 on urination, suprapubic sensitiveness, infrapubic tender- 
 ness, mark cystitis. In cystitis vaginal examination does 
 not develop pain except where the space anterior to the 
 uterus is pressed upon. In pelvic peritonitis the lateral 
 fornices are most sensitive. Again, in pelvic peritonitis 
 there is not marked disturbance of bladder function, 
 while in cystitis there is, and there is usually pronounced 
 inflammation of the uterus in cases of peritonitis which 
 which is not present in cystitis. The uterus, tubes, ova- 
 ries and peritoneum are uninvolved in cases of cystitis. 
 
 Ureteritis. — Inflammation of the ureters is usually sec- 
 ondary to cystitis. A careful urinalysis will show pus, 
 ureteral epithelium and often blood in the urine drawn 
 by catheter. There is the same pain in the lateral pelvic 
 walls as is found in adnexal disease, but there is no fixity 
 of the uterus, and moving the uterus with the finger does 
 not increase the pain. Ureteral calculi cause spasmodic 
 pain similar to that of acute salpingitis, but it radiates 
 down to the urethra, produces bloody urine, and the 
 spasm is often accompanied by involuntary discharge of 
 urine. The pain of pelvic peritonitis is constant, and the 
 fever produced by tubal inflammation is usually higher 
 than that seen with cystitis and ureteritis. 
 
 Siippurating Ovarian Cyst. — There is the same mass, 
 tenderness and fixity as accompany tubal disease. In 
 fact, the symptoms produced by such a cyst are more 
 due to the concomitant peritonitis than to the cyst. It 
 
PELVIC INFLAMMATION. 
 
 59 
 
 is exceedingly difficult to differentiate between a large 
 pyosalpinx or ovarian abscess and a small inflamed ovar- 
 ian cyst. If the cyst is of sufficient size it will press the 
 uterus upward and forward, whereas a large adnexal 
 abscess will displace it laterally. 
 
 Haste in making examinations will lead the surgeon 
 into many errors. I have seen a good man cut open 
 the belly for typhoid fever in a woman with gonorrhea, 
 thinking he had tubal disease to deal with. 
 
 From what has been said, it will be seen that the seat 
 of pain and its character are invaluable in making a 
 diagnosis. Therefore, opiates are not to be used until 
 the diagnosis is clearly made, if at all. I have laid some 
 stress upon the evidence of disease as developed by the 
 cul-de-sac operation. This exploratory procedure being 
 free from danger, and occupying but a few minutes 
 time, can be resorted to where a positive diagnosis is 
 necessary. Lesions being by it revealed, the removal of 
 which would endanger life or is forbidden, the operator 
 can not only retreat without having damaged his patient, 
 but in most cases of pelvic disease, he will afford some 
 measure of relief by that operation alone. Such can not 
 be said of the abdominal section. 
 
 General Suppurative Peritonitis. — In some cases of 
 diffuse pelvic suppuration, with sudden and sharp exten- 
 sion of the infection, it will be hard to differentiate be- 
 tween a local and a general infection of the peritoneum. 
 General purulent peritonitis produces great shock. The 
 pulse is generally above 120, the temperature ranging 
 about 103°. Tympanites is pronounced, vomiting in- 
 cessant; restlessness, sordes on teeth and lips, dry, 
 cracked -tongue, mental anguish, pinched face, muscular 
 twitchings and delirium, mark general peritonitis. As 
 each hour passes the symptoms become rapidly more 
 grave. There is no remission. Without an examina- 
 tion, the experienced physician can, by carefully study- 
 ing the symptoms, determine whether the case is one of 
 localized lesions, with severe general symptoms, or one 
 of general peritonitis. Examination will be of little ser- 
 
Co PET.VIC INFLAMMATION. 
 
 vice in making a differential uiagnosis between local and 
 general peritonitis. I have seen at ten in the morning a 
 case, apparently, of bilateral pyosalpinx due to abortion, 
 which when operated upon at three in the afternoon was 
 almost moribund. Certain cases of virulent pelvic in- 
 flammation will, in a few hours, become general through- 
 out the peritoneal cavity. This is especially true of 
 cases of post-partum and post-abortum infection. 
 
 General peritonitis is one of the results to be expected 
 from a policy of delay. The vomiting, rapid pulse, dry 
 tongue, stupor and tympanites, which result from the 
 use of opiates in a grave case of pelvic inflammation will 
 often render a diagnosis of the extent of the infection 
 utterly impossible. The cases where surgeons have 
 opened the belly and found all the disease in the pelvis 
 are many. The surest way to mask the symptoms of 
 pelvic inflammation is to give opium. 
 
 Treatment. — Opiates. — These I rarely use and for a 
 number of reasons. To relieve pain by opiates is to 
 mask the symptoms of extension and complications. 
 The bowels become blocked, and this permits the migra- 
 tion of the intestinal germs ; the stomach is deranged, 
 and the bladder function disturbed. Brought to a case 
 of pelvic inflammation, if he contemplates possible oper- 
 ation, the surgeon should withhold opiates. Other 
 means are at his command to ease pain, and the relief 
 afforded by opiates is but a borrowed ease, to be paid 
 back by vomiting, tympanites, and spread of the in- 
 fection. 
 
 Intestinal Cleanliness. — From the first I insist upon 
 this. Placing the patient upon the left side with the hips 
 elevated, I insert a Martin's tube (Fig. 13) and throw 
 into the bowel a quart of tepid normal salt solution. 
 Part of this is retained. To obtain retention the injec- 
 tion should be given at night, or when the bowels do 
 not habitually operate. This cleanses out the colon, 
 flushes the kidneys and allays thirst. I do this each 
 night. The maneuvre is very simple. The outflow tube 
 is corked up, and the fountain syringe is raised four feet 
 
PELVIC INFLAMMATION. 6l 
 
 above the bed. The water should be of a temperature 
 of 103° to 105° F. These irrigations, by removing hard 
 fecal masses, and relaxing muscular spasm, relieve pain 
 and prevent tympanites. Purgatives I never use, but 
 mild cathartics, as an ounce of Rubinat water every 
 second morning in a glass of plain water an hour before 
 breakfast, I employ. 
 
 There are but two v/ays of treating these cavity in- 
 flammations : the locking-up plan (opiates), and the 
 eliminative. I prefer the latter. No man who has ever 
 contrasted the two will accept the first. 
 
 Douches. — Some patients express themselves as re- 
 lieved of pain by douches, others dislike to be disturbed. 
 
 Fig. 13. — Martin's tube for rectal irrigation. 
 
 But they are demanded where there is much discharge. 
 I prefer to use lysol )^ per cent., at a temperature of 
 1 10° F., every four hours. 
 
 Abdominal Dressings. — Poultices cause effusions of 
 blood beneath the skin and vary in temperature from 
 90° to that at which they are put on. I prefer to use an 
 ice-bag over the pubes. It is easier handled and relieves 
 pain, and tends to limit the peritonitis a very little. 
 
 Fluids. — I encourage these women to drink large 
 quantities of water. A good plan is to administer three 
 ounces each hour when awake. Ten drops of lemon 
 juice added will keep the tongue clear. Milk, koumyss, 
 etc., having poor food value, I do not use. Besides, it is 
 difficult to get rid of the cheese left after such prepara- 
 tions. Alcoholics are never indicated. In women deep 
 in infection, and with bad kidneys and thready pulse, I 
 do intravenous infusion. Anesthesia is unnecessary for 
 this. (See Article on Transfusion.) Far better than all 
 drugs is this procedure. It flushes the kidneys, elimi- 
 
62 PELVIC INFLAMMATION. 
 
 nates toxins and stimulates the heart. The amount of 
 urea excreted is increased and the albumen diminished. 
 The effect is immediate. 
 
 Diet. — Half diet is indicated in mild cases. Farina, 
 hominy, an egg, and a little coffee for breakfast; a little 
 meat, as beef, chicken, chops, etc., with potatoes and 
 cream at midday ; chicken soup and toast at four o'clock ; 
 and squeezed beef-juice and toast at eight. But all the 
 time an abundance of water. 
 
 To those very ill I do not give solids. In the morn- 
 ing, toast, and a very little coffee. Once every three 
 hours after that, either two ounces of chicken broth or 
 one ounce of squeezed beef-juice is given, each time with 
 a little toast. No milk. To those who vomit continu- 
 ously, I give nutrient enemata. Prepared foods, pre- 
 digested foods and fermented foods are not to be used. 
 
 Local Applications. — Pelvic pain, due to inflamma- 
 tion, is diminished by ice-bags over the suprapubic region. 
 Spasmodic pain is eased by poultices. To the vagina, 
 lo per cent, ichthyol in glycerin, applied by means of a 
 syringe, will reduce pain and act beneficially upon the 
 inflammation at all stages. Local blood-letting, applied 
 to the cervix, is of great value in relieving pain and vas- 
 cular stasis. 
 
 To me, the free purgation used by some is as bad as 
 the opium treatment. All that is needed is a through 
 and through stool once every day or so, but the colon 
 must be kept empty. It is unwise to irritate by strong 
 saline cathartics the thirty feet of intestinal mucosa. 
 Sepsis in the pelvis is not checked by it, and shock is 
 increased. Perfect rest in bed is imperatively necessary. 
 The non-operative treatment of pelvic inflammations 
 seeks : the improvement of the tissue-resistance ; limita- 
 tion of the infecting agent; and maintenance of the gen- 
 eral strength while the invaded organs are overcoming 
 the infection. 
 
SALPINGITIS. 
 
 63 
 
 SALPINGITIS. 
 
 Gonorrheal Salpingitis | chronic 
 
 Septic Salpingitis } chronic. 
 
 Tubercular Salpingitis | Chronic. 
 
 ACUTE GONORRHEAL SALPINGITIS. 
 
 The causative germs are gonococci. These may have 
 entered fresh from an acute clap in the male, or from a 
 gleet, or may be the result of a rekindling of the spark 
 which has for some time been dormant and latent in 
 some other part of the genito-urinary tract of the woman 
 (Fig. 14). The disease is usually bilateral, though differing 
 often in severity upon the two sides. The first stage is one 
 of congestion and edema. When the infection reaches 
 the fimbriated end, a local peritonitis results. The pe- 
 ritonitis is secondary to the salpingitis, because the gon- 
 orrhea travels through the tubes and not through the 
 lymphatics. The fimbriae of the affected tube turn in 
 and their peritoneal surfaces cohere, owing to a circum- 
 scribed peritonitis about the fimbriae. Thus the tubal 
 contents become locked in, and, secretion continuing, a 
 cyst of retention is formed (Fig. 15). Usually this latter is 
 a pyosalpinx, occasionally a hydrosalpinx. Or, the secreted 
 fluids may become almost wholly absorbed and the con- 
 dition be marked by the production of new connective 
 tissue in the walls of the tube, which, contracting, con- 
 stitutes tubal sclerosis. Sclerosis with hydrosalpinx, or 
 with pyosalpinx, is very common. 
 
 In the first or acute stage, the tube is deeply discol- 
 ored and easily torn. It may measure as much as an 
 inch in diameter. Upon section the lumen is found not 
 
64 
 
 PELVIC INFLAMMATION. 
 
 much' distended and the increase in size is due to sub- 
 mucous infiltration. 
 
 The tissues are so swollen that the rugae are almost 
 
 
 
 :^^ 
 
 ll^ 
 
 Fk;. 14. — Section of the normal Fallopian tube near the abdorninal ostinm 
 
 (Beyea). 
 
 obliterated as separate folds. The uterine end of the 
 affected tube is still patent, and the creamy purulent 
 contents of the tube escape into the uterine cavity. 
 
SALPINGITIS. 
 
 65 
 
 After a time the uterine end of the tube is also closed, 
 and there is formed a permanent fluid accumulation in 
 the tube. The tube may be knotted and twisted or 
 sausage-like. Spontaneous cure is rare, the case usually- 
 resulting in some permanent deformity. The heavy tube 
 is prone to sink down behind the broad ligament. Com- 
 monly the adjacent ovary as well as the pelvic peritoneum 
 is involved. 
 
 Fig. 15. — Longitudinal section of Fallopian tube, exposing the complicated 
 longitudinal plications of the mucosa which expand into the fimbriae (Sappey). 
 
 Symptoms. — Added to the symptoms of acute gonor- 
 rheal endometritis we have certain others. In addition 
 to the uterine pain and cramps are pains originating in 
 the neighborhood of the tubes and shooting down the 
 thighs or upward. There is also pain in the sacroiliac 
 region. Spasm of the affected part is common, I find, 
 before peristalsis is stopped by the intensity of the in- 
 flammation The temperature (rectal) may reach 103° F. 
 and the pulse nearly 120, but commonly the pulse is 
 below no. There is often vomiting and nausea. Tym- 
 panites and costiveness are common. The symptoms 
 are most severe before the stage of stasis, that is, up to 
 the fifth day. They then usually begin to subside some- 
 
 5 . 
 
66 PELVIC INFLAMMATION. 
 
 what and the case resolves into some one of the chronic 
 forms. Upon vaginal examination the lateral pelvic 
 walls are found tense and the uterus fixed by plastic ef- 
 fusion and tubal enlargement. The lateral fornices are 
 exquisitely sensitive and a thorough examination may 
 be impossible without narcosis. In seeking the enlarged 
 tube, the viscera above are supported by a firm steady 
 pressure of the palmar surfaces of the fingers applied 
 over the ovarian region. One finger is inserted into the 
 vagina and the cervix found. The finger is then crowded 
 high up alongside the uterus, and as it is swept out to- 
 ward the pelvic wall it will feel the tube roll over it. 
 The tube is not very movable, and where marked fixation 
 exists the finger can very accurately determine its size. 
 The physician should stand at the patient's side, she 
 being in the lithotomy posture. Placed in this way he 
 can pronate and supinate his hand so as to feel all parts 
 of the pelvis. 
 
 Upon opening the cul-de-sac there is usually at once 
 an escape of serum containing flakes of lymph. When 
 the examining finger is inserted (see cul-de-sac explora- 
 tion) it appreciates the presence of recently effused lymph, 
 for the rectum is often found attached to the posterior 
 surface of the uterus by tender union, and the inflamed 
 tubes are sealed to whatever structures they rest against, 
 usually the broad ligaments. If the affected tube is low 
 down, it is felt to be a rounded firm yet elastic mass, 
 extending from one cornu of the uterus to the ovary or 
 broad ligament. To one of these it is usually attached 
 at its fimbriated end. At the cornu the tube is small, 
 but as the free end is reached it is found to enlarge into 
 a blunt knob. The false union between the tube and 
 other structures is easily severed by the finger, and this 
 produces slight parenchymatous oozing. Upon freeing 
 the tube and ovary from abnormal attachments they can 
 be brought into view at the vaginal vault. To accom- 
 plish this it is better to introduce a gauze pad above the 
 affected tube and then draw down the tube below the 
 pad. In manipulating the tube the finger only should 
 
SALPINGITIS. 
 
 67 
 
 be used, as instruments tend to break the swollen and 
 friable structure. The gauze pad keeps the intestines 
 above the vagina, but if these continue to prolapse into 
 the vagina the table may be lowered. Upon inspecting 
 the tube it will present the signs of intense inflammation 
 described at the first of this chapter. 
 
 Diag-iiosis. — There are nearly always present other 
 evidences of gonorrhea, and in most cases the pus from 
 the uterus shows the gonococcus to be present. The 
 various pelvic neuralgias are devoid of the symptoms of 
 acute inflammation, general as well as local. 
 
 Ectopic gestation in the early months may present the 
 same symptoms of pain, a mass, and tenderness; but in 
 ectopic gestation there are not acute purulent endome- 
 tritis, erosions, fever, etc. Inspection through the cul- 
 de-sac will positively determine the question of the exist- 
 ence of acute salpingitis. 
 
 Treatment. — As soon as a gonorrheal process has 
 passed outside the uterus involving the tubes and pelvic 
 peritoneum, the disease has progressed too far to be 
 cured by any form of treatment applied solely to the 
 uterus. It is necessary to attack the complications. 
 The uterus is curetted (see curettage). After this is 
 done the posterior cul-de-sac is opened. If this explora- 
 tor)' incision shows that both adnexa are involved, one 
 of two courses may be taken : either break up all the 
 adhesions, split open the tubes (see conservative treat- 
 ment) and pack the pelvis with gauze, or also make a 
 vaginal ablation. Merely opening the tubes and swab- 
 bing them out with iodoform gauze will suffice in cases 
 in the acute stage and before pus has become encapsu- 
 lated within them. Of course the pelvic peritoneum is 
 exposed to the dripping from the tubes, but this is 
 caught by the gauze. If distinct pus sacs have already 
 formed, they are to be treated as described under chronic 
 inflammation. My experience teaches me that all cases 
 of gonorrheal tubal disease at some time either relapse 
 or become reinfected. To always do an ablation is to 
 enter the dangerous field of preventive surgery. I pre- 
 
68 PET.YTC INFLAMMATION. 
 
 fer in most cases of first attack to perform the palliative 
 operation, aiding- repair by evacuation and drainage in the 
 acute cases, and in the more chronic seeking the obliter- 
 ation of the tubes by connective tissue hyperplasia ; and 
 then if a relapse occurs I ablate. Necessarily the woman's 
 surroundings, position in life and her general condition 
 will greatly govern my action. The palliative operation 
 in the worst cases enables the operator to remove the 
 case to another class : those in whom an elective radical 
 operation can be performed, with all that that means to 
 her and the surgeon. 
 
 If upon making the exploration through the posterior 
 cul-de-sac, I find one tube alone involved, and the indi- 
 cation is apparently clear to remove it, I would preferably 
 perform the palliative operation (which see) ; or else, not 
 do a laparotomy, but ablate the uterus and both adnexa 
 through the vagina. The relapses are so frequent where 
 one tube is removed through the abdomen, the remain- 
 ing one becoming infected often before the woman leaves 
 her bed after the first operation, that I cannot lend my 
 endorsement to the practice of abdominal unilateral sal- 
 pingo-oophorectomy in these cases. I am clear in my 
 conviction that we must either be wholly conservative or 
 most thorough in our treatment. (See conservative treat- 
 ment). 
 
 If we could only keep these women away from men, 
 the ideal operation, one with permanent results so far as 
 prevention of further suppurative processes is concerned, 
 would be the palliative operation through the cul-de-sac. 
 But the unfortunate creatures will return to the husbands 
 or lovers who infected them. 
 
 Sequelae. — The neglected cases go on to the formation 
 of either a sacculated pyosalpinx through closure of both 
 ends of the tube, or a sclerosis, or to a chronic relapsing 
 type ; rarely does hydrosalpinx result from gonorrhea. 
 
 If the currettage and cul-de-sac operation is done in a 
 first attack of gonorrheal salpingitis, return of the tubes 
 to a normal state is possible. I have had one patient on 
 whom this operation was done report herself pregnant. 
 
SALPINGITIS. 69 
 
 But where gonorrhea has been allowed to proceed un- 
 checked to the formation of a pyosalpinx, and where re- 
 peated attacks have occurred, which, while not produc- 
 ing pyosalpinx, have wrought permanent lesions in the 
 walls of the tubes, the cul de-sac operation is merely pal- 
 liative, and the restoration of the tubes is but partial. 
 
 ACUTE SEPTIC SALPINGITIS. 
 
 The usual causative germs are staphylococci or strep- 
 tococci (Fig. 16). Sometimes these reach the tube by ex- 
 tension along the lining of the uterine and tubal lining 
 membranes. In most cases, however, the tube is involved 
 subsequently to the pelvic peritoneum, the infecting 
 process first reaching the pelvis through the lym- 
 phatics which extend from the uterus between the broad 
 ligaments to the iliac glands. For this reason we most 
 often find this form of infection following interrupted or 
 completed gestation, for in this state the lymph streams 
 are sufficiently developed to carry the infecting agent. 
 The infection is more apt to affect one tube than is the 
 case with gonorrhea. The lesions induced in a tube so 
 inflamed are identical with those which follow gonorrhea. 
 
 The appearances, both gross and microscopic, are the 
 same, except regarding the causative cocci. 
 
 Syniptonis. — Very often there is a chill ushering in 
 the septicemia. The temperature rises rapidly and the 
 pulse is disproportionately high. For example, the 
 temperature may be but 102° and yet the pulse range 
 from 120 to 140 beats a minute. Local pain is severe, 
 at first spasmodic in the uterus, and then becoming con- 
 tinuous, as the general pelvic cavity becomes involved. 
 Altogether the clinical picture is not significant of the 
 cause of the infection except that it is more commonly 
 found following gestation or unclean operations, and that 
 the examination may reveal the peritonitis occurring be- 
 fore tubal enlargement can be appreciated. 
 
 It is never possible without the use of the microscope 
 to differentiate positively the cause of the inflammation. 
 
70 
 
 PELVIC INFLAMMATION. 
 
 But given a history of an operation upon the uterus, or 
 abortion, or labor, followed by fever, pain, peritonitis, 
 
 •-. .. '■■"'■'■ .J;.-fovS-. 
 
 
 H. 
 
 Fig. i6. — Acute septic salpingitis. Note the cellular infiltration in the walls 
 of the tube as well as in the plications of the mucous membrane. Section 
 aljout the middle of the tube (Beyea). 
 
 and later a swollen tube, we may infer that the case is 
 septic and not gonorrheal. This inference becomes a 
 
SALPINGITIS. 
 
 71 
 
 Strong probability when we fail to find signs of gonorrhea 
 elsewhere, notably in the urethra and vulvo-vaginal 
 glands; and the diagnosis is rendered certain by the 
 microscopic examination of the discharge. But the 
 possibility of mixed infection must be remembered, for 
 all pyogenic germs may be in the same case. Upon 
 bimanual examination the same signs are found as exist 
 with salpingitis due to gonorrhea. 
 
 The cul-de-sac incision and examination do not aid in 
 differentiating the cause of the salpingitis, and the af- 
 fected tube presents the same adhesions, discoloration, 
 swelling, etc., as are found in gonorrheal infection. But 
 there is apt to be more peritonitis with sepsis than with 
 gonorrhea. 
 
 Treatment. — Unimpregnated Cases. — The moment 
 the tube or the peritoneum shows evidences of being in- 
 volved, the uterus should be curetted. If this is done 
 before there is actual death of cells with the formation 
 of pus, a cure will be started in the vast proportion of 
 cases, no matter how extensive the peritonitis may be. 
 The first indication for treatment of a septic uterus with 
 complications short of the formation of pus is the re- 
 moval of the causative focus, the infected endometrium 
 or decidua. If a plastic operation has caused the trouble, 
 all sutures must be ripped out and the uterus cleansed 
 by irrigation with boric acid. The raw surfaces of the 
 wound should then be painted with pure carbolic acid. 
 
 By employing this curettage early more women have 
 been saved needless mutilating operations than by any 
 other treatment. Suffice it to say that the ability of the 
 tube to recover after the causative focus is removed by 
 curettage is far greater when sepsis starts the inflamma- 
 tion, and less when gonorrhea is the cause. 
 
 Still here, as in the article on gonorrheal salpingitis, 
 the rule holds good to open the cul-de-sac in addition to 
 curetting in all cases of relapsing septic salpingitis and 
 in those seen after labor or abortion, and always when 
 evidences of pus formation are present. The combined 
 procedure removes the diseased endometrium and drains 
 
72 
 
 PELVIC INFLAMMATION. 
 
 away the complications in the pelvis. Enormous quan- 
 tities of muddy toxins escape through the cul-de-sac 
 gauze in such cases, showing to what extent the lym- 
 phatics are drained. The technic of this incision and 
 the method of dressing these cases are found in an appro- 
 priate chapter. 
 
 If I find one tube only involved to a degree which 
 would seem to warrant its removal, I always apply con- 
 servative treatment to its cavity, and do not debate the 
 propriety of its removal. If I find both tubes acutely 
 inflamed in a first attack I do not remove them or con- 
 sider ablation ; for I have seen apparently hopelessly 
 involved tubes completely recover when freed and 
 drained. But in cases many times before infected, and 
 in those relapsing after conservatism has failed to cure, 
 the repair power is so damaged that it is unwise to at- 
 tempt conservatism. I therefore advise the radical vagi- 
 nal operation. From the difference between the treat- 
 ment applied to the gonorrheal and the septic cases will 
 be seen the importance of a differential diagnosis. 
 
 CHRONIC SEPTIC AND GONORRHEAL SALPINGITIS. 
 
 Unchecked septic and gonorrheal infections always 
 leave the invaded tube permanently damaged. If the 
 tissues have marked resistant power there may be merely 
 a production of new connective tissue. A repetition of 
 the infection results in more scar tissue, until in time the 
 tube and ovary become but masses of cord-like connective 
 tissue, constitutingthe condition known diS pachysalpingitis 
 or sclerosis (Figs. 17, 18). This is commonly bilateral, and 
 the process frequently involves the uterus. Or, for some 
 unknown reason, the infection merely causes occlusion of 
 both the fimbriated and uterine ends of the tube. The 
 tubal secretion is retained, and the tube becoming pro- 
 gressively enlarged, hangs at the cornu like a large grape, 
 with thin walls and clear contents. Sometimes a com- 
 bination of sclerosis and retention is met with, forming a 
 sacculated hydrosalpinx (Fig. 19). I have found much 
 
SALPINGITIS. 
 
 73 
 
 the larger number of hydrosalpinx cases to be due to 
 mild sepsis after abortion and labor. The explanation is 
 that sepsis here closes the fimbriated end of the tube, 
 and inflicts but slight damage upon the tubal lumen. 
 
 The graver results of pelvic inflammation are pyosal- 
 pinx and ovarian abscess. Very frequently we find them 
 
 Fig. 17. — Chronic salpingitis witli general adhesions of tubes, ovaries, and 
 uterus (Bandl). 
 
 associated in the same case. The tube is filled with pus, 
 its walls thickened, and recent lymph, as well as old ad- 
 hesions, are found upon its surface. The adhesions are 
 very dense. If the ovary be purulent, there may be one 
 main sac with the ovarian stroma riddled by communi- 
 cating sinuses ; or the pus may be in isolated localities. 
 These organs are always firmly attached to the adjacent 
 structures. The longitudinal .plicae of the endosalpinx 
 are obliterated, and the cavity of the tube is lined by a 
 roughly granular membrane, " pyogenic membrane." 
 
74 
 
 PELVIC INFI^AMMATION. 
 
 Sclerosis. — There is usually a history of many attacks 
 of endometritis, and many cases have been subjected to 
 repeated curettages. The menses are diminished. Inter- 
 menstrual leucorrhea is present, but is not profuse. 
 There is continuous pelvic pain, which at irregular inter- 
 vals is exacerbated. There is no fever, and no evidences 
 exist of more than the local distress. The pain is severe; 
 in many cases the women appear to suffer more than do 
 pus cases. The effort to menstruate from the sclerosed 
 
 Fig. i8. — Removed by vaginal ablation. Pachysalpingitis or sclerosis. * 
 
 endometrium produces great pelvic tenesmus. Most of 
 the cases are stout. Fever and acceleration in pulse rate 
 are absent. The condition is exceedingly common in 
 old prostitutes. Upon examination the uterus is found 
 atrophied and high in the pelvis ; it is fixed there by 
 adhesions and not by plastic or other masses in the lateral 
 fornices. The sides of the vagina are drawn to the cer- 
 vix by contraction in the pericervical tissues. The tubes 
 can be felt as cords extending from the cornua up to the 
 pelvic brim. The ovaries cannot often be felt. Com- 
 monly the uterus is diminished in size, but often cases are 
 met with where the organ is enlarged (Fig. 20). There 
 
 * The wire screens used in these illustrations are all of half-inch mesh. 
 
<>• S) 
 
 F - ^ 
 
 S 
 
SALPINGITIS. 
 
 79 
 
 is a fixity about these uteri, without evidences of effusion, 
 which is characteristic. The pain is produced, not by 
 inflammatory tension, but by constriction of the nerves 
 by connective tissue. Nature has employed her surest 
 method of obHterating the affected organs, that is by 
 connective tissue hyperplasia. These women are always 
 sterile (Fig. 21). 
 
 Opening the cul-de-sac is difficult. The tissues are 
 firm and the scissors must be used freely. Even when 
 entered, not much space can be secured, owing to the 
 contracted vaginal vault. There are commonly felt firm 
 old bands between the contents of the pelvis. The tubes 
 
 Fig. 21. — A case of genital sclerosis with hypertrophy of the corpus uteri. 
 From an old prostitute who had been repeatedly aborted. Vaginal ablation. 
 
 can be traced to the lateral pelvic walls, or lower, behind 
 the broad ligaments, as hard cords. They are freed with 
 difficulty; in fact, sometimes it is utterly impossible to 
 release them at this point. Upon direct inspection they 
 are not pink as in health, nor brawny as are pus tubes, 
 nor livid as in acute salpingitis. They appear as firm, pale 
 cords, sometimes nodular. The ovaries are shrunken 
 and scar-like. 
 
 Treatment. — A cure can be effected by ablation only. 
 Ichthyol 10 per cent., on tampons or injected into the 
 vagina, sometimes relieves the pain. The lesions are 
 
8o TELVIC INFLAMMATION. 
 
 permanent and progressive. The cul-de-sac incision and 
 conservative treatment afford no relief. 
 
 Hydrosalpinx. — As most of these cases follow abor- 
 tion or labor, there may be elicited a history of perhaps 
 mild infection at that time. There are not repeated 
 attacks of peritonitis arising from the tube, but, of course, 
 an affected endometrium may give rise to them. Still, 
 as a rule, the course of a case of hydrosalpinx is more 
 free from attacks of peritonitis than are pus cases. There 
 is no fever and no continuous pain. Over-distention ot 
 adherent bowels produces pain in the tubal locality. 
 Women may have large dropsical tubes and suffer but 
 little. They are very commonly felt when examination 
 is made, because of other conditions, as retroversion. 
 The masses are not very sensitive, are not firmly attached 
 by lymph, and communicate the sensation of very fluid 
 contents. Upon opening the cul-de-sac they are readily 
 found and easily freed (Fig. 22). Presenting at the vagi- 
 nal incision they appear translucent and opalescent, or 
 perfectly clear. Their sacs are transparent and exceed- 
 ingly thin. They are easily ruptured by handling, and 
 can be confounded with subperitoneal cysts only. Of 
 course they are attached at the cornua, and may exist 
 as single large cysts or as sacculated bunches of separate 
 cysts occupying the tube cavity (Fig. 23), 
 
 Treatment. — They are to be treated by opening the 
 cul-de-sac, freeing the sacs, and incising them with scis- 
 sors. As the clear sterile fluid escapes, it is caught by 
 gauze. The affected tube should be slit open for an inch. 
 It is not necessary to do more. The tube oozes but little 
 after incision and is returned into the pelvis. Preferably 
 the incision should extend from the fimbriated end along 
 the top of the tube. After the operation is finished the 
 cul-de-sac is plugged with gauze which extends just 
 within its cut edges. The first dressing is made in about 
 eight days. No fever follows the operation. These 
 cysts do not call for removal. (See conservative cul-de- 
 sac operation.) 
 
 Pyosalpinx. — This is a purulent cyst of retention (Fig, 
 
Fig. 23. — Showing a hydrosalpinx projecting into the vagina through a cul-de- 
 sac incision. 
 
SALPINGITIS. 
 
 83 
 
 24). The tube is more dilated near its fimbriated end, and 
 at the cornu of the uterus it is quite small and hard, and 
 its lumen obliterated (Fig. 25). Very often the pus tube is 
 associated with an ovary of normal appearance, but in 
 most cases the ovary also is involved in the mass of in- 
 flammatory products, sometimes producinga tubo-ovarian 
 
 
 Fig. 22. — a, a, Hydrosalpinx. A lesion readily relieved by conservative 
 operations through the vagina (Winckel). 
 
 abscess. There are commonly many adhesions between 
 the tube and adjacent organs. Some of the adhesions 
 exist as old bands, but recent lymph is generally always 
 found. 
 
 Symptoms. — These are essentially those of acute gon- 
 orrheal or septic salpingitis in some cases, and in others 
 there are no subjective symptoms other than a sense of 
 moderate dscomfort. Beyond a history of an infection, 
 
84 
 
 PELVIC INFLAMMATION. 
 
 with possibly the presence of some evidence of gonor- 
 rhea, there are no symptoms different from those found 
 
 Fk;. 24. — An old pyosalpinw (/, Tlie thickened tubal wall ; b, the occluded 
 fimbriated end ; c, the tube split open, showing the " pyogenic membrane " 
 (Winckel). 
 
 in other suppurative processes in the pelvis. Purulent 
 endometritis commonly coexists. 
 
SALPINGITIS. 
 
 85 
 
 Upon examination of a case of salpingitis which has 
 gone on to the formation of a pyosalpinx, the uterus is 
 found more or less fixed. On the infected side is felt a 
 hard yet fluctuating mass. This may be low down in the 
 cul-de-sac, or high near the pelvic brim ; usually it occu- 
 pies a position somewhat below the level of the normal 
 tube. It is sensitive upon pressure, the pain produced 
 depending largely upon the acuteness of the stage of the 
 inflammation. The mass is felt to be pedunculated, that 
 
 Fig. 25. — Bilateral pyosalpinx. Vaginal ablation. 
 
 is, there is a distinct sulcus between it and the uterus. 
 This is not always so, and the distended tube may be 
 closely matted to the posterior and lateral walls of the 
 uterus by plates of dense exudate (Fig. 26). In size these 
 pus-cysts may reach the dimensions of the pelvic cavity, 
 crowding the uterus deep into the vagina, or high up 
 upon the brim to one side. Fluctuation can nearly always 
 be detected. In eliciting this it will be necessary to 
 firmly support the tube by pressure from above while the 
 vaginal finger determines the fluidity of its contents. 
 Usually the disease is bilateral, the common association 
 being a larger tubal abscess upon one side and a purulent 
 salpingitis on the other. But both tubes maybe of equal 
 size. If the sac communicates with the gut, profound 
 
86 
 
 PELVIC INFLAMMATION. 
 
 septicemia may set in, with high temperature and quick 
 pulse. Even in those cases devoid of acute symptoms 
 the evening temperature is higher than the morning. 
 
 Upon opening the cul-de sac, the finger appreciates the 
 presence of dense adhesions. At once there escapes a 
 variable quantity of serum. In old cases the cul-de-sac 
 may be entirely obliterated and the finger be unable to 
 enter except high up on the posterior surface of the 
 uterus. Sometimes the first thing felt will be a knuckle 
 
 Fig. 26. — Right pyosalpinx. Left pyosalpinx. Vaginal ablation. 
 
 of small gut or of omentum. If the pus tube be low 
 down, the finger will reach up unobstructed for a short 
 distance, and then, being swept out to one side, will feel 
 the mass. It is adherent behind the broad ligament, 
 elastic but firm, as though there were fluid locked within 
 a thick capsule. With the finger circling the periphery 
 of the tube, it is gently freed below and will then be felt 
 attached to the cornu of the uterus by a narrow neck. 
 These tubes vary greatly in size and position. Direct 
 inspection reveals a discolored sac, with bleeding points 
 where adhesions have been severed, and flakes of lymph 
 
SAr.PINGITIS. 87 
 
 covering the surface. There are points of deep injection. 
 If there be an ovarian abscess alone or coexisting, it can 
 be differentiated from the tube only by tracing its attach- 
 ments. Usually an ovarian abscess is attached higher 
 than a pus tube, through the influence of the infundibulo 
 pelvic ligament. The appearance of each is much the 
 same. Ovarian abscess is usually firmer and more 
 rounded than a pus tube. Very often the finger imme- 
 diately upon penetrating the peritoneal cavity will meet 
 with two deeply prolapsed tubes, the peripheries of which 
 are agglutinated. The peritoneum of the cul-de-sac is 
 much thickened and often must be severed by scissors. 
 The evidences of intense inflammation, its attachments 
 and shape, usually that of an elongated pear, will deter- 
 mine the character of a pus tube. If the trocar be plunged 
 directly into the mass the diagnosis will be established 
 by the escape of pus, often greenish and stinking, or even 
 blood stained. 
 
 In tubercular pyosalpinx, tubercles may often be seen 
 upon the surface of the sac. Upon the right side very 
 often the tube is attached to the vermiform appendix, 
 and at all points the omentum and small intestines may 
 be found attached. 
 
 Diagnosis. — There are a history and evidence of infec- 
 tion. A suppurating ovarian cyst is usually unilateral 
 and if of large size pins the uterus up against the pubes. 
 An ectopic gestation is also on one side, is harder than a 
 pyosalpinx, and gives subjective symptoms presumptive 
 of its existence, such as irregular bleedings, stabbing 
 pains, attacks of syncope^ etc. Abroad ligament cyst or 
 abscess is always sessile upon the uterus, giving no sulcus 
 between the cyst and the uterus, and is always situated 
 laterally. Broad ligament fibroids are of cartilaginous 
 hardness and are also sessile upon the uterus. All broad 
 ligament growths are part of the uterus so far as mobility 
 is concerned. Exploratory puncture is not a safe pro- 
 cedure, inasmuch as very often other abdominal contents 
 lie between the tube and the vaginal vault. Besides, 
 failure to find the pus upon puncture is no proof of its 
 
88 rEI.VIC INFLAMMATION. 
 
 absence. Infected hematoma following ruptured ectopic 
 gestation, where the clot is in the folds of the broad 
 ligament assumes the characteristics of other fluid accum- 
 ulations in the ligament. Blood clotted and free in the 
 pelvis, infected and encapsulated by lymph, forces the 
 uterus forward and immovably fixes it. The lateral for- 
 nices are symmetrically occupied by the clot. In some 
 cases a positive diagnosis cannot be made without a 
 posterior vaginal incision, a perfectly safe procedure. 
 
 Treatment. — Pus in a preformed sac (pyosalpinx) is 
 radically cured only upon extirpation of the sac. In- 
 cision and drainage will relieve, but not insure against a 
 relapse at some distant day. Inasmuch as a pus tube is 
 rarely found upon one side and normal adnexa upon the 
 other, vaginal ablation of uterus and adnexa is the indi- 
 cated radical operation in all cases. If ablation is not 
 accepted the preferable operation in all cases of pyosal- 
 pinx purely pelvic in their relations and important asso- 
 ciations, is evacuation through the vagina by broad in- 
 cision. This treatment is to be practiced to the exclusion 
 of laparotomy and removal in all except a limited number 
 of cases. The excepted cases are the few in which 
 appendicitis coexists with a pyosalpinx, and cases where 
 a fistula exists between the small gut and tube. I have 
 never seen a gonorrheal pus tube upon one side, in which 
 there was not sufficient tubal or ovarian disease upon the 
 other to warrant its removal if it existed alone. The 
 treatment is either wholly conservative (see Conservative 
 Treatment) or thoroughly radical. 
 
 ' SeqiielcB. — Very rarely these pus tubes rupture into 
 the general peritoneal cavity. But in many cases they 
 leak slowly, causing the effusion of large masses of iso- 
 lating lymph, beneath the plates of which the pus oozes 
 (see Diffuse Pelvic Suppuration). Pus tubes form adhe- 
 sions with the intestines, usually with the sigmoid, and 
 may rupture into it. If the opening is into the sigmoid 
 the pus is discharged /i'r/rr/?/ wand the pus-sac becomes 
 additionally infected from the gut. If the fistula is into 
 a knuckle of small gut the pus will be absorbed. The 
 
SALPINGTTTS. 
 
 89 
 
 pus may also find its way into the vagina or even into 
 the bladder. The fistulse are not permanent, but open 
 and close in obedience to the distention of the pus-sac. 
 Pyosalpinx upon the right side is very frequently asso- 
 ciated with, and adherent to, a diseased appendix vermi- 
 formis. Life is destroyed by the prolonged suppuration, 
 and nephritis is a common sequela. In questioning over 
 three hundred cases of phthisis, I found that four in 
 every seven never had any lung symptoms until the onset 
 of an attack of pelvic inflammation. The general debility 
 
 Fig. 27. — Tuberculosis of the Fallopian tubes. The disease has extended to 
 the peritoneum, which is covered with tubercles (Penrose). 
 
 following the latter conduced to the inception of the 
 -former. Not pelvic inflammation but nephritis and 
 phthisis end the lives of most of these sufferers. 
 
 TUBERCULAR SALPINGITIS. 
 
 This is always chronic; and it is doubtful if it arises 
 primarily, being secondary to tubercular peritoneal dis- 
 ease. I have seen one case in which I thought it pri- 
 mary. The disease may be due to a general tuberculosis, 
 to extension from a tubercular intestinal ulcer, or be set 
 up by tubercle bacilli introduced through the uterus by 
 
9° 
 
 PELVIC INFLAMMATION. 
 
 means of ditty instruments (Fig. 27). The tubercles lie 
 upon the peritoneal surface of the tube, as well as in the 
 cavity, forming miliary tubercular salpingitis. Or the 
 disease may assume either of the two other common' 
 tubercular types: caseous infiltration, or chronic fibroid 
 tuberculosis. In one instance, there will be a tube filled 
 with cheesy pus and studded with tubercles ; while, in 
 another, the tubercles are few, and the production of 
 connective tissue marked. Tubercular disease consti- 
 tutes about fifteen per cent, of all inflammatory pelvic 
 disease of a chronic type. 
 
 The symptoms and sig-iis are those of pyosalpinx, or 
 other chronic tubal disease, due to other causes. 
 
 Treatment. — Whenever upon exploratory vaginal sec- 
 tion tubercular adnexal disease is found, ablation should 
 be performed. But this statement may be qualified some- 
 what by excluding operation when general peritoneal 
 tuberculosis coexists. 
 
 PELVIC PERITONITIS. 
 
 The normal pelvic peritoneum is generally transparent, 
 and through it the color of the underlying tissue maybe 
 detected. In certain portions of the pelvis it is thicker 
 than at other points, notably over the rectum and the 
 iliac vessels, and at these points the peritoneum is 
 opaque. Over the uterus the peritoneum is thin, and 
 the peritoneal covering of the tubes is exceedingly 
 delicate. 
 
 When inflamed the peritoneum becomes deeply in- 
 jected. Its color will vary from a delicate pink to a 
 livid hue, according to the severity of the process. At 
 first serum is poured out in a variable quantity. As the 
 circulatory stasis increases the endothelial cells shrink 
 away from each other, and the underlying lymph spaces 
 are exposed. White blood-corpuscles and plasma cells pass 
 out upon the surface of the membrane, where they form 
 
PELVIC rERITONITIS. 
 
 91 
 
 masses of " lymph." If the process subsides, these lymph 
 masses change into connective tissue bundles or " adhe- 
 sions," which become supplied with blood-vessels and 
 are covered with endothelial cells. If the infecting 
 agent overwhelms the vital forces, the cells die and pro- 
 duce pus. According to the nature of the result of the 
 infection, we have either a slightly injected peritoneum 
 with serum as a result, or one deeply colored, smooth, 
 and shining generally, but at points unglazed, and cov- 
 ered by lymph ; or one livid in hue, rough in appearance, 
 and devoid of endothelium, studded here and there by 
 small lymph masses, and showing frequent spots of puru- 
 lent lymph. Pus in the pelvic peritoneal cavity may be 
 whitish, yellow, or greenish-yellow. Usually it is odor- 
 less, but it may be tainted with intestinal gases without 
 there being an opening into the gut. 
 
 Causes. — The causes of pelvic peritonitis may be classi- 
 fied as direct and contributing. 
 
 Direct. — Pelvic peritonitis in women is caused by 
 colon bacilli, gonococci, staphylococci, streptococci, tubercle 
 bacilli, and more rarely by other pathogenic germs. A 
 certain form of peritonitis is also produced by the chem- 
 ical irritants which are contained in antiseptic dressings, 
 when these touch the peritoneum. According to the 
 nature of the infection the character of the lesions will 
 vary. Where colon bacilli cause the inflammation, there is 
 but little lymph produced, and not much of serum ; but 
 it is doubtful if suppurative peritonitis is ever set up by 
 the colon bacillus alone. Peritonitis caused by the colon 
 bacillus is less active than any other, and the local dis- 
 turbances are slight. It is found most commonly as a 
 result of inflammation of the colon when this is accom- 
 panied by bowel distention and retention of feces. Clin- 
 ically, we meet with it most often after it has produced 
 adhesions, or in its acute stage as a complication in the 
 after-treatment of intrapelvic operations. Very slight 
 toxemia is produced by it, and hence, the rise in tem- 
 perature and pulse rate may be so slight as to be 
 unnoticed. In cases of adherent retroposed uteri which 
 
g2 PELVIC INFLAMMATION. 
 
 we meet with in young women who have never had 
 uterine or tubal inflammation, the adhesions are probably 
 always due to the colon bacillus. Whenever any organ 
 rests immovable upon one spot of the large gut for a 
 length of time, migration of the colon bacillus is apt to 
 result, causing limited effusion of lymph, and the ulti- 
 mate formation of delicate adhesions. In the mistaken 
 treatment of abdominal diseases by opiates, the migration 
 of colon bacilli is facilitated. 
 
 Where peritonitis is caused by g'ouococci, scrum and 
 lymph are produced. Under ordinary conditions gono- 
 cocci do not produce purulent peritonitis. Suddenly 
 flooding the pelvic cavity by a large quantity of virulent 
 gonorrheal pus will set up a purulent peritonitis. Pelvic 
 peritonitis due to gonorrhea may be caused by the 
 gonococci reaching the peritoneum through the uterus 
 and Fallopian tubes, through the bladder, or through a 
 ureter. By far the greater number of cases of this form 
 of peritonitis are produced by the infection coming 
 through the uterus and tubes. Gonorrhea causes peri- 
 tonitis by extending directly along the continuity of the 
 tissue, and not through the medium of the lymphatics. 
 As a consequence we have the peritonitis secondary to a 
 salpingitis. The first effusion of plastic lymph occurs at 
 the fimbriated end of the affected tube, effectually closing 
 it, and causing it to unite to any adjacent organ. As the 
 infection progresses, lymph is thrown out upon the sur- 
 face of the uterus as well as on the tube. The produc- 
 tion of serum is slight, and altogether the tendency of 
 the peritoneal inflammation is to localization. A char- 
 acteristic of gonorrheal peritonitis is its tendency to 
 recurrence. The younger the subject infected, the more 
 pronounced the peritonitis. The puerperal state after 
 the third month appears to grant a certain immunity 
 against this form of infection. It is generally seen in 
 unimpregnated women. For the lesions induced in the 
 ovaries and tubes by this infection the reader is referred 
 to "Salpingitis" and "Ovaritis." 
 
 Pelvic peritonitis due to stapliylococci usually results in 
 
PELVIC PERITONITIS, 
 
 93 
 
 the limited production of both serum and lymph. I do 
 not believe that primary purulent peritonitis is ever 
 caused by staphylococci. The infection may reach the 
 peritoneum through either the medium of the tubes or 
 through the lymphatics, or by both channels. In the 
 former case the peritoneum at the fimbriated end of the 
 tube is first affected, resulting in the closure of the tube. 
 Here the pelvic peritonitis is limited. Where the infec- 
 tion passes to the peritoneum through the lymphatics, 
 the peritonitis occurs as a primary disease. According 
 to the extent of the infection the severity of the periton- 
 itis will vary. The passage of an unclean sound which 
 bruises a slight area of endometrium will cause but a 
 limited degree of infection and a small amount of lymph 
 will be poured out upon the broad ligament or uterine 
 wall. The same kind of infection occurring at the site 
 of a recently detached placenta may result in an infec- 
 tion which will be the cause of a general plastic pelvic 
 peritonitis. The degree of the peritonitis will corres- 
 pond to the number of lymphatics which are involved. 
 If this infection occurs in the puerperal state, and results 
 in the production of a broad ligament phlegmon, this 
 may be the means of starting a suppurative type of peri- 
 tonitis. But this suppurative peritonitis will be second- 
 ary to a plastic form, and the pus will be locked in. 
 Diffuse suppuration in the pelvis will result, but not 
 primary purulent peritonitis. There is a vast difference, 
 both in the local lesions and danger to life. The tend- 
 ency of infection by the colon bacillus is to produce 
 lymph-effusion at the point of migration of the bacillus, 
 and this will result in attaching that point to any organ 
 which rests upon it. Primary tubal and ovarian diseases 
 are not produced by the colon bacillus. 
 
 The tendency of infection by the gonococcus is to 
 produce primary suppurative salpingitis with secondary 
 peritonitis about the tubal orifices. This focus of sup- 
 puration in the tube becomes the agent by which other 
 attacks of peritonitis are produced. Recurrent plastic 
 peritonitis is characteristic of gonorrheal infection. The 
 
94 
 
 PELVIC INFLAMMATION. 
 
 tubal lesions are more marked than those of the peri- 
 toneum. 
 
 Staphylococcus infection tends to produce : (a) tubal 
 inflammation with secondary peritonitis ; and, (d) pelvic 
 lymphangitis with primary peritonitis. The extent of 
 the peritonitis is greater than where the gonococcus is 
 the infecting agent. 
 
 None of these pathogenic germs tends ordinarily to 
 produce primary purulent peritonitis. They are usually 
 local in their activity and produce but mild toxemia. 
 
 Such is not the tendency of the streptococcus. From 
 its first introduction into the system this germ produces 
 the greatest amount of septicemia relative to the degree 
 of the local disturbance. Introduced into an unimpreg- 
 nated uterus, it produces either tubal inflammation with 
 peritonitis secondary to that, or primary peritonitis by 
 extension through the lymphatics. Occurring in the 
 absence of a recent gestation it results in the liberal out- 
 pouring of serum and the widest effusion of lymph by 
 the peritoneum. As a result, there is suppuration in the 
 tube or ovary, or both, which is surrounded by large 
 masses of lymph. There is never intermission, however, 
 in an inflammation produced by the streptococcus. It 
 never becomes strictl)^a local disease, but there is a con- 
 tinuation of acute manifestations with marked exacerba- 
 tions. After a time the pus leaks into the lymph planes 
 and the gravest form of diffuse pelvic suppuration is pro- 
 duced. The streptococcus is found in the product's of 
 inflammation in such pelves, but there are such marked 
 differences in the gravity of the symptoms in various 
 cases, that we are forced to believe that there is a great 
 variability in the virulence of this germ. 
 
 Occurring in a uterus recently aborted or delivered, 
 this form of infection may result in primary purulent peri- 
 tonitis. This is the gravest form of peritoneal inflam- 
 mation. Large quantities of serum are produced ; the 
 peritoneum is livid in color ; the effusion of plastic lymph 
 is limited, and as a result, there is little or no tendency 
 to localization of the disease. Death may occur before 
 
PELVIC PERITONITIS. 
 
 95 
 
 any lymph is effused upon the pelvic peritoneum, there 
 being induced a complete stasis in the local vital forces. 
 From the first initiative chill to death may be less than 
 three days. 
 
 If, however, the septicemia is not so rapidly fatal, the 
 infection tends to cause death of the cells thrown out by 
 the peritoneum. The pelvic peritoneum becomes granu- 
 lar in appearance, and isolated spots of pus and lymph 
 are scattered over its surface. There is slight tendency 
 to union between the organs in contact. The lower pel- 
 vis is filled with fluid, sometimes straw-colored, with iso- 
 lated pus cells and flocculi of lymph, or cream-colored 
 from admixture of pus. The fluid has a putrid odor in 
 many cases. The least touch suffices to break the peri- 
 toneum, which is denuded of its endothelium. The ten- 
 dency of purulent pelvic peritonitis is to become purulent 
 general peritonitis. It is always fatal, unless checked by 
 operation, causing death either by heart paralysis from 
 the effects of its toxins, or by producing endocarditis, 
 pneumonia or nephritis. 
 
 Sometimes, usually in cases not aborted, or in those 
 aborted before the third month, the peritoneum will be 
 able to resist the streptococci sufficiently to produce large 
 masses of vitalized lymph. If it does this, the pus which 
 the infection has produced in the broad ligament or tube 
 or ovary will be locked in. If this localization of the 
 suppuration is once obtained, the peritoneum throws out 
 enormous masses of lymph. The intestines, omentum, 
 bladder and fundus uteri become firmly united at the 
 pelvic brim, and the pelvic suppuration is effectively 
 locked in. 
 
 Streptococcus infection, if not fatal in a few days, 
 always results in suppuration somewhere. Occurring in 
 the unimpregnated uterus, the pus may be produced in 
 tube, ovary or broad ligament, with diffuse plastic peri- 
 tonitis as a complication. Occurring free in the pelvic 
 cavity, the pus is located according to the posture of the 
 patient, as any other fluid would be. 
 
 Contributing Causes. — Although we find that all 
 
gO PELVIC INFLAMMATION. 
 
 forms of pelvic peritonitis are due to some irritant, either of 
 a germ or chemical nature, these direct causes are not 
 alvva3^s operative unless there exist local conditions which 
 are propitious to their activity. The peritonitis due to 
 gonorrhea we find more often occurring at the ■})ie}istnial 
 periods. At this time tlie physiological exfoliation of the 
 epithelium of the endometrium conduces to the introduc- 
 tion of the gonococcus into the pelvis. Furthermore, 
 gonorrhea may for years remain latent in the cervical 
 canal, and a general gonorrheal infection of the pelvis be 
 set up by operations upon a uterus so infected. We may 
 consider trauma as a contributing cause. Any injury to 
 the general system which will produce marked stasis in 
 the pelvic circulation will also suffice to bring on an 
 attack of peritonitis where latent pathogenic cocci are 
 present. Such an agency may be prolonged exposure to 
 cold, and great physical effort. Those germs which are 
 common in the bowel operate as causes of peritonitis when 
 the bowels are inactive and feces are retained. Chronic 
 constipation undoubtedly conduces to peritonitis of one 
 form. The breaches of surface incident to abortion and 
 labor are particularly conducive to the onset of an attack 
 of peritonitis, by furnishing points for the entrance of 
 germs into the system. 
 
 Syinptonis. — As pelvic peritonitis produces three kinds 
 of effusion, serum, lymph, (resulting in adhesions recent 
 or old), and pus, the local signs will vary greatly. The 
 degree of toxemia will be largely governed by the nature 
 of the infecting agent, and there is a wide range in symp- 
 toms. The peritonitis which accompanies gonorrheal and 
 septic infections is so commonly associated with or 
 caused by tubal diseases that the reader is referred to 
 the chapter on " Salpingitis " for its description. 
 
 There is undoubtedly a period of incubation from the 
 introduction of pathogenic germs to the first evidence of 
 peritonitis. Just how long this is we do not know, but 
 I have thought that where the infection travels through 
 the tubes it more rapidly produces peritonitis than where 
 the lymphatics are the carriers. To this, however, I 
 
PELVIC PERITONITIS. 
 
 9 7 
 
 must make the exception that in infection occurring after 
 the third month of gestation the peritonitis usually occurs 
 directly as a result of the lymphatic infection, and not 
 through the medium of the tubes. In any case, from 
 two to three days elapse from the time the germ of in- 
 flammation is introduced into the uterus to the first evi- 
 dence of peritonitis ; and a few hours only are needed 
 for the peritoneum to develop some evidence of inflam- 
 mation after being brought into contact with germs. 
 
 There is usually at first a free effusion of serum. This 
 I have never been able to determine upon examination, 
 and have found it only after the peritoneum has been 
 severed. 
 
 When lymph is first thrown out it is colorless. Within 
 a few hours vessels appear in it, and it becomes organized 
 into a new tissue. Lymph tends to hold immobile the 
 organs between which it lies. As a consequence we have 
 fixity. If the lymph be exuded upon the broad ligaments 
 only, these are thereby stiffened, and bilateral mobility of 
 the uterus becomes limited. Furthermore, the thickened 
 broad ligaments have lost their elasticity, and the exam- 
 ming finger finds a density in each lateral vaginal fornix, 
 where formerly there was perfect elasticity. The uterus 
 is fixed, and at the sides of the cervix are dense masses 
 of exudate. In extreme cases of plastic effusion the 
 uterus will be as immovable as though resting in the 
 knot-hole of a board, and the density, inelasticity and in- 
 filtration will be all around the uterus. If the lymph be 
 effused upon one broad ligament only, the cervix can not 
 be moved away from the affected side, and in drawing 
 down the uterus the cervix will swing toward the firmer 
 ligament, — it will not come down in the middle line of 
 the vagina. Masses of recent lymph are soft, but do not 
 give out fluctuation. The sense of a mass is produced 
 as much by the edema of the tissues as by the lymph. 
 Where the lymph has been effused about a tumor or pus 
 focus, it increases the bulk of the mass and fixes it. And 
 when the outpouring of lymph has been repeated, the 
 density of fluid accumulations is increased, leading to 
 7 
 
98 
 
 PELVIC INFLAMMATION. 
 
 their being mistaken for solid tumors. The effect of 
 thick lymph accumulations upon involved organs is of 
 interest. If the effusion has taken place about a bladder 
 which has been neglected in over distention, that organ 
 will be fixed high up and cannot be completely emptied 
 And if distention of the bladder is prevented by ofc- 
 repeated catheterization while the lymph is being poured 
 out, the bladder will be fixed in systole, and distention 
 will be impossible so long as the adhesions remain. As 
 I have pointed out, lymph tends to fixation of the uterus. 
 The same is true of the ovaries and tubes where they are 
 implicated in the effusion ; they remain attached to what- 
 ever organs they may rest against at the time the lymph 
 was effused about them, and can move only as those or- 
 gans move. Where the lymph is secreted about a rectum 
 distended by feces or gas, the gut remains canalized. As 
 a consequence we have a distended rectum, one whose 
 walls are never collapsed, a common feature of diffuse 
 pelvic peritonitis. If the rectum be empty when large 
 masses of lymph are produced about it, it will be partially 
 strictured. The ureters pass beneath both broad liga- 
 ments under the peritoneum. Recent effusion of lymph 
 has little effect upon them. If a knuckle of small gut is 
 caught and fastened by lymph in the pelvis, its function 
 is markedly interfered with, chiefly in the matter of rhyth- 
 mical peristalsis. The adhesions which result from lymph, 
 while much less than would be expected to follow so 
 generous a production of this material, yet produce grave 
 consequences. The bladder may be held at the fundus 
 uteri, permanently distended. The retroverted uterus 
 may be fixed to the rectum and be capable of replacement 
 only by ballooning out the rectum. The contraction of 
 the lymph upon the broad ligament causes stricture of 
 the ureter and hydro-ureter. The tubes are distorted 
 and strictured, the pelvic vessels obstructed, and a con- 
 dition of atrophy in the genital organs results from im- 
 peded circulation. The adhesions to the small intestines 
 are continuously pulled against. As a result, they are 
 teazed out so as to be many inches in length, forming 
 
PELVIC PERITONITIS. 
 
 99 
 
 bridges across which loops of intestine may fall and be- 
 come strangulated. Adhesions between the adnexa and 
 the peritoneum over the psoas muscles may be so stout 
 as seriously to impede bodily movements. An interest- 
 ing tendency of these false unions is that their vessels 
 furnish additional nourishment to the attached organs. 
 An ovary may become detached from its normal site and 
 be entirely supported through false bands. The appen- 
 dix vermiformis may receive its sole blood supply through 
 a new attachment to the right appendages, and slough 
 off when these are severed. Neoplasms have been found 
 separated from the uterus and nourished through adhe- 
 sions. The spleen, if attached in this way, becomes en- 
 larged. Omental adhesions often produce at the seat of 
 attachment large masses of fat tumor through the influ- 
 ence of the vessels running through the new bands. 
 
 Where intraperitoneal pus is the result of peritonitis, 
 the pelvic organs are all fixed, partly by lymph and partly 
 by subserous edema. There is marked lack of elasticity 
 in the vaginal vault. If the pus be very fluid it cannot 
 be detected, but when thick a spongy bulging may be felt 
 in the posterior vaginal fornix. This changes with 
 change in the posture of the patient, and, unlike very re- 
 cent lymph, can be displaced upward by pressure. Sen- 
 sitiveness to pressure is slight when serum alone is pro- 
 duced; where lymph is effused it is marked ; and in pri- 
 mary suppurative peritonitis the lack of pelvic sensitive- 
 ness and pain is a marked feature. In fact, in the worst 
 cases of purulent peritonitis there is pelvic analgesia. 
 This is an important sign. 
 
 Tympanites. — This is noticeable in cases of purulent 
 and lymph effusion, but is not present in serous effusion. 
 It is dependent upon the degree and kind of infection, 
 the state of the bowels, and the medication. If the 
 bowels are kept empty by washings and no opiates 
 given, the tympanites is not marked in pelvic peritonitis. 
 
 Subjective Symptoms. — Pain is slight where serum 
 alone is produced and when the infection is followed by 
 very gradual effusion of lymph. When intraperitoneal 
 
lOo PELVIC INFLAMMATION. 
 
 pus (purulent peritonitis) is present, pain is not marked 
 and may be entirely absent. Where a sudden sharp out- 
 pouring of lymph takes place, the pain is severe and 
 continuous. It is exceedingly difficult to say how much 
 pain is the result of the involvement of the peritoneum, 
 and how much is caused by coincident inflammation of 
 uterus, ovaries or tubes. Movement of the organs over 
 which lymph is effused increases the pain. Sudden 
 pelvic pain, accompanied by grave general symptoms, 
 pyrexia, and septicemia, and followed by a rather abrupt 
 cessation of the pain, points to purulent peritonitis. 
 
 Temperature. — Where serum alone is produced, the 
 temperature is seldom elevated one degree. (I consider 
 99f ° as normal rectal temperature.) The height of the 
 fever accompanying lymph effusion will vary with the 
 patient's general condition, the kind of infection present, 
 and the degree of the infection. Gonorrheal peritonitis 
 rarely produces a temperature above I02j^°. The 
 same is true with staphylococcus infection. In strepto- 
 coccus poisoning the temperature rapidly reaches 103°, 
 and is more often above than below that point. The 
 evening temperature is generally a degree above the 
 morning. A temperature holding steadily for more 
 than a day above 103° should create great uneasiness in 
 the medical attendant. This is particularly necessary 
 when the fever comes on after operation, abortion, or 
 labor. There are marked fluctuations in the tempera- 
 ture in most cases. The falls in temperature will be 
 found to correspond pretty accurately with an increased 
 excretion of urine and evacuation of the bowels. 
 Through the kidneys and the bowels toxins are elimi- 
 nated. 
 
 The pulse in gonorrheal peritonitis seldom reaches 
 1 10°. Where the infecting agent is the streptococcus, 
 the pulse rarely falls below 110° beats a minute. Ot 
 more value in determining the nature of the infecting 
 agent than either pulse or temperature alone, are their 
 relative marks. Thus, a temperature of 103° with a 
 pulse less than 110° need cause little apprehension as to 
 
PELVIC PERITONITIS. loi 
 
 the ultimate result, while the same temperature with a 
 pulse of 130° calls for immediate interference, and is 
 indicative of a virulent infection, probably streptococcic. 
 The effusion of lymph does not cause the rapid pulse 
 and fever. Great masses of lymph may be thrown out 
 about a gauze drain in the pelvis, and yet the pulse be 
 but slightly accelerated and fever be absent. The fever 
 and quick pulse accompanying those degrees of infec- 
 tion which result in lymph effusion are produced, not by 
 the lymph, but by the toxins of the invading germs. 
 We find slight rise in temperature attending the produc- 
 tion of large plaques of lymph, and high temperature 
 where no lymph is produced. The fever is due to the 
 toxemia, not to the outpouring of lymph 
 
 Rigors. — Chills are not features of peritonitis, except 
 when there is a sudden rise in temperature from a point 
 near 101° to one 4° or 5° higher. Then a slight 
 rigor will mark the inception of the rise in many cases. 
 Rigors may be stated to be features rather of a general 
 septicemia than of a localized peritonitis. 
 
 Digestive Symptoms. — There being an overproduction 
 of bile, vomiting is apt to follow overloading the stomach 
 in cases of pelvic peritonitis. Beyond this, vomiting is 
 rarely present as a symptom of pelvic peritonitis. The onset 
 of persistent vomiting, where not produced by improper 
 food and drugs, if accompanied by high pulse and tem- 
 perature, is alarming. It is indicative of a peritonitis 
 which is extending above the pelvic brim. The bowels 
 are prone to costiveness in pelvic peritonitis, on account 
 of interference with their peristalsis by adhesions, and in 
 part to the increase in pain produced by defecation. In 
 purulent peritonitis there is, on the contrary, very com- 
 monly a diarrhea. 
 
 The kidneys are rarely affected in any forms of infection 
 save one. The urine is increased in amount and the per- 
 centage of urea is increased. In streptococcus infection 
 acute parenchymatous nephritis is a common compli- 
 cation. 
 
 The heart and the lungs are not affected in any form of 
 
T02 PELVIC INFLAMMATION. 
 
 peritonitis, except that due to streptococcus, the purulent 
 form. Endocarditis, pneumonitis, and pleuritis are very 
 often met with in cases of purulent peritonitis. It is rare 
 for a case of streptococcus infection to recover without 
 some grave complication. 
 
 Diag-uosis. — The diagnosis of pelvic peritonitis is 
 generally embraced in that of some one of its accom- 
 panying lesions, salpingitis endometritis, etc. It is not 
 so difficult to detect an effusion of lymph in the pelvis. 
 I have never been able to determine the presence of the 
 serum which I have evacuated so many times. The im- 
 portant and difficult task is to diagnosticate the presence 
 of primary purulent pelvic peritonitis. I may mention 
 the more usual features of this disease: usually a history 
 of criminal abortion or instrumental labor, often an initia- 
 tive chill, pulse from the first iio° or more, temperature 
 at or above 103°, tympanites, not much pain, stupid face, 
 tendency to somnolence, sordes on teeth, red furred 
 tongue, muttering delirium ; uterus fixed in pelvis, vagi- 
 nal vault hardened, spongy mass in posterior cul-de-sac, 
 not much sensitiveness. The woman looks very ill in a 
 a day. It is especially difficult to differentiate suppura- 
 tive pelvic peritonitis from general suppurative periton- 
 itis. I have never found a case of suppurative pelvic 
 peritonitis in which there was not a history of either 
 abortion, labor or trauma. In general suppurative peri- 
 tonitis there is no such history; it is usually due to 
 appendicitis. It is impossible to determine just when a 
 suppurative peritonitis arising in the pelvis ceases to be 
 pelvic and becomes general. 
 
 Prog-nosis. — Where the effusion is purely of serum 
 and lymph there is no risk to life. All cases of purulent 
 peritonitis die unless operated upon, and most of these 
 perish. In early surgical interference lies the only hope 
 of saving the lives of these women. 
 
 If lymph effusions are allowed to remain they produce 
 permanent lesions. 
 
 When a woman has once had pelvic peritonitis with 
 the production of lymph she has before her all her life 
 
pp:lvic peritonitis. 
 
 103 
 
 the possibility of an operation of some sort. The prog- 
 nosis of peritonitis is markedly influenced by the nature 
 of the causative lesion, whether gonorrheal endometritis, 
 salpingitis, pelvic lymphangitis, etc. These are discussed 
 elsewhere. 
 
 Treatment. — If an effusion of serum alone is sus- 
 pected the treatment consists in preventing further 
 extension of the process by removing the causative 
 focus of infection. The serum will then be absorbed. 
 If lymph is effused, the cul-de-sac should be opened, 
 and all attachments between the viscera should be 
 severed, after the focus of infection (usually the uterus) 
 has been cleansed. (See Exploratory Vaginal Section). 
 This is necessary because the lymph in contracting into 
 bands produces such distortion of the viscera as will 
 destroy their function, partially at least. It is to prevent 
 tubal and ovarian suppuration, as well as future adhe- 
 sions, that this operation is recommended. (See Salpin- 
 gitis.) 
 
 Suppurative pelvic peritonitis demands the most 
 energetic measures. The operation to be applied is 
 purely an evacuative one. In most cases it will suffice 
 to open the posterior cul-de-sac, let out the pus and fill 
 the pelvis with iodoform gauze. But in all cases of 
 purulent peritonitis, the Mikulicz dressing of iodoform 
 gauze is absolutely necessary to remove the large quan- 
 tities of septic fluid which escape after the operation, and 
 to furnish iodine in the form of iodoform in order that 
 the streptococci may be destroyed. The author has 
 shown that this result follows the use of a certain form 
 of gauze in these cases. 
 
 I have had no experience with the use of antistrepto- 
 coccus serum in these cases, and cannot see how it 
 can benefit them before an operation. Given after an 
 operation it may prevent those complications which 
 commonly cause death. Certainly, preliminary reports 
 warrant its trial, but not to the exclusion of measures 
 here recommended. 
 
 General Treatment. — When a heart stimulant is 
 
I04 
 
 PELVIC Ix\FLAMMATION. 
 
 needed in pelvic peritonitis I emplo}' strychnin. As a 
 rule this will be found necessary in the purulent type 
 only. Here large doses must be administered, begin- 
 ning with gr. Jjj q. 4. h. hypodermically and gradually 
 increasing. I dislike to give alcohol except in the form 
 of champagne. If strong liquors are given, brandy in 
 six parts of iced water is best. Of brandy 5ss. q. 3. h. is 
 an average dose. Again this is needed in the purulent 
 type only. For local pain, blood-letting from the cervix 
 and ichthyol tampons 10 per cent, furnish greatest relief. 
 The colon should be washed out daily with a quart of 
 normal salt-solution. In most cases I allow half diet; but 
 in the purulent type I employ an exclusive liquid diet — 
 one ounce of beef juice every four hours and two ounces 
 of chicken broth every four hours. These are made to 
 alternate, at two-hour intervals. Between feedings an 
 abundance of water, with a few drops of lemon juice to 
 acidulate it, is given if vomiting is present. 
 
 The general treatment of pelvic peritonitis should be 
 sustaining. Inasmuch as the effusion of lymph serves a 
 good purpose at first, it is to be interfered with o\\\y after 
 the causative focus of infection is cleansed. Then, for 
 evident reasons, the effusion of lymph must be checked. 
 If pus is present, it must be evacuated so soon as 
 discovered. 
 
 TUBERCULAR PELVIC PERITONITIS. 
 
 I have reserved a description of tubercular pelvic peri- 
 tonitis for a separate section, since its lesions differ in 
 character from those produced by pathogenic cocci. 
 The bacilli reach the peritoneum through either the 
 blood or the lymphatics. It is of interest that tubercular 
 peritonitis is not a result of a similar process in the 
 uterus, but that the peritonitis produced through the 
 blood is merely part of a general tuberculosis, and that 
 
TUBERCULAR PELVIC PERITONITIS. 
 
 105 
 
 which extends through the lymphatics is from some 
 tuberculous focus in the abdomen. The origin of cer- 
 tain cases, however, is obscure. 
 
 When the tubercles appear beneath the peritoneum, 
 they are in the form of gray nodules. The peritoneum 
 is at first unchanged. Soon serum is effused'. The peri- 
 toneum becomes congested, and the endothelium be- 
 comes multiplied and exfoliates. Leukocytes escape 
 from the vessels, and blood may tinge the serous fluid. 
 The process may stop here, and recovery may take place. 
 Or, lymph may result from the presence of the tubercles 
 and intervisceral adhesions result. The tubal orifices 
 may close, and retention cysts be formed. The tubercles 
 tend to invade the tubes and produce tubercular salpin- 
 gitis. Where suppuration results the pus-producing 
 agent is not the tubercle bacillus, but some complicating 
 pyogenic coccus. 
 
 The syniptoiiis are those of pelvic peritonitis due to 
 other causes that produce serum and lymph. Neither by 
 symptoms nor examination can the disease be differen- 
 tiated from other forms. It may be suspected when 
 peritonitis occurs slowly, without marked acute symp- 
 toms, without evidences of primary uterine and tubal 
 disease, and when great emaciation and debility appear 
 without assignable cause. 
 
 The treatment is always to be evacuative. The 
 uterus need not be curetted. The cul-de-sac is opened 
 and all adhesions severed. After this the pelvis is irri- 
 gated with normal salt-solution and a high Mikulicz 
 dressing is applied. The strips of gauze should extend 
 quite to the fundus. If secondary tubal and ovarian dis- 
 ease are present, vaginal ablation is indicated. The 
 exposure to air, the trauma incident to the operation, 
 and the iodine in the gauze probably effect the cure. 
 
 Serous pelvic peritonitis is innocent; plastic lymph- 
 producing peritonitis is beneficent, but purulent periton- 
 itis is the most fatal of all diseases affecting the human 
 body. 
 
 Peritonitis is not to be considered in the light of the 
 
To6 PELVIC INFT>AMMATTON. 
 
 results of the process, but rather in a knowledge of its 
 causes. 
 
 The greater the lymph effusion the less immediate 
 danger to the patient, for the lymph tends to lock in the 
 infection and limit it, and in that sense it is beneficent. 
 But in so considering it we must not be consoled into an 
 ignorance of the ultimate results of a generous outpour- 
 ing of lymph; and it is our duty to check it while check- 
 ine the infection. 
 
 INFLAMMATORY DISEASES OF THE OVARIES. 
 
 Acute Peri-ovaritis. — The infection may extend to the 
 peritoneal covering of the ovary from the tube; or the 
 ovarian peritoneum may become inflamed conjointly with 
 the adjacent pelvic peritoneum from an infection which 
 has reached it through the lymph streams. In other 
 words, pelvic peritonitis from any cause may implicate 
 the peritoneum of the ovary. The type of inflammation 
 is the same here as in other portions of the pelvic perito- 
 neum. There is an effusion of lymph which causes the 
 ovary to become attached to adjacent organs, most com- 
 monly to the tube and to the broad ligament. The en- 
 tire ovary enlarges and appears edematous. Upon its 
 surface flakes of lymph are seen, or the entire organ may 
 be covered by a thick plastic deposit. If the process 
 subsides, there result delicate false bands attaching the 
 ovary to some portion of the pelvic contents, or the 
 union may be so broad that the ovary is firmly plastered 
 to the uterus, broad ligament, tube, or lateral pelvic wall. 
 United in this way, and repeated attacks of peritonitis 
 occurring, the ovary may be entirely isolated from the 
 general pelvic cavity and lie in a pocket formed by sheets 
 of new membrane. In all cases the capsule of the ovary 
 is thickened. Periovaritis may extend to the stroma of 
 the ovary and to the follicles. The stroma may become 
 infiltrated with new connective tissue elements and on con- 
 
INFLAMMATORY DISEASES OF THE OVARIES. 
 
 T07 
 
 trading produce " ovarian sclerosis " (see Fig. 21). If the 
 follicles are involved, they become enlarged and, unable to 
 discharge their contents through the thickened capsule, 
 they present the characteristics of permanent cysts. The 
 ovary is " cystic " and enlarged. Between the cysts are 
 found areas of sclerosed tissue (Fig. 28). The cysts project 
 beneath the capsule and appear as pearl-like bodies. Upon 
 evacuating one a thin serous or tenacious glairy fluid es- 
 capes, and the cyst wall collapses. The cysts maycom- 
 
 FlG. 28. — Salpingitis with partial inversion of the fimbriae, 
 degeneration of the ovary (Penrose). 
 
 Cystic 
 
 municate with each other and large cavities be thus formed. 
 Cysticdegeneration must not be confounded with ovarian 
 cystoma (ovarian cyst). They are essentially different. 
 Ovules are found in the cysts of cystic ovaritis and women 
 with such ovaries conceive. We may therefore consider 
 this lesion unimportant, and inasmuch as the organs so 
 affected functionate they should be preserved. Blood 
 may be extravasated into one or more of the cysts, con- 
 stituting " ovarian apoplexy." The walls of the blood 
 cavity are lined by a membrane, sometimes dark, in other 
 cases yellow, which is loosely attached to the surround- 
 ing ovarian stroma. There may be but one such blood 
 
,io8 
 
 PELVIC INFLAMMATION. 
 
 cyst, often several inches in diameter, or there may be a 
 number of small ones. 
 
 The lymphatics of the ovary may be chiefly affected 
 and the ovary become soft, edematous and much enlarged, 
 even four times its normal size. Upon splitting such an 
 ovary it appears gelatinous. This is "edematous ova- 
 ritis " (Fig. 29). The kind of infection brought to the 
 ovary by the lymph streams may be so virulent that sup- 
 puration takes place in the stroma-, or an acutely inflamed 
 
 #:^'fe^; 
 
 Miii^flMiliBiiiiii 
 
 Fig. 29. — Bilateral pyosalpinx, left edematous ovaritis, and subserous cyst 
 Vaginal ablation. 
 
 tube may become sealed to the ovary and the ovary sup- 
 purate from proximity to the pus tube. " Ovarian ab- 
 scess " results (Fig. 30). These pus ovaries are always 
 enlarged. Sometimes there are a great number of small 
 foci of pus ; in other instances the ovarian capsule sur- 
 rounds one large pus cavity, I have removed by the 
 vagina one which lifted the uterus up out of the pelvis 
 and completely filled the latter. 
 
 Surgically the inflammatory states of the ovary may 
 be divided into non-purulent and purulent. If pus is not 
 present, attempts should always be made to save at least 
 portions of the organ. Sclerosis of the ovaries may co- 
 exist with a like process in the tubes and the uterus. 
 Manifestly it is useless to preserve the diseased ovaries 
 
INFLAMMATORY DISEASES OF THE OVARIES. 
 
 109 
 
 when there exists an indication for removing the uterus 
 and tubes in such a case. 
 
 Symptoms. — It is the author's behef that non-purulent 
 inflammatory disease of the ovaries produces few symp- 
 
 FlG. 30.- 
 
 -Very large ovarian abscess, and half the uterus. Vaginal 
 ablation. 
 
 toms. It is not the cystic or apoplectic ovary which 
 causes the distress, but the co-existing tubal and perito- 
 neal disease that is commonly found in these cases. Such 
 being my view, I am disposed to apply conservative treat- 
 ment to cystic and apoplectic ovaries. 
 
 In the young girl the ovary is pink and has a delicate 
 capsule. After hundreds of ova have torn their way 
 
no PELVIC INFLAMMATION. 
 
 through the capsule, it becomes scarred and pale; the 
 capsule is thickened, and the ovary distorted. No two 
 ovaries are exactly alike; some are round, some long, 
 some of hourglass shape; some measure a half inch in 
 length, others as much as two inches. In other words, 
 there is the greatest variety among perfectly normal 
 ovaries. ]3ut surgeons have spayed thousands of women 
 because their ovaries did not conform to some ideal 
 organ, and many of these women have been sent to the 
 mad-house. Hystero-epilepsy, epilepsy, neuroses of all 
 sorts, chronic pelvic pain, in short almost every obscure 
 complaint in women, has been treated by the removal of 
 ovaries that were cystic, apoplectic, or "atrophied." I 
 believe that non-purulent ovaries produce few symptoms 
 other than a sense of weight when they are large. When 
 adherent in the cul-de-sac and compressed by other 
 organs, they give pain; but it is the lack of freedom in 
 mobility and position, rather than essential disease, which 
 is to blame. 
 
 Periovaritis gives no distinguishing symptoms, inas- 
 much as it is always accompanied by some more impor- 
 tant lesion, as salpingitis or pelvic peritonitis. 
 
 Ovarian Abscess can not be differentiated from pyosal- 
 pinx. The history will sometimes presumptively indi- 
 cate the character of the abscess. Ovarian abscess is 
 usually due to infection after abortion or labor, and when 
 due to gonorrhea, it is found as a lesion secondary to 
 salpingitis (Fig. 31). The symptoms are the same as those 
 of pyosalpinx. Upon examining a pus-ovary case we do 
 not get fluctuation. A firmly adherent, dense, sensitive 
 mass is found to one side or behind the uterus. There 
 are evidences of acute pelvic peritonitis, fever, pain, etc., 
 just as are found with pyosalpinx. Still I have seen a 
 case of an enormous pus-ovary holding a pint in which 
 there was absolutely no evidence of fever. 
 
 Treatment. — Acute Periovaritis. — Inasmuch as this 
 condition is not found existing alone, but as a concomi- 
 tant of inflammation of other portions of the pelvic peri- 
 toneum, there is no special treatment to be directed to it. 
 
INFLAMMATORY DISEASES OF THE OVARIES. m 
 
 Blisters and iodin applied to the abdomen over the 
 ovaries are classical, but are of doubtful efficacy. I have 
 found that the maintenance of a definite warmth over the 
 abdomen by employing moist dressings which are cov- 
 ered by rubber tissue, painting the vault of the vagina 
 with 10 per cent, to 20 per cent, ichthyol in boroglycer- 
 ide, and keeping the bowels washed out so that hard 
 fecal masses do not press on the ovaries, afford the 
 greatest relief. If this condition is found to exist after a 
 cul-de-sac operation is made, the ovaries should be 
 detached from their false attachments. 
 
 Fig. 
 
 31- 
 
 -Right pyosalpinx and ovarian abscess. Left ruptured ectopic 
 gestation. Left ovarian apoplexy. Vaginal ablation. 
 
 Ovarian sclerosis cannot be cured by any means. 
 Such ovaries may be removed when indications exist for 
 removing the uterus, but sclerosis of the ovaries only 
 does not warrant their removal. 
 
 Edonatoiis ovaritis I have not met with except under 
 circumstances which required removal of all the genera- 
 tive organs. 
 
 Cystic Ovaries. — Upon opening the cul-de-sac I first 
 attempt to free the ovary of one side. When this is 
 loose I introduce a posterior retractor into the pelvis, and 
 with the trowel lift the uterus into the abdomen. A 
 gauze pad is next introduced between the retractors, and 
 
112 PELVIC INFLAMMATION. 
 
 the head of the table is lowered. If the intestines are not 
 adherent they will escape into the abdomen. The ovary- 
 is now grasped with Luer's forceps and pulled down. 
 A pair of stout mouse-tooth forceps or bullet forceps 
 may be substituted for Luer's instrument. The surface 
 of the ovary is inspected carefully, and all cysts are 
 stabbed with a tenotomy knife. The bleeding is trivial. 
 When all the cysts are evacuated, the ovary is returned 
 to the pelvis and the other ovary similarly treated. I am 
 opposed to igni-puncture with the Paquelin cautery. 
 This method of evacuation is uselessly complicated, and 
 the healing after it is not normal. After returning the 
 ovaries, the pelvis is wiped dry, and the gauze pad is 
 
 Fig. 32. — Suture of resection wound in tlie ovary. 
 
 removed. The rent in the cul-de-sac is sewed up, if the 
 uterus is not retroposed, if the patient has not purulent 
 endometritis, and if there is not pronounced oozing in 
 the pelvis. When either of these exists it is better to 
 introduce a plug of iodoform gauze into the opening and 
 pack the vagina. 
 
 Ovarian Apoplexy. — Having released the ovary from 
 false attachments, it is pulled into the vagina. In doing 
 this care is exercised and the forceps should grasp the 
 more normal portions of the organ. Steadying the ovary 
 the surgeon splits the periphery of the blood-sac with 
 scissors. Fluid and old blood escape and should be 
 caught with gauze. Holding apart the lips of the rent, 
 the lining cavity of the sac is easily pulled out. When 
 this is removed it will be found to measure sometimes a 
 
INFLAMMATORY DISEASES OF THE OVARIES. 
 
 ^13 
 
 sixteenth of an inch in thickness. The cavity left after 
 this will ooze a little, and the organ will appear much 
 shrunk. Nothing more is needed where the apoplexy is 
 small ; but where the accumulation is large and its evacu- 
 ation leaves flabby flaps, these should be trimmed and 
 sutured (Fig. 32). The suture material may be either fine 
 chromic kangaroo tendon or fine carbolized silk. The 
 needles should penetrate beneath the cavity and a contin- 
 
 FlG. 33. — Bilateral purulent salpingitis. Bilateral cystic degeneration ot 
 ovaries, the right large. Vaginal ablation. 
 
 uous suture be used. The ovary is returned, and, after 
 cleansing the pelvis and removing the protecting pads, 
 the opening in the vagina is either sutured or plugged 
 with gauze. Of course, whenever retroversion accom- 
 panies either cystic or apoplectic ovary, the cul-de-sac is 
 not to be closed, but is to be treated according to the 
 method described elsewhere (see page 117). 
 
 Ovarian Abscess. — The treatment of this is similar to 
 that of pyosalpinx, both as regards palliative operations 
 and extirpation (Fig. 33). 
 
TT4 
 
 PELVIC INFLAMMATION. 
 
 BROAD-LIGAMENT CYST. 
 
 Upon examining the broad ligament spread out before 
 a strong light, the various component parts of the par- 
 
 FiG. 34. — Diagram of the structures in and adjacent to the broad ligament. 
 a, Framework of the parenchyma of the ovary, seat of ^, simple or glandular 
 multilocular cyst; c, tissue of hilum, with d, papillomatous cyst; e, broad liga- 
 ment cyst, independent of parovarium and Fallopian tube;/^ a similar cyst in 
 broad ligament above the tube, but not connected with it ; h, a similar cyst 
 developed close to ovarian fimbria of tube ; /, the hydatid of Morgagni ; k, 
 cyst developed from horizontal tube of parovarium. Cysts e, f, h,J, and k 
 are always lined internally with a simple layer of endothelium. /, The paro- 
 varium ; the dotted lines represent the inner portion, always more or less obso- 
 lete in the adult ; m, a small cyst developed from a vertical tube ; cysts that 
 have this origin, or that spring from the obsolete portion, have a lining of 
 cubical or ciliated epithelium, and tend to develop papillomatous growths, as 
 do cysts in c, tissue of the hilum ; n, the duct of Gartner, often persistent in the 
 adult as a fibrous cord ; o, track of that duct in the uterine wall ; unobliterated 
 portions are, according to Coblenz, the origin of papillomatous cysts in the 
 uterus. (After Doran.) 
 
 ovarium may be seen either as fibrous cords or as minute 
 tubes (Fig. 34). Any infection passing from the uterus to 
 the iliac glands through the lymph channels in the broad 
 
BROAD-LIGAMENT CYST. u^ 
 
 ligament will set up an inflammation in one or more of 
 these embryonic tubes. If one only be inflamed, a single 
 broad ligament cyst will be produced; if more become dis- 
 tended, a multiple cyst is the result. Most women who 
 have suffered infection after abortion and labor will in time 
 develop one or more such cysts of greater or less size. 
 As the cysts grow they spread apart the folds of the broad 
 ligament. They have no pedicles. At first, while small 
 and if situated far out in the ligament, they can be moved 
 with the ovary and tube ; but when they have grown to 
 touch the side of the uterus, they are always sessile upon 
 the uterus. Their sacs are exceedingly thin and are easily 
 ruptured. The fluid in them is perfectly clear, watery, 
 and of a pale straw color. It is entirely innocent and 
 devoid of harmful properties. Sometimes these tumors 
 are of large size, reaching even to the umbilicus. In 
 growing they displace the uterus laterally. They are 
 never of acute formation, but are of gradual growth. 
 
 Symptoms. — Whatever distress attaches to fixity of 
 the uterus and, if the tumor be large, to the presence of 
 a mass, accompanies these growths. There is not the 
 pelvic pain, nor the fever, nor the recurrent inflammation 
 which accompany pus in the pelvis. The history is usu- 
 ally that of a mild degree of infection following abortion 
 or labor. Upon examination there is felt upon one side 
 of the uterus a very fluid tumor, but slightly sensitive. 
 The uterus is firmly fixed to the tumor and may be 
 pushed away from the tumor to one side only. The arch 
 of the base of the broad ligament upon the side of the 
 tumor is destroyed, and the finger when swept away from 
 the cervix on the tumor side appreciates that the tumor 
 and uterus are but one mass. This is an invariable sign 
 of all broad ligament growths, whether fluid or solid, 
 whenever they reach the side of the uterus. By repeated 
 attacks of peritonitis, purulent foci in the ovary and tube 
 may imitate this relation ; but such lesions commonly 
 occupy a position further behind the uterus. Broad 
 ligament abscess causes the general symptoms of pus, 
 while ruptured ectopic gestation and broad ligament 
 
. Il6 PELVIC INFLAMMATION. 
 
 fibroid are much firmer. The marked fluidity, the thin- 
 ness of the walls, and the clinical history will usually 
 make the diagnosis clear. 
 
 Ti-catnieiit. — If the growths are small and purely 
 pelvic in location, they are easily treated through the 
 cul-de-sac. But where they are large and extend above 
 the pelvic brim they should be removed through the 
 abdomen. Upon opening the cul-de-sac the diagnosis 
 is easily made. A gauze pad is introduced into the 
 pelvis above the tumor, and the head of the table low- 
 ered. The anterior trowel and posterior retractor read- 
 ily expose the tumor to view. Its surface is smooth and 
 glistening, and through its thin sac the clear fluid is 
 seen. Having inspected the tumor, enough gauze pads 
 are introduced into the pelvis to keep all intestines above 
 the brim^ and the patient is brought to a horizontal posi- 
 tion. A pair of closed blunt scissors are shoved into the 
 tumor, and its contents escape through the vagina. It is 
 the posterior layer of the broad ligament which is punc- 
 tured by the scissors. As the scissors are withdrawn 
 the blades are opened so as to make a wide rent in the 
 sac. The pelvis is wiped dry and the finger seeks the 
 opening in the sac. So flimsy are its walls that it is with 
 difficulty found, but when entered its cavity is explored 
 for secondary cysts. These are ruptured. Removing 
 the gauze pads from the pelvis, the surgeon packs the 
 cul-de-sac opening with iodoform gauze which passes 
 just within the cut edges of the vagina. The uterus is 
 replaced and the vagina packed with gauze. I do not 
 pack the cyst cavity. It closes spontaneously without 
 artificial drainage, there being no pus present. 
 
 The first dressing is made in seven to ten days and 
 repeated as often as soiled. After the second dressing 
 the patient is allowed out of bed. 
 
ADHERENT RETROPOSITIONS. 
 
 117 
 
 ADHERENT RETROPOSITIONS* 
 
 While this book does not treat of all forms of displace- 
 ment, there is one so commonly associated with inflam- 
 mation of the adnexa that I may describe my method of 
 dealing with it through the vagina. I shall exclude from 
 this discussion all cases of congenital displacement and 
 
 Fig. 35. — Retroveision with old firm adhesions (Winckel). 
 
 shall deal only with those which have been accom- 
 panied or caused by either gonorrheic or septic infection, 
 for I believe the congenital cases are incurable (Fig. 35). 
 
 The difference between the free and the adherent retro- 
 positions is that the latter are complicated by false bands 
 which bind the displaced uterus to the lower and pos- 
 terior portions of the pelvis, and also commonly present 
 some degree of tubal disease. 
 
 Before any attempt at replacement of an adherent 
 
irS TELVIC INFLAMMATION. 
 
 uterus can be made, the false bands of union must be 
 severed. This can be done in one of two ways: either 
 tlirough the abdomen or through the vagina. If the 
 operation is performed through the belly, the fundus 
 uteri is suspended from the anterior abdominal wall 
 (Kelly's method), or else the anterior surface of the 
 uterus is stitched to the upper wall of the bladder 
 (Pryor, N. Y. Jour. Gynec. and Obstet., July, 1893). 
 Few objections can be made to either operation, except 
 that both necessitate an invasion of the abdominal cavity 
 and conservative treatment of the inflamed adnexa is 
 limited in scope. Of the vaginal methods there are 
 two, one of anterior colpotomy (Diihrssen-Machenrodt, 
 etc.), which is condemned because it interferes so often 
 with subsequent pregnancies; and the other, the opera- 
 tion I have for years been performing. I have been 
 struck with the invariable observance of one of two 
 rules in all operations which succeed in keeping a retro- 
 posed uterus forward: either this is accomplished by 
 fastening the corpus uteri forward, or else by fixing the 
 cervix high and backward so that the intra-abdominal 
 pressure will force the body of the utorus forward. This 
 latter is the way a pessary acts, and this is the idea 
 embodied in my operation. 
 
 Operation. — The patient is prepared locally and gen- 
 erally as for a capital operation. I begin the operation 
 with a curettage. The cul-de-sac is then opened (see 
 Exploration). Upon entering the pelvic cavity I make 
 a careful digital exploration. If I find a pus focus. 
 / abandon all ficrther attempts at replacement by the 
 vagina, and treat the case as one of suppuration. But if 
 I find any condition of the adnexa that will not require 
 their removal (see Conservatism), I continue the opera- 
 tion. Occluded tubes are opened and other adhesions 
 are severed. The pelvis is then wiped dry, and a gauze 
 pad inserted. The patient is tilted into the Trendelen- 
 burg posture and the gauze pad is removed. The 
 uterus is packed with iodoform gauze. The operator 
 selects a piece of iodoform gauze wide enough to fill 
 
ADHERENT RETROPOSITIONS. 
 
 119 
 
 the vaginal opening and about one and a lialf inches 
 long. This is inserted just ivitliin the edges of the 
 vaginal rent. Over this enough strips are placed to fill 
 the incision in the vagina. This gauze plug, together 
 with the uterus, is next replaced. It is easily done, as 
 the patient is head down and the intestines have left the 
 pelvis. Holding the uterus in position, by means of the 
 trowel or any depressor pushing against the cervix, 
 pieces of gauze are inserted to the sides of the cervix 
 and in front of it until the vagina is filled to the margin 
 of the levator ani muscle. The operator now takes a 
 stout roll of gauze as thick as his thumb and as long as 
 the width of the distended vagina, usually two inches. 
 This I call my gauze pessary. One end of this is intro- 
 duced in front of one side of the cervix, just behind the 
 levator ani fibers, and the other end is pushed into a 
 similar position on the other side. This plug will lie 
 transversely across the vagina and in front of the cervix. 
 (Fig. 36). It will prevent descent of the cervix even in 
 face of the most violent vomiting. The uterine packing 
 should be so arranged that it can be removed without 
 disturbing this anchoring plug. 
 
 A self-retaining catheter is introduced and is emptied 
 every two hours for two days. The bladder is then 
 irrigated with boric acid solution and the catheter with- 
 drawn. The uterine packing is now removed without 
 disturbing the vaginal. In seven to ten days the patient 
 is placed in Sims' position. All dressings are removed 
 and replaced exactly as were the first. The operation 
 will fail unless the supporting plug is properly inserted. 
 This is as important as the suture in other operations. 
 The second dressing is applied a week later, is painless, 
 and after it the patient sits up. I keep up these dress- 
 ings as long as there is any raw surface at the vaginal 
 vault; the supporting tamponade I use for six weeks. 
 The woman is then allowed intercourse. 
 
 If at any time the dressings are so applied that they 
 allow of descent of the uterus, they have been improperly 
 inserted. The cervix must be kept high and backward 
 
PELVIC INFLAMMATION. 
 
 until the cul-de-sac opening closes and the post-cervical 
 scar has contracted. The operation leaves the corpus 
 uteri perfectly free. Pregnancy resulting after the oper- 
 ation is uninterrupted, and labor is normal. Lacerations 
 and disease'lin the cervix and perineum are to be cor- 
 
 FiG. 36. — Showing schematically the position of the dressings in tlic 
 cul-de-sac operation of replacement. 
 
 rected after the patient has recovered from the replace- 
 ment operation, and are made purely to supplement the 
 first operation. The rules governing these plastic oper- 
 ations are the same as apply after hysterorrhaphy, etc. 
 The operation in my hands takes the place of all other 
 
r,ROAD-T,K;AMENT AltSCESS. 121 
 
 operations. It has a wider range of application than any 
 other procedure, and can be used in all cases not pre- 
 senting pus. When the retroposition is accompanied by- 
 occluded tubes, by hydrosalpinx, by cystic ovaries, etc., 
 this is the preferable operation. But when pus is pres- 
 ent in either ovary or tube removal of this and replace- 
 ment can only be accomplished by laparotomy. 
 
 BROAD-LIGAMENT ABSCESS. 
 
 This rare condition almost invariably follows labor or 
 abortion. The infection passes along the lymph streams 
 between the folds of the broad ligament, and causes sup- 
 puration there. The pus forms very slowly usually. In 
 the epidemic of puerperal fever which occurred in New 
 York in 1881-82, the author saw a great many of these 
 cases, but they are now comparatively rare. I have met 
 with but six in the last 1,000 clinic cases. As the pus 
 accumulates, it separates the folds of the broad ligament. 
 The bladder in front prevents much bulging anteriorly, 
 so the greater part of the distention of the broad liga- 
 ment is posteriorly. As this grows larger, the periton- 
 eum is stripped from the posterior surface of the uterus 
 and is lifted up ; the peritoneum of the pelvic floor behind 
 the broad ligament is also lifted, and the masses may be so 
 large as to reach Poupart's ligament. The fluid is essen- 
 tially extraperitoneal. It is suppuration in continuity of 
 tissue, and is far different in all its bearings from suppu- 
 ration in a preformed sac (pyosalpinx). Coexistent with 
 this formation, there is a great amount of peritonitic ef- 
 fusion about the broad ligament. There may also be a 
 pyosalpinx or ovarian abscess present. After the abscess 
 reaches a large size, the gross lesion presented is of an 
 abscess cavity lying upon the pelvic floor, to one side of 
 which is the displaced uterus, and above which lies the 
 matted mass of omentum and intestines. In rare cases 
 the abscess is bilateral. In such the pus may extend 
 
122 PELVIC INFLAMMATION. 
 
 in front of the uterus and between tlie bladder, so that 
 the two abscesses communicate. 
 
 Symptoms. — These are at first not suj^gestive of broad 
 ligament abscess. After a long attack of continuous 
 pelvic inflammation, in the course of which there have 
 been many rigors and violent fluctuations in tempera- 
 ture, this condition may be suspected. Upon examina- 
 tion, the uterus is found crowded up high and to one 
 side. It is sometimes so displaced that the cervix can- 
 not be felt. Extending from the side of the uterus to the 
 lateral pelvic wall is a large mass, tense and fluctuating. 
 This mass is sessile upon the uterus, i. c, there is no 
 sulcus between the mass and the uterus. It is immovable 
 and fixes the uterus. It projects in all directions when 
 large, and can be felt behind the bladder, above Poupart's 
 ligament and deep in the pelvic floor. There are evi- 
 dences of a severe type of pelvic inflammation. The 
 bladder is capable of holding but a few ounces of urine 
 when the abscess is large, and the lumen of the rectum 
 is almost closed. Upon rectal examination, the mass is 
 found apparently attached to the rectum if it has stripped 
 up the pelvic floor. About the only conditions simu- 
 lating this are, dermoid cysts, ectopic gestation ruptured 
 and septic, and broad ligament cyst. But the history of 
 a labor or abortion, long-continued sepsis, and a gradu- 
 ally enlarging tumor, which is always sessile, even when 
 small, and which undoubtedly occupies the broad liga- 
 ment, will render the diagnosis clear. When the accu- 
 mulation is small, the finger readily enters the incised 
 cul-de-sac. The enlargement is found to be upon one 
 side of the uterus, and the posterior wall of the broad 
 ligament bulges backwards. A slight pressure against 
 the mass suffices to evacuate the pus, rendering the diag- 
 nosis clear. With this pus formation, there has been 
 much peritonitis, and the examining finger evacuates 
 the lymph and serum produced by this. The pelvic 
 viscera, where they can be reached, are found matted to- 
 gether. The ovary and tube upon the affected side are 
 raised high in the pelvis. When the abscess is large, the 
 
DIFFUSE PELVIC SUPPURATION. 
 
 123 
 
 finger cannot be made to enter the cul-de-sac at all ; and 
 upon incising the vaginal mucosa, the finger enters a 
 cavity of loose cellular tissue which bleeds freely. This 
 is produced by the abscess lifting the peritoneum from 
 the pelvic floor. After inserting the finger behind the 
 uterus up to the level of the internal os, it will enter the 
 pus sac at once, or will find it if turned laterally toward 
 the fluid mass. 
 
 This lifting of the pelvic peritoneum is characteristic 
 of all large broad ligament accumulations. 
 
 Treatment. — All these accumulations should be 
 treated through the vagina. They should be opened 
 through the posterior cul-de-sac and evacuated. For this 
 purpose the fingers alone are to be used after the vaginal 
 wall is incised, as the position of the vessels is not con- 
 stant. If the cul-de-sac is entered before the abscess is 
 emptied, it, as well as the abscess cavity, must be packed 
 with gauze. If the examining finger enters at once into 
 the pus cavity, it is to be widely stretched and packed. 
 The after dressings are governed by the amount of dis- 
 charge and the temperature. It is wise to curette the 
 uterus before opening the cul-de-sac. After dressing the 
 abscess cavity the uterus is to be packed with iodoform 
 gauze, which in two days is withdrawn. 
 
 DIFFUSE PELVIC SUPPURATION. 
 
 This must not be confounded with primary purulent 
 peritonitis. There has been suppuration in either the 
 ovary, the tube, or the broad ligament. Accompanying 
 this there has been a virulent form of peritonitis, and a 
 great outpouring of plastic lymph has ensued. Some- 
 times this lymph breaks down into pus; in other cases 
 the original pus focus leaks into the lymph masses. As 
 a result the pus has ceased to be confined in either tube, 
 ovary, or broad ligament, but has wormed its way be- 
 tween adherent lymph planes, omentum, and intestines. 
 
J 24 PELVIC INFLAMMATION. 
 
 More lymph is jiroduccd, and wider burrowing of pus 
 ensues, thus presenting a picture of indistinguishable 
 organs within and between which are pus pockets and 
 connecting sinuses. This is diffuse suppuration. 
 
 Syinptoius. — The history is usually one of prolonged 
 suffering, recurrent attacks of peritonitis, emaciation, and 
 hopelessness. The woman is practically bed-ridden. 
 Upon examination the uterus is found firmly imbedded 
 in a mass of exudate. The uterus, ovaries, tubes, and 
 other pelvic organs form one dense conglomerate rnass. 
 The diagnosis from small fibroid or ruptured ectopic 
 pregnancy with pus is impossible. Broad ligament 
 cysts, ovarian tumors, simple fibroids, etc., do not present 
 the immobile sensitive uterus, profound sepsis, emacia- 
 tion, and mal-nutrition which accompany diffuse suppu- 
 ration. Nephritis and phthisis are common accompani- 
 ments. I have usually found the rectum permanently 
 distended in these cases. It cannot contract. 
 
 Very often sinuses form between the bowel and the pus 
 foci, affording a temporary relief when the pus escapes 
 into the gut, followed by gi-eat increase in the lesions 
 from contamination by bowel filth. 
 
 Upon opening the cul-de-sac, the finger at once evacu- 
 ates pus lying free in the pelvis. The exploration is 
 purely digital, and as the finger maps out the various 
 organs it enters pocket after pocket of pus. The livid 
 lymph-covered intestines are found low down usually, 
 pressed down by tympanites, and tend to protrude into 
 the vagina when freed. Above the uterus and adnexa is 
 an impenetrable dome of matted intestines and omentum. 
 
 Treatment. — Many of these women are so critically 
 ill that a radical operation is contraindicated. The first 
 step is usually to inject a quart of sterile and filtered 
 normal salt-solution into the elbow vein. The uterus is 
 curetted. The cul-de-sac is opened, and all pus pockets 
 emptied. The pelvis is wiped dry with gauze. Irriga- 
 tion should never be employed for this purpose, lest the 
 pus be washed into the higher pelvis and abdomen. 
 After evacuating all the pus cavities and thoroughly 
 
ANESTHETIC. 
 
 125 
 
 cleansing the pelvis, the dressing is made. The long 
 perineal retractor draws down the posterior vaginal wall 
 while the trowel lifts up the uterus. An abundance of 
 light is by this means thrown into the pelvis, and the 
 gauze can be inserted between two smooth metal planes. 
 Each piece of iodoform gauze is three inches wide and 
 a yard long. It is folded many times, and is inserted 
 up to the level of the fundus uteri. With a lateral 
 retraqtor this piece is pulled to one side while another is 
 inserted, and progressively the pelvis is filled. 
 
 The first dressing will not require narcosis, and should 
 be made as soon as the temperature rises. The opening 
 is kept carefully packed until it is closed by granulation. 
 Every pocket of pus is sought out and entered. Its sac 
 is widely opened by the finger, and after swabbing it dry 
 it is packed. The operator must not fail to insert a stout 
 gauze drain into every pus pocket. 
 
 This operation is purely palliative, and a relapse is to 
 be expected. But before this occurs the case can be 
 carefully prepared for a radical operation. After the 
 general condition has been improved the uterus, ovaries, 
 and the tubes are to be removed through the vagina by 
 hemisection. 
 
 ANESTHETIC 
 
 The vaginal operations do not demand that complete 
 physical relaxation which is essential in laparotomy. An 
 incomplete narcosis is sufficient, and chloroform again 
 becomes the preferable anesthetic. I have extensively 
 tried the Schleich mixture, but have returned to chloro- 
 form and ether. I always administer chloroform upon 
 an Esmarch mask, and usually precede it by a hypoder- 
 mic of strychnin, gr. 5^. Ether I give through a Sims' 
 inhaler, sterile gauze being employed to hold the anes- 
 thetic. The cones with bag attachments I have thought 
 conduced to th^ occurrence of pneumonia. 
 
126 PELVIC INFLAMMATION. 
 
 CURETTAGE. 
 
 The patient, having previously been prepared, is 
 placed upon the back in the lithotomy position. The 
 perineum is retracted with a short speculum, or the 
 cervix may be exposed by means of a bivalve speculum. 
 If the latter be used its blades must be short. The cervix 
 is next seized with a pair of blunt bullet forceps fastened 
 into the anterior lip, and the cervix is gently drawn down. 
 This at once brings the cervix nearer and straightens the 
 canal very materially. The direction and depth of the canal 
 are determined by the sound. The dilator is introduced, 
 the cervix being still firmly held (Fig. 37). In selecting a 
 dilator the operator should avoid those operated by screws. 
 These are positively dangerous, inasmuch as the force can 
 not be released if tearing begins, so that rupture of the 
 cervix may be produced. Some modification of Sims' 
 instrument is best. If the cervix is so stenosed that the 
 dilator cannot be introduced, I do not hesitate to enlarge 
 the canal with a blunt bistory, cutting bilaterally. The 
 dilatation is done progressively, the force being inter- 
 mittent and the dilator turned a little from side to side. 
 The dilatation in all cases reaches a half inch, and greater 
 space is secured in many cases. The larger the cavity to 
 be scraped, the more open should be the cervix. If the 
 dilatation is properly done and a good deal of traumatism 
 inflicted upon the cervix, the cervical ganglia are obtunded, 
 and uterine contractions with expulsion of the dressings 
 do not follow the operation. Having dilated the cervix 
 the uterus is to be curetted. I use the sharp instrument 
 of Sims, and prefer a small one for hard uteri and a large 
 one for soft organs. The curette is introduced to the 
 fundus gently, and the force is used in withdrawing the 
 instrument. The pressure is made all along the instru- 
 ment, and the cervix must not be used as a fulcrum. The 
 operator proceeds all around the inside of the uterus, 
 
Fig. 37. — Demonstrating the method of dilating the cervix preliminary to 
 curetting' the uterus. 
 
CURETTAGE. 
 
 1 29 
 
 paying particular attention to the lateral angles and tubal 
 openings. The fundus is scraped by sweeping the curette 
 from one tubal orifice to the other several times. The 
 uterus may now be irrigated with saturated solution of 
 boric acid or normal salt-solution. The ordinary fountain 
 syringe is the best irrigator (see page devoted to steriliza- 
 tion). I employ the Fritsch-Bozeman double current 
 catheters. If the debris removed by the curette are small 
 they are readily washed out, but large plugs of tissue 
 must be wiped away. To accomplish this the uterus is 
 packed with gauze and the dressing is made to revolve 
 within the uterus by means of a tampon screw. When 
 it is withdrawn, all portions of membrane are caught in 
 the folds of the gauze. I have abandoned irrigation ot 
 the uterus where the organ is small and a small irrigating 
 tube must be used. Instead I swab out the cavity by 
 iodoform gauze. The sole object is to remove all debris 
 produced by the curette. In many irrigated cases where I 
 have opened the cul- de-sac, I have found fluid in the 
 pelvis which was blood-stained. I have thought that 
 perhaps in certain cases of small uteri the irrigating fluid 
 may have escaped into the pelvic cavity through the tubes. 
 Having cleansed the uterus, it is next packed with gauze. 
 I use for this purpose a stout metal applicator which is 
 slightly curved. The gauze is folded over the end, and is 
 fed into the uterus by means of successive holds with the 
 applicator. The tampon screw can be used for the same 
 purpose (Fig. 38). The organ should be completely filled. 
 The object of this is to have within the uterus a sufficient 
 amount of dressing to exert pressure, to absorb all dis- 
 charges, and to act as a protection to the repair-cells 
 while they are forming a new membrane. The first few 
 days are the most critical in this matter. If the repair is 
 started properly, it will proceed to the formation of a his- 
 tologically perfect membrane. But if the first emigrated 
 cells are destroyed, either by iodin, carbolic acid or by 
 infection, a distorted endometrium results, which will pro- 
 duce painful menstruation and sterility. Asepsis of the 
 most precise nature is the only method to bring success. 
 9 
 
I30 
 
 PELVIC INKL\MMATION. 
 
 It will not suffice merely to remove the endometrium ; 
 the zinc pencil will do that. But the removal and treat- 
 ment must be so done as to insure a reproduction of a 
 perfect new membrane. That is impossible when even 
 mild sepsis follows the operation. As antiseptics destroy 
 cells they should never be used within the uterine cavity, 
 for dead cells disturb healing and furnish the most pro- 
 pitious culture medium for germs. Antiseptics have no 
 place in cavity work like this. Some of the worst cases 
 of dysmenorrhea and pelvic neuritis I have found in women 
 who have been curetted by careful men, men perfectly 
 cleanly in their methods, but who, believing the endome- 
 trium to be a mucous membrane, have painted it with 
 carbolic acid, thereby promoting the production of scar 
 tissue within the uterus without a trace of lymphoid ele- 
 ments. The operation of curettage must be done with a 
 knowledge of the anatomy of the uterus and a conscious- 
 ness of its function. 
 
 The vagina is usually packed with iodoform gauze. 
 If uterine cramps follow the operation a suppository of 
 ext. opii and ext. belladonna, each gr. i^, may be given. 
 The vaginal gauze is removed on the third day and the 
 uterine packing withdrawn. The uterus is neither irri- 
 gated nor again packed, but the vagina is packed again, 
 and the woman allowed out of bed, provided the curet- 
 tage has been done for an uncomplicated endometritis. 
 The bowels are moved on the third day. The vaginal 
 dressings are removed once in four days for two weeks, 
 and then all treatment ceases. A new endometrium forms 
 in from four to six weeks. Douching and amatory ap- 
 proaches from the male are forbidden until after the period 
 following the operation. Such is the usual course and 
 the usual operation. 
 
 Time for Operating. — Preferably one week after men- 
 struation is the elective time. The special conditions 
 under which the operation is done will modify this and 
 may be referred to. 
 
 Infected Cei'vix. — When I operate in acutely inflamed 
 cases and when the cervix is the seat of gonorrhea, I 
 
Fig. 38.— Packing the uterus with iodoform o-a 
 
CURETTAGE. 
 
 UZ 
 
 always paint its cavity with pure carbolic acid, both before 
 and after dilating. Equal parts of tinct. iodin and car- 
 bolic acid make a powerful antiseptic. In using these 
 caustics care must be exercised not to allow of the pas- 
 sage of a particle into the uterine cavity above the 
 internal os. The carbolic does not cause sloughing in 
 the cervix, because its lining membrane is a very dense 
 mucous structure. I consider it exceedingly important 
 to sterilize the cervix in all gonorrheal cases. The best 
 means of doing this is by means of carbolic applied before 
 the glands are emptied by pressure and after. 
 
 Repeated Irrigations. — Whenever I have to deal 
 with a large acutely infected uterus, and especially if 
 there be peritoneal or adnexal lesions beginning, I deem 
 it necessary to irrigate the uterus when I withdraw the 
 uterine packing. In these cases the infection is usually 
 deeper than the surface, and repeated washings with boric 
 acid may be necessary during the process of repair. After 
 washing out the uterus a filament of gauze is introduced 
 to the fundus and the vagina again packed. The filament 
 of gauze ensures an open cervix. I remove this second 
 dressing in three days, and am governed by the appear- 
 ance of the discharges as to whether I shall repeat the 
 washing or not. If puSj or even broken-down material 
 in quantity, follows the withdrawal of the second gauze, 
 I again wash and pack as a precaution against re-infec- 
 tion. Cases which are infected post abortum or post 
 partum always need at least one renewal of the washing 
 and uterine drain. 
 
 Gonorrheal cases and those infected by uterine tinker- 
 ing sometimes require this washing.but no packing after 
 the first dressings are removed. It is almost needless to 
 caution the operator regarding cleanliness all during the 
 treatment. The sterilization must be as complete at 
 dressings as at the operation. 
 
 The two causes for infection after curettage I have 
 found to be in the faulty removal of debris and the appli- 
 cation of escharotic antiseptics. So long as the operation 
 performed has these two attributes, of course the question 
 
T34 
 
 PELVIC INFLAMMATION. 
 
 will arise, Does gauze drain or not? Thus far 1 have not 
 found it necessary to concern myself with this, but I may 
 answer the question. Gauze does drain, for the vaginal 
 
 packing is often wet through 
 with secretions such as are 
 found in the uterine packing. 
 
 Quantity of Gauze in Ute- 
 rus. — The girl's uterus measur- 
 ing three inches will hold a 
 strip of gauze one inch wide and 
 a yard long. The uterus aborted 
 at the third month will contain 
 a strip four inches wide and a 
 yard long. The full term uterus 
 will receive a roll of gauze one 
 yard wide and five yards long. 
 The Instruments. — I prefer 
 the short specula of Jackson 
 (Fig. 39). They are simple, 
 depress the perineum properly, 
 and are as useful when laparo- 
 tomy or vaginal hysterectomy 
 is done as in curettage. The 
 traction forceps should be very 
 dull (Fig. 40), so as not to tear 
 the tissues. I can see no neces- 
 sity for the multitude of dilat- 
 ors offered for sale (Fig. 41). The instrument of Sims', 
 roughened as I have had done, is sufficient. Dilatation 
 
 Fig. 39. — Jackson speculum. 
 
 Fig. 40. — The author's bkuit bullet forceps. 
 
 by graduated bougies is always imperfect. The bougies 
 are shoved in against the force of the traction forceps, and 
 
CURETTAGE. 
 
 135 
 
 Fig. 41. — The author's uterine dilator, 
 
 dilatation is effected by shoving up 
 against the pulHng down. The pro- 
 cedure has always seemed to me a bit 
 ridiculous. The curettes are of Sims' 
 pattern (Fig. 42). They are all sharp, 
 and the staff while stiff can be bent 
 
 Fig. 42. — Sims' curettes. Showing the blades only. 
 
 to operate in very flexed organs. The 
 instrument of Recamier has too long 
 a curetting surface. I have abandoned 
 the cervical specula through which to 
 pack the uterus (Fig. 43), The heavy 
 applicator can be adj usted to the curves 
 of the organ, and with it I pack more 
 
 thoroughly than is possible with the tra-uterine ird- 
 
 speculum. I always use a double cur- s^tors 
 
 Fig. 45.— Four 
 calibres of the in- 
 
 FlG. 44. — Fritsch-Bozeman double-current irrigating tubes. 
 
PELVIC INFLAMMATION. 
 
 rent irritjating tube (Fig. 44). It is improper to inject 
 irrigating fluid into the uterus with a bulb syringe. 
 Such an instrument can not be cleansed, and no pro- 
 vision is made in it for the return of the fluid. I use 
 the Fritsch-Bozeman uterine irrigator. 
 
 EXPLORATORY VAGINAL SECTION. 
 
 The bar to a thorough inspection of the pelvic cavity 
 through the vagina is the uterus; and a great embar- 
 rassment experienced in the procedure is prolapse 
 of the intestines into the vagina. If a posture can be 
 secured which will prevent the latter, and an incision 
 adopted which will remove the uterus out of the way 
 without injuring it, vaginal exploration of the pelvis will 
 supersede the abdominal. The author believes that his 
 procedure secures both the desirable factors essential to 
 success. 
 
 It must be remembered that the distance from the 
 vulva to the cul-de-sac is even less than from the abdo- 
 men. Therefore the cavity explored from below is not 
 as deep as when sought from above. The ability to see 
 the pelvic structures through the vagina is then depen- 
 dent upon the space secured. The space is not so much 
 limited by the vulva as by the condition of the tissues 
 about the cervix. If the vaginal incision posterior to the 
 cervix is one and a half inches from side to side, the 
 elastic tissue will yield under the pressure of the retrac- 
 tors to make the opening at least one and a half inches 
 wide by over two inches antero-posteriorly. But in the 
 rare cases of pronounced sclerosis the elasticity of the 
 vaginal vault may be found so limited that sufficient 
 space cannot be secured through which to make an ade- 
 quate visual inspection. The operator will then have to 
 depend wholly upon his sense of touch. Still this con- 
 tingency is not as often met in the vaginal operation as 
 in the abdominal. 
 
EXPLORATORY VACCINAL SECTION. 
 
 '37 
 
 Opei'Jitioii. — The local and general preparation of the 
 patient will be found on pages i6i to 163. The patient 
 is placed upon the (Fig. 47) table in the lithotomy pos- 
 
 FlG. 47. — The cul-de-sac is opened. The posterior vaginal wall is held 
 down by the retractor, while with the trowel the uterus is shoved up against 
 the bladder. The space obtained is estimated by comparing the length of the 
 operator's index finger with the distance between the blades of the retractors. 
 In this case it was 2I inches. 
 
 ture, with the ischial tuberosities over the edge of the 
 table. The perineum is retracted by a short Jackson 
 speculum, and the uterus is pulled down. The uterus 
 is curetted and swabbed out, but not packed with gauze. 
 The vagina is wiped dry. Upon shoving the cervix 
 upward a fold will be seen to form just opposite the cer- 
 vico-vaginal junction (Fig. 48). The vagina is incised 
 here, scissors being used for the purpose. The scissors 
 
I -.8 
 
 PELVIC INFLAMMATION. 
 
 cut through vaginal mucous membrane only. The inci- 
 sion is commonly an inch long and extends to the lateral 
 borders of the cervix (Figs. 49, 50). There now remains 
 
 Fig. 48. — The fold behind die cervix wliich lies over the cervico-vaginal 
 junction is well shown. The vagina is to be incised here (from life). 
 
 but one layer of tissue to sever, — the peritoneum. The 
 uterus is held firmly down, and the operator pushes 
 his index finger into the cul-de-sac. In doing this 
 he is careful to keep the point of the finger accurately 
 
EXPLORATORY VAGINAL SECTION. 
 
 139 
 
 in the middle line and pressed up against the posterior 
 uterine wall. If after pushing the tissues up to the level 
 of the internal os the finger has not entered the periton- 
 eal cavity, the point of the finger is directed backwards 
 
 Fig. 49. — The vagina is incised, and the point at which the peritoneum is 
 reflected from tlie uterus is shown as the deepest part of tiae cut. The peri- 
 toneum is to be torn tlirough at this point (from life). 
 
 and pushed into the cavity. If the peritoneum is very 
 thick it is caught with toothed forceps and incised with 
 scissors. Commonly serum escapes when the cavity is 
 entered. 
 
l^o PELVIC INFLAMMATION. 
 
 In making the incision one small vessel is severed, — the 
 azygos artery of the vagina. 
 
 It requires forcipressure very rarely, being an insignifi- 
 cant vessel. Having en- 
 
 „'' --..^ tered the pelvic cavity 
 
 ^ a gauze pad, to which 
 
 N a string is attached, is 
 
 introduced. While the 
 
 •^ ^-^^ ^^^^^^3*^ ,''' "^ operator washes his 
 
 hands, an assistant low- 
 
 FlG. so. — 1-2, The anterior incision, used CrS the table mto the 
 
 when hysterectomy is to be performed. Trendelenburg pOSition. 
 
 3-4, The posterior incision, employed when a <. <.f 1 j 
 
 the pelvic contents are to be examined and ■^'- oncC all unattacuecl 
 
 the viscera treated conservatively. viscera leave the pelvis. 
 
 The operator now in- 
 serts his two index fingers into the rent, and upon separat- 
 ing his hands the incision is spread laterally (Fig. 52). This 
 tear takes place in the line of the incision. A careful digi- 
 tal examination is now made of the pelvic contents. The 
 finger glides up along the smooth posterior uterine wall 
 as high as the fundus and is then swept laterally over 
 one cornu and tube. The ovary and tube upon one side 
 are carefully palpated. If tender adhesions are met with, 
 they are torn with the finger. Unless pus is suspected, 
 the effort is made to free the ovary and tube from adven- 
 titious union. The operator remembers that his finger 
 has entered bclozv the plane of the bases of the broad 
 ligaments, and that his manipulations are behind the 
 broad ligaments, upon their posterior surfaces. At once 
 this will indicate to him the method of separating adher- 
 ent adnexa. In doing this the finger is moved between 
 the surfaces of union from the side of the uterus upward 
 and outward, a sort of lifting motion being made. All 
 the time the adnexa are being manipulated, the uterus is 
 firmly held down with the bullet forceps. The pelvis is 
 now Aviped free from blood. If firmly adherent adnexa, 
 or cystic accumulations are met with, it is better not to 
 complete their separation before inspecting them. In- 
 spection of the pelvis is next made. A medium Pean 
 
Fig. 51. — Arterial blood supply of the uterus and adnexa : O. A., ovarian 
 artery; a' , a' , a', branches to ampulla of Fallopian tube ; r', c'. c' , branches 
 to ovary ; c, branch to fundus ; d, branch anastomosing with uterine ; i, branch 
 to round ligament; e, uterine artery ; ^, ^, ^, vaginal arteries; d, b, azygos 
 artery of vagina. 
 
EXPLORATORY VAGINAL SECTION. 
 
 141 
 
 retractor is introduced (Fig. 53), and the perineum, 
 vagina, and posterior edge of the incision are held down 
 by it. The cervix is loosed from the grasp of the bullet 
 forceps, and a Pean-Pryor trowel is inserted behind the 
 uterus. The soiled pad is now removed, and several 
 clean ones are inserted. The uterus is pushed up behind 
 the symphysis and out of the pelvic cavity by the trowel. 
 This is the very essence of the procedure, for by it the 
 
 Fig. 52. — The index fingers are inserted into the opening in the cul-de-sac, 
 and tlie incision is enlarged by blunt tearing with the fingers (from life). 
 
 obstructing uterus is lifted out of the way. By dexterous 
 manipulation of the trowel the adnexa of first one side 
 and then the other are exposed to view. When seen they 
 may be grasped with Luer's forceps and brought down 
 into the vagina, where they may as readily be operated 
 upon as is the cervix in plastic work (Fig. 54). 
 
i4i 
 
 PELVIC INFLAMMATION. 
 
 Pelvic exostoses, adherent vermiform appendix, rectal 
 cancer, ectopic gestation, both unruptured and ruptured, 
 ovarian cystoma, ovarian sarcoma, uterine fibroids, hydro- 
 salpinx, pyosalpinx, cystic and apoplectic ovaries, occluded 
 tubes, dilated ureters, and in fact every form of pelvic 
 disease I have seen are most of them treated through 
 such an incision. By relaxing somewhat the perineal 
 
 Fig. 53. — The uterus is held up behind the symphysis (5) with the bladder 
 {B) by the trowel (X), while the rectum {J?) and the posterior vaginal wall 
 are pulled down by the retractor ( V). 
 
 retraction and forcibly pushing up the uterus and bladder 
 the ureters are made tense and appear as curved ridges 
 beneath the lateral pelvic peritoneum. The space gained 
 between the trowel and retractor is nearly that made by 
 separating the fingers. The further operative treatment 
 depends upon what the inspection reveals. Suffice it to 
 say that I pack the uterus with gauze, remove the gauze 
 pads, insert gauze into the pelvic opening or close the 
 
EXPLORATORY VAGINAL SECTION. 
 
 143 
 
 opening with fine silk, and replace the uterus. The cul- 
 de-sac is entered^ in two minutes; the entire procedure 
 occupies but ten. I commonly employ a partial chloro- 
 form narcosis, as complete relaxation is^not necessary. 
 
 Fig. 54. — The adnexa have been freed, and are brought down into the 
 vagina. Above them are coils of intestine (from life). 
 
 There are but two conditions in which this method of 
 exploration is not a completely successful one, and in 
 them the indication for radical operation is so clear that 
 
I 44 
 
 PELVIC INFLAMMATION. 
 
 exploration is unnecessary. I refer to ectopic gestation 
 ruptured into the broad ligament, and to intraligament- 
 ous fibroid tumors. In all forms of adnexal inflamma- 
 tory disease and ovarian neoplasms I have found it emi- 
 nently satisfactory. 
 
 All cavity operations are in their first stage explora- 
 tory, and my operation occupies that position with regard 
 to future work. 
 
 I will contrast the abdominal method and that by sec- 
 tion in front of the uterus with my operation. In abdomi- 
 nal section the following anatomical layers are severed : 
 skin (usually infected), fat, fascia, muscle, and peritoneum. 
 In anterior colpotomy (separating the bladder from the 
 uterus) the vagina is severed, the tissues uniting the blad- 
 der and cervix (pericervical) are cut, the peritoneum is 
 cut. In my operation two layers are severed, the vaginal 
 wall and the peritoneum. 
 
 In abdominal section many small vessels are cut often 
 requiring ligation. In anterior colpotomy the large 
 branches of the superior vesical and uterine arterial anas- 
 tomosis are severed and require ligature. In my opera- 
 tion no vessel needs more than a few minutes forcipres- 
 sure. After laparotomy a number of sutures are required 
 to close the wound, and few operators are agreed how 
 this should be done. 
 
 With anterior colpotomy the bladder must be again 
 sutured to the uterus by a complicated method. In my 
 operation no sutures are needed. 
 
 There is little danger of wounding any important 
 structure during abdominal section, but there is great 
 danger of wounding the bladder in doing anterior col- 
 potomy. There is no possible risk run in my operation 
 of wounding any organ, as the finger does the operating 
 after the vaginal mucosa is severed. 
 
 Mural abscess, hernia, inter-intestinal adhesions, and 
 adhesions between the scar and viscera, result often from 
 abdominal section, and an ugly scar is left as a reminder 
 of an unpleasant experience. After anterior colpotomy 
 the uterus is held low in the pelvis and can not readily 
 
EXPLORATORY VAGINAL SECTION. 
 
 145 
 
 rise because of thickening in the pericervical tissues. 
 Hence pregnancy is often interrupted. No sequelae fol- 
 low my operation, and the uterus is not limited in upward 
 movement. 
 
 The entire pelvic contents can be seen by abdominal 
 incision ; anterior colpotomy necessitates pulling the 
 uterus down into the field of vision, and hence nothing 
 is seen until dragged into the vagina ; the whole pelvis 
 can be explored by means of rny procedure. Abdominal 
 section necessitates a profound narcosis, a partial one 
 suffices for the operation I advocate. 
 
 To sum up, abdominal section and anterior colpotomy 
 inflict needless traumatism, furnish no drainage space, 
 and are most complicated in every way, while my opera- 
 tion merely requires a special table and instruments to 
 be simply and easily done, and with ample drainage space 
 for all discharges. 
 
 In the discussion of " conservatism " diseased organs 
 will be mentioned as cured without removal which would 
 have been sacrificed had laparotomy or anterior col- 
 potomy been done. 
 
 The after treatment is that of the " operation for 
 adherent retropositions," which see. 
 
 If this method of inspecting the pelvis accomplished 
 nothing else, it should have an accepted place in our 
 procedures as a means of clearing the diagnosis of a sus- 
 pected ectopic gestation. It is no longer necessary to 
 wait for symptoms of hemorrhage and exsanguination. In 
 three minutes or less the diagnosis can be made, and with 
 no risk. A special table is not necessary for ordinary 
 vaginal work. One may be improvised which will give 
 an angle of 60° by sawing off two legs of a stout kitchen 
 table. The shoulder braces can be arranged by boring 
 two rows of parallel holes down the centre of the table 
 into which pins may rest. Against these the shoulders 
 may be supported, or assistants m.ay support the body 
 while in position. This I have often done. 
 
1^6 PELVIC INFLAMMATION. 
 
 CONSERVATIVE TREATMENT. 
 
 General Considerations. — When we attack diseased 
 adnexa either through the abdomen or through the 
 vagina, up to a certain stage the operation is in all cases 
 exploratory: for, be the presumptive evidence what it 
 may as corroborative of the diagnosis, the absolute diag- 
 nosis can be made only after inspection of the diseased 
 structures. When operating through the belly, meeting 
 with a hydrosalpinx or a large cystic or apoplectic ovary, 
 or a small broad ligament cyst, removal seems rather too 
 severe for the pathological lesions. Still it would appear 
 unsafe to return the organs after evacuating fluids and 
 inflicting extensive traumatism. 
 
 So long as pus foci only are removed through the 
 abdomen, without drainage, little criticism can be passed. 
 Still, even pus tubes can be conservatively treated by 
 another method. But when lesions of the adnexa are 
 treated by extirpation, which lesions by no possibility 
 can endanger life, not only the operator, but his art as 
 well, is brought into disrepute. There is legitimate 
 ground for debate regarding the propriety of treating 
 pus foci by any method other than extirpation through 
 the belly. But there is no excuse for sacrificing organs 
 trivially affected, when there is at our command a method 
 difficult to be sure, but perfectly safe, which radically 
 cures and yet saves. 
 
 But local conservatism must not be carried too far. 
 There is a broader conservatism which seeks the preser- 
 vation of the general health at the sacrifice of even im- 
 portant organs. To illustrate, the attempt to benefit per- 
 manently the condition of a woman suffering from diffuse 
 pelvic suppuration by any operation other than the most 
 radical is absurd. Equally so is it to expect conserva- 
 tive surgery of any sort to relieve the pains of genital 
 sclerosis affecting uterus, ovaries, and tubes. I cite 
 
CONSERVATIVE TREATMENT. 
 
 147 
 
 these two extremes to demonstrate the necessity for a 
 careful differentiation before determining upon a particu- 
 lar operation, 
 
 I suppose in no field of surgery is our art more ham- 
 pered, modified, and with reason influenced by the 
 extraneous circumstances surrounding the patient. A 
 young girl of nineteen with large pus tubes is of course 
 better without them. But to check the new function of 
 menstruation at its inception is to create a very unhappy 
 woman. Therefore, here the vaginal conservative opera- 
 tion is pre-eminently indicated; whereas, in a woman of 
 forty, with children, the question would not be consid- 
 ered except as bearing upon risk to life. The young 
 woman again may have pus tubes due to an abortion, and 
 be phthisical. No matter what his sentiments and desires, 
 the surgeon will be governed by his knowledge of the 
 effects upon such a constitution of prolonged suppura- 
 tion, and of the great improvement induced in the gen- 
 eral nutritive functions by artificially inducing meno- 
 pause. Here the radical operation is always indicated. 
 
 The ability to determine upon the proper operation, 
 whether radical or conservative, depends upon so many 
 factors entering into the surroundings of the patient and 
 her station in life, the equipments of the operator and 
 the place in which he works, that I can not possibly fore- 
 see them all. The statements I have here made are 
 occasionally modified, and I can but give a description 
 of my usual course in dealing with the different condi- 
 tions. 
 
 ■ But what argument can be offered against the point of 
 view of the conservative man? I take it, none. Then 
 criticism can justly lie upon his results only. And of 
 these I will now speak. 
 
 Thousands of cystic ovaries are every year removed 
 through the abdomen. The patient may be hjgh-strung 
 and nervous. She has pre-menstrual pain in the ovarian 
 region ; her flow is scanty; her uterus is small and ante- 
 flexed; she has severe pelvic tenesmus; she is hysterical 
 and is given to introspection and self-pity; she never has 
 
1^8 PELVIC INFLAMMATION. 
 
 fever; the ovaries are low down and sensitive. Com- 
 monly, the woman is in advanced maidenhood. An 
 operation is advised and accepted. Upon opening the 
 belly, no adhesions are found, unless intra-uterine tinker- 
 ing has produced peritonitis. The tubes are normal. 
 The ovaries are large and filled with cysts, some small, 
 some large. The ovarian capsules are thick and tough. 
 What is to be done ? To enucleate all the cysts and 
 suture the cut surfaces of the ovaries is eminently proper. 
 But the same train of nervousness, introspection, regrets, 
 remain, only now she has a belly-scar to study twice a 
 day, when she dresses and undresses. This she will 
 watch carefully for hernia. But the woman is not physi- 
 cally cured. To remove the ovaries is to add the distress 
 of the artificial menopause to her other symptoms, and 
 make her still more hopeless. Although she has never 
 expected to have children, she is now relegated to the 
 class of " the spayed." This picture is not one bit over- 
 drawn. 
 
 Through the vagina these cystic ovaries can be success- 
 fully treated, cysts emptied, and cut surfaces sutured with 
 perfect safety, no possibility of hernia, no intestine adhe- 
 rent to the scar, and no interintestinal adhesions. 
 
 The lesions existing in cystic ovaries never require re- 
 moval of the organs. Most of the symptoms accompany- 
 ing them are due to other conditions. In hydrosalpinx 
 we have another condition productive of few symptoms 
 and never threatening life. To open the belly and remove 
 these simple cysts of retention, is to perform an unneces- 
 sarily severe operation. To evacuate them through the 
 abdomen and leave them, is to undoubtedly run some 
 risk. Still, evacuation is the proper operation when it is 
 done through the vagina. The same applies to ovarian 
 apoplexy and small broad ligament cysts, to occluded 
 tubes free from pus, and to pelvic adhesions. The great 
 obstacle heretofore to this has been the difficulty inherent 
 in the operations. The incision and posture I recommend 
 render the operations as easy when done through the 
 vagina as through the abdomen. 
 
CONSERVATIVE TREATMENT. 
 
 T49 
 
 Coming now to a consideration of acutely inflamed 
 tubes, my task is more difficult. So long as we removed 
 pus tubes and ovaries by celiotomy, our work was emi- 
 nently proper. Those were the cases which were not 
 checked by the let-alone treatment. But we began to 
 remove the inflamed adnexa in the acute stage, before 
 trying any other measure. There we made a mistake. In 
 many of these cases I checked the infection by an early 
 curettage. But what could be done in the older cases ? 
 It is useless to deny to organs so highly vitalized as are 
 the ovaries and tubes, great power of recuperation after 
 infection. The size of the arteries supplying them proves 
 that this possibility exists. It has not heretofore been 
 taken advantage of, because not understood. The acutely 
 inflamed tube becomes rapidly occluded. This is a wise 
 provision of Nature, for no woman could live if a con- 
 tinuous stream of pus was poured into her peritoneum. 
 But this isolating occlusion, while saving life, destroyed 
 the integrity of the affected tube ; for the suppuration 
 continuing in the closed tube results in the formation of 
 a pyosalpinx. 
 
 Naturally the question is suggested, whether this occlu- 
 sion would occur if free escape of the tubal nastiness were 
 possible. In other words, the pathological peritonitis is 
 beneficent, in that it saves life, but it is unnecessary where 
 life is not in jeopardy. And where unnecessary, it does 
 not occur. Furthermore, when not present, because relief 
 from the infection is found, the vitality of the affected tube 
 is but little interfered with, and its power of repair is 
 vastly greater than it would otherwise be. 
 
 Simply expressed, if I relieve a causative endometritis 
 by curettage, open the cul-de-sac, and open and drain the 
 resultant acutely-inflamed tube, that tube will get well. 
 Women so treated have recovered symptomatically, and 
 their pelves have become free from appreciable lesions. 
 They conceive and go to full term. I can not do this 
 always, because I cannot always accurately measure the 
 extent of damage done. To extirpate an acutely-inflamed 
 tube during a first attack, is simply to deny the possibility 
 
i^o TELVTC INFLAMMATION. 
 
 of repair. Still we have all seen women stupid enough 
 to refuse operation, and they have got well without it. 
 These few women can be made the many if those forces 
 which bring recovery to the few are appreciated and taken 
 advantage of. 
 
 I can safely say that pelvic suppuration can be pre- 
 vented. The rules governing these operations are laid 
 down under endometritis and salpingitis. 
 
 No man nowadays dare assume responsibility for the 
 results following the morphin-poultice-douche treatment 
 of pelvic inflammation. As surely is he responsible for 
 the hysterectoiny which will some day be the result of 
 his timidity, as he will be for a death from the neglected 
 disease. It is to teach how to prevoit suppuration, as 
 well as how to cure it, that I have .written this book. 
 
 The conditions to which I invariably apply conservative 
 procedures through the vagina are : hydrosalpinx, whether 
 unilateral or bilateral; cystic ovaries; apoplexy of the 
 ovary ; occluded tubes ; small h'oad ligament cysts, single 
 and multilocular ; adherent retropositions. 
 
 The conditions to which I generally apply conservative 
 operations are : Acute pnrident salpingitis ; acute puerperal 
 pelvic lymphangitis and peritonitis ; pyosalpinx in young 
 women when seen in first attacks of the inflammation ; 
 recurrent salpingitis. 
 
 I occasionally do a palliative operation in : Diffuse pel- 
 vic suppuration ; ovarian abscess, and in other cases of 
 pelvic suppuration where the general symptoms are too 
 grave to warrant an immediate ablation. 
 
 The conditions in which I generally do a radical opera- 
 tion are : Diffuse pelvic S2ippuration ; genital sclerosis ; go- 
 norrheal pyosalpinx in women over thirty ; relapses after 
 conservative operations ; 7itcrine tubeirulosis ; chroinc me- 
 tritis with infected ligatures after abdominal operations 
 upon the adnexa; abdominal sinus left after celiotomy for 
 adnexal disease; ectopic gestation which has ruptured, or 
 unruptured and associated with adnexal disease on the 
 other side ; small bilateral ovarian cystomata. 
 
 Having classified my cases in this way, I may state that 
 
CONSERVATIVE TREATMENT. 
 
 151 
 
 the extraneous circumstances surrounding my patient 
 often compel me to operate in the face of what my judg- 
 ment indicates would be for her better ultimate interests. 
 To some women the possession of even badly diseased 
 organs is more precious than health ; and to others the 
 consciousness that they have lost their special organs is 
 worse than death. These, I know, are sentiments; but I 
 believe them to be held by men also. Castration is an 
 excellent operation for hypertrophy of the prostate, but 
 I am not aware that it is received philosophically by men, 
 nor often allowed. The worst that can be said of con- 
 servative operations is that they sometimes fail to relieve. 
 The same is true of all radical work. But when conser- 
 vatism fails the patient is in no worse state than before, 
 and radical work may still be done. 
 
 In those cases, such as pronounced suppuration, where 
 conservatism does not succeed in affording that measure 
 of relief expected, at least the operation removes the 
 patient from the class of emergency operations to one in 
 which the radical operation can be made elective. That 
 much cannot be claimed with reason to attach to the 
 primary radical operation. 
 
 Failing to cure by a conservative procedure applied to 
 a pus case, the necessary mutilating operation can later be 
 done in a comparatively clean field, with the kidneys not 
 taxed to eliminate toxins, with the bowel functions restored, 
 with the heart muscle recovered, and altogether with the 
 general condition most propitious to a successful result. 
 No man who has operated in the stage of acute infection 
 with breaking down of the tissues, but will eagerly grasp 
 the opportunity to convert his case into one free from the 
 disagreeable and dangerous elements attaching to the first 
 state. Where conservatism does not succeed in curing, 
 it at least accomplishes that. 
 
PELVIC INFLAMMATION. 
 
 CONSERVATIVE OPERATIONS UPON THE INFLAMED 
 ADNEXA UTERI. 
 
 Acute Salping-o-ooplioritis. — If the case has pro- 
 gressed too far to be reheved by curettage alone, the 
 efforts of the surgeon should be directed to the preven- 
 tion of suppuration. Up to recent years two lines of pro- 
 cedure were open to us : either to let the case alone, or 
 else to remove the diseased adnexa. Let us consider a 
 case in its early stages before suppuration has begun. 
 The pelvic peritoneum in its efforts to limit and shut in 
 this infection throws about the adnexa a mass of lymph. 
 This is a beneficent and protective act and is usually 
 effective. Were it not for this isolation of the diseased 
 organs, it is to be presumed that a general and fatal 
 involvement of the peritoneum would result. But at the 
 same time a struggle is going on in the parts inflamed, 
 between the invadmg germs and the resistant power of 
 the tissues. To overcome the invasion, either a suppur- 
 ating, destructive process results, or else a connective 
 tissue hyperplasia follows. Either destroys, partially at 
 least, the functions of the organs involved. Is it not pos- 
 sible to check these processes somewhere ? It has been 
 determined that removing the causative focus and drain- 
 ing the uterine ends of the tubes and lymph streams by 
 curettage is not sufficient to restore the diseased adnexa 
 to- a condition approaching the normal. We must go 
 outside the uterus and drain. Whereas we consider the 
 effusion of lymph and the production of connective tissue 
 essential in the natural process, they are still destructive. 
 Up to a certain stage we can check them and effect a 
 cure. It is in the very earliest stage of the adnexal dis- 
 ease that we can do this. 
 
 Operation. — If the uterus has not been previously cur- 
 etted this is now done (see curettage). If curettage has 
 been done some days before, the uterus is irrigated with 
 boric acid solution. Upon opening the posterior cul-de- 
 
CONSERVATIVE TREATMENT. 
 
 153 
 
 sac, serum and lymph flakes escape. The finger is 
 inserted into the cavity behind the uterus, and proceed- 
 ing toward the lateral pelvic walls all the tender lymph 
 planes are easily severed by the finger. The tubes are 
 freed from their attachments to broad ligament or vis- 
 cera and gently brought to the vaginal vault for inspec- 
 tion. It is not a difficult matter to open the fimbriated 
 ends with any blunt instrument, the tubes being held by 
 Luer's forceps. A strip of iodoform gauze is inserted 
 into the tube to the uterus. This is left in place until 
 the operation is over. A small amount of fluid may 
 escape from the tubes, clear or cloudy. It is now pro- 
 per to wipe the pelvis dry. The ovaries are palpated and 
 loosened from adhesions. The operator makes his 
 investigation of the broadest kind. No false attach- 
 ments between the organs should be overlooked. Every 
 lymph plane should be entered and broken up. Convinced 
 that the tubes are opened and that no organs have been left 
 matted together, the gauze pads are removed, the pelvis 
 is carefully wiped dry, and the strip of gauze in the tube is 
 withdrawn. The uterus is packed with iodoform gauze. 
 Into the opening in the cul-de-sac strips of iodoform 
 gauze are inserted so as to snugly fill the opening. 
 These extend up behind the uterus to the level of the 
 internal os. The uterus and dressings are lifted up into 
 their normal position in the pelvis, and the vagina is 
 packed with gauze. In two days the vaginal and uterine 
 packings are removed and the vagina "again packed. 
 The cul-de-sac dressing can usually remain for a week. 
 It is then removed and renewed, sometimes under 
 chloroform. The dressings are renewed about once 
 in five days until the wound closes. The opera- 
 tor seeks to open the lymph streams and tubes so 
 as to cause them to leak. This he would not dare do 
 had he not provided through his gauze a means of 
 escape for the discharges. There no longer being a 
 necessity for locking-in infection, the tissues do not 
 attempt it. The curetting having cut short the source 
 of infection, no fresh supply is furnished. The causative 
 
,-^ PELVIC INFLAMMATION. 
 
 focus in the uterus is removed, and the comphcations are 
 attacked by evacuation. The question is suggested, 
 Does not lymph form about the gauze in the cul-de-sac ? 
 Undoubtedly ; but I wish to call attention to the differ- 
 ence between the character of the lymph which forms 
 about an absorbent antiseptic dressing and that which is 
 the exponent of infection. The first is not accompanied 
 by pain, by fever, nor by pus; it is evanescent and pro- 
 duces but (qw bands of adhesions and these not perma- 
 nent. Furthermore, it is limited to the cul-de-sac and 
 does not implicate the tubes. Lymph the result of 
 infection is absolutely different. Its production is accom- 
 panied by fever, by occlusion of the tube, by thickening 
 of the ovarian capsule, by great pain; and it is permanent 
 or else results in the stoutest kind of adhesions. More- 
 over, it is extensive in its distribution. The operation is 
 the counterpart of another where the infected focus is 
 cleaned out and the limb above incised to allow of escape 
 of the products of the results of the progressing infection, 
 as in cellular infection of the hand and arm. In very 
 many cases I have done this operation, and never have I 
 failed to check the process. The operation goes a step 
 further than curettage. It is not only conservative, but 
 is curative. To deny it to the woman is to refuse to 
 believe that her most highly vitalized organs have power 
 of repair when aided by incision and drainage. It is 
 absurd to state, as some do, that there is nothing between 
 the let-alone policy of the midwife, and the mutilating 
 operation. From the moment the adnexa are attacked 
 by infection, evacuation and drainage govern us. This 
 operation becomes in the hands of the practitioner the 
 means by which he prevents suppuration, and by apply- 
 ing it early he cures his cases permanently. It certainly 
 takes some courage to come from behind the protection 
 of the hypodermic syringe and thrust oneself into the 
 position of responsibility for the result. Morphin, the 
 poultice, and hot douche but lull the patient into a state 
 of insensibility to her danger. To apply these is to do 
 nothing ; to replace them with this operation is to speed- 
 
CONSERVATIVE TREATMENT. 
 
 155 
 
 ily and permanently cure these patients. Not the least 
 attractive attribute of the operation is theease with which 
 it may be done. It is entirely free from danger. 
 
 Clirouic Salping^o-ooplioritis. — In case the disease 
 has progressed beyond this first stage of cellular infiltra- 
 tion and there has been a production of pus, the treat- 
 ment is different. It matters not whether the pus be in 
 the tubes or ovaries. The uterus, unless previously cu- 
 retted, is cleaned out by curettage and irrigation. The 
 patient is placed in the lithotomy position. Upon open- 
 ing the cul-de-sac, the operator cautiously works his finger 
 up behind the uterus. When he has reached the fundus, 
 and while doing this he makes firm down-traction by 
 means of blunt bullet-forceps hooked into the cervix, he 
 carefully determines the contour of the ovaries and tubes. 
 When sufficient space has been secured above the diseased 
 adnexa, gauze pads secured by strings are gently inserted 
 above them. If a pus-sac is found low down, it is opened 
 by inserting a closed pair of blunt scissors. As the pus 
 escapes the scissors are opened and withdrawn, thus 
 making a broad rent. A finger is now inserted into the 
 opening, and the whole interior of the cavity is explored. 
 All pouches are entered and the pus evacuated. After 
 the flow of pus ceases, the edges of the sac are grasped 
 with Luer's forceps and held apart, while the operator 
 temporarily packs the sac with iodoform gauze. The 
 pelvis and vagina are wiped dry, and after cleansing his 
 hands the operator seeks possible foci in the other ovary 
 or tube. When found these are similarly treated. After 
 cleaning out all the pus sacs, the field of operation is 
 thoroughly sponged. Under no conditions should the 
 pelvis be irrigated, lest pus be washed up into the higher 
 cavity. It is not advisable to sever the adhesions above 
 the diseased organs. The isolating dome of lymph 
 which usually exists at the pelvic brim is to be left undis- 
 turbed. So far the operation has been one of evacuation 
 only. By means of the dressings to be applied the oper- 
 ator seeks the obliteration, by production of connective 
 tissue, of the affected cavity. The gauze pads are removed. 
 
T56 
 
 PET,VIC INFLAMMATION. 
 
 Molding open the pus-sacs, each is filled with iodoform 
 gauze, the ends of which project into the vagina. After 
 this the pelvis itself is tightly packed with the same dress- 
 ing. The uterus is now packed with gauze. No attempt 
 at replacement is made, but the organs are left in the posi- 
 tion in which they are found. The vagina is packed. 
 The uterine packing is removed in two days. At the first 
 general dressing in a week chloroform is given. As the 
 gauze is removed from each pocket, it is renewed before 
 other pieces are taken out. After all packings in the pus 
 sacs are removed and replaced by fresh dressing, the 
 gauze in the pelvis is renewed. Future dressings are 
 made every four days until the openings close. The 
 operation leaves the organs in a damaged state. These 
 women are sometimes cured of all symptoms, but com- 
 monly they have some pelvic pain. They menstruate, 
 but are sterile when the adnexa of both sides have been 
 involved. In the course of time the tube or ovary so 
 treated becomes a mere mass of connective tissue. The 
 case assumes the characteristics of genital sclerosis, and 
 the after-treatment is that of sclerosis. Before the scle- 
 rosis becomes complete, another infection may set up 
 suppuration again ; but where both ovaries and tubes 
 have been treated in this way and have become finally 
 obliterated, I have not seen suppuration occur. 
 
 Pus formation is not to be expected in tissues sclerosed 
 by connective tissue. In no sense does this operation 
 resemble the old puncture by means of trocar. When 
 the trocar showed pus, it did not thoroughly evacuate it, 
 and no protection was afforded against future suppuration. 
 If the trocar failed to find pus, it was not evidence that 
 pus did not exist. The trocar puncture was a blind pro- 
 cedure, and the trocar entered all tissues lying in its 
 path. The operation described is safe, thorough, and 
 essentially scientific. 
 
 Should a patient so treated, at some subsequent time 
 again become infected, with the production of pus in the 
 pelvis, an immediate evacuation or the radical operation 
 is indicated. The urgency in the indication lies in the 
 
CONSERVATIVE TREATMENT. 
 
 157 
 
 fact that the organs no longer have unbroken walls, and 
 hence pus soon tears through into the general pelvic 
 cavity. 
 
 Repeated bacteriological examinations have shown that 
 no matter what the cause of the suppuration, after a few 
 dressings the field of operation is sterilized. No pyo- 
 genic cocci are found, but the colon bacillus is very con- 
 stantly present. All that is apparently necessary to in- 
 duce the presence of this germ is any traumatism inflicted 
 upon the vagina or retro-uterine structures. 
 
 Chronic Lesions. — Hydrosalpinx. — These simple cysts 
 of retention have heretofore been treated by removal 
 through the abdomen. As early as 1891 I became con- 
 vinced that they were inocuous, but up to five years ago 
 had not attempted their treatment through the vagina. 
 The fluid they contain is very generally sterile serum, and 
 its evacuation into the pelvis produces no more reaction 
 than the presence of peritoneal fluid. No tube the seat 
 of hydrosalpinx should ever be sacrificed. 
 
 Operation. — The cul-de-sac is opened after curettage 
 of the uterus. The uterus is held down by the traction 
 forceps, and the affected tube is easily freed. When it is 
 exposed, with a blunt pair of scissors it is incised for an 
 inch along its upper border, beginning at the fimbriated 
 end. The fluid is caught with gauze as it escapes, and 
 the pelvis is wiped dry. But little oozing takes place un- 
 less many adhesions have been severed. Unless an indi- 
 cation exists for draining the pelvis, the incision in the 
 vagina is sutured by a continuous suture of chromic cat- 
 gut, and the uterus is packed with iodoform gauze. It is 
 then replaced and the vagina tamponed with iodoform 
 gauze. The uterine packing is removed in two days and 
 the vaginal dressing renewed. The patient is allowed 
 out of bed on the tenth day, the vagina being kept 
 tamponed until it is entirely healed and until the sutures 
 have become absorbed. This latter occurs in about two 
 weeks. Whenever the operator is in doubt regarding 
 the propriety of closing the vaginal incision, it may be 
 kept open by a packing of gauze. The convalescence is 
 
158 
 
 PELVIC INFLAMMATION. 
 
 afebrile and the recovery complete. Sometimes the walls 
 of an old hydrosalpinx are thick and ooze when incised. 
 Beginning at the fimbriated end of one side of the cut a 
 running suture of fine catgut is taken down one side of 
 the cut to the angle of the incision in the tube, and then 
 along the other side to the fimbriated end. In this way 
 the peritoneum of the incision is folded over to the lining 
 membrane of the tube (Fig. 55). Oozing is thus checked 
 
 "'^. 
 
 Fu;. 55. — Salpingostomy. The occluded tube has been incised along its 
 upper border, and a running suture is being taken so as to bring the mucous 
 lining to the serous covering of the tube, and in this way maintain the tube's 
 patency. 
 
 and closure of the tube prevented, "salpingostomy." 
 The cul-de-sac is not closed in such a case, but is packed 
 lightly with gauze. In all hydrosalpinx cases the uterus 
 if retroverted is replaced. 
 
 Cystic Ovaries. — These should never be removed. 
 They produce but little pain and cause only mild reflex 
 symptoms. The uterus is curetted and the cul-de-sac 
 
CONSERVATIVE TREATMENT. 159 
 
 opened. The ovary is freed from false adhesions and 
 brought down into the vagina; where it is held by bullet 
 forceps. One by one the cysts are stabbed with a ten- 
 otomy knife. Sometimes a cyst is met with of large 
 size, even one inch in diameter. It is to be evacuated, 
 its edges are trimmed, and the membrane which usually 
 lines it is peeled out. The cut edges are then brought 
 together by a running suture of fine chromic catgut. 
 
 After all cysts are emptied the ovary will be found 
 much shrunk. (See Fig. 32.) It is returned to the pel- 
 vis, and the vaginal incision closed or packed as indi- 
 cated. The uterus is packed with iodoform gauze and 
 replaced by a vaginal tamponade of the same material. 
 The after-treatment is the same as for hydrosalpinx. 
 
 Ovarian Apoplexy. — The uterus is curetted and the 
 cul-de-sac opened. The ovary is freed and pulled into 
 the vagina with bullet forceps. While held there the 
 blood cyst is incised, and the contained clot evacuated. 
 The edges of the cyst are trimmed with scissors, and 
 then the lining of the sac is peeled out with Luer's or 
 other suitable forceps. After this is done it will be found 
 that the ovary is much reduced in size. If the resultant 
 cavity is large, I trim it so as to form two thick flaps 
 which I suture readily with a running suture of fine silk 
 or chromic catgut. I prefer the latter. If the cavity is 
 small, I leave it open and do not bother to sew it. It 
 may ooze a little, but no more than would a ruptured 
 Graafian follicle. 
 
 I usually leave the vagina open in these cases and 
 pack with gauze, because these cysts are prone to be of 
 remote septic origin. The uterus is packed with gauze 
 as also is the vagina. The after-treatment is similar to 
 that of other non-suppurating cases. 
 
 Adherent Ovaries and Occluded Tubes. — The 
 uterus is curetted and the cul-de-sac opened. All adhe- 
 sions are broken with the fingers or else held up with a 
 blunt hook and severed with scissors. The occluded 
 tube is drawn into the vagina and incised along its 
 superior border for an inch from its fimbriated end. 
 
l6o PELVIC INFLAxMMATiUN. 
 
 Thefimbrije are teased apart with forceps. While hold- 
 ing apart the edges of the V-shaped cut, a running 
 suture of fine catgut is taken from the upper border of 
 the fimbriae down to the angle and up to the fimbriae of 
 the lower flap. (See Fig. 55.) This suture is so applied 
 as to unite the peritoneal surface with the lining of the 
 tube, and is used for the purpose of preventing closure 
 of the tube. The uterus is packed, and the opening in 
 the cul-de-sac filled with gauze which reaches just within 
 the cut edges. The vagina is packed with gauze. The 
 usual after-treatment is employed. 
 
 Broad Ligament Cysts. — When these are purely 
 pelvic, whether single or multiple, they can be treated 
 through the vagina. When they reach up to the pelvic 
 brim they should be removed by laparotomy. 
 
 The uterus is curetted and the cul-de-sac opened. At 
 once the smooth thin-walled cyst is felt. It has no pedi- 
 cle; therefore, the uterus is held up with a trowel while 
 the posterior vaginal wall is drawn down. Gauze pads 
 are inserted above the cyst and the intestines kept up. 
 With blunt scissors the cyst is split open and emptied. 
 A portion of the flaccid posterior walls of the cyst is torn 
 away with Luer's forceps. The pelvis is wiped dry, and 
 the pads removed. No bleeding of consequence results. 
 The uterus is packed with gauze, the cul-de-sac is filled 
 with the same material which reaches up to lower margin 
 of the cyst cavity, and the vagina is packed. The usual 
 after-treatment is employed. 
 
 The After-Treatmeiit in Non-Purulent Cases. — In 
 two days the vaginal dressings are removed and the uter- 
 ine packing withdrawn. The vagina is again packed. 
 From eight to ten days after the operation the patient 
 is placed in Sim's position and the cul-de-sac dress- 
 ing taken out. In doing this the uterus must be sup- 
 ported by the trowel. Fresh dressing is inserted and the 
 vagina again packed. 
 
 The second dressing is made in a week more, after 
 which the patient is allowed up. The cul-de-sac is kept 
 packed until closed. 
 
PREPARATION FOR A VAGINAL SECTION. i6i 
 
 If the vaginal incision has been sutured, the sutures 
 are removed in two weeks, and the vagina kept packed 
 until the scar is stout. 
 
 I do not give douches until the wound is healed, and 
 forbid intercourse for six weeks after the patient is dis- 
 cha'rgfed. 
 
 PREPARATION OF PATIENT FOR A 
 VAGINAL SECTION. 
 
 General. — The presence of nephritis, of cardiac dis- 
 ease, or of phthisis is no bar to the operation. Where 
 patients have influenza I prefer waiting for a few days 
 until this subsides, lest the narcosis excite a broncho- 
 pneumonia. Five days before the operation the patient 
 is given a calomel purge. I prefer triturates of calomel 
 each of gr. ^, given at 7, 8, 9, and 10 p.m., to be 
 followed next morning by a saline purge, like Seidlitz 
 powder. The diet is general and includes everything 
 but the more indigestible foods and luxuries. I exclude 
 everything fried, whether vegetable or flesh; stimulants 
 are withdrawn, and narcotics, if previously used, are not 
 allowed. The patient is made to lie down most of the 
 time, reading periodicals, seeing few friends, and alto- 
 gether assuming a semi-invalid state. She is encouraged 
 to drink large quantities of water. Each night she is 
 given a high enema of normal salt solution, of two pints. 
 This she is encouraged to retain. The object is to charge 
 the tissues with fluid. This has been shown not only to 
 actually increase the amount of urine, but also to facilitate 
 the elimination of urea. I have the urine analyzed for 
 sugar, albumen, and per cent, of urea, the total for 
 twenty-four hours being carefully measured. If fever has 
 existed before this treatment is instituted, it usually 
 diminishes, and if there is albumen in the urine this 
 decreases. I strive to get the emunctories cleansed out 
 and at the same time store up an excess of fluid for the 
 day following the operation, when the kidneys take away 
 
x62 PELVIC INFLAMMATION. 
 
 at least from half a quart to a quart of urine and no fluids 
 are invested. The shock, both surg^ical from hemor- 
 rhage, and vasomotor from traumatism to these impor- 
 tant pelvic structures, is much diminished. 
 
 Local. — Two days before operating I prepare the 
 patient. The pubes and vulva are shaved, the abdomen 
 is covered by a wet dressing of ^^ per cent, lysol solu- 
 tion, and the vagina is packed with gauze wet in bichlorid 
 solution j^Vff. These dressings are changed twice more 
 before the operation. The day before operating I give 
 meat once, potatoes, bacon, eggs, tea, soup, as much as 
 needed. All the time the patient is instructed to drink 
 two quarts of water a day. I do not like milk. In the 
 first place it has poor food value for an adult, and its 
 digestion results in the formation of " bullets " in the 
 bowels. Furthermore, the intestinal gases are increased 
 by it. For the. same reason I do not use koumyss. 
 
 After the first purge of calomel and salts, it is rarely 
 necessary to use another laxative; but if needed, one pil. 
 rhei. comp. may be given two days before operating. 
 
 The day I operate I give no food or drink after mid- 
 night, if the narcosis is to be in the forenoon. If I 
 operate in the afternoon, I give coffee and toast for 
 breakfast and a pint of water at 1 1 a. m. I do not give 
 stimulants either before or during the operation. Cer- 
 tain very desperate cases are met with: those with 
 nephritis and prolonged suppuration. In such cases I 
 perform transfusion into the elbow vein, using c. p. nor- 
 mal salt solution, and introducing as much as sixteen to 
 sixty ounces at the time of operating. To old drunkards 
 and to women with fatty hearts, I sometimes give a 
 hypodermic of strychnia, gr. ^V, before beginning the 
 narcotic. But I do not do this often. 
 
 Cleaiising- the Patient. — The position is that for 
 lithotomy, with the coccyx hanging over the table. 
 The thighs and vulva are scrubbed with lysol solu- 
 tion 2 per cent. The packing is withdrawn from the 
 vagina, and the latter is scrubbed with i per cent, lysol 
 solution, using for this purpose a long brush (jeweller's, 
 
VAGINAL ABLATION. 
 
 163 
 
 (Fig. 56). The perineum is depressed and the brush 
 moved up and down and rotated within the vagina while 
 an assistant pours the solution into the vagina. After 
 
 JOUN KEYNDKRS—CO. NJiW yuciK. '^ 
 
 Fig. 56. — Brusli for scruljbing tlie vagina. 
 
 using the lysol the external parts and vagina are scrubbed 
 gently with Thiersch solution. The legs and all parts 
 of the field of operation are covered by sterilized towels 
 or stockings. The operator then proceeds. 
 
 VAGINAL ABLATION/ 
 
 General Cousidei'ation^. — The vaginal mucosa and 
 peritoneum only are severed in vaginal hysterectomy; 
 whereas, in laparotomy, the skin, fat, fascia, muscle and 
 peritoneum are cut. In vaginal hysterectomy no vessels 
 are cut by the incisions which require ligation, but many 
 small arterial trunks must often be secured in making an 
 abdominal wound. It is not necessary to sever the peri- 
 toneum in performing vaginal ablation, for sufficient space 
 may be secured without that. It is necessary to dissect 
 the uterus from the bladder in both vaginal and abdomi- 
 nal ablation, but in the former the advantage is present 
 of having the cervix as a guide. The uterus and adnexa 
 to be removed are not masked by the viscera which lie 
 above them when vaginal ablation is done. 
 
 Separation of Adhesions. — It is usually necessary to 
 work through a mass of adherent intestines before the 
 organs we seek are seen in laparotomy, while the work 
 in vaginal ablation proceeds below the matted intestines 
 which lie above the uterus. This attribute of the vaginal 
 operation is worthy of a moment's discussion. We find 
 two kinds of adhesions : Those which have formed 
 
164 
 
 PELVIC INFLAMMATION. 
 
 between the various coils of intestine, the intcr-intcstinal ; 
 and those which exist between the organs to be sacri- 
 ficed and the intestines. We do not disturb the inter- 
 intestinal adhesions at all when we perform vaginal abla- 
 tion. The point may be raised that it is advisable to 
 dissect the intestines free ; but the weight of opinion 
 is in support of the belief that when this is done, not 
 only do the adhesions re-form, but that the secondary 
 union is more general when we deal with pus cases, 
 such as are under discussion. Certainly the experience 
 is exceptional with all of us to find upon making a sec- 
 ond laparotomy that there are not evidences throughout 
 the track of the operation of a pretty general infection 
 resulting from the first section. Furthermore, in per- 
 forming even a primary section in these pus cases, the 
 inter-intestinal adhesions are so firm that breaches are 
 made in the intestinal walls, often requiring suture. 
 Regarding the adhesions between the uterus and the 
 organs to be removed, whatever raw surfaces are made 
 upon the intestines in the vaginal operation, remain 
 turned down toward the point best adapted for drainage ; 
 whereas, in the abdominal operation all the raw surfaces 
 are dragged up above the pelvic brim, with a possibility 
 of infecting all points from which manipulation has 
 removed the endothelium. 
 
 In the vaginal operation, only those false unions are 
 severed which bind the diseased organs to be removed, 
 and these are much less important than those which exist 
 at and above the pelvic brim. 
 
 We are forced to the conclusion that any operation 
 which, other attributes being about equal, will furnish an 
 escape from the tedious dissection often incident to a 
 laparotomy in pus cases, will bestow the greatest immun- 
 ity from one most disagreeable sequela of laparotomy. In 
 abdominal section very often a grave intra-peritoneal 
 operation has been done before the organs sought for are 
 even seen. Usually the uterus and adnexa are removed 
 per vaginain without a knuckle of movable intestine 
 being- seen. 
 
VAGINAL ABLATION. 165 
 
 Direction of Efl'oit in the Eimcleatioii. — In lapar- 
 otomy the operation proceeds through an incision which 
 is expected to heal by first intention and through a mass 
 of adherent intestines. The infected organs are dragged 
 up between the raw surfaces left after separating the 
 adherent intestines and between the margins of the 
 abdominal incision. The fingers whether naked or 
 gloved repeatedly take the same path, and no hand 
 which has been engaged in liberating and removing 
 pus foci can be insured as clean. In laparotomy the 
 organs removed are dragged from their pelvic attach- 
 ments through the lower part of the abdomen. In vagi- 
 nal ablation the direction of the effort is in the direction 
 of drainage at the lowest part of the peritoneal pouch. 
 The pelvic filth remains pelvic and is never led into the 
 abdomen. It does not pass by tissues which are to be 
 sutured, and does not infect areas of intestine from which 
 the endothelium has been removed by manipulation. 
 
 Hemostasis. — In laparotomy this is by means of liga- 
 tures which must be absorbed ; certainly those upon the 
 ovarian vessels are cut short and left in. These ligatures 
 are so frequently infected, being placed in an infected 
 field, that they are often sources of trouble although 
 isolated in a mass of lymph. All the problems embraced 
 in a consideration of the choice of ligature material, its 
 preparation and its fate, are factors when the operation is 
 done through the abdomen. They are not considered 
 in the vaginal operation. 
 
 Dralnag-e. — In laparotomy this must sometimes be 
 employed, particularly in cases of streptococcus infec- 
 tion, diffuse suppuration, and where tubo-rectal fistul^e 
 exist. As a result the isolation of the area drained is 
 effected by a matted mass of lymph thrown out by the 
 intestines, and a breach is left in the abdominal scar. 
 Besides, the pelvic filth is drained through the normal 
 abdominal cavity, and is up-hill. In vaginal ablation the 
 drainage is always used ; it is at the lowest part of the 
 pelvic cavity; the intestines do not become adherent to 
 the drain or area drained, the pelvic filth remains pelvic, 
 and drainage is down-hill. 
 
ir,6 PELVIC INFLAMMATION. 
 
 Drainage after laparotomy, though not often used 
 now-a-days, infects tlie entire area adjacent to the drain 
 from the pelvic floor to the abdominal skin. Drainage 
 after vaginal ablation passes for not over an inch through 
 the lowest part of the pelvic peritoneum, and most of it 
 is through the vaginal tube which is particularly adapted 
 to carry off the material drained away without absorbing 
 any. The infected drainage space after laparotomy re- 
 mains for a large part an abdominal complication, and 
 for weeks. 
 
 After vaginal ablation, the drainage track is in a few 
 hours made extraperitoneal by the union of bladder to 
 rectum. 
 
 Sutures. — These are not used in vaginal ablation. So 
 important a matter is the method by which the abdomi- 
 nal wound should be closed that there are about as 
 many varieties as there are operators. Shall the wound 
 be closed by buried catgut, buried kangaroo tendon, or 
 buried silver wire ? Shall the wound be united by 
 suturing in tiers or through-and-through suturing, or 
 shall the fat be left open ? Shall the sutures be applied 
 as interrupted or mattress or continuous sutures? 
 
 Hei-nia. — The percentage of hernias after laparotomy 
 is not known, but there are many of them. They are not 
 known to follow the vaginal ablation by forceps. The 
 intra-abdominal effort is almost wholly borne above the 
 symphysis, while the vaginal vault is protected from this 
 force by the posture of the body and the sacral promon- 
 tory. 
 
 Accidents. — In abdominal hysterectomy the bowel 
 must sometimes be sutured; the ureters have been cut; 
 abdominal fistulas are known to exist, and ligatures have 
 worked their way into the bladder. After vaginal abla- 
 tion intestinal suture and resection must be exceedingly 
 rare procedures ; in the few cases in which the bladder 
 has been wounded the rents closed without suture, un- 
 less made by the veriest tyro; no wandering ligatures are 
 heard of, and no abdominal fistula are found. 
 
 Instruments. — In laparotomy knives, scissors, needles, 
 
VAGINAL ABLATION. 1 67 
 
 sutures, ligatures, needle-holders, etc. In vaginal ablation 
 no needles, no sutures and no ligatures. Much less com- 
 plicated is the preparation for vaginal section. 
 
 Narcosis and Time. — Abdominal hysterectomy ne- 
 cessitates an abdominal section and a hysterectomy. 
 Vaginal ablation is a hysterectomy only, without the 
 abdominal section. Few men can perform 2i finished 2iQ- 
 dominal hysterectomy in less than three-quarters of an 
 hour in pus cases. Twenty minutes only need be con- 
 sumed in vaginal ablation. In order to secure relaxation 
 of the abdominal muscles profound narcosis is necessary 
 in laparotomy. With vaginal ablation the narcosis is in- 
 complete and short, and chloroform again becomes the 
 preferable anesthetic. 
 
 Coiivalesceuce. — No man who has seen a number of 
 similar cases treated by the two methods but will decide 
 that the ability to turn over in two days, the assumption 
 of regular diet in four days, the regularity of the bowels 
 from the first, the absence of nausea and vomiting, the 
 early getting-up, make the convalescence from vaginal 
 ablation much less disagreeable than from laparotomy. 
 
 Results. — No case of mine has died either from the 
 operation or from complications. There are no fecal 
 fistulas to report, no sinuses, no vesicovaginal fistulae, and 
 no hernias. There have been no cases of phlebitis and 
 no intestinal obstructions. The vagina has in no case 
 been shortened, and intercourse is painless. 
 
 These are the reasons why I perform vaginal ablation 
 in pus cases. 
 
 Having stated my reasons for preferring the vaginal 
 route, I may properly mention what cases I exclude from 
 the list of those to which I apply this method. Any im- 
 portant bowel complication above the pelvic brim must 
 be treated through the abdomen. Whenever a suppu- 
 rating ovary or tube communicates with a purulent ver- 
 miform appendix, and whenever a pus focus in the adnexa 
 opens into the small intestine, or the large intestine above 
 the pelvic brim, the bowel lesion so far overshadows the 
 pelvic disease that the case must be viewed from the ab- 
 
I 58 PELVIC INFLAMMATION. 
 
 doriiinal side, for the delicate suturing of the intestine can 
 not be done through the vagina. The question is natural, 
 Can these facts be determined by vaginal .section? I have 
 not found any difficulty in doing so since the perfected 
 technic has been adopted. 
 
 Whenever hysterectomy is indicated upon a puerperal 
 uterus, the vessels are so large that by hemisection too 
 much blood is lost, hence the uterus must be removed 
 en masse ; and the tissues are so friable that the requisite 
 down-traction is impossible. Vaginal ablation of a puer- 
 peral uterus is truly a deplorable operation and one which 
 should never be done. 
 
 But there are a number of cases which when treated 
 by laparotomy give a very high rate of mortality — I refer 
 to cases of diffuse suppuration. When approached by 
 the vagina these are as successfully handled as any 
 others. 
 
 Posture. — The uterus can be removed per vaginam 
 with the patient in the lithotomy posture throughout the 
 entire manoeuvre; but the operator will find that he can 
 proceed with greater comfort to himself and safety to his 
 patient if he employs a table which enables him to secure 
 the Trendelenburg posture. The one I have devised 
 can be employed in all gynecological work and is par- 
 ticularly useful in the vaginal operations; but a suitable 
 table may be improvised by sawing off two of the legs 
 of a stout kitchen table so that the incline of the table 
 will be 60°. To retain the patient in the lithotomy pos- 
 ture I employ Ott's or Clover's crutch ; but a sheet pass- 
 ing over her shoulders and tied to the legs will answer. 
 
 Having a table which enables him to secure the 
 Trendelenburg posture at any moment, the operator can 
 avoid all those accidents which accompany improperly 
 applied and imperfectly protected forceps. If he so 
 desires, he can operate in a pelvis which is entirely free 
 from abdominal viscera (Figs. 57, 58, 59). 
 
 Operation. — I operate standing. The field of opera- 
 tion is cleansed, and the uterus is curetted and swabbed 
 out, but is not packed. All instruments used in the 
 
Fig. 57. — Operating table folded for transportation. 
 
 ^^^ 
 
 Fig. 58. — The table in exaggerated Trendelenburg position for laparotomy. 
 
 169 
 
I 70 
 
 PELVIC INFLAMMATION. 
 
 curettage are laid aside, and the operator again washes 
 his hands. 
 
 The Incisions. — I always attempt and rarely fail in 
 inflammatory cases to enter the posterior cul-de-sac as 
 
 Fjr,. 59. — 'Ilie author's table arranged for vaginal operations in the litliotoiny 
 
 posture. 
 
 the first step. This is the true exploratory part of my 
 operation (see Exploration, page 136). 
 
 Having become convinced that an ablation is neces- 
 sary, the operator proceeds to spread the vaginal incision 
 from side to side (Fig. 52). The posterior incision hav- 
 ing been completed a gauze pad is introduced into the 
 opening to catch fluids. The anterior incision is next 
 made. I introduce into the uterus a pair of my intra- 
 
VAGINAT, AP.LATTON. 
 
 lyr 
 
 uterine traction forceps, and spread them until a firm ^rasp 
 is secured upon the organ (Fig. 6i). 
 
 The cervicovesical fold is accurately determined, and, 
 
 /^ 
 
 c 
 
 
 Fig. 60. — The lines of incision in the vaginal operations. A-B, the extent 
 of the incision into the posterior cul-de-sac for the purpose of severing adhe- 
 sions. X-Y, the incision for evacuating pus, in puerperal fever and in hys- 
 terectomy. C-D, The anterior incision for dissecting off the bladder. 
 
 cutting against the cervix, the latter is circled to within 
 an eighth of an inch of the posterior cut. Thus a nar- 
 row strip of vaginal mucosa is left upon each side, I do 
 
 Fig. 61. — The author's intra-uterine traction forceps. 
 
 not make this anterior incision near the external os. I 
 wish to cut above the very dense tissues about the exter- 
 nal OS and yet to leave abundance of vagina. If the dis- 
 section is made near the os, bilateral space is secured 
 
1^2 PELVIC INFLAMMATION. 
 
 with difficulty, for the incision will be surrounded by a ring 
 of inelastic tissue (Fig. 62). In other words, the anterior 
 incision should be made in vaginal tissue and not in cer- 
 vical. So soon as the scissors have cut through the 
 vaginal mucosa, they are closed and laid sideways upon 
 
 
 Fig. 62. — Shows microscopic section (vertical) of fetal bladder, urethra, 
 anterior vaginal wall, and anterior lip of cervix, a lies above loose tissue, 
 between bladder and cervix and vagina; 3, bladder; u, urethra; v, vagina; c, 
 cervix uteri. X marks the point at which the anterior incision is made, so 
 that the dissection may proceed through the loose tissue between cervix and 
 bladder (Hart). 
 
 their edge in the cut. Bearing down hard upon the cer- 
 vix, the tissues are shoved up for a short distance or 
 until the looser tissues are reached. The closed scissors 
 used in this way act as does a periosteum elevator. 
 After the dissection has proceeded upon the anterior face 
 
VAGINAL ABLATION. 
 
 173 
 
 of the cervix for about half an inch, a short retractor is 
 inserted into the wound and the bladder held up. Upon 
 wiping the wound dry a few bands of connective tissue 
 and muscular fiber may be noticed extending from the 
 sides of the incision toward the center and angle of the 
 denudation. These are snipped with the scissors. After 
 this all attempts to enter the anterior peritoneal pouch 
 are made with one finger. Holding the uterus firmly 
 with the intra-uterine traction, the vesico-uterine tissues 
 are pushed up. The operator does this by bearing hard 
 
 .•^ C- 
 
 
 \3 ' '^^ 
 
 Fig. 63. — Transverse section of right half of uterus at level of the internal os. 
 c, bladder; a, uterus; i, parametric tissue; X, uterine vessels (Hart). 
 
 down upon the uterus with the index finger and literally 
 rubbing the bladder tissues from the uterus. This is 
 done not with the nail, but with the palmar surface of the 
 finger. It is in this bladder dissection that the great 
 value of my forceps is seen. With them the uterus can 
 be rotated so as to differentiate the loose pericervical 
 tissues from the uterine ; and in stripping the bladder 
 from the uterus they furnish a most admirable point of 
 counter-pressure. " They give the operator a fixed body 
 to work against and not a movable one. I have never 
 found it necessary to sever the peritoneum with instru- 
 ments. The finger, whenever it can reach the fundus 
 anteriorly, will easily penetrate ; and in cases where the 
 peritoneum is attached high on the uterus, the periton- 
 eum should not be blindly opened until the uterus can 
 
1^4 PELVIC INFLAMMATION. 
 
 be pulled down after hemisection. Having entered the 
 anterior fornix or made the dissection as high as the finger 
 will reach, the bladder is separated from the uterus to 
 the sides. The anatomical fact must here be noted that 
 the width of the bladder is greater than that of the 
 uterus, and that the organ extends laterally upon the 
 broad ligaments. The operator sticks to the middle 
 line in separating the bladder and makes the lateral 
 separation by moving the finger, laid flat upon the 
 uterus, from side to side. The uterine vessels at the 
 sides can be felt pulsating, and the dissection should not 
 be carried beyond their level (Fig. 62,). If the operator 
 is rough he can very easily rupture the uterine vessels. 
 So far there has been but littls bleeding. The azygos 
 artery on the posterior vaginal wall has been severed in 
 opening the cul-de-sac, and temporarily clamped if prom- 
 inent. The small vessels from the uterine arteries which 
 enter the cervix give some trouble if wounded. They 
 anastomose freely with the vesical arteries. I do not pay 
 attention to them until I am ready to clamp the uterines. 
 The operation has progressed to the point where the 
 uterus is free from its attachments to the bladder and 
 posterior vaginal wall. I have termed this the first 
 stage ; for it is done in all cases, be the further manceu- 
 vres what they may. In making these incisions and 
 separating the bladder, what is the position of the ure- 
 ters ? At the point where the uterine artery springs 
 from the internal iliac, the ureter lies at least a quarter 
 of an inch below the artery. As the artery abruptly 
 crosses the pelvis to the side of the uterus it passes 
 across the ureter. This point of crossing is always at 
 least an inch from the normal cervix, and is where the 
 broad ligament spreads out for its attachment to the 
 side of the pelvis (Fig. 64). After this the ureter and 
 uterine artery are never in relation. The ureter sweeps in 
 a graceful curve to the bladder and is hi front of the uter- 
 ine artery. The uterine artery does not curl around the 
 ureter, as pictured by Bourgery and Jacob. From the 
 time the ureter crosses the pelvic brim, it begins to sink 
 
Fig. 64. — A., abdominal aorta; I. I., internal iliac artery; E. I., external 
 iliac artery ; O. A., ovarian artery ; U. A., uterine artery ; R., rectum ; F., a 
 fibroid nodule springing from the fundus; Ut., uterus; O., over the right 
 ovary which is adherent to the posterior surface of the broad ligament. 
 Above O is a right hydrosalpinx ; U., ureter into which has been introduced 
 a probe ; B, bladder ; S. V., superior vesical artery. The pelvis is somewhat 
 tilted to the right to show the relations. The peritoneum has not been 
 removed, but the course of the vessels has been shown by painting over their 
 course beneath the peritoneum. 
 
VAGINAL ABLATION. 
 
 177 
 
 below the internal iliac artery ; and when the uterine 
 artery is reached, the ureter is easily a quarter inch below 
 the uterine. The ureter proceeds anteriorly to the bladder, 
 while the uterine artery crosses the pelvis to the cervix. 
 Upon separating the bladder from the uterus and lifting 
 it up, the ureters are swung outward and further up- 
 ward ; and pulling the uterus down and toward the 
 
 Fig. 65. — A photograph of a suprapubic hysterectomy, introduced for the 
 purpose of demonstrating the position of the ureter, which may be seen cross- 
 ing beneath the uterine artery at the outer margin of tlie spHt broad hgament. 
 
 sacrum while lifting the bladder still further moves the 
 uterine artery to a deeper and more, posterior position. 
 When the bladder is separated and held up, and the 
 uterus pulled down, the ureters and uterine arteries are 
 further apart than they were before the operation. But 
 if the bladder is not separated and lifted, down-traction 
 
178 
 
 PELVIC INFLAMMATION 
 
 upon the uterus decreases the angle of divergence 
 between the artery and ureter, and they may be made to 
 touch for the outer half of the artery and up to a half 
 inch of the cervix. Repeated dissections show this. 
 
 Fiu. 66. — K, kidney; U, ureter; a, ovarian artery; B, external iliac vein ; 
 Ut, uterus; i, abdominal aorta; 2, vena cava inferior, on each side of which 
 is a common iliac artery; 2', internal iliac vein ; x, middle sacral artery; 3, 
 external iliac artery ; 4, internal iliac artery ; 5, internal pudic artery ; 6, uterine 
 artery; 6', point where uterine artery joins the severed ovarian artery; 7, 
 vaginal artery ; 8, 8', superior vesical artery ; 9, obturator artery ; 10, common 
 origin of the gluteal and sciatic arteries. 
 
 The ureters can not be wounded by any force applied at 
 the sides of the uterus, provided such force does not 
 tend to draw the cervix and bladder together, as, for 
 iiistance, an improperly applied ligature does. 
 
-h 
 
 yf^;-'- • :: 
 
 Fig. 66.* — Surgical Anatomy of the Internal Iliac. 
 
VAGINAL ABLATION. 
 
 179 
 
 I leave a narrow strip of vaginal mucous membrane 
 upon each side and between my anterior and posterior 
 incisions for two reasons. When I apply the forceps to 
 the uterine vessels, this strip of tissue prevents tearing 
 off the forceps during future manipulations. Further- 
 more, I have thought this prevented to some extent sag- 
 ging down of the vagina after completion of the process 
 of healing, inasmuch as the vaginal vault and the bases 
 of the broad ligament are one. 
 
 I have never found that my incisions gave me less 
 room than Segond's. This surgeon circles the cervix 
 entirely, and makes upon each side a cut at the base of 
 the broad ligament. I never find it necessary to incise 
 the perineum to gain space. Could I not perform the 
 operation without this, I would always do laparotomy. 
 One attractive feature about this vaginal operation is 
 absence of traumatism to normal structures. This is 
 lost when the perineum is incised. 
 
 When Segond has separated the bladder he has two 
 flaps, and his first pair of forceps do not grasp vaginal 
 mucous membrane at all. Segond contends that his 
 incision enables him the better to avoid the ureters. In 
 one way it does, inasmuch as there is a greater separation 
 of the anterior (bladder and ureters) segment from the 
 posterior (uterus), not in the middle, but at the sides of 
 the uterus. I have used both incisions and prefer the 
 one illustrated, for the reasons stated. 
 
 In certain cases the bladder is attached so high up on 
 the anterior surface of the uterus that the operator cannot 
 reach the anterior peritoneum with his finger. He should 
 then make his dissection as high as he can, and withdraw 
 the intra-uterine traction forceps. In order to enter the 
 peritoneum it is necessary for him to pull down the ante- 
 rior surface of the uterus. In order to do this, he grasps 
 each side of the cervix with bullet forceps, and splits the 
 anterior lip of the cervix in the middle line to a little 
 above the level of the internal os. (See Hemisection.) 
 Upon rotating the bullet-forceps outward the cervical 
 canal will flare out, and a portion of the anterior uterine 
 
I So TELVIC INFLAMMATION. 
 
 wall will come down. This is cut with scissors in the 
 middle line. While making this anterior median section 
 of the uterus, the bladder should be held up by a narrow 
 retractor, and as each successive portion of the anterior 
 wall of the uterus conies into view, it is grasped by trac- 
 tion forceps. After a time, at the upper angle of his in- 
 cision, the operator will see the smooth peritoneal cover- 
 ing of the uterus. He has, perhaps unconsciously, entered 
 the anterior peritoneal pouch by holding up the bladder 
 and progressively sj^litting the anterior face of the uterus. 
 It is well after entering the peritoneum posteriorly 
 and anteriorly to make a careful digital exploration of the 
 pelvis. Now is the time for the operator to obtain an 
 accurate knowledge of the regional anatomy of the par- 
 ticular pelvis he is dealing with. This completes the first 
 stage of the operation, and the procedure is employed in 
 all cases. 
 
 ABLATION EN MASSE. 
 
 Freeing' the Adnexa. — If this can possibly be done 
 before the application of the forceps, it should be, for 
 forceps take up room. The gauze pad in the cul-de-sac 
 is removed. Still pulling the uterus down, the operator 
 inserts his finger into the pouch of Douglas. Taking the 
 posterior surface of the uterus as a guide, he enters the 
 finger to the level of the tubes. After one tube is found, 
 attempts are made to free its attachments at the fimbriated 
 end. In doing this the effort is made to pusJi up the tube 
 and ovary. The operator is working from behind the 
 broad ligament. If the adnexa are attached low, they 
 can readily be freed. If they are high at the pelvic brim, 
 the effort to release them is made in front of the uterus, 
 the fingers being between the bladder and uterus. Here 
 the uterus is again the fixed guide. In working from in 
 front of the uterus the operator seeks to free the adhe- 
 rent organs by getting his finger outside of them and' 
 separating the attachments toward the cornu. The action 
 is very similarto that used in like cases when laparotomy 
 is done. Having released the adnexa on one side, those 
 
VAGINAL ABLATION. i8i 
 
 of the other are released. Too much emphasis can not 
 be laid upon the importance of persisting in efforts to 
 release the adnexa from inflammatory union to other or- 
 gans before putting on any forceps. No vessels of im- 
 portance have so far been severed ; the narcosis is not 
 profound, and the patient is in no sort of danger. The 
 operator need not be embarrassed if he finds the adnexa 
 firmly adherent, but must persist in his efforts to free them 
 both by working from behind and from in front of the 
 uterus. It is well to have a firm grasp upon the cervix 
 with blunt traction forceps or the intra-uterine traction 
 forceps, and to work with all specula removed. As few 
 instruments as possible should be in the vagina. While 
 drawing down the uterus with the left hand and manipu- 
 lating the adnexa, the assistant will render material 
 aid by pressing down from above the pubes. When 
 he has released the adnexa, the operator withdraws 
 his hand and introduces the anterior and posterior 
 retractors (Fig. 67). 
 
 Taking in his right hand a pair of hysterectomy for- 
 ceps, the operator introduces one blade into the anterior 
 incision, to the left of the cervix, and the other blade into 
 the posterior incision. The forceps is crowded, still 
 open, hard up alongside the cervix, and when in position 
 the operator carefully inspects and feels each blade to see 
 that no intestine or omentum is caught. The forceps is 
 then locked. A forceps is similarly applied upon the right 
 side. It will now be seen that all bleeding about the cer- 
 vix has ceased. Into the posterior cul-de-sac a gauze pad 
 is inserted to hold up the intestines; and the tissues upon 
 each side of the cervix between the cervix and the two for- 
 ceps are cut with scissors almost to the points of the for- 
 ceps. The intra-uterine traction forceps or a male sound 
 is now used to antevert the uterus. As high on the ante- 
 rior face of the uterus as he can see, the operator takes a 
 firm grasp of the uterus with toothed forceps and with- 
 draws the intra-uterine traction (Fig. 68). He shoves 
 the cervix upward while he pulls down on the body of 
 the uterus until he can see more of it, and again takes a 
 
I.S2 
 
 I'la.VIC; INFLAMMATION. 
 
 good grasp near tlic fundus. He can now draw the fun- 
 dus forward beneath the bladder until the cornua appear. 
 While supporting the fundus in this way he inserts his 
 fingers above the uterus, and seizes the right adnexa. 
 
 Fig. 67. — The cul-de-sac has l)eeii opened and llie bladder dissected from 
 the uterus. The uterine arteries are grasped by forceps and the eervi.x has 
 been dissected from the lateral stumps (photograph -of operation). 
 
 Either with his fingers alone, or assisted by Luer's for- 
 ceps (Fig. 69), he drags the right adnexa in front of the 
 uterus and applies forceps to the right ovarian artery 
 outside the right ovary. This forceps is applied from 
 above, and the operator can guide the anterior blade with 
 
VACINAL Mil.ATION. 
 
 183 
 
 his index finger, and the posterior blade with his middle 
 finger, so that there is no danger of catching any intestine. 
 It is well to withdraw the gauze pad before applying this 
 forceps lest it be caught in the forceps. When he feels 
 that this forceps laps the one on the right uterine artery, 
 
 Fig. 68. — 'I'he cervix has been shoved up so as to permit the operator to 
 drag the fundus out beneath the bladder. Both cornua uteri are shown with 
 the attached tubes (photograph of operation). 
 
 he clamps it. In isolating the right adnexa and applying 
 this forceps, if retractors are used and are in the way, 
 they should be withdrawn. The upper forceps grasps 
 the round ligament as well as the broad ligament. The 
 uterus is now cut loose upon the right. At once it 
 swings out of the pelvis so that its posterior face is for- 
 
184 
 
 PELVIC INFLAMMATION. 
 
 ward, and it becomes an easy matter to bring forward the 
 left adnexa and secure the left ovarian artery outside the 
 ovary. The uterus can now be cut away (Fig. 70). 
 
 The specula are next introduced. Holding the bladder 
 
 l''l(i. 69. — Aiier delivering lue fundus the eni.ic uienne bod\ is |Hilled to 
 the operator's right, in order that the riglit adnexa may be seized. Tlie oper- 
 ator's thiunl5 rests on the ovar}', wliile his two first fingers grasjj the corpus 
 uteri. The forceps are being apphed to tlie right ovarian artery. Notice the 
 aljsence of retractors (photograph of operation). 
 
 up and depressing the, perineum and posterior wall, the 
 operator introduces a gauze pad into the pelvis and pushes 
 the intestines away from the stumps secured by his for- 
 ceps, so that he may make a careful inspection of the 
 
VAGINAT, ABLATION. 
 
 t8: 
 
 Stumps and see if any bleeding is going on. If the ad- 
 nexa have been thoroughly freed before extirpation is 
 attempted, it will be seen upon completion of the opera- 
 
 FlG. 70. — Having clasped the right ovarian artery, the uterus is cut away 
 upon that side. The operator rotates the uterus, so that the cervix is deliv- 
 ered and the posterior surface of the uterus presents. He grasps the left broad 
 ligament between his index and middle fingers, and applies the forceps to the 
 left ovarian artery. The method of applying these forceps is shown (photo- 
 graph of operation). 
 
 tion that the bite of each pair of forceps is in the upper 
 part of the vagina. No forceps, if possible, should ever 
 be applied so as to project up into the pelvic cavity among 
 the intestines. The gauze pad supporting the intestines 
 
T M6 
 
 I'ELVIC INFLAMMATION. 
 
 is now removed, and a piece of iodoform 
 gauze is inserted between the forceps and 
 the wall of the vagina on each side to pre- 
 vent pressure-slough. The operator now 
 takes squares of iodoform gauze, each 
 about two inches wide and three inches 
 long, and introduces one piece along the 
 side of the forceps on the left, a little above 
 their tips. This piece of gauze is sup- 
 ported by a smooth, narrow speculum in- 
 troduced to the right of it; the dressing 
 forceps is removed, another piece of gauze 
 : introduced alongside the speculum, the 
 I speculum withdrawn, and this piece of 
 ] gauze also supported. In this way the 
 L" operator proceeds from one side to the 
 : other, filling the opening in the vagina 
 i entirely with iodoform gauze, which pro- 
 3 jects a little above the points of the for- 
 3 ceps. A ^e\\f more pieces of gauze are in- 
 : troduced lower down in the vagina, so as 
 ? to fill it to the vulvar orifice. Sterilized 
 \ gauze is wrapped around all the forceps 
 T and tied. A self-retaining catheter is in- 
 \ troduced into the bladder upon a sound 
 and pinned to a piece of plaster fastened 
 to the skin above the pubes (Fig. 71). 
 The sphincter ani is dilated, and the pa- 
 tient put to bed. 
 
 Sometimes, when the adnexa of one side 
 are so firmly attached to the intestines, or 
 are so large, or the vulva is so small that 
 the operator cannot loosen both adnexa to 
 his satisfaction, he may proceed as follows : 
 If the difficulty be limited to one side only 
 — for example, the right side — he may free 
 the adnexa on the left side, secure the 
 uterine arteries on both sides, and the 
 ovarian artery on the left side outside the ovary and tube; 
 
. IVAGINAL AI5T,ATI()N. 187 
 
 he then cuts the uterus free on the left side. Having 
 done this, he introduces a pair of forceps close to the 
 uterus upon the right side where the adnexa have not been 
 freed, and removes the uterus and adnexa of the left side, 
 leaving in the tissues which embarrassed him. It will 
 now be found that he will have room for removing the 
 remaining adnexa under the guidance of the eye. To 
 do this the operator will secure the ovarian artery outside 
 the ovary and tube. This will render the forceps which 
 was applied between the uterus and right adnexa unne- 
 cessary, so it may be removed. This is in reality but 
 a form of morcellation or removal in fragments. 
 
 While the removal of the uterus en masse is more gen- 
 erally accepted than any other method, I am pursuaded 
 that it is responsible for many of those ill results 
 which lend arguments to the opponents of the vaginal 
 method. In certain cases it is utterly impossible to 
 remove the uterus and adnexa entire. Such cases are 
 those where the uterus is much enlarged, where the pus 
 foci are enormous or attached high at the pelvic brim, 
 and cases of advanced genital sclerosis. It may be 
 found impossible to free the adnexa before applying 
 forceps, and equally so after forceps have fixed the 
 tissues. 
 
 Appreciating the difficulty of ablation en masse, I have 
 for several years practised exclusively ablation by hemi- 
 section. This I sometimes supplement by morcellation, 
 but the morcellation is employed merely as a step pre- 
 liminary to the hemisection. 
 
 ABLATION BY HEMISECTION. 
 
 " I divide my difficulties by splitting the uterus." 
 This is the operation which I always employ. It is the 
 operation of election in all cases, whether associated with 
 fibroid degeneration or not. In such cases it is some- 
 times associated with, but never supplanted by morcella- 
 tion. By means of this procedure, the time consumed 
 in operating is rarely twenty minutes, and the operation 
 
1 88 PELVIC INFLAMMATION. 
 
 is "always complete. Rcineiiibering his anatomy, the 
 operator recalls that both upon its anterior and posterior 
 surfaces, the uterus is comparatively sparsely supplied 
 with vessels, along the middle line. Therefore, an abso- 
 lutely median section produces but little hemorrhage. 
 The time of operating is short, for, by means of the 
 hemisection, each set of adnexa and its corresponding 
 half of the uterus are rendered movable. Further, as 
 one-half of the severed uterus is shoved up into the 
 pelvis, out of the way, the hand is enabled to work high 
 in the pelvis to the side of that half of the uterus which 
 is drawn down, and the fingers have all the space to one 
 side in which to work, from the bladder to the perineum. 
 One other advantage is that, as each half of the uterus is 
 liberated and drawn down, it is swung outside the vagi- 
 nal outlet, giving an unobstructed orifice in which to 
 work. 
 
 Operation. — First Stage. — The patient is on the back 
 and in the lithotomy position. A short Jackson specu- 
 lum draws down the perineum. The uterus is curetted 
 and swabbed out, but not packed. The intra-uterine 
 traction-forceps is introduced, and the posterior cul-de- 
 sac is opened (Fig. 72). All adhesions posterior to the 
 uterus along the middle line are severed by the examin- 
 ing finger up to the fundus. No attempt is made to fur- 
 ther separate the adherent organs at this stage. It can 
 not be now properly done and is a waste of time. The 
 posterior incision is carried around the cervix, almost to 
 the middle line. Drawing down the uterus and holding 
 up the bladder, the anterior cervico-vaginal juncture is 
 severed by means of the scissors. This cut is not to be 
 made close to the external os, but is above the dense 
 cervical structure, and in the loose pericervical tissue. 
 The fold at which the incision is made is easily seen 
 when the uterus is shoved up. This incision is carried 
 laterally toward the posterior cut, but stops one-eighth 
 inch from it on each side. As this incision is made, a 
 few fine arterioles spurt. They are not important, being 
 but small anastomotic branches between the uterine 
 
Fig. 72. — Showing the method of incising the vagina at the point x in Fig. 
 62. The intra-uterine traction forceps is shown pulling the uterus down. 
 The second step in all vaginal ablations (from a photograph of an operation 
 by the author). 
 
Fig. 73. — The cervix is split anteriorly. The first step in hemisectioii (from 
 a photograph of an operation by the autlior). 
 
F.IG. 74- — Showing the effect of sphtthig the anterior uterine wall so that 
 the uterus may be rolled from beneath the bladder (from a photograph of an 
 operation by tlie author). 
 
VAGINAL ABLATION. 
 
 193 
 
 and vesical arteries. The assistant digs the shorty narrow 
 Jackson retractor into the anterior cut, with the edge 
 planted hard against the cervix. This is the way to 
 avoid wounding the bladder. The uterus is then rotated 
 by twisting the intra-uterine traction forceps, and the 
 operator is thus enabled accurately to determine the 
 loose tissue between the bladder and uterus which he is 
 to cut. As these fibers are severed with scissors the 
 retractor draws the bladder further and further upward, 
 while the uterus sinks lower as it becomes free. Another 
 simple way of severing the connection between the uterus 
 and bladder is by blunt dissection with the finger. In 
 doing this, the traction forceps is invaluable, as it fur- 
 nishes a hard surface upon which to press. This dis- 
 section is made by shoving up the pericervical tissues 
 with the finger pressed hard against the cervix. The 
 point of the finger is never allowed, to wander away from 
 the uterus. If this rule is adhered to, the bladder 
 will not be wounded. The dorsum of the finger is 
 upward, and the actual dissection is effected by a sort of 
 rubbing motion with the palmar face of the end of the 
 finger : the bladder is rubbed off the uterus. If the 
 incision is made close to the external os, this dissection 
 is most difficult ; but if made as I suggest, it is easy. 
 After the uterus is free in front and behind, the first stage 
 is finished. 
 
 Second Stage. — Two pairs of bullet forceps are made 
 to grasp the angles of the external os, and the intra- 
 uterine traction forceps are withdrawn. The two index 
 fingers are introduced between the bladder and the 
 uterus, and the bladder is further separated from the 
 uterus to the sides of the latter. This will remove the 
 ureters from all possibility of injury. The bladder is 
 held up out of the way, while assistants draw down on 
 the bullet forceps. The blunt scissors are inserted as a 
 sound to determine the direction and shape of the uter- 
 ine cavity, and are then withdrawn. As far up on the 
 anterior surface as the operator can see, he splits the 
 uterus in the middle line. The assistants evert these 
 
194 
 
 PELVIC INFLAMMATION. 
 
 edges by twistin<^ the bullet forceps outward, and the 
 upper end of each side is grasped with P'rencli traction 
 forceps (Fig. 73). As these are drawn upon and rotated 
 outward, it will be found that more of the uterine body 
 comes into view, and is unfolded so that the uterine cav- 
 ity is flattened out. All of the uterine cavity that can be 
 seen is split in the middle line, and other traction forceps 
 are entered higher up. In this way the fundus is reached 
 and severed (Fig. 74). All specula are now withdrawn, 
 
 Fli;. 75. — Tiie author's retracting grooved director. Of 
 soft, friable uteri. 
 
 n-eat service with 
 
 and my grooved director (Fig. 75) is introduced behind 
 the uterus, entering behind the cervix. A finger is in- 
 serted behind the bladder and the director is felt; and 
 again the finger is forced behind the uterus to see that no 
 guts lie between the director and the uterus. The assistant 
 is told to press down the perineum hard with the director, 
 
 Fir,. 76. — Ijistourv for sphltiiig tlie uteru.s 
 
 while the curved portion of the instrument pulls forward 
 the uterus. A short speculum is inserted behind the blad- 
 der until the groove in the director is seen. Into this a 
 special bistoury is inserted (Fig. yG), and the uterus is 
 split accurately in two halves. This completes the sec- 
 ond stage (Fig. jf). 
 
 Third Stage. — The director is drawn out. The right 
 (on operator's left) adnexa and half of uterus are shoved 
 into the pelvis, while traction is made upon the left half 
 
•,\\ 
 
 
 Fig. 77. — The anterior wall of the uterus has been split until the organ has 
 been rolled from beneath the bladder. The author's grooved director is 
 shown circling the uterus and the bistoniy is in place preparatory to the final 
 step in heniisection. 
 
VAGINAL AliLATION. 
 
 197 
 
 of the uterus. Did I not leave a narrow strip of vaginal 
 mucosa upon each side when I shove up this half of the 
 uterus, the uterine artery would be torn from its bed and 
 its branches to the cervix broken. After this has been 
 
 Fig. 78. — The uterus having been split into halves, one half is rolled out 
 beneath the bladder, and the hand is thus allowed to enter the pelvis. All 
 adherent organs can be liberated even though attached to the pelvic brim. 
 Note the absence of retractors and artery forceps (from a photograph of an 
 operation by the author). 
 
 turned out from beneath the bladder, it is swung to the 
 patient's left, and all of the left hand except the thumb is 
 inserted into the pelvis (Fig. 78). The left adnexa are 
 readily liberated from all adhesions behind the broad lig- 
 ament, as the operator can reach the pelvic brim. If the 
 
198 
 
 PELVIC INFLAMMATION. 
 
 vagina is relatively small, the operator allows the left 
 half of the uterus and the free adnexa to escape into the 
 pelvis, and draws down the right half of the uterus, and 
 liberates the right adnexa (Fig. 80). But if there is ample 
 room, after freeing the left adnexa, they arc drawn in front 
 of the cornu and a forceps is applied from above downward 
 outside the ovary (Fig. 81). This is the first attempt at hemo- 
 
 stasis. The broad ligament 
 is cut to near the ends of 
 the forceps, and then the 
 uterine artery on that side 
 is clamped from above 
 downward or from below 
 upward close to the cervix, 
 as may be most conve- 
 nient. The points of the 
 two forceps lap, the one on 
 the uterine artery being 
 exterior to that on the ova- 
 rian artery when put on 
 from below, but internal to 
 the ovarian forceps when 
 applied from above (Fig. 
 79). . In this way splitting 
 of the broad ligament is 
 avoided, and when the up- 
 
 FlG. 79. — 1 lie forceps on tlie uterine r ■ _, A t- 
 
 artery has been placed from below, while P^f lOrCCpS IS droppeo It 
 
 that on the ovarian artery has been will He alongside the loWCr. 
 
 placed from above. It will be noticed t„ J „ ' 1^ 4-W „ f^..^^^r^ 
 
 'that the points lap. I" dropping this forccps 
 
 (Fig. 82) the upper portion 
 of the broad ligament is folded over the forceps on the 
 uterine artery, and this forceps is kept from touching the 
 bladder. Further, the weight of the upper forceps posi- 
 tively keeps the ovarian artery stump on a level with 
 the uterine, and at the vaginal vault. 
 
 The methods pictured in Figs. 83 and 84 are both 
 faulty; the latter for the reason that the forceps will tear 
 the ligament when dropped, and the former because some 
 risk is run in putting the upper forceps on from below 
 
-rM' 
 
 
 X( 
 
 %. 
 
 i I 
 
 ■M'^ 
 
 Fig. 8o.- The right adnexa are shown drawn out ot the pelvis i^reliminary to 
 applj'ing the first pair of forceps to the right ovarian artery. 
 
VXl' 
 
 Fl<;. 8i. — The right adnexa are drawn across the face ot the right half of the 
 uterus and forceps is being applied to the right ovarian artery. 
 
VAGINAL ABLATION. 
 
 Upward, because (a) the points of the forceps project too 
 high in the pelvis among the intestines, and (/;) the ova- 
 rian artery is insecurely grasped. The left half of the 
 uterus is cut loose, and removed together with the left 
 adnexa. The adnexa and that half of the uterus upon 
 the right side are similarly treated. 
 
 The relation of the ureter to the cervix is greatly modi- 
 
 Fin. 82. — After the forceps are applied and dropped down, the upper forceps 
 on the ovarian artery drags down the broad ligament so that it is folded over 
 the lower forceps on the uterine artery. 
 
 fied by the hemisection. In applying the forceps to the 
 uterine artery the cervix is sharply drawn to the opposite 
 side. This straightens the curved portion of the uterine 
 artery, and markedly increases the distance between the 
 cervix and the point at which the uterine artery is in re- 
 lation with the ureter. It m^U be noticed that no retrac- 
 tors are employed during this stage. They are only in 
 the operator's way. Gauze pads, each secured by a stout 
 string, are introduced into the pelvis above the forceps. 
 The perineum is drawn down by a long Jackson retrac- 
 tor, while the bladder is held up by a trowel. The table 
 is lowered, and a careful inspection is made of the stumps 
 
PELVIC INFLAMMATION. 
 
 and pelvic contents. If bleeding points arc seen, they 
 are grasped ; but if the operator has done his work proj)- 
 erly, four pairs of forceps are all that will be needed. 
 The gauze pads are removed, and the pelvis is carefully 
 
 Fig. 83. - Application of clamps 
 from below. Faulty method, as the 
 ovarian forceps projects too high. 
 
 Fir.. 04. — Application of 
 clamps from above and from 
 below. Faulty method, .is the 
 forceps will not lie loosely when 
 dropped, and will tear the liga- 
 ment. 
 
 cleansed by gauze swabs, particular attention being paid 
 to the cul-de-sac. This completes the third stage. 
 
 FoJirth Stage. — Dressings. — " The pelvic Mikulicz." A 
 piece of iodoform gauze is inserted between the forceps 
 and the vagina upon each side. Each set of forceps is 
 then drawn toward the lateral pelvic wall- by means of a 
 
Fig. 85. — The application of the pelvic Mikuhcz dressing. The method 
 of liolding the dressing to one side while successive pieces of gauze are intro- 
 duced is to be noted. 
 
VAGINAL ABLATION. 
 
 205 
 
 long, narrow retractor. Between them enough strip.s of 
 gauze are inserted to fill the space. These strips project 
 up above the points of the forceps (Fig. 85). The patient 
 is lowered to the horizontal position, and a self-retaining 
 
 / 
 
 Fig. 
 
 -The completed operation. The forceps are shown surrounded by 
 the dressings. 
 
 catheter is introduced on a sound. The sphincter ani is 
 dilated thoroughly. This is done to allow of the easy 
 escape of intestinal gases, and to allay spasm of the leva- 
 tor ani muscle. The opposing muscle to the levator ani 
 is the sphincter. Under the bruising and stretching to 
 
2o6 PELVIC INFLAMMATION. 
 
 which the levator is subjected, it is apt to spasmodically 
 contract if held down hard by the undilated sphincter. 
 Patients who have the sphincter dilated are more com- 
 fortable than are those in whom this is not done. A 
 piece of plain gauze is wrapped around the forceps and 
 tied. The operation is completed (Fig. 86). 
 
 The method of making these dressings is radically dif- 
 ferent from that employed elsewhere, I consider it an 
 essential feature of my method. The Mikulicz dressing 
 is employed here to absorb all discharges. It should be 
 of sufficient volume to do this during the week in which 
 plastic union is taking place between the rectum and 
 bladder. But there is another reason why I pack these 
 cases so snugly. It is to avoid an accident which not 
 infrequently happens to those who use the gauze in slen- 
 der strips only. When the latter dressing is used, at the 
 time the forceps are removed, the sloughing ovarian 
 stumps very often snap back into the pelvis, causing sec- 
 ondary infection. The pelvic Mikulicz dressing holds 
 these stumps immovably fixed at the vaginal vault, and 
 I have never seen such secondary infection. 
 
 In a case of what I supposed was a secondary hemor- 
 rhage from an ovarian vessel, when I removed the forceps 
 on the second day, I made a rapid section of the belly. 
 There was even at this early day found firm plastic union 
 between the bladder and rectum, and the field of my va- 
 ginal operation was found completely shut out from com- 
 munication with the general pelvic cavity The after 
 treatment usual after vaginal hysterectomy is employed. 
 
>%.•.. 
 
 1 
 
 4 
 
 / \ 
 
 P 
 
 ^^^^^-l«„Mi^ ■ 
 
 Fig. 87. — Dissection of a body upon whom years before a vaginal hyster- 
 ectomy had been performed. L, a calcified silk hgature upon the right uter- 
 ine artery ; U, the left uterine artery. No trace of ligature was found on this 
 vessel and the artery still contained a small channel throughout its entire 
 length; B, bladder; R, rectum. The manner in which the vault of the 
 vagina becomes closed by a thin transverse line of union is well shown. 
 Notice how the bases of the broad ligaments hold up the vagina. There is no 
 tendency to hernia, and the posterior cul-de-sac is just as deep as ever it was. 
 This specimen is of value to us as showing the manner in which the vaginal 
 vault continues to be supported even after removal of the uterus. 
 
MORCELLATION. 
 
 209 
 
 MORCELLATION. 
 
 The uterus is removed in fragments by a process of 
 decentralization. 
 
 There are certain cases of very large ovarian abscess 
 which pin the uterus up against the symphysis and im- 
 movably fix it there. In such cases the anterior perito- 
 neal space cannot be reached until the uterus is either 
 split or partially cut away as the abscess is evacuated. 
 AH broad ligament accumulations demand either hemi- 
 section or morcellation. Such are broad ligament abscess, 
 broad hgament hematoma produced by ruptured ectopic 
 gestation, broad ligament cyst of large size, and fibroids 
 with intraligamentous nodules. Morcellation is here ne- 
 cessary because the uterus is displaced so far upwards or 
 to one side and the pelvis so blocked that to even feel 
 the ovarian region the uterus must be removed. In such 
 cases the morcellation is atypical. The peculiar relation 
 of these broad ligament growths to the posterior cul-de- 
 sac must be remembered (see Exploratioti). 
 
 The necessity for morcellation is not usually deter- 
 mined until the attempt at removal by hemisection has 
 been found impracticable. Indeed, by whatever method 
 the ablation is attempted, a resort can always be had to 
 morcellation. A most accurate knowledge of the minute 
 and regional anatomy of the parts is needed for this op- 
 eration. Remembering that the blood supply of the 
 uterus approaches the cervical and cornual points and has 
 lateral anastomoses between the upper and lower vessels, 
 and that the arteries which course across the anterior and 
 posterior surfaces of the uterus are small, the operator 
 feels secure in severing all tissue which lies between the 
 lateral ovarian-uterine anastomoses. The object in doing 
 this is to so weaken the tissue in view that more can be 
 pulled down from above by the process of decentraliza- 
 14 
 
2IO PELVIC INFLAMMATION. 
 
 tion, or removing the center, and allow of diminution of 
 the bilateral diameter of the organ. There are two chief 
 ways of doing this. The one most successful in dealing 
 with large uteri associated with pus (the condition we are 
 discussing) is to weaken the anterior uterine wall by re- 
 moving successive vertical strips of tissue. Mere fixation 
 of the uterus is no indication for morcellation ; the fixa- 
 tion must be accompanied by marked enlargement. Typi- 
 cal or symmetrical morcellation is rarely possible when 
 dealing with pus cases, the operator often combining sev- 
 eral methods in excavating the uterine wall. 
 
 Operation. — It is a great aid if the posterior cul-de-sac 
 can be opened. This is first done; next the bladder is 
 dissected from the uterus until the anterior peritoneal 
 pouch is opened up as far as is possible. While the blad- 
 der is held up by a Jackson speculum and the intestines 
 protected by a gauze pad, the anterior wall of the uterus 
 is split as high as possible. Holding the everted edges 
 of the cut with bullet forceps, the operator trims a strip 
 of tissue about a quarter of an inch wide, first from one 
 side, and then from the other (Fig. 88, i and 2). A half- 
 inch has now been taken out of the entire visible anterior 
 uterine wall. The removal of this amount of tissue from 
 the cervix will usually be all that can be taken away with- 
 out reaching its sides. The other slices cut out will be 
 above the cervix and limited to the body of the uterus. In 
 most cases it will be found that the removal of the first two 
 strips has so weakened the anterior uterine wall that the 
 median splitting of the anterior wall can be continued, 
 and the cornua uteri can be brought into view beneath 
 the bladder (3 and 4 of Fig. 88). But in some cases the 
 bladder is attached so high up upon the uterus that the 
 dissecting finger can not effect the separation. Then it 
 will be necessary to split the uterus up as high as possi- 
 ble and remove from each side one, and perhaps two 
 wedge-shaped pieces with their bases upward (5 and 6 of 
 Fig. 88). The stumps are firmly grasped and the ante- 
 rior wall pulled further down, while the bladder is pushed 
 up so as to expose more of the uterine tissue. What 
 
MORCELLATION. 
 
 appears is again split in the middle line, and from each 
 side a wedge of tissue is removed (7 and 8 of Fig. 88). 
 Progressively pulling down the uterus and cutting out 
 pieces, the cornua appear. So far there has been free cap- 
 illary bleeding, but none from vessels of large size. There 
 has been no hemostasis. When the cornua come into 
 
 Central inclsfon 
 
 Fig. 88. — A scheme of symmetrical morcellation. The segments are 
 removed as numbered. Sometimes it will be necessary to remove segments 
 I, 2, 3, 4 only, and this is especially true in pus cases with hypertrophy of the 
 uterus. But in fibroid cases the procedure will have to be pursued so as to 
 embrace most of the tissue included within the dotted lines. 
 
 view, if necessary, a large wedge is cut from the fundus, 
 the base of which is at the top of the uterus. This piece 
 will encroach upon the posterior surface of the uterus, 
 and at once upon its removal the cornua with their tubes 
 
212 PELVIC INFLAMMATION. 
 
 come still further into view. The grooved guide is now 
 inserted behind the uterus and the organ spUt in two 
 parts. The further steps of tlie operation are described 
 under Hemisection, third and fourth stages. In reahty 
 morcellation is not a very important factor in the removal 
 of inflamed uteri. In fibroid extirpation it is an invalu- 
 able essential. In these pus cases the morcellation is use- 
 ful only as a step preliminary to hemisection. Without 
 it in certain cases hemisection is difficult. If there be 
 absolute fixity of the cervix, such as we see in bilateral 
 broad liganient abscess, it will be necessary to secure the 
 uterine arteries and cut the cervix loose at the sides be- 
 fore beginning with the hemisection and morcellation; 
 but I consider it a misfortune when I am compelled to 
 apply hemostasis before the adnexa are free (Fig. 89). 
 
 Sometimes the operator will find that even after he has 
 removed all the visible portion of the anterior uterine 
 wall he can not turn down the cornua beneath the peri- 
 cervical ring. Either the adhesions above the uterus are 
 so dense that the cornua are fixed, or else there is a mass 
 behind the lower zone of the uterus which prevents de- 
 scent of the organ. When he comes to a standstill in his 
 anterior morcellation he proceeds as follows : The uter- 
 ine arteries are clamped by two forceps and the cervix is 
 freed with scissors. The cervix is then amputated at the 
 level of the internal os. A firm grasp is taken of the 
 stumps, and the posterior uterine wall is morcellated as 
 was the anterior. After proceeding half way up the 
 uterus in this manner it may often be found that the 
 uterus is so shelled out that it may be partially inverted, 
 or that one cornu may be brought so far into view that 
 forceps may be applied to the ovarian artery close to the 
 cornu. If this can be done it is an easy matter to cut 
 the uterus loose upon one side and to swing the muti- 
 lated organ out of the vagina. The enucleation of the 
 adnexa attached to this large portion of the uterus is 
 then made as though the uterus had been split in half, 
 and it is removed with the adnexa of that side as in 
 hemisection. Then the adnexa outside the forceps 
 
MORCELLATION. 
 
 213 
 
 which was first placed on the ovarian artery of the oppo- 
 site side is freed and brought out; the ovarian artery 
 secured outside the ovary and the adnexa together with 
 
 g/m . ~ ^ 
 
 Fig. 89. — Showing the effect of morcellation as outlined in Fig. 88. The 
 traction forceps draw tlie cornua together so that the fundus is made to roll 
 out beneath the bladder. 
 
 the provisional forceps are removed. By this method of 
 irregular morcellation very large uteri can be taken out 
 through the vagina with the use of only four forceps 
 
214 
 
 PELVIC INFLAMMATION. 
 
 (Fig. 90). All through such an operation as described 
 repeated palpations nuist be made of the arterial anasto- 
 moses at the sides of the uterus, and the utmost care 
 must be exercised not to wound them either by scissors 
 
 Fig. 90. — Symmetrical morcellation of the fibroid uterus. The uterus 
 reached the level of the umbilicus. Miss L., aet. 42. Vaginal Ablation. Four 
 pairs forceps used. Recovery. 
 
 or traction forceps. I employ for morcellation very 
 stout scissors curved on the flat, one blade blunt and the 
 other pointed (Figs, 91 and 92). The pointed blade can 
 
 Fig. 91. — Sharp heavy scissors, especially useful in morcellation. 
 point can be driven into the tissues, however hard. 
 
 Either 
 
 be driven into the tissue. I am further careful always to 
 cut from without in. 
 
 An assistant can lend material aid by pressing down 
 above the pubes, employing the closed fist for this pur- 
 
VAGINO-ABDOMINAL HYSTERECTOMY. 
 
 215 
 
 pose. Such support prevents the uterus being drawn up 
 in case the traction forceps tear through. The operator 
 should strive to avoid lacerating the uterine tissue by 
 pulling his traction forceps through it. This may hap- 
 pen to him once, but the one experience should teach 
 him the degree of traction the tissues will tolerate with- 
 out tearinpf. 
 
 Fig. 92.— Stout blunt scissors used in vaginal hysterectomy. 
 
 Like all very technical manoeuvres pages of descrip- 
 tion of the various steps do not become mental pictures 
 until applied. But one operation upon a difficult case 
 will suffice to make clear the necessity for all I have 
 written. If the operator meets fibroid nodules within the 
 uterine walls they are shelled out of their beds. The 
 removal of each of such isolated growths aids in the 
 progress of the operation. 
 
 VAGINO-ABDOMINAL HYSTERECTOMY IN 
 THE PUERPERAL STATE, 
 
 Indications. — It is supposed that a possible malarial 
 paroxysm has been eliminated by cinchonizing the 
 patient by means of a rectal injection of quinin solution 
 (see formulae). Faithful trial of intra-uterine irrigations 
 (see septic endometritis) have failed to subdue the symp- 
 toms of septicemia, and the operator determines to open 
 the posterior cul-de-sac. This he does after per- 
 forming curettage. When the cul-de-sac is open 
 the propriety of performing hysterectomy may be set- 
 tled, but it is impossible before. Upon inspecting the 
 
2x6 PELVIC INFLAMMATION. 
 
 uterus it is fouMcl livid and usually studded with isolated 
 flakes of lymph. The curettage has shown the inside of 
 the uterus to be necrotic, and after the cul-de-sac is 
 opened slight pressure with the examining finger will 
 break the uterine wall. The uterus is in a necrotic con- 
 dition. The fluid evacuated from the cul-de-sac may be 
 muddy serum containing more or less lymph, or sero- 
 pus may be present in large quantities lying free in the 
 pelvic cavity. Almost any one of the various lesions of 
 the ovaries and tubes may be found. But the indica- 
 tions for ablation are the necrotic or gangrenous condi- 
 tion of the uterine walls, and a septicemia which will not 
 yield to curettage and cul-de-sac evacuation. The pres- 
 ence of pus in the pelvis with a firm uterus does not call 
 for ablation. A sufificiently effective evacuative opera- 
 tion can be made through the cul-de-sac without remov- 
 ing the uterus; and the presence of enormous amounts 
 of recent lymph not only does not call for the ablation, 
 but rather contra-indicates it, if the uterus be firm. If 
 by bacteriological examination of the discharge strepto- 
 cocci have been found, this is but another reason for has- 
 tening ^le operation. I wish to be clearly understood as 
 opposed to this formidable operation for septicemia 
 where there is absence of signs of uterine necrosis. 
 Streptococci may be present and large quantities of pus 
 produced, and yet the cul-de-sac evacuation will suffice 
 to effect a cure. If the uterus is beyond saving, so long 
 as it remains it feeds the lymphatics with septic material. 
 These women die, not from the peritonitis and pus foci, 
 but from septicemia. 
 
 Operation. — Rapidity in operating is essential. The 
 uterus is curetted, irrigated, and packed with gauze. 
 The posterior cul-de-sac is opened, and the bladder is 
 partially separated from the cervix by incising the vagi- 
 nal mucous membrane. Into the posterior incision iodo- 
 form gauze is stuffed. While he cleanses his hands, the 
 operator has the patient placed in Trendelenburg's posi- 
 tion and prepared for laparotomy. The abdomen is opened 
 from the umbilicus to the pubis. As soon as it is entered 
 
VAGINO-ABDOMINAL HYSTERECTOMY. 
 
 2T7 
 
 the intestines are gently brought above the pelvic brin. 
 and held there by large gauze pads. Stout hysterectomy 
 forceps are made to clamp the broad ligaments outside 
 the ovaries, and the broad ligaments are severed internal 
 to and alongside the forceps. Smaller forceps secure 
 the spouting ovarian arteries at the sides of the uterus. 
 The operator then lifts the uterus up and draws out the 
 plug of gauze in the posterior cul-de-sac. He inserts 
 two fingers into the vaginal opening, so as to hold the 
 uterus in the palm of his hand, and hooks his fingers in 
 the vagina in front of the cervix. Upon these as a guide 
 he strips the bladder from the anterior face of the cervix. 
 This is done by first making an incision through the per- 
 itoneum at the uterovesical fold which extends across the 
 face of the uterus, and then by means of the fingers of 
 the right hand literally rubbing the bladder tissues away 
 from the uterus. As the anterior vaginal wall was incised 
 at the time the curettage was done, it is easy to dissect 
 the bladder from the uterus. Two pairs of forceps which 
 are. inserted alongside the uterus are made to grasp the 
 central portions of the broad ligaments. The ligaments 
 are cut to near their points. Two other forceps are made 
 to grasp all the remaining tissues at the sides of the cer- 
 vix. These last forceps secure the uterine arteries, and 
 their points project into the vagina. The uterus is then re- 
 moved. The pelvis is wiped dry, and the vagina is packed 
 with gauze from above. The six forceps are lifted up in 
 a bunch and are carefully surrounded by iodoform gauze 
 strips, which project above the skin of the abdomen. At 
 no point must the forceps touch the pelvic floor or lateral 
 pelvic walls. They will produce slough wherever they 
 rest. The pelvic dressing is very large, the pelvis being 
 completely filled with gauze. A few stout silver wire 
 sutures are passed so as to approximate the peritoneal, 
 fascial, and muscular planes around the gauze. The ab- 
 domen is dressed in such a way that no pressure can be 
 brought upon the forceps. This is most important. Into 
 the elbow vein from thirty to ninety ounces of normal 
 salt solution are injected. If the patient lives, the forceps 
 
2i8 PELVIC INFLAMMATION. 
 
 are removed in forty-eight (48) hours. Under chloroform 
 all dressings are changed in one week, great care being 
 exercised to fill the pelvis. In doing this the intestines 
 are held back by retractors, and as a soiled- strip of gauze 
 is removed, a clean one is inserted. The intestines must 
 not be allowed to leak down into the pelvis. After re- 
 moving the abdominal dressings, the patient is placed in 
 the lithotomy position and the vaginal dressings are re- 
 newed. Other dressings are made as indicated. The 
 outpouring of serum at first is enormous. After the first 
 dressing the production of pus is pronounced. It is dirty 
 surgery, but it is life-saving. To use ligatures is to make 
 sinuses even if the ligatures hold in the rotten tissues. 
 To close the belly is to lose the patient. Not alone the 
 uterus, but all the retroperitoneal tissues are infected, 
 and provision must be made for the escape of their septic 
 contents. The gauze is not used alone for drainage, but 
 to isolate the entire pelvis. Iodoform poisoning may 
 occur, but it is a risk which must be encountered. To 
 save even fifty per cent, of these women is a triumph,.for 
 all would die without the operation. Those which have 
 died were those in whom the tedious ligature operation 
 was done and the belly closed. It will be noticed that 
 both pelvic and abdominal Mikulicz dressings are made. 
 The general treatment is important. Hypodermics of 
 strychnin, gr. zt>, are given q. 3 h. for a day and then 
 diminished gradually. If the kid)ieys are damaged, glo- 
 noin, gr. tuo, hypodermically, is given q. 3 h. or as often 
 as needed, and the day after the operation another intra- 
 venous injection of salt solution is made without narcosis. 
 Having met and cured the most desperate cases of puer- 
 peral fever at all stages of the disease, I am warranted in 
 advising this radical work where irrigation, curettage, 
 and cul-de-sac evacuation fail. I cannot sit by and fill a 
 woman's stomach and skin with drugs when I know that 
 she holds within her body a rotten mass filled with 
 myriads of germs each reproducing millions a day. 
 These cases of puerperal "fever energetically treated as 
 soon as seen, will rarely die. Only those vicious infec- 
 
AFTER-TREATMENT OF HYSTERECTOMY. 
 
 219 
 
 tions, as gangrene of the uterus and thrombophlebitis, 
 will resist the irrigation, or the curettage and cul-de-sac 
 incision. Fortunately such cases are rare, but when met 
 with hysterectomy ,alone will save them. Too many 
 hundreds of women die in America every year because 
 the let-alone policy is adopted. The higher the authority 
 — speaking against the surgical treatment of this essen- 
 tially surgical disease — the greater the mischief, for weak 
 brothers applaud high authorities when they preach inac- 
 tivity. But I desiie to utter a warning against the appli- 
 cation of this operation in cases which do not strictly 
 demand it. It is in those sudden virulent infections due 
 to streptococci that I have practiced this operation. Such 
 a case will from the first carry a temperature rarely below 
 103° and a pulse more often above than below 130. And, 
 as I have said above, the curettage and examination of 
 the uterus through the cul-de-sac will demonstrate that 
 the soft, flabby, friable, and discolored uterus is in a con^ 
 dition of cellular disintegration. If even the most viru- 
 lent infections are treated surgically from the first, it is 
 doubtful if a hysterectomy will be required. It is in the 
 early application of the curettage and cul-de-sac opera- 
 tion in those cases which do not yield to intra-uterine 
 irrigations that we must find a substitute to hysterectomy, 
 or rather a means to render it unnecessary. 
 
 AFTER-TREATMENT OF HYSTERECTOMY 
 AND VAGINAL SECTION, 
 
 General. — If the patient has been properly prepared 
 for the operation, I give absolutely no drink or nourish- 
 ment for six hours after the operation. In debilitated 
 women and those profoundly septic, it is advisable to 
 administer fluids at this time. I give one ounce of cold 
 sterile water with five drops of lemon juice every hour. 
 As a rule, this will allay vomiting, and, in those women 
 who have regurgitation of bile into the stomach (green 
 vomit), this is particularly useful. The acidulated water 
 
2 20 PELVIC INFr.AMMATION. 
 
 tends to check the vomiting, and seems to cause the bile 
 to flow in the right direction. At any rate, these cases 
 often have several bile-stained stools in twelve hours 
 after the administration of the acidulated water is begun. 
 But my general rule is to keep the stomach perfectly 
 empty for twelve hours, and then begin the administra- 
 tion of either rubinat or apenta water. This is given in 
 half ounce quantities, each dose being followed by a half 
 ounce of sterile water. This is administered every hour, 
 until six ounces are taken. Two hours after the last 
 dose a small enema is given composed of a half ounce of 
 glycerin and five ounces of water. In those cases which 
 have green (bile) vomit I do not give salines until all 
 vomiting ceases. Women with alcoholic stomachs who 
 vomit even in spite of the acidulated water must be given 
 a little iced champagne, about one ounce an hour. The 
 entire object of the first after-treatment is to get the 
 bowels open, and, at the same time, to prepare the 
 stomach for the reception of food. After the bowels 
 have operated, I give a half ounce of hot chicken broth, 
 every hour or so, for the first day, with a bite or two of 
 toast occasionally. The third day I allow coffee and 
 toast in the morning, four ounces of broth and toast 
 at eleven, scraped beef at two, more broth at five. Be- 
 tween the feedings I give abundance of water. Grad- 
 ually the patient gets upon regular diet, with the excep- 
 tion of fruits and vegetables. These I do not allow until 
 after the first dressing. The third night after the opera- 
 tion, 1 generally give one compound rhubarb pill, fol- 
 lowed next day by a small enema. After the first dress- 
 ing, I give cooked fruits, meat, soups, potatoes, rice, 
 simple puddings. But all the time, abundance of water. 
 I never give milk. During convalescence cream and 
 oatmeal or hominy are allowed. The prepared foods in 
 the market are useful for rectal injection only, where the 
 stomach refuses to retain anything. 
 
 Catlietor. — Every two hours after operation, the self- 
 retaining catheter is opened and the quantity of urine 
 escaping is measured. A specimen is analyzed. On 
 
AFTER-TREATMENT OF HYSTERECTOMY. 221 
 
 the second clay the bladder is washed out with saturated 
 solution of boric acid, and the catheter is withdrawn. 
 The urine is drawn every four hours after this. Some- 
 times the bladder leaks around the stationary catheter, 
 puzzling the inexperienced. 
 
 Anodynes. — These I never use except with epileptics. 
 Then I give a little morphin. Cavity work and morphin 
 are incompatible. The pain is pretty severe. It is a new 
 kind of pain to the woman, but is easily endurable. Any 
 relief obtained from the use of morphin is but temporary; 
 it is borrowed. It must be paid back later in vomiting, 
 tympanites, repeated enemata, etc. After the bowels 
 operate the patients are quiet. Usually five hours of 
 refreshing sleep are obtained the second night. The 
 sick-room is to be kept quiet, no visitors being admitted ; 
 particularly none of the family, until the patient is out 
 of danger, on the fourth day. In operating in private, if 
 the surroundings are controlled as they are in hospitals, 
 the results will be the same. After operations on 
 women who have the opium habit I give hypodermically 
 morphin gr. | and hyoscyamin gr. t^o. It is seldom 
 necessary to repeat this. 
 
 Position of Patient. — This is generally dorsal, the 
 knees drawn up and supported on a hard pillow. After 
 the forceps are removed* the patient is kept on the back 
 for six hours longer, so as not to cause bleeding by 
 moving, and after this time she is allowed to turn on 
 her side. 
 
 Removal of Forceps. — This is done at the end of forty- 
 eight hours. Selecting the lowest forceps, the keys are 
 applied and the forceps unlocked. The catch is sepa- 
 rated one-quarter inch. The operator will now appre- 
 ciate the importance of having his forceps all made alike, 
 for the separation at the lock will tell him the distance 
 between the points which are hidden within the patient's 
 body. The keys are removed and the forceps is twisted 
 about 10° one way, held in that position a moment and 
 then twisted 10° in the opposite direction. Usually 
 this will_suffice_to loosen the stump from the forceps. 
 
2 22 PELVIC INFLAMMATION. 
 
 While twisting the forceps back and forth gentle traction 
 is made upon the instrument. No force must be used. 
 If the forceps does not slip out readily, either the stumps 
 are stuck to it and must be freed by repeated twisting of 
 the instrument, or else the gauze has become stuck to 
 the forceps and must be liberated by introducing a blunt, 
 flat instrument of some sort between the gauze and the 
 forceps. In this manner each forceps is removed. 
 
 Time in Bed. — Cases of cul-de-sac exploration and 
 replacement are allowed out of bed after the third dress- 
 ing. This is true also of hysterectomy cases, unless the 
 vagina be widely opened and the perineum gaping. In- 
 asmuch as the third dressing is usually made on the 
 seventeenth day, the patients are out of bed generally be- 
 fore the expiration of three weeks. I make no attempt 
 to hasten their discharge, but allow the surfaces to heal 
 without much physical effort by them, and their minds 
 to recover from the disturbance incident to facing and 
 enduring so serious an operation. 
 
 Dressings. — In hysterectomy cases, on the eighth day, 
 I put the patient in Sims' position. While the woman is 
 in this position and perfectly still a careful removal and 
 renewal of the dressings are made. In removing the 
 gauze strips the centre ones are first taken out, so as to 
 loosen those next the vessels. At the top of the cavity 
 will be seen the lymph-covered rectum red and oozing, 
 and upon each side the dead stumps already beginning 
 to blacken. The instruments used in this first dressing 
 are a long-bladed Sims' speculum, my trowel depressor, 
 and a dressing forceps. Sims' tampon screw is a valua- 
 ble instrument in all these dressings. The second dress- 
 ing is made a week later. 
 
 The method of dressing cul-de-sac and replacement 
 eases is described under the proper chapter. 
 
 Behaviour of the Wounrt. — The sloughs produced 
 by the forcipressure smell badly. There are two ways 
 of removing this : one by douching, after the first dress- 
 ings are removed ; the other, by ample, repeated dress- 
 ings. I prefer the latter. There is no odor about my 
 
ACCIDENTS AND COMPLICATIONS. 223 
 
 patients, although I do not dress them more often than 
 once in a week. The sloughs are blackened shreds and 
 masses at each side of the vaginal incision. They 
 should not be pulled off, but should be allowed to sepa- 
 rate gradually. Healing does not really begin until the 
 sloughs have separated, after which it is very rapid. I 
 renew the dressings whenever discharges escape through 
 them, and prefer Sims' position in doing this. 
 
 Sometimes in healing there will be produced at the 
 vault of the vagina a knob of granulation tissue. It is 
 better not to make application to this, but to pull it off 
 with Luer's forceps. 
 
 Occasionally gonorrheal urethritis is aggravated, and 
 a coincident cystitis induced by the operation and cathe- 
 terism. Repeated irrigations of the bladder by saturated 
 boric acid solution will correct the latter, and silver 
 nitrate, grs. v. to fs'i once a day, will cure the former. 
 
 ACCIDENTS AND COMPLICATIONS. 
 
 Bladder. — The bladder is wounded more often than 
 any other viscus. There are two ways in which the 
 bladder may be injured. In the digital separation of the 
 bladder from the uterus, the finger may enter the blad- 
 der cavity. Carelessness in making the separation be- 
 tween the two viscera leads to this. The rent is usually 
 transverse. Upon suspecting such an injury the cathe- 
 ter is passed, and if the mucosa vesicae is even bruised 
 bloody urine will be withdrawn. Further dissection is 
 effected by the use of mouse-tooth forceps and scissors, 
 as manual violence will but enlarge the opening. Trans- 
 verse rents in the bladder do not require suture, as they 
 close if the bladder is kept empty. 
 
 In that method of separating the bladder from the 
 uterus which is accomplished by progressively dividing 
 the anterior uterine wall and dissecting away the bladder 
 in stages, a vertical rent may be made by the scissors. 
 The contracting bladder tends to keep such an opening 
 
2 24 TELVIC INFLAMMATION. 
 
 permanent. Here, therefore, continuous sutures of fine 
 chromicised catgut should be employed to close the 
 rent and the bladder should be kept empty. The after- 
 treatment is modified by this accident in but one parti- 
 cular, namely, that the bladder should not be allowed to 
 distend. The catheter is left in place a week and is 
 opened every hour. Each day the bladder is irrigated 
 with a saturated solution of boric acid, but at one time 
 no more than an ounce of the solution is to be injected. 
 After the stationary catheter is removed, cathetcrism is 
 done every two hours and the intervals progressively 
 lengthened. The nurse should be instructed to notify 
 the attending surgeon if no urine flows, for clots may 
 block the catheter. The injection of a little boric acid 
 solution will clear the tube. 
 
 The rubber catheter may be pressed so snugly against 
 the pubes that flow of urine through it will be stopped. 
 This condition will be differentiated from stoppage due 
 to clot by rotating the catheter and pushing it up a half 
 inch. If it be pressure obstruction the urine will then 
 flow. 
 
 Bowel Wounds. — I have never wounded the gut. 
 But in several cases I have found pus tubes opening 
 into the rectum. After the operation of ablation is com- 
 pleted a continuous suture of fine chromic catgut closes 
 the bowel opening. These openings also tend to close 
 spontaneously, and even an awkward method of suturing 
 will be effective. The rectum should be rendered incon- 
 tinent in these cases by paralyzing or dividing the 
 sphincter ani. 
 
 If the pus sac opens into a coil of small gut, or this 
 latter be wounded, the rules governing the treatment of 
 this accident during laparotomy will apply here. If re- 
 section is to be done the attempt should be made to use 
 Murphy's button, but the general rule is that laparotomy 
 and careful suturing are needed to properly close wounds 
 in the small gut. 
 
 AVoiinds of the Ureter. — These are not recognized 
 when made. In fact, ureteral fistulae commonly occur 
 
ACCIDENTS AND COMPLICATIONS. 
 
 225 
 
 late as the result of sloughing produced by improperly 
 protected forceps. As the lower half of the pelvic ureter 
 is nourished by vesical arteries, when slough occurs it 
 commonly involves at least an inch of the ureter if pro- 
 duced by grasping the ureter in the forceps; and no me- 
 thod of anastomosis can be applied later on. If such an 
 accident is detected during the operation, laparotomy 
 should be done at once and the severed ends of the ure- 
 ter be either sutured or the ureter implanted into the 
 bladder. If the ureteral fistula occurs during convales- 
 cence, the case should be let alone until no lesion remains 
 other than an uretervaginal fistula. Then the case 
 should be treated as though the accident resulted from 
 laparotomy. At first, attempts are made to close the 
 fistula through the vagina. These usually fail and the 
 surgeon must resort to implantation into the bladder or 
 to nephrectomy. This accident has not befallen me. 
 
 Pneumonia. — This occurs not infrequently, as we 
 often operate upon those with phthisis or influenza. The 
 pneumonia commonly develops on the second day, and 
 is of the lobular type. I look with suspicion upon every 
 rise in temperature on the third day and carefully ex- 
 amine the lungs. For this pneumonitis catarrhalis — 
 usually due to streptococcus — I give potassium iodid 
 only, 5 grains q. i h. to three doses ; stop three hours, 
 and then 5 grains q. i h., three doses as before. Until 
 resolution becomes complete, I give 10 grains a day. I 
 have not seen a fatal result from pneumonia following 
 vaginal ablation. The general treatment embraces strych- 
 nin hypodermatically and other heart stimulants as 
 needed. So soon as possible the posture of the patient 
 must be changed from the dorsal to the lateral, to check 
 the tendency to hypostatic congestion. 
 
 Nephritis. — The method of preparing the patient very 
 much lessens the liability to this complication. For 
 three days after operating all urine is measured and each 
 day an analysis is made. Upon the appearance of symp- 
 toms of nephritis, I at once give a high saline enema of 
 three pints. If this is retained, I shall expect to repeat 
 15 
 
2 26 PELVIC INFLAMMATION. 
 
 it in eight hours. I also order large draughts of Buffalo 
 Lithia water in hourly administrations. In aggravated 
 cases I give glonoin hypodermatically and use either 
 subcutaneous or intravenous injections of normal salt 
 solution. Digitalis is indicated in cases properly de- 
 manding it and should be given as infusion by the rectum. 
 But it is so slow in its action that the diluent normal salt 
 solution must be employed first. 
 
 Intestinal Paralysis. — From the first the vomiting is 
 severe and frequently gets worse. Blood may be vomited. 
 The bowels can not be moved and tympanitis becomes 
 marked. The temperature rises, and the pulse becomes 
 quick and weak. The patient is pale, anxious, and in 
 great distress. Neither she nor the physician can detect 
 intestinal peristalsis. This condition I have seen three 
 times, and only in women who had the most firm and 
 extensive adhesion of the small gut to the uterus and 
 adnexa, requiring careful dissection to remove them. 
 
 The stomach should be kept absolutely empty. Once 
 every three hours one pint of normal salt solution at a 
 temperature of iOO° should be injected into the descend- 
 ing colon through'a Wales tube (Fig. no). 
 
 Hypodermatically strychnin is indicated, gr. so q. 6 h. 
 The first fluid administered by mouth should be a little 
 chicken broth, but should not be given until the stomach 
 has been at rest for twelve hours. In a severe case last- 
 ing four and a half days, no food was given, but the pa- 
 tient was kept alive by the salt solution enemata alter- 
 nating with nutrient enemata. The old treatment of at- 
 tacking the stomach with cerium, cocain, belladonna, 
 calomel, etc., is irrational. The stomach is normal, and 
 the vomiting is due to intestinal paralysis, regurgitation 
 of bile into the stomach, and reversed peristalsis. Mor- 
 phia ^ut aggravates the trouble. 
 
 Convnlsions. — Epileptics and hystero-epileptics will 
 have repeated convulsive attacks. These are best con- 
 trolled by very minute quantities of morphin, gr. tV oc- 
 casionally. These are the only cases in which I employ 
 morphin, and it is indicated because the seizures are due 
 
SECONDARY HEMORRHAGE. 
 
 227 
 
 to the traumatism inflicted upon the sympathetic gangha 
 of the pelvis. 
 
 SECONDARY HEMORRHAGE* 
 
 Whenever large vessels in the body are secured, either 
 in continuity of tissue or en masse, this accident may fol- 
 low; and the vaginal operation is no exception to this 
 rule. The vessels maybe perfectly secure under the for- 
 ceps, and yet secondary bleeding occur any hour between 
 the time they are removed and two weeks later. The 
 bleeding usually springs from one uterine artery, and is 
 readily controlled by bilateral pressure. (Fig. 93.) A narrow 
 
 Fig. 93. — Pean's Ion 
 
 I use two in makinc 
 packing. 
 
 the pelvic Mikulicz 
 
 retractor is introduced through the center of the column 
 of gauze, and one-half of the gauze — that upon the side 
 from which the bleeding comes — is pulled hard against 
 the lateral pelvic wall. A similar retractor is entered 
 alongside the first, and the other half of the gauze pulled 
 to one side. When it is seen that the pressure is suf- 
 ficient to stop the bleeding, the vaginal packing is in- 
 creased by the introduction of additional pieces of gauze 
 between the two retractors. The retractor which holds 
 back the gauze over the bleeding vessel is not to be 
 moved until the dressing is complete, but the adjustment 
 and compression of all fresh pieces of gauze are effected 
 
2 28 PELVIC INFLAMMATION. 
 
 by means of the opposite blade. After waiting a few 
 minutes to sec whether the bleeding is stopped, the pa- 
 tient is put to bed, the foot of the bed being elevated. 
 
 If the pressure does not control the hemorrhage, the 
 patient is placed in Sims' position and given chloroform. 
 All dressings are removed, and the bleeding vessel sought 
 for. Descent of the intestines is prevented by gauze pads, 
 and the bladder is sharply retracted with the trowel, 
 while the perineum is held back by a Sims' speculum. 
 When the spouting vessel is seen, it is grasped with 
 bullet-forceps, which take a firm hold on the tissues, and 
 the stump is lifted away from the vaginal wall. It is 
 then an easy matter to grasp the stump with forceps. 
 The vagina is to be packed with iodoform gauze. If 
 after searching carefully the bleeding is seen to come 
 from above the vaginal vault, and the vessel cannot be 
 found, the hemorrhage springs from an ovarian artery. 
 When the operator is convinced that this is the case, he 
 does not attempt to secure the vessel through the vagina 
 with forceps, nor to compress it with gauze, but, after 
 packing the vagina with gauze to prevent descent of the 
 intestines, he throws the patient into Trendelenburg's 
 position and opens the belly. When he has found the 
 source of the bleeding, the artery is tied with silk and 
 the stump trimmed. The same is done with the other 
 ovarian artery. The ligatures are cut short, and the 
 pelvis cleared of clots. The abdomen is closed. It is well 
 to give a high enema of three pints of salt solution before 
 the patient leaves the table, or to inject sterile filtered 
 normal salt solution into a median cephalic vein. I have 
 seen this accident but once, in one of my earliest cases. 
 
 If it be found that the bleeding comes from the azygos 
 artery or other vaginal branch, it is best secured bypass- 
 ing a curved needle around it and tying en masse with 
 silk. I can not conceive it possible that so tortuous 
 and long a vessel as the ovarian artery can bleed after 
 its current has been completely shut off for two days. 
 It is probable that the ovarian artery bleeds because the 
 occlusion has been partial and incomplete, and after the 
 
INTRAVENOUS INJECTION. 
 
 229 
 
 removal of the forceps the blood stream bursts through 
 whatever clot has formed in the vessel. It is not so 
 with the uterine artery. After this vessel is clamped, 
 but little of its length remains between the forceps and 
 the internal iliac artery, and, consequently, when the 
 forceps are removed the end of the artery feels the full 
 force of the pressure from the iliac. 
 
 I can not explain the very late hemorrhage occasion- 
 ally occurring when the patient is ready to get up, ex- 
 cept upon the hypothesis that the repatency of the artery 
 becomes established. That this does occur I have 
 shown. It has been observed after abdominal hysterec- 
 tomy with ligature, and has heretofore been ascribed to 
 bleeding from anastomotic vessels. It is always from 
 the uterine artery or its branches, and is easily checked 
 by forceps applied through the vagina. 
 
 INTRAVENOUS INJECTION OF NORMAL SALT 
 SOLUTION. 
 
 A seven-tenths of one per cent, solution of chemically 
 pure sodium chlorid in soft water is made. This is fil- 
 tered into either a Florence 
 flask — to be found in all drug 
 stores — or else into a perfectly 
 clean agate kettle. It is then 
 boiled ten minutes and is cool- 
 ed by placing on ice. The 
 solution is employed at a tem- 
 perature of 105° F. The in- 
 fusion apparatus is composed 
 of a twelve-ounce glass funnel, 
 eight feet of pure gum rubber 
 
 tubing to fit this, and a Canula p-j^, 9^._Transfusion apparatus. 
 
 (Fig. 94), The apparatus is 
 
 boiled twenty minutes in plain water. The hand grasps the 
 arm above the elbow and compresses the veins. The 
 median basilic vein will show running across the bend of 
 
230 TELVIC INFF. ANIMATION. 
 
 the elbow from without in (Fig. 95). Flic skin is drawn 
 upward and is incised carehilly alongside the upper border 
 of the vein. Upon rolling the skin down into position 
 the cut is found to be over the vein. The vein is care- 
 fully dissected out of its bed. The distal or outer end 
 of the vein is grasped across with an artery forceps, and 
 a half inch internal to this the vein is caught with mouse- 
 tooth forceps. While this is being done an assistant 
 whose hands are absolutely clean, has filled the infusion 
 funnel. This he holds six feet above the patient. The 
 clothing in the patient's axilla has been loosened. The 
 operator severs the vein entirely across and takes the 
 canula in his right hand while holding the bleeding end 
 of the vein with toothed forceps. The saline solution is 
 allowed to flow against the cut end of the vein until the 
 solution feels warm, then the canula is inserted well into 
 the vessel ; at the same time, the pressure on the arm is 
 loosed. The assistant watches the flow of water from 
 the funnel, and warns the operator when he is to refill it, 
 so that the operator may compress the tube and prevent 
 entrance of air. To avoid this, all the water is not al- 
 lowed to flow from the funnel before refilling. The speed 
 of flow is about six ounces in three minutes, or about a 
 quart in a quarter hour. Having introduced the desired 
 amount of fluid, the canula is withdrawn and pressure 
 made around the arm. The two ends of the vessel are 
 secured by fine catgut, and the wound stitched by the same 
 material- Iodoform gauze dressing. 
 
 Svibcntaiieous Injection. — The material is prepared 
 as before. Opposite the angle of the scapula and over 
 the margin of the latissimus dorsi muscle, the skin is 
 cleansed. A few drops of cocain solution is injected, or 
 the skin is frozen with a stick of ice dipped in salt and 
 applied. It is incised for a quarter inch. While the edges 
 are held apart, the solution is allowed to flow through the 
 canula until warm, and the canula is plunged into the cel- 
 lular tissue between the skin and muscle. Ten ounces of 
 fluid are allowed to enter, when the canula is withdrawn 
 and a stitch of catgut used to unite the surfaces. lodo- 
 
Fig 95. — The superficial veins at the bend of the elbow (after Quain): 
 6. The median basilic vein, into vi^hich intravenous salt infusion is made. 4. 
 Cephalic vein. 3. Basilic vein 2. Venag comites of the brachial artery x- 
 As these latter lie beneath the deep fascia of the arm, they are not in danger in 
 the operation of intravenous infusion of salt solution. (The reader's attention 
 is called to the fact that the elbow vein into which the infusion is made is 
 sometimes the median cephalic, as the veins of the elbow are not constant in 
 their arrangement). 
 
INSTRUMENTS. 
 
 231 
 
 form gauze dressing. Upon the other side a similar in- 
 jection is made. As the fluid enters the cellular tissue a 
 large swelling appears which subsides in a few minutes. 
 The injection may be repeated lower down in eight hours. 
 I have made three such injections in twenty-four hours in 
 a desperate case of sepsis, altogether sixty ounces. If 
 the fluid is sterile and careful cleansing of skin and ap- 
 paratus has been made, there is no danger of suppuration 
 following. 
 
 The author has observed the following immediate 
 effects of intravenous- infusion : the temperature rapidly 
 falls if it has been high, and the pulse has been seen to 
 come from 160 to no even during operation. In other 
 words, it is a positive remedy for shock. Remotely, the 
 amount of urine is greatly increased, the specific gravity 
 falls, owing to the dilution, but the actual amount of 
 urea excreted is increased, and albumen, if present, is 
 either markedly diminished or disappears altogether. 
 The procedure is thus particularly applicable to cases of 
 septicemia and hemorrhage. After operation it is de- 
 manded whenever the kidneys exhibit evidences of sup- 
 pression. 
 
 INSTRUMENTS. 
 
 Short Retractors. — There should be two of these — 
 ort narrow, and one broad. I like Jackson's pattern. 
 Iwo Sims Specula (Fig. 96). 
 
 Long- Retractors. — One long Jackson and one Pean 
 anterior retractor; two long narrow Pean blades for 
 making lateral pressure ; one Pryor Pean trowel (Figs. 
 97, 98, 99, 100, lOl). 
 
 Ti-actiou Instruments. — One Pryor's intra-uterine 
 traction forceps to be used during the first stage of hys- 
 terectomy. Two bullet forceps, strong and with short 
 blunt points. Four French traction, the instruments of 
 Pean. These have four teeth, and behind these upon 
 
PELVIC INFLAMMATION. 
 
 Fig. 96.— Jackson speculum. FlG. 97.— The wide, long Jackson posterior 
 
 retractor. 
 
 each blade are deep serrations. It is important that the 
 teeth look outward when the instruments are open, so 
 as to grasp flat, hard surfaces, as fibroid nodules. The 
 
 Fig. 
 
 -Pc.in's anterior retractor. Useful also as a perineal retractor in 
 small vulvee. 
 
INSTRUMENTS. 
 
 233 
 
 serrations enable the for- 
 ceps to hold in soft tissue 
 through which the teeth 
 would otherwise tear (Fig. 
 102). The short fenes- 
 trated forceps of Pean as- 
 sist in holding the ad- 
 nexa, and for this purpose 
 Luer's forceps are also 
 valuable (Fig. 103). 
 
 Cutting Instruments. 
 — One straight blunt bis- 
 toury for bisecting the 
 cervix in stenosis (Fig. 
 104). Two scalpels with 
 good bellies. One Pryor's 
 bistoury hollow-ground, 
 so as to be easily sharp- 
 ened. Four pairs of scis- 
 sors, one Sims vesico- 
 vaginal scissors (Fig. 105) 
 to trim ovaries and tubes ; one blunt curved on the 
 flat and short; one long, blunt-pointed; and one long 
 
 Fig. 99. — Pean's posterior retractor. 
 
 Fig. 100. — The author's narrow trowel. 
 
 sharp-pointed. Both of the latter have blades curved 
 on the. flat. 
 
 Fig. ioi. — The author's wide trowel. Used with women who have large 
 
 vulvae. 
 
-.u 
 
 PELVIC INFLAMMATION. 
 
 The curettes are the pattern of Sims, and are of three 
 sizes. 
 
 Fl(J. 102. — French traction forceps. Without them hemiscction and niorcel- 
 lation would be inost dilficult. 
 
 The intra-iitevinc catheters are of the Fritsch-Boze- 
 nian pattern, and of four sizes. 
 
 Fig. 103. — Luer's polypus forceps. The best for holding the adnexa. 
 
 As dressing- instruments I use Sims' tampon screw, 
 a long, slender packing forceps, Hunter's sponge-holder 
 (Fig. 106), and Pryor's packing applicator. Two stout 
 
 jaHH.PcvtiDr.usaciJ 
 
 Fn;. 104. — Bistoury for splitting the cervix. 
 
 ^^^^^ J.JUN XihySDER.—i,^. iJJity yuuK. 
 Fig. 105, — Fine scissors for conservative work on the adnexa. 
 
INSTRUMENTS. 
 
 2.35 
 
 pairs of mouse-tooth forceps are needed — one long and 
 one short. 
 
 Fig. io6. — Hunter's forceps. I use these for applying dressings. 
 
 Hemostatic Forceps. — Four Sims' artery forceps 
 (Fig. 107), eight pairs of Pryor's hysterectomy forceps 
 
 Fig. 107. — Sims's stout artery forceps. 
 
 (Fig. 108). These latter are strong, and have transverse 
 serrations. The blades are one and a half inches long. 
 
 
 Fig. 108. — The author's forceps. No handles are in the way of the patient's 
 movement. 
 
 I use the needle-holder of Sims, and any stout half- 
 curved needles (Fig. 109) with bayonet points. The 
 best instrument for giving high enemata after operation 
 
236 
 
 TELVIC INFLAMMATION. 
 
 is a'Wales bougie (Fig. 1 10). To .secure the patient's legs 
 I employ Ott's crutch. 
 
 Fig. 109.— Sims's needle-holder. The simplest and best. 
 
 l/RS—CO. NEW YORK. 
 
 Fig. no. — Wales bougie for giving high saline injections. 
 
 OPERATING TABLE. 
 
 I have devised and for a long time used the one shown. 
 It can be employed for any kind of gynecological work, 
 and is portable. (See Figs. 56, 57, 58.) Without it, 
 much of my pelvic work would be most difficult and 
 tedious. The distances in America are so great that 
 those of us who operate over the entire country must go 
 prepared for any work. My table is strong enough for 
 the heaviest woman, and weighs seventy pounds. It is 
 dressed for the operation with blankets and a rubber 
 sheet, or piece of oil cloth. The shoulder brace can 
 slide on the table, so as to support any size of body. 
 
FORMULAE. 
 
 237 
 
 FORMULAE. 
 
 Thiersch Solntiou. — Boric acid crystals, 12 parts; 
 salicylic acid crystals, 2 parts; water, looo parts. Tab- 
 lets to make one quart are sold by Reeder Brothers, 
 Thirty-first Street and Fourth Avenue, New York. 
 
 Normal Salt Solution. — This is a .7 per cent, of 
 sodium chlorid in water. 
 
 Solution of Quinin. — Quin. sulph. grs. xx, acid tar- 
 taric grs. xvii, aquae oiii- Give warm by rectum. 
 
 Lysol. — This is five times as antiseptic as carbolic 
 acid, and but one-eighth as poisonous. I use it for my 
 hands as a 2 per cent, solution, and on the patient in a 
 I per cent, solution. It soponifies fat and cleanses 
 mechanically as well as chemically. 
 
 Iodoform Gauze. — The gauze is sterilized. It is 
 then dipped in a 5 per cent, or 10 per cent, solution of 
 iodoform, in ether, and laid on a sterile sheet to dry. 
 When dry, it is blue and unfit for use. It is now dipped 
 in a hot bichlorid of mercury solution, i : 4,000, when the 
 yellow color returns. It is wrung as dry as possible and 
 packed in glass jars. The mouths of these are stuffed 
 with cotton, after which the jars are inverted in a steam 
 sterilizer and sterilized for an hour. The dressing is 
 expensive, but as it is non-poisonous, and requires 
 renewal once where other dressings are changed three 
 times, it is worth the difference. It can be readily made 
 by a careful nurse or assistant. I am using the 2 per 
 cent, and 5 per cent, strengths more than formerly, and 
 find them as good as the stronger. 
 
 Cliicken Broth. — A fowl is cleaned and skinned. It 
 is chopped into pieces, bones and flesh. These are put 
 into three quarts of water, and actively boiled for eight 
 hours. As the water evaporates, the quantity is kept to 
 three pints by adding boiling water. Strain into a clean 
 
^^s 
 
 PELVIC INFLAMMATION. 
 
 bowl and put on ice. This jelly is heated when needed. 
 The flesh of fowl is the only flesh that dissolves in water. 
 This is the first food my patients get after operation. 
 
 Beef Juice. — The steak is broiled medium, chopped 
 up and squeezed in a press or lemon squeezer. It is 
 served warm. 
 
 Xiitrient Kiienia. — One raw egg, two ounces squeezed 
 beef juice, two ounces milk, one tube of Fairchild's pep- 
 tonizing powder, warm to ioo°. Give this once in four 
 hours. 
 
 STERILIZATION* 
 
 Tlie Siirg-eou. — It is exceedingly important that the 
 operator's hands be technically clean, even in dealing 
 with pus cases; but it is difficult to obtain absolutely 
 aseptic hands. The finger nails should be short. The 
 sleeves are rolled up to the biceps, and the hands and 
 arms are scrubbed with hot water and soap. At least 
 five minutes should be devoted to this. This will soften 
 the nail filth. A sterilized sharp steel nail cleaner is 
 used to cleanse the nails. Particular attention should be 
 paid to the base of the nails, as here the loose epithelium 
 is most often found. Not only is all dirt under and 
 behind the nails removed, but the nails should be scraped 
 as well. They are again scrubbed with the brush. The 
 operator hollows his left hand and fills it with chlorid of 
 lime, "bleaching powder." He adds to this a little water 
 and makes a paste in his hand. Selecting a stick "of car- 
 bonate of soda, " washing soda," he rubs this into the 
 lime paste, and over his hands and arms. The soda is 
 used much as a cake of soap would be. As he contin- 
 ues the process, he will notice that the grains of lime 
 gradually disappear, and when no more grains are 
 present, he puts aside the soda, and washes off the white 
 paste. By this procedure he develops upon his hands 
 and arms nascent chlorin gas, a most powerful disinfec- 
 tant. Both the essentials can be procured at small cost 
 
STERILIZATION. 
 
 239 
 
 anywhere. After doing this, the hands are almost cer- 
 tainly clean ; but I go further, and scrub the nails and 
 hands in 2 per cent, lysol solution, after which they are 
 rinsed in Thiersch solution. The operator now puts on 
 a sterile gown, and is prepared to operate. While thus 
 preparing himself, one of his assistants who has previ- 
 ously sterilized his hands, has been cleaning the patient's 
 buttocks and vagina. (Vide " Preparation of Patient.") 
 During the operation the surgeon frequently washes in 
 Thiersch solution. 
 
 lustriinients. —These are boiled in 5 per cent, carbon- 
 ate of soda solution for fifteen minutes, the knives and 
 scissors being given half this time. The boiling water 
 is poured off, and the instruments allowed to cool or are 
 cooled by cold boiled water. No instrument pans are 
 used, but the instruments are laid out upon a sterile 
 sheet and kept covered from dust. The boiling soda 
 solution not only sterilizes them, but dissolves all fat, 
 pus, and blood upon them. Chemical sterilization, as by 
 formaldehyd gas, is uncertain. I usually boil the nail 
 scrubs with the instruments. 
 
 Rubber Goods. — The rubber irrigator (fountain syr- 
 inge) is half-filled with water and the clip loosened. It, 
 together with the vaginal brush and self-retaining cathe- 
 ter, are boiled in plain water fifteen minutes. 
 
 Irrig-atiiig- Fluids. — I use boiled normal salt solution 
 or boiled boric acid solution 4 per cent. But I have 
 about abandoned irrigation except to wash out large 
 uteri after curettage. 
 
 Transfusion Fluid. — Ordinary table-salt is dissolved 
 in soft water to make a tV of i per cent, solution. It is 
 then filtered and boiled in a new kettle, the neck of which 
 is plugged with cotton. This solution is cooled to about 
 105° F. In handling it, care should be taken not to agi- 
 tate the contents of the kettle, lest sediment be put in 
 suspension. Whenever there is sediment in the solution, 
 it should be carefully strained through several thick- 
 nesses of sterile plain gauze into the transfusion funnel. 
 The gauze may be tied over the spout of the kettle. This 
 
240 PELVIC INFLAMMATION. 
 
 is an impromptu apparatus. In my practice I use chemi- 
 cally pure sodium chloric!. The solution is made and 
 filtered into a glass bottle. In this it is boiled. The 
 transfusion apparatus is boiled for twenty minutes in plain 
 water. 
 
 .Silk, Silver Wire, and Silkworm (Jut. — This is ren- 
 dered sterile by boiling for seven minutes in 5 per cent, 
 carbolic solution. 
 
 Catgut and Kauj»ai-oo Tendon cannot be prepared 
 by the surgeon as reliably as by several manufacturers. 
 That made by Van Horn, Forty-first Street and Fourth 
 Avenue, is recommended. » 
 
 Gowns, Gauze, Sheets, Towels. — These are subjected 
 to a continuous column of live steam in a closed chamber 
 for at least one hour. There are several excellent steri- 
 lizers, notably the Arnold, sold for a few dollars. If a 
 steam sterilizer can not be secured, the fabrics may be 
 boiled in plain water for a half hour. Before using they 
 should be wrung dry. The gauze and gauze pads may 
 be fastened in bundles in towels, boiled and then dried in 
 a not too hot oven. 
 
 Transfusion solution and irrigation are so seldom re- 
 quired, that the preparation for an operation becomes 
 very simple. Every physician should own a steam steri- 
 lizer for the preparation of his dressings. A very good 
 one can be procured for ten dollars, just as effective as 
 one costing hundreds. 
 
 Hand-basins. — These I always boil in plain water. 
 Perfect cleanliness can not be secured by using basins 
 which have not been sterilized. 
 
INDEX. 
 
 Abdominal dressings in pelvic in- 
 flammation, 6i. 
 Ablation of uterus by hemisection, 
 187. 
 dressings in, 202. 
 first stage, 188. 
 fourth stage, 202. 
 second stage, 193. 
 third stage, 194. 
 en masse, 180. 
 vaginal, 163. See also Vagi?ial 
 ablation. 
 Abortion, infection after, 34. 
 pelvic peritonitis from, 96. 
 Abscess of broad ligament, 121. 
 symptoms, 122. 
 treatment, 123. 
 ovarian, 108. 
 symptoms, no. 
 treatment, 113. 
 Accidents in hysterectomy, 166. 
 Acute gonorrheal endocervicitis, 
 
 25- 
 
 endometritis, 47. See Endo- 
 metritis. 
 salpingitis, 63. See Salpin- 
 gitis. 
 peri-ovaritis, 106. 
 treatment, no. 
 salpingo-odphoritis, conserva- 
 tive treatment of, 152. 
 septic endometritis, 26. See 
 
 EndoDietritis. 
 septic salpingitis, 69. See also 
 Salpingitis. 
 16 
 
 Adherent ovaries, conservative 
 treatment of, 159. 
 retropositions, 117- 
 operation for, 118. 
 Adhesions, separation of, in vag- 
 inal ablation, 164. 
 After-treatment of hysterectomy, 
 
 219. 
 Analgesia in pelvic peritonitis, 
 
 99. 
 Anesthetic, 125. 
 Anodynes in after-treatment of 
 
 hysterectomy, 221. 
 Apoplexy, ovarian, 107. 
 
 conservative treatment of, 159. 
 treatment, 112. 
 Appendicitis, diagnosis of pelvic 
 inflammation from, 57. 
 
 B 
 
 Beef juice, 238. 
 
 Bladder, wounding of, in vaginal 
 
 ablation, 223. 
 Bowel, wounds of, in vaginal ab- 
 lation, 224. 
 Broad-ligament abscess, 121. 
 symptoms, 122. 
 treatment, 123. 
 cyst, 114. 
 
 conservative treatment of, 160. 
 symptoms, 115. 
 treatment, 116. 
 
 C 
 
 Catgut, sterilization of, 240. 
 Cervical polypi, 22. 
 treatment, 24. 
 
 241 
 
24: 
 
 INDEX. 
 
 Csirvix uteri, cystic degeneration 
 of, 21. 
 
 treatment, 24. 
 polypus of, treatment, 24. 
 Cliicken broth, 237. 
 Chills in pelvic peritonitis, loi. 
 Chronic gonorrheal endocervi- 
 citis, 25. See Endocervi- 
 citis. 
 endometritis, 50. See Endo- 
 
 Dietritis. 
 salpingitis, 72. See also Sal- 
 pingilis. 
 salpingo-oophoritis, conserva- 
 tive operation for, 155. 
 septic salpingitis, 72. See also 
 Salpijigitis. 
 Colon bacillus as a cause of pelvic 
 
 peritonitis, 91. 
 Conservative treatment, 146. 
 
 of acute salpingo-oophoritis, 
 
 152- 
 of adherent ovaries, 159. 
 of broad-ligament cj-sts, 160. 
 of chronic salpingo-oopho- 
 ritis, 155. 
 of cystic ovaries, 158. 
 of hydrosalpinx, 157. 
 of occluded tubes, 159 
 of ovarian apoplexy, 159. 
 Constipation a cause of pelvic 
 
 peritonitis, 96. 
 Convulsions after vaginal ablation, 
 
 226. 
 Cul-de-sac operation in puerperal 
 
 endometritis, 44. 
 Curettage, 126. 
 in puerperal endometritis, 43. 
 instruments for, 134. 
 packing after, 129. 
 repeated irrigations in, 133. 
 
 Currettage, time for, 130. 
 Curette, Sims', 135. 
 Curettes, 234. 
 Cyst of broad ligament, 114. 
 
 conservative treatment, 160. 
 symptoms, 115. 
 treatment, 116. 
 Cystic degeneration of cervix uteri, 
 21. 
 
 treatment, 24. 
 of ovaries, 107. 
 ovaries, T07. 
 conservative treatment of, 158. 
 treatment, in. 
 Cystitis, diagnosis of pelvic in- 
 fiammation from, 58. 
 
 Diet in pelvic inflammation, 62. 
 
 Diffuse pelvic suppuration, 123. 
 See also Pelvic suppura- 
 tion. 
 
 Digestive symptoms in pelvic 
 peritonitis, loi. 
 
 Douches in pelvic inflammation, 
 61. 
 
 Drainage in. vaginal ablation of 
 uterus, 165. 
 
 Dressing instruments, 234. 
 Mikulicz pelvic, 202. 
 
 Dressings in after treatment of 
 hysterectomy, 222. 
 sterilization of, 240. 
 
 Edematous ovaritis, loS. 
 
 treatment, in. 
 Endocervicitis, acute septic, 20. 
 gonorrheal, acute, 25. 
 diagnosis, 25. 
 symptoms, 25. 
 
INDEX. 
 
 243 
 
 Endocervicitis, gonorrheal, acute, 
 treatment, 25. 
 gonorrheal, chronic, 25. 
 symptoms, 26. 
 treatment, 26. 
 gonorrheal, latent. See En- 
 docervicitis, gonorrheal, 
 chronic. 
 septic, diagnosis, 22. 
 symptoms, 20. 
 treatment, 24. 
 Endometritis, 17. 
 general considerations, 17. 
 gonorrheal, acute, 47. 
 diagnosis, 48. 
 sequelae, 49. 
 symptoms, 47. 
 treatment, non-operative, 
 
 48. 
 treatment, operative, 49. 
 gonorrheal, chronic, 50. 
 diagnosis, 51. 
 symptoms, 50. 
 treatment, 51. 
 non-virulent, 18. 
 puerperal septic, 35. 
 cul-de-sac operation in, 44. 
 curettage in, 43. 
 irrigation in, 42. 
 septic, treatment, 41. 
 virulent, 18. 
 septic, 26. 
 acute, 26. 
 acute, differential diagnosis 
 
 30- 
 sequelae, 30. 
 symptoms, 26. 
 treatment, 30 
 tubercular, 52. 
 diagnosis, 52. 
 sequelae, 53. 
 
 Endometritis, tubercular, symp- 
 toms, 52. 
 treatment, 52. 
 Exploratory vaginal section, 136. 
 advantages of, over abdo- 
 minal method, 144. 
 Exposure as a cause of pelvic 
 peritonitis, 96. 
 
 F 
 
 Fluids in pelvic inflammation, 6r. 
 Forceps, French traction, 234. 
 
 Hunter's, 235. 
 
 Luer's polypus, 234. 
 
 Pryor's, 235. 
 
 removal of, after hysterectomy, 
 221. 
 
 Sims' artery, 235. 
 Formulae, 237. 
 
 French traction forceps, 234. 
 Fritsch-Bozeman double-current 
 irrigating tubes, 135. 
 
 Gauze, iodoform, 237. 
 sterilization of, 240. 
 
 Genital sclerosis, 26. 
 
 Gonococci as a cause of pelvic 
 peritonitis, 92. 
 
 Gonorrhea a cause of pelvic peri- 
 tonitis, 92. 
 
 Gonorrheal endocervicitis, acute, 
 
 25- 
 
 endocervicitis, chronic, 25. See 
 Endocervicitis. 
 
 endocervicitis, latent, 25. 
 
 endometritis, acute, 47. See 
 E?idometritis. 
 chronic, 50. See Endome- 
 tritis. 
 
 peritonitis, 92. 
 
!44 
 
 INDEX. 
 
 Gonorrheal salpingitis, acute, 63. 
 See also Scj/J>i>/,i;;i/is. 
 chronic, 72. See also Salpin- 
 gifts. 
 
 H 
 Hand-basins, sterilization of, 240. 
 Heart in pelvic peritonitis, loi. 
 Hemorrhage, secondary, after va- 
 ginal ablation, 227. 
 Hemostasis in vaginal ablation of 
 
 uterus, 165. 
 Hemostatic forceps, 235. 
 Hernia after hysterectomj', 166. 
 Hunter's sponge forceps, 235. 
 Hydrosalpinx, 80. 
 conservative operation for, 157. 
 treatment. So. 
 Hysterectomy, vaginal, 163. See 
 Vaginal Ablation. 
 after treatment of, 219. 
 anodynes in after-treatment of, 
 
 221 
 behavior of wound after, 222. 
 removal of forceps after, 221. 
 vagi no-abdominal, in puerperal 
 state, 215. 
 
 I 
 
 Infection, puerperal, 34. 
 Inflammation, intra-uterine. See 
 Endonietritis. 
 of ovaries, 106. 
 
 pelvic, 54. See Pelvic I)ifla>n- 
 mation. 
 Instruments, 231. 
 
 sterilization of, 239. 
 Intestinal paralysis after vaginal 
 
 ablation, 226. 
 Intra-uterine catheters, 234. 
 Intra-venous injection of normal 
 salt solution, 229. 
 
 Iodoform gauze, 237. 
 Irrigating fluids, 239. 
 Irrigation of uterus after curet- 
 tage, 129. 
 puerperal endometritis, 42. 
 Irrigations, repeated, 133. 
 
 J 
 
 Jackson's speculum, 134, 
 
 i ^ 
 
 Kangaroo tendon, sterilization of, 
 
 240. 
 
 Kidneys in pelvic peritonitis, loi. 
 
 L 
 
 Latent gonorrheal endocervicitis, 
 25. See Endocervicitis. 
 
 Local applications in pelvic in- 
 flammation, 62. 
 
 Luer's polypus forceps, 234. 
 
 Lungs in pelvic peritonitis, loi. 
 
 Lysol, 237. 
 
 M 
 
 Mikulicz pelvic dressing, 202. 
 Morcellation, 209. 
 
 N 
 Nephritis after vaginal ablation, 
 
 225. 
 Non-purulent endometritis, 18. 
 Normal salt solution, 237. 
 
 intra-venous injection of, 
 
 229. 
 subcutaneous injection of, 
 230. 
 Nutrient enema, 23S. 
 
 O 
 
 Occluded tubes, conservative 
 
 treatment, 159. 
 Operating table, 236. 
 
INDEX. 
 
 245 
 
 Operator, sterilization of, 238. 
 Opiates in pelvic inflammation, 
 
 60. 
 Ovarian abscess, 108. 
 symptoms, no. 
 treatment, 113. 
 apoplexy, 107. 
 
 conservative treatment of, 
 
 159- 
 treatment, 112. 
 sclerosis, 107. 
 treatment, in. 
 Ovaries, adherent, conservative 
 treatment, 159. 
 cystic, 107. 
 conservative treatment, 158. 
 treatment, in. 
 cystic degeneration of, 107. 
 inflammatory diseases of, 106. 
 Ovaritis, acute, 106. 
 edematous, 108. 
 treatment, in. 
 symptoms, 109. 
 
 Pachysalpingitis, 72, 74. 
 
 treatment of, 79. 
 Packing applicator, Pryor's, 135. 
 Packing of uterus after curetting, 
 
 129. 
 Pain in pelvic peritonitis, 99. 
 P^an retractor, 140, 231, 232. 
 
 long retractor, 227. 
 Pelvic inflammation, 54. 
 
 abdominal dressings in, 61. 
 
 diagnosis, 57. 
 
 diagnosis from appendicitis, 
 
 57- _ 
 diagnosis from cystitis, 58. 
 diagnosis from general sup- 
 purative peritonitis, 59. 
 
 Pelvic inflammation, diagnosis 
 from suppurating ovarian 
 cyst, 58. 
 diagnosis from ureteritis, 58. 
 diet in, 62. 
 fluids in, 61. 
 douches in, 61. 
 intestinal cleanliness in, 60. 
 local applications in, 62. 
 opiates in, 60. 
 treatment, 62. 
 Mikulicz dressing, 202. 
 peritonitis, 90. 
 analgesia in, 99. 
 causes, 91. 
 chills in, loi. 
 colon bacillus in, 91. 
 diagnosis, 102. 
 digestive symptoms in, loi. 
 gonococci in, 92. 
 heart in, loi. 
 kidneys in, loi. 
 lungs in, loi. 
 pain in, 99. 
 prognosis, 102. 
 pulse in, 100. 
 staphylococci in, 92. 
 streptococci in, 94. 
 suppurative, treatment, 103. 
 symptoms, 96. 
 temperature in, 100. 
 treatment, 103. 
 tubercular, 104. 
 
 symptoms, 105. 
 
 treatment, 105. 
 tympanites in, 99. 
 suppuration, diflfuse, 123. 
 
 symptoms, 124. 
 
 treatment, 124. 
 Peri-ovaritis, acute, 106. 
 symptoms, no. 
 
-46 
 
 INDEX. 
 
 Peri-.ovaritis, treatment, no. 
 Peritonitis, pelvic, 90. 
 causes, 91. 
 diagnosis, 102. 
 prognosis, 102. 
 symptoms, 96. 
 treatment, 103. 
 tubercular, 104. 
 symptoms, 105. 
 treatment, 105. 
 primary purulent, 94. 
 Pneumonia after vaginal ablation, 
 
 225. 
 Polypus of cervix uteri, 22. 
 
 treatment, 24. 
 Pryor-P^an trowel, 231, 233. 
 Pryor's blunt bullet forceps, 134. 
 forceps, 235. 
 intra-uterine traction forceps, 
 
 231. 
 operating table, 236. 
 packing applicator, 135. 
 retracting grooved director, 194. 
 trowel, 233. 
 uterine dilator, 135. 
 Puerperal endometritis, septic, 35. 
 See Endometritis, puer- 
 peral. 
 infection, 34. 
 
 state, vagino-abdominal liyster- 
 ectomy in, 215. 
 Pulse in pelvic peritonitis, 99. 
 Purulent endometritis, 18. 
 Pyosalpinx, 80. 
 diagnosis, 87. 
 sequelcC, 88. 
 symptoms, 83. 
 treatment, 88. 
 
 Quinin solution, 237. 
 
 Repeated irrigations after curet- 
 tage of uterus, 133. 
 Retractors, 231. 
 
 Pean's, 227. 
 Retroposition, adherent, 117. 
 
 operation for, 118. 
 Rubber goods, sterilization of, 
 239- 
 
 S 
 
 Salpingitis, 63. 
 gonorrhea], acute, 63. 
 diagnosis, 67. 
 sequelae, 68. 
 symptoms, 65. 
 treatment, 67. 
 septic, acute, 69. 
 
 treatment, 71. 
 tubercular, 89. 
 symptoms, 90. 
 treatment, 90. 
 Salpingo-oophoritis, acute, con- 
 servative operation for, 
 
 155- 
 Salpingostomy, 158. 
 Sclerosis, genital, 26, 74. 
 treatment of, 74. 
 ovarian, 107. 
 
 treatment, in. 
 tubal, 63. 
 Secondary hemorrhage after vag- 
 inal ablation, 227. 
 Section, vaginal, preparation of 
 
 patient for, 161. 
 Speculum, Jackson, 134. 
 Segond's incisions, 179. 
 Septic endocervicitis, 20. 
 diagnosis, 22. 
 symptoms, 20. 
 treatment, 24. 
 
INDEX. 
 
 247 
 
 Septic endometritis, 26. See E11- 
 doinetritis. 
 puerperal endometritis, 35. 
 
 treatment, 41. 
 salpingitis, acute, 69. See also 
 Salpingitis. 
 chronic, 72. See also Salpin- 
 gitis. 
 Sheets, sterilization of, 240. 
 Silks, sterilization of, 240. 
 Silkworm gut, sterilization of, 
 
 240. 
 Silver wire, sterilization of, 240. 
 Sims' artery forceps, -235. 
 curettes, 135. 
 needle-holder, 236. 
 tampon screw, 135. 
 Staphylococci, as a cause of pelvic 
 
 peritonitis, 92. 
 Sterilization, 238. 
 Streptococci as a cause of pelvic 
 
 peritonitis, 94. 
 Subcutaneous injection of normal 
 
 salt solution, 230. 
 Suppuration, dififuse pelvic, 123. 
 symptoms, 124. 
 treatment, 124. 
 Suppurative pelvic peritonitis, 
 
 treatment, 103. 
 Sutures in hysterectomy, 166. 
 sterilization of, 240. 
 
 T 
 
 Tampon screw, Sims', 135. 
 Temperature in pelvic peritonitis, 
 
 100. 
 Thiersch solution, 237. 
 Towels, sterilization of, 240. 
 Traction instruments, 231. 
 Transfusion fluid, sterilization of, 
 
 239- 
 
 Trauma as a cause of pelvic peri- 
 tonitis, 96. 
 Treatment, conservative, 146. See 
 
 Conservative Ireatinenl. 
 Tubal sclerosis, 63. 
 Tubercular endometritis, 52. See 
 Endometritis. 
 pelvic peritonitis, 104. 
 symptoms, 105. 
 treatment, 105. 
 salpingitis, 89. 
 Tympanites in pelvic peritonitis, 
 99- 
 
 U 
 
 Ureter, wounds of, in vaginal ab- 
 lation, 224. 
 Ureteritis, diagnosis of pelvic in- 
 flammation from, 58. 
 Uterine colic in gonorrheal endo- 
 metritis, 48. 
 dilator, Pryor's, 135. 
 Uterus, ablation of, en masse, 180. 
 by hemisection, 187. 
 curettage of, 126. 
 morcellation of, 209. 
 packing of, after curetting, 129. 
 vaginal ablation of, 163. See 
 also Vaginal ablation of 
 icterus, 163. 
 
 Vaginal ablation of uterus, 163. 
 
 accidents and complica- 
 tions, 223. 
 accidents in, 166. 
 after-treatment, 219. 
 convalescence from, 167. 
 drainage in, 165. 
 enucleation in, 165. 
 general considerations, 163. 
 
248 
 
 INDEX. 
 
 Vaginal ablation of uterus, hemos- 
 
 tasis in, 165. 
 hernia after, 166. 
 instruments for, 166. 
 operation, 168. 
 posture for, 168. 
 results of, 167. 
 secondary ii e m o r r h a g e 
 
 after, 227. 
 separation of adhesions in. 
 
 Vaginal ablation of uterus, hyste- 
 rectomy, 163. See Fi/^z- 
 7tal ablation. 
 sutures in, 166. 
 section, exploratory, 136. 
 preparation of patient for, 161. 
 Vagino-abdominal hysterectomy 
 in puerperal state, 215. 
 
 Wales bougie, 236. 
 Womb cramps, 27. 
 
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 Atlas and Epitome of General Pathological Histology. With an 
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 5 
 
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8 
 
 PV. B. SAUNDERS' 
 
 *AN AMERICAN TEXT-BOOK OF APPLIED THERAPEU- 
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 Frederick A. Packard, Philadelphia, Pa. 
 Theophilus Parvin, Pbiladelphia, Pa. 
 Beaven Rake, London, England. 
 E. O. Shakespeare. Philadelphia. Pa. 
 Wharton Sinkler, Philadelphia, Pa. 
 Louis Starr, Philadelphia, Pa. 
 Henry W. Stelwagon, Philadelphia, Pa. 
 James Stewart, Montreal, Canada. 
 Charles G. Stockton, Euffalo, N. Y. 
 James Tyson, Philadelphia, Pa. 
 Victor C. Vaughan, Ann Arbor, Mich. 
 James T. Whittaker, Cincinnati, O. 
 J. C. Wilson, Philadelphia, Pa. 
 
CATALOGUE OF MEDICAL WORKS. 
 
 *AN AMERICAN TEXT-BOOK OF OBSTETRICS. Edited by 
 Richard C. Norris, M. D. ; Art Editor, Robert L. Dickinson, M. D. 
 One handsome octavo volume of over looo pages, with nearly 900 coloied 
 and half-tone illustrations. Prices: Cloth, ^7.00 net; Sheep or Half 
 Morocco, ;g8.oo net. 
 
 The advent of each successive volume of the series of the American Text- 
 Books has been signalized by the most flattering comment from both the Press 
 and the Profession. The high consideration received by these text-books, and 
 their attainment to an authoritative position in current medical literature, have 
 been matters of deep international interest, which finds its fullest expression in 
 the demand for these publications from all parts of the civilized world. 
 
 In the preparadon of the "American Text-Book of Obstetrics" the 
 editor has called to his aid proficient collaborators whose professional prominence 
 entitles them to recognition, and whose disquisitions exemplify Practical 
 Obstetrics. While these writers were each assigned special themes for dis- 
 cussion, the correladon of the subject-matter is, nevertheless, such as ensures 
 logical connection in treatment, the deductions of which thoroughly represent 
 the latest advances in the science, and which elucidate the best ??iodern methods 
 of procedure. 
 
 The more conspicuous feature of the treatise is its wealth of illustrative 
 matter. The production of the illustrations had been in progress for several 
 years, under the personal supervision of Robert L. Dickinson, M. D., to whose 
 artistic judgment and professional experience is due the most sumptuously 
 illustrated work of the period. By means of the photographic art, combined 
 with the skill of the artist and draughtsman, conventional illustration is super- 
 seded by rational methods of delineation. 
 
 Furthermore, the volume is a revelation as to the possibilities that may be 
 reached in mechanical execution, through the unsparing hand of its publisher. 
 
 CO]VTRIBUTORS ; 
 
 Dr. James C. Cameron. 
 Edward P. Davis. 
 Robert L. Dickinson. 
 Charles Warrington Earle. 
 James H. Etheridge. 
 Henry J. Garrigues. 
 Barton Cooke Hirst. 
 Charles Jewett. 
 
 Dr. Howard A. Kelly. 
 Richard C. Norris. 
 Chauncey D. Palmer. 
 Theophilus Parvin. 
 George A. Piersol. 
 Edward Reynolds. 
 Henry Schwarz. 
 
 "At first glance we are overwhelmed by the magnitude of this work in several respects, 
 viz. : First, by the size of the volume, then by the array of eminent teachers in this depart- 
 ment who have taken part in its production, then by the profuseness and character of the 
 illustrations, and last, but not least, the conciseness and clearness with which the text is ren- 
 dered. This is an entirely new composition, embodying the highest knowledge of the art as 
 it stands to-day by authors who occupy the front rank in their specialty, and there are many 
 of them. We cannot turn over these pages without being struck by the superb illustrations 
 which adorn so many of them. We are confideiit that this most practical work will find 
 instant appreciation by practitioners as well as students." — Netu York Medical Times. 
 
 Permit me to say that your American Text-Book of Obstetrics is the most magnificent 
 medical work that 1 have ever seen. I congratulate you and thank you for this superb work 
 which alone is sufficient to place you first in the ranks of medical publishers. 
 
 With profound respect I am sincerely yours, Alex. J. C. Skene. 
 
lO ff^. B. SAUNDERS' 
 
 * AN AMERICAN TEXT-BOOK OF THE THEORY AND 
 . PRACTICE OF MEDICINE. By American Teachers. Edited 
 by \Vil,Ll.\M I'KrPKU, M. 1).. l.I, I)., Provost and Professor of the Theory 
 and Practice of Medicine and of Clinical Medicine in the University of 
 Pennsylvania. Complete in two handsome royal -octavo voliunes of about 
 lOOO pages each, with illustrations to ehu itlate the text wherever necessary. 
 Price per \olume : Cloth, SS-OO nit ; Sheep or Half-Morocco, ;g6.00 net. 
 
 VOL.IJIWE I. COXrAIJ^I*: 
 
 Hygiene.— Fevers (tphemeral, bimple Con- myc^si^, 'jl.mders, and Tetanus. — I'ubercu- 
 nnuect. Typhus, Typhoid, Epidemic Cerebro- , lo^^is, Scroiula, Syphilis, Diphtheria, Erysipe- 
 jpinal Meningitis, and Relapsing) — Sc;irla- I Ia3, frialaria. Cholera, and Vellow Fever. — 
 :ina. Measles, Rotheln, Varii^la, Varioloid, 1 Nervous, Muscular, and iMental Diseases etc. 
 Vjccinia. Varicella, Mumps, Whooping cciish. i 
 Anthrax. Hydrophobia, Trichinosis. Acr.ino. i 
 
 ■Jrine (Chemistry and MicrosLipy) —Kid- [ — Herirrneuiii, Livci and f?.ncreas. — Uiathet- 
 r.ey and Lungs. — Air-passages (Laryii.ic and [ ic Diseases (Kheum.itism, Khcumatoid Ar- 
 Bronchi) and Pleura. — Pharynx, (E'ioph.igns. I tliritis. Gout, Liiha:ini.i, ami Diabetes.) — 
 Stomach and Intestines (including Inti^siinal Blood and Spleen. — lnflaminati..n. Embolism, 
 Parasites), Heart, Aorta, Arteries and Veins. | Thrombosis, Fever, and Bacteriology. 
 
 The articles are not wriiten as thouoh addressed to student- in lectures, but 
 are exhaustive descriptions of diseases, with the newest facts as regards Causa- 
 tion, Symptomatology, Diagnosis, Prognosis, and Treatment, including a large 
 number of approved formulae. The recent advances made in llie study 
 of the bacterial origin of various diseases are fully described, as well as the 
 bearing of the knowledge so gained upon prevention and cure. The subjects 
 of Bacteriology as a whole and of Immunity are fully considered in a scoaraie 
 section. 
 
 Methods of diagnosis are given the most mmute and careful attention, thus 
 enabling the reader to learn the very latest methods of investigation without 
 consultine works specially devoted to the suhiect. 
 
 CONTK.IBrTOB!»» - 
 
 i>r. I. S. Billings, Philadelphia. I D:. V'illiam Pepper, Philadelohla. 
 
 Francis Delafield, New York. V. Oilman Thompson, New York 
 
 Reginald H. Fitz, Boston. i W. H. Welch, Baliimore 
 
 James W. Holland, Philadelphia. | James T. Whiitaker. Cincinnati 
 
 Henry M. Lyman, Chicagc. James C. Wilson. Philadeipni i. 
 
 William Osier. Baltimore TJoratio C. Wood, Philadelphia. 
 
 '' We reviewed the first volume of tnis work, and said; ' It is undoubtedly one ot tne best 
 text-books on the practice ol medicine which we possess.' A consideration of the secon'J 
 a.nd last volume leads us to modify that verdict and to say that the completed work K, in out 
 opinion, the best of its kind it has ever been our toriune to see. It is complete, thorough, 
 accurate, and clear. It is well written, well arranged, well printed, well illustrated, and well 
 Dound. It is a model of what the modern text-book should he/'—Ne^v Vot k Medical Journal. 
 
 'A library upon modern medical art. Tne work must promote the wider diffusion ef 
 sound knowledge." — American Lane*. 
 
 " A trusty counsellor for the practitioner Oi- senior student, on winch ne may implicitly 
 -••IV.'' — Jieiiniurg-h Medical 'fovrna.1 
 
CATALOGUE OF MEDICAL WORKS. II 
 
 *AN AMERICAN TEXT-BOOK OF SURGERY. Edited by Wil- 
 liam W. Keen, M. D., LL.D., and J. William White, M. D., Ph. D. 
 Forming one handsome royal octavo volume of 1230 pages (10 x 7 inches), 
 with 496 virood-cuts in text, and 37 colored and half-tone plates, many of 
 them engraved from original photographs and drawings furnished by the 
 authors. Price : Cloth, $7.00 net; Sheep or Half Morocco, ^8.00 net. 
 
 THIRD EDITION. THOROUGHLY REVISED. 
 
 In the present edition, among the new topics introduced are a full considera- 
 tion of serum-theiapy; leucocytosis ; post-operative insanity; the use of dry heat 
 at high temperatures ; Kronlein's method of locating the cerebral fissures ; 
 Hoffa's and I.orenz's operations of congenital dislocations of the hip ; Allis's re- 
 searches on dislocations of the hip-joint ; lumbar puncture ; the forcible reposi- 
 tion of the spine in Pott's disease; the treatment of exophthalmic goiter; the 
 surgery of typhoid fever ; gastrectomy and other operations on the stomach ; 
 new methods of operating upon the intestines; the use of Kelly's rectal specula; 
 the surgery of the ureter ; Schleich's infiltration-method and the use of eucain 
 for local anesthesia ; Krause's method of skin-grafting ; the newer methods of 
 disinfecting the hands ; the use of gloves, etc. The sections on Appendicitis, 
 on Fractures, and on Gynecological Operations have been revised and enlarged. 
 A considerable number of new illustrations have been added, and enhance the 
 value of the work. 
 
 The text of the entire book has been submitted to all the authors for their 
 mutual criticism and revision — an idea in book- making that is entirely new and 
 original. The book as a whole, therefore, expresses on all the important sur- 
 gical topics of the day the consensus of opinion of the eminent surgeons who 
 have joined in its preparation. 
 
 One of the most attractive features of the book is its illustrations. Very 
 many of them are original and faithful reproductions of photographs taken 
 directly from patients or from specimens, 
 
 CONTRIBCTOKS : 
 
 Dr. Phineas S. Conner, Cincinnati. 
 Frederic S. Dennis, New York. 
 William W. Keen, Philadelphia. 
 Charle.s B. Nancrede, Ann Arbor, Mich. 
 Roswell Park, Buffalo, New York. 
 Lewis S. Pilcher, New York. 
 
 Dr. Nicholas Senn, Chicago. 
 
 Francis J. Shepherd, Montreal, Canada. 
 
 Lewis A. Slimson, New York. 
 
 J. Collins Warren, Boston. 
 
 J. William White, Philadelphia. 
 
 "If this text-book is a fair reflex of the present position of A.merican surgery, we must 
 admit it is of a very high order of merit, and that English surgeons will have to look very 
 carefully to their laurels if they are to preserve a position in the van of surgical practice." — 
 London Lancet. 
 
 Personally, I should not mind it being called THE Text-Book (instead of A Text-Book), 
 for 1 know ot no single volume which contains so readable and complete an account of the 
 science and art of Surgery as this does." — Edmund Owen, F. R. C. S., Member of the Board 
 nf Examiners of the Royal College of Surgeons, Rns:iand 
 
12 IV. B. SAUNDERS' 
 
 * AN AMERICAN TEXT-BOOK OF GYNECOLOGY, MEDICAL 
 AND SURGICAL, for the use of Students and Practitioners. 
 Edited by J. M. Bai.dy, M. D. Forming a handsome royal-octavo volume 
 of 718 pages, with 341 illustrations in the text and 38 colored and half- 
 tone plates. Prices : Cloth, $6.00 net ; Sheep or Half-Morocco, ;^7.oo net. 
 
 SECOND EDITION, THOROUGHLY REVISED. 
 
 In this volume all anatomical descriptions, excepting those essential to a clear 
 undeistanding of the text, have been omitted, the illustrations being largely de- 
 pended upon to elucidate the anatomy of the parts. This work, which is 
 thoroughly practical in its teachings, is intended, as its title implies, to be a 
 working text-book for physicians and students. A clear line of treatment has 
 been laid down in every case, and although no attempt has been made to dis- 
 cuss mooted points, still the most important of these have been noted and ex- 
 plained. The oper.ations recommended aie fully illustrated, so tliat the reader, 
 having a picture of the i)rocedine described in the text under his eye, cannot fail 
 to giasp the idea. All extraneous matter and discussions have been carefully 
 exchuled, the attempt being made to allow no unnecessary details to cumber 
 the text. The subject-matter is brought up to date at every point, and the 
 work is as nearly as possible the combined opinions of the ten specialists who 
 figure as the authors. 
 
 In the revised edition much new material has been added, and some of the 
 old eliminated or modified.- More than forty of the old illustrations have been 
 replaced by new ones, which add very materially to the elucidation of the 
 text, as they picture methods, not specimens. The chapters on technique and 
 after-treatment have been considerably enlarged, and the portions devoted to 
 plastic work have been so greatly improred as to be practically new. Hyste- 
 rectomy has been rewritten, and all the descriptions of operative procedures 
 have been carefully revised and fully illustrated. 
 
 CODTTRIBUTORS : 
 
 Dr. Henry T. Byford. 
 John M. Baldy. 
 Edwin Cragin. 
 1. H. Etheridge. 
 William Goodell. 
 
 Dr. Howard A. Kelly. 
 Fiorian Krug. 
 E. E. Montgomery. 
 William R. Pryor. 
 George M. Tuttle. 
 
 "The most notable contribution to gynecological literature since 1887 and the most 
 
 complete exponent of gynecology which we have. No subject seems to have been neglected, 
 .... and the gynecologist and surgeon, and the general practitioner who has any desire 
 to practise diseases of women, will find it 01" practical value. In the matter of illustrations 
 and plates the book surpasses anything we have seen." — Boston Medical and Surgical 
 yournal. 
 
 " A thoroughly modern text-book, and gives reliable and well-tempered advice and in- 
 struction." — Edinburgh Medical Journal. 
 
 " The harmony of its conclusions and the homogeneity of its style give it an individuality 
 which suggests a single rather than a multiple authorship."— ^««a/.r 0/ Surgery. 
 
 " It must command attention and respect as a worthy representation of our advanced 
 clinical teaching." — American Journal of Medical Sciences. 
 
CATALOGUE OF MEDICAL WORKS. 
 
 13 
 
 *AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHIL- 
 DREN. By American Teachers. Edited by Louis Starr, M. D., 
 assisted by Thompson S. Westcott, M. D. In one handsome reyal-Svi 
 volume of 1244 pages, profusely illustrated with wood-cuts, half-tone and 
 colored plates. Net Prices: Cloth, ^7.00; Sheep or Half- Morocco, p.oo. 
 
 SECOND EDITION, REVISED AND ENLARGED. 
 
 The plan of this work embraces a series of original articles written by some 
 sixty well-known pcediatrists, representing collectively the teachnigs of the most 
 prominent medical schools and colleges of America. The work is intended to 
 be a PRACTICAL book, suitable for constant and handy reference by the practi- 
 tioner and the advanced student. 
 
 Especial attention has been given to the latest accepted teachings upon the 
 etiology, symptoms, pathology, diagnosis, and treatment of the disorders of chil- 
 dren, with the introduction of many special formulae and therapeutic procedures. 
 
 In this new edition the whole subject matter has been carefully revised, new 
 articles added, some original papers emended, and a number entirely rewritten. 
 The new articles include " Modified Milk and Percentage Milk-Mixtures," 
 " Lithemia," and a section on " Orthopedics." Those rewritten are " Typhoid 
 Fever," "Rubella," "Chicken-pox," "Tuberculous Meningitis," "Hydroceph- 
 alus," and "Scurvy;" while extensive revision has been made in "Infant 
 Feeding," " Measles," " Diphtheria," and " Cretinism." The volume has thus 
 been much increased in size by the introduction of fresh material. 
 
 CONTRIBUTORS 1 
 
 Dr. S. S. Adams, Washington. 
 
 John Ashhurst, Jr., Philadelphia. 
 A. D. Blackader, Montreal, Canada. 
 David Bovaird, New York. 
 Dillon Brown, New York. 
 Edward M. Buckingham, Boston. 
 Charles W. Burr, Philadelphia. 
 W. E. Casselberry, Chicago. 
 Henry Dwight Chapin, New York. 
 W. S. Christopher, Chicago. 
 Archibald Church, Chicago. 
 Floyd M. Crandall, New York. 
 Andrew F. Currier, New York. 
 Roland G. Ciirtin, Philadelphia 
 J. M. DaCosta, Philadelphia. 
 I. N. Danforth, Chicago. 
 Edward P. Davis, Philadelphia. 
 John B. Deaver, Philadelphia. 
 G. E. de Schweinitz, Philadelphia. 
 John Doming, New York. 
 Charles Warrington Earle, Chicago. 
 Wm. A. Edwards, San Diego, Cal. 
 F. Forchheimer, Cincinnati. 
 J. Henry Fruitnight, New York. 
 J. P. Crozer Griffith, Philadelphia. 
 W. A. Hardaway. St. Louis. 
 M. P Hatfield, Chicago. 
 Barton Cooke Hirst, Philadelphia. 
 H. lUoway, Cincinnati. 
 Henry Jackson, Boston. 
 Charles G. Jennings, Detroit 
 Henry Koplik. New York. 
 
 Dr. Thomas S. Latimer, Baltimore. 
 
 Albert R. Leeds, Hoboken, N. J. 
 
 J. Hendrie Lloyd, Philadelphia. 
 
 George Roe Lockwood, New York. 
 
 Henry M. Lyman, Chicago. 
 
 Francis T. Miles, Baltimore. 
 
 Charles K Mills, Philadelphia. 
 
 James E. Moore,. Minneapolis. 
 
 F. Gordon Morrill, Boston. 
 
 John H. Musser, Philadelphia. 
 
 Thomas R. Neilson, Philadelphia. 
 
 W. P. Northrup, New York. 
 
 William Osier, Baltimore. 
 
 Frederick A. Packard, Philadelphia. 
 
 William Pepper, Philadelphia. 
 
 Frederick Peterson, New York. 
 
 W. T. Plant, Syracuse, New York 
 
 William M. Powell. Atlantic City. 
 
 B. K. Rachford, Cincinnati. 
 
 B. Alexander Randall, Philadelphia. 
 
 Edward O. Shakespeare, Philadelphia 
 
 F. C. Shattuck, Boston. 
 
 J. Lewis Smith, New York. 
 
 Louis Starr, Philadelphia. 
 
 M. Allen Starr, New York. 
 
 Charles W. Townsend, Boston. 
 
 James Tyson, Philadelphia. 
 
 W. S. Thayer, Baltimore. 
 
 Victor C. Vaughan, Ann Arbor, Mich 
 
 Thompson S. Westcott, Philadelphia. 
 
 Henry R. Wharton, Philadelphia. 
 
 J. William White, Philadelphia. 
 
 J. C. Wilson, Philadelphia. 
 
14 
 
 IV. B. SAUNDERS' 
 
 *AN AMERICAN TEXT-BOOK OF GENITO-URINARY AND 
 SKIN DISEASES. Dy 47 Eminent Specialists and Teachers. Edited 
 by L. Bolton Bangs, M. D., Piofessor of Genito-Uriiiary Surgery, Uni- 
 versity and Bellevue Hospital Medical College, New York ; and W. A. 
 Hardaway, M. D., Professor of Diseases of the Skin. Missouri Medical 
 College. Imperial octavo volume of 1229 pages, vi^ith 300 engravings and 
 20 full-page colored plates. Cloth, $7.00 net ; Sheep or Half Morocco, 
 $8.00 net. 
 
 This addition to the series of " American Text-Books," it is confidently be- 
 lieved, will meet the requirements of both students and jiractitioners, giving, as 
 it does, a comprehensive and detailed presentation of the Diseases of the 
 Genito-Urinary Organs, of the Venereal Diseases, and of the Affections of the 
 Skin. 
 
 Having secured the collaboration of well-known authorities in the branches 
 represented in the undertaking, the editors have not restricted the contributors 
 iu regard to the particular views set forth, but have oftered every facility for the 
 free e.xpressiun of their individual opinions. The work will therefore be found 
 to be original, yet homogeneous and fully representative of the several depart- 
 ments of medical science with which it is concernea. 
 
 €OXTRIBlJTORS : 
 
 Dr. Chas. W. Allen, New York. 
 1. E. Atkinson, Baltimore. 
 L Bolton Bangs, New York. 
 P. R. Bolton, New York. 
 Lewis C. Bosher, Richmond, Va. 
 John T. Bowen, Boston. 
 J. Abbott Cantrell. Philadelphia. 
 William T. Corlett, Cleveland, Ohio. 
 B. Farquhar Curtis, New York. 
 Condict \V. Cutler, New York. 
 Isadore Dyer, New Orleans. 
 Christian Fenger, Chicago. 
 John A. Fordyce, New York. 
 Eugene Fuller, New York. 
 R. H. Greene, New York. 
 Joseph Grindon, St. Louis. 
 Graeme M. Hammond, New York. 
 \V. A. Hardaway, St. Louis. 
 M. B. Hartzell, Philadelphia. 
 Louis Heitzmann, New York. 
 James S. Howe, Boston. 
 George T. Jackson, New York. 
 Abraham JacobI, New York. 
 James C. Johnston. New York. 
 
 Dr. Hermann G. Klotz, New Ybrle. 
 J. H. Linslcy, Burlington, Vt, 
 G. F. Lydston, Chicago. 
 Hartwell N. Lyon, St. Louis. 
 Edward Martin, Philadelphia. 
 D. G. Montgomery, San Francisco. 
 James Pedersen, New York. 
 S. Pollitzer, New York. 
 Thomas R. Pooley, New York. 
 A. R. Robinson, New York. 
 A. E. Rtgensburger, San Francisco. 
 Francis J. Shepherd, Montreal, Can. 
 S. C. Stanton, Chicago, ill. 
 Emmanuel J. Stout, Philadelphia. 
 Alonzo E. Taylor. Philadelphia. 
 Robert W. Taylor, New York. 
 Paul Thorndike, Boston. 
 H. Tuholske, St. Louis. 
 Arthur Van Harlingen, Philadelphia. 
 Francis S. Watson, Boston. 
 J. William White, Philadelphia. 
 J. McF. Winfield, Brooklyn. 
 Alfred C. Wood, Philadelptiia. 
 
 "This voluminous work is thoro\ighly up to date, and the chapters on genito-urinarv ais- 
 eases are especially valuable. The illustrations are fine and are mostly original. The section 
 on dermatology is concise and in every way admirable."— VoM^'wa/ of the Atnerican Medical 
 Association. 
 
 "This volume is one of the best yet issued of the publisher's series of 'American Te.\t- 
 Books.' The list of contributors represents an e.vtraordinary array of talent and extended 
 experience. The book will easily take the place in comprehensiveness and value of the 
 half dozen or more costly works on these subjects which have hitherto been necessary to a 
 well-equipped library." — New York Polvdinic. 
 
-ATALOGUE OF MEDICAL WORKS. 
 
 * AN AMERICAN TEXT-BOOK OF DISEASES OF THE EYE, 
 EAR, NOSE, AND THROAT. Edited by Geokge E. de Sen weinitz, 
 
 A. M., M. D., Professor of Ophthalmology, Jefferson Medical College; and 
 
 B. Alexander Randall, A. M., M. D., Clinical Professor of Diseases of 
 the Ear, University of Pennsylvania. One handsome imperial octavo 
 volume of 1251 pages; 766 illustrations, 59 of them colored. Prices: 
 Clotu, S7.00 net; Sheep or Half-Morocco, ^8.00 net. 
 
 dust Issued, 
 
 The present work is the only book ever published embracmg diseases of the 
 intimately related organs of the eye, ear, nose, and throat. Its special claim 
 to favor is based on encyclopedic, authoritative, and practical treatment ol the 
 subjects. 
 
 Each section of the book has been entrusted to avi author who is specially 
 identified with the subject on which he writes, and who therefore presents his 
 case in the manner of an expert. Uniformity is secured and overlapping pre- 
 vented by careful editing and by a system of cross-references which forms a 
 special feature of the volume, enabling the reader to come into touch with all 
 that is said on any subject in different portions of the book. 
 
 Particular emphasis is laid on the most approved methods of treatment, so 
 that the book shall be one to which the student and practitioner can refer for 
 information in practical work. Anatomical and physiological problems, also, 
 are fully discussed for the benefit of those who desire to investigate the more 
 abstruse problems of the subiect. 
 
 €0?rTRIBUTOBS : 
 
 Dr. Henry A. Alderton, Brooklyn. i 
 
 Harrison Allen, Philadelphia. j 
 
 F'.ank All port, Chicago, 1 
 
 Morris J. Asch, New York. I 
 
 S. C. Ayres, Cincinnati. i 
 
 R. O. Beard, Minneapolis. j 
 
 Clarence J. Blake, Boston. 
 Arthur A. Bliss, Philadelphia. 
 Albert P. Brubaker, Philadelphia. 
 J. H. Bryan, Washington, D. C. 
 A.lbert H. Buck, New York. 
 F. Buller, Montreal, Can. 
 Swan M. Burnett, Washington, D C. 
 ^'lemming Carrow, Ann Arbor, Mich. 
 W. E. Casselberry, Chicago. 
 Colman W. Cutler, New York. 
 Edward B. Dench, New York. 
 William S. Dennett, New York. 
 George E. de Schweinitz, Philadelphia. 
 Alexander Duane, New York. 
 John W. Farlow, Boston, Mass. 
 Walter J. Freeman, Philadelphia. 
 H. Gifford, Omaha, Neb. 
 W. C. Glasgow, St. Louis. 
 J. Orne Green, Boston. 
 Ward A. Holden, New York.. 
 Christian R. Holmes, Cincinnati. 
 William E. Hopkins, San Francisco. 
 F. C. Hotz, Chicago. 
 Lucien Howe, Buffalo, N. Y. j 
 
 Dr. Alvin A. Hubbell, Buffalo, W. Y. 
 Edward Jackson, Philadelphia, 
 j. Ellis Jennings, St. Louis. 
 Herman Knapp, New York. 
 Cha^. W. Kollock, Charleston, S. C- 
 G. A. Leland, Boston. 
 J. A. LippiHCOtt, Pittsburg, Pa. 
 G. Hudson Makuen, Philadelphia. 
 Tohn H. McCollom, Boston. 
 Vi. G. Miller, Providence, R. L 
 B. L. Milliken, Cleveland, Ohio. 
 P.obert C Myles, New York. 
 James E. Newcomb, New York. 
 R. J. Phillips, Philadelphia. 
 George A. Piersol, Philadelphia. 
 W. P. Porcher, Charleston, S. C. 
 B. Alex. Randall, Philadelphia. 
 Robert L. Randolph, Baltimore. 
 John O. Roe, Rochester, N. Y 
 Charles E. de M. Sajous, Philadelphia. 
 J. E. Sheppard, Brooklyn, N. Y. 
 E. L. Shurly, Detroit, Mich. 
 William M. Sweet, Philadelphia. 
 Samuel Theobald. Baltimore, Md. 
 A. G. Thomson, Philadelphia. 
 Clarence A. Veasey, Philadelphia. 
 John E. Weeks, New York. 
 Casey A. Wood, Chicago, til. 
 Jonathan Wright, Brooklyn. 
 H. V. Wiirdemann, Milwaukee, Wis. 
 
i6 
 
 IV. B. SAUNDERS' 
 
 * AN AMERICAN YEAR-BOOK OF MEDICINE AND SUR- 
 GERY. A Yearly Digest of Scientific Progress and Autliuritative 
 Opinion in all branches of Medicine and Surgery, drawn from journals, 
 monographs, and text-books of the leading American and Foreign authors 
 and investigators. Collected and arranged, with critical editorial com- 
 ments, by eminent American specialists and teachers, under the general 
 editorial charge of George M. Gould, M. D. Volumes for 1896, '97, 
 '98, and '99 each a handsome imperial octavo volume of about 1200 pages. 
 Prices : Cloth, $6.50 net ; Half-Morocco, $7.50 net. Year- Book for 1900 in 
 two octavo volumes of about 600 pages each. Prices per volume : Cloth, 
 ;^3.oo net; Half- Morocco, $3.75 net. 
 
 In Two Volumes. No Increase in Price, 
 
 In response to a widespread demand from the medical jirofession, the pub- 
 lisher of the "American Year-Book of Medicine and Surgery" has decided to 
 issue that well-known work in two volumes, Vol. I. treating of General Medi- 
 cine, Vol. II. of General Surgery. Each volume is complete in itself, and 
 the work is sold either separately or in sets. 
 
 This division is made in such a way as to appeal to physicians from a class 
 standpoint, one volume being distinctly medical, and the other distinctly surgi- 
 cal. This arrangement has a two-fold advantage. To the physician who uses 
 the entire book, it offers an increased amount of matter in the most convenient 
 form for easy consultation, and without any increase in price ; while the man 
 who wants either the medical or the surgical section alone secures the com])lete 
 consideration of his branch without the necessity of purchasing matter for which 
 
 he has no use. 
 
 CONTRIBUTORS : 
 
 Vol. I. 
 Dr. Samuel W, Abbolt, Boston. 
 Archibald Church, Chicago. 
 Louis A. Duhring, Philadelphia. 
 D. L. Edsall, Philadelphia. 
 Alfred Hand, Jr., Philadelphia. 
 M. B. Hartzell, Philadelphia. 
 Reid Hunt, Baltimore. 
 Wyatt Johnston, Montreal. 
 Walter Jones, Baltimore. 
 David Riesman. Philadelphia. 
 Louis Starr, Philadelphia. _ 
 Alfred Stengel, Philadelphia. 
 A. A. Stevens, Philadelphia. 
 G. N. Stewart. Cleveland. 
 Reynold W. Wilcox, New York City. 
 
 Vol. n. 
 Dr. J Montgomery Baldy, Philadelphia. 
 Charles H. Burnett, Philadelphia. 
 J. Chalmers DaCosta. Philadelphia. 
 W. A. N. Dorland, Philadelphia. 
 Virgil P. Gibney, New York City. 
 C. H. Haniann, Cleveland. 
 Howard F. Hansell, Philadelphia. 
 Barton Cooke Hirst, Philadelphia. 
 E. Fletcher Ingals, Chicago. 
 W. W. Keen, Philadelphia. 
 Henry G. Ohls, Chicago. 
 Wendell Reber, Philadelphia. 
 J. Hilton Waterman, New York City. 
 
 "It is difficult to know which to admire most— the research and industry of tne distin- 
 guished band of experts whom Dr. Gould has enlisted in the service of the Year-Book, or the 
 wealth and abundance of the contributions to every department of science that have been 
 deemed worthy of analysis. ... It is much more than a mere compilation of abstracts, for, 
 as each section is entrusted to experienced and able contributors, the reader has the advan- 
 tage of certain critical commentaries and expositions . . . proceedmg from writers fully 
 qualified to perform these tasks. ... It is emphatically a book which should find a place in 
 every medical library, and is in several respects more useful than the famous ' Jahrbucher 
 of Germany." — Londoti Lancet. 
 
CATALOGUE OF MEDICAL WORKS. ly 
 
 * ANOMALIES AND CURIOSITIES OF MEDICINE. By George 
 
 M. Gould, M.D., and Waltkr L. Pyle, M.D. An encyclopedic collec- 
 tion of are and extraordinary cases and of the most striking instances of 
 abnormality in all branches of Medicine and Surgery, derived from an ex- 
 haustive research of medical literature from its origin to the present day, 
 abstracted, classified, annotated, and indexed. Handsoiiie imperial octavo 
 volume of 968 pages, with 295 engravings in the text, and 12 full-page 
 plates. Cloth, ^3.00 net ; Half-Morocco, $4.00 net. 
 
 POPULAR EDITION REDUCED FROM $6.00 to $3.00. 
 
 In view of the greatsuccess of this magnificent work, the publisher has decided 
 to issue a " Popular Edition " at a price so low that it may be procured by every 
 student and practitioner of medicine. Notwithstanding the great reduction in 
 price, there will be no depreciation in the excellence of typography, paper, and 
 binding that characterized the earlier editions. 
 
 Several years of exhaustive research have been spent by the authors in the 
 great medical libraries of the United States and Europe in collecting the mate- 
 rial for this work. Medical literature of all ages and all languages has 
 been carefully searched, as a glance at the Bibliographic Index will show. The 
 facts, which will be of extreme value to the author and lecturer, have been 
 arranged and annotated, and full reference footnotes given. 
 
 "One of the most valuable contributions ever made to medical literature. It is, so far as 
 we know, absolutely unique, and every page is as fascinating as a novel. Not alone for the 
 medical profession has this volume value : it will serve as a book of reference for all who are 
 interested in general scientific, sociologic, or medico-legal topics." — Brooklyn Medical jfour- 
 nal. 
 
 NERVOUS AND MENTAL DISEASES. By Archibald Church, 
 M. D., Professor of Clinical Neurology, Mental Diseases, and Medical 
 Jurisprudence, Northwestern University Medical School ; and Frederick 
 Peterson, M. D., Clinical Professor of Mental Diseases, Woman's Medi- 
 cal College, New York. Handsome octavo volume of 843 pages, with 
 over 300 illustrations. Prices: Cloth, ^5.00 net; Half-Morocco, ^6.00 
 net. 
 
 Second Edition. 
 
 This book is intended to furnish students and practitioners with a practical, 
 working knowledge of nervous and mental diseases. Written by men of wide 
 experience and authority, it presents the many recent additions to the subject. 
 The book is not tilled with an extended dissertation on anatomy and pathology, 
 but, treating these points in connection with special conditions, it lays particular 
 stress on methods of examination, diagnosis, and treatment. In this respect the 
 work is unusually complete and valuable, laying down the definite courses of 
 procedure which the authors have found to be most generally satisfactory. 
 
 " The vforV. is an epitome of what is to-day known of nervous diseases prepared for the 
 student and practitioner in the light of the author's experience . . . We believe that no work 
 presents the difficult subject of insanity in such a reasonable and readable way." — Chicago 
 Medical Recorder, 
 
1 8 PV. B. SAUJ^ DENS' 
 
 DISEASES OF THE NOSE AND THROAT. By D. Bradkn Kyle. 
 • M. D., Clinical Professor of Laryngology and Rlunology, Jefferson Medi- 
 cal College, Philadelphia; Consulting Laryngologist, Rhinologist, and 
 Otologist, St. Agnes' Hospital. Octavo volume of 646 pages, with over 
 150 illustrations and 6 lithographic plates. Cloth, ^4.00 net; Half-Mo- 
 rocco, ^5.00 net. 
 
 tTust Issued. 
 
 This book presents the subject of Diseases of the Nose and Throat '.n as con- 
 cise a manner as is consistent with clearness, keeping in mind the needs of the 
 student and general practitioner as well as those of the specialist. The arrange- 
 ment and classilication are based on modern pathology, and the pathological 
 views advanceil are supported by drawings of microscopical sections made in the 
 author's own laboratory. These and the other illustrations are particularly fine, 
 lieing chiefly original. With the practical purpose of the book in mind, ex- 
 tended consideration has been given to details of treatment, each disease being 
 considered in full, and delinite courses being laid down to meet special condi- 
 tions and symptoms. 
 
 " Itisa thorough, full, and systematic tre.itise, so classified and arranged as greatly to facili- 
 tate the teachina; of laryngology and rhinology to classes, and must prove most convenient 
 and satisfactory as a reference book, both for students and practitioners." — International 
 Medical Magazine. 
 
 THE HYGIENE OF TRANSMISSIBLE DISEASES ; their Causa- 
 tion, Modes of Dissemination, and Methods of Prevention. By 
 A. C. Abbott, M. D., Professor of Hygiene in the University of Pennsyl- 
 vania; Director of the Laboratory of Hygiene. Octavo volume of 311 
 pages, v/ith charts and maps, and numerous illustrations. Cloth, ^2.00 net. 
 
 Just Issued. 
 
 It is not the purpose of this work to present the subject of Hygiene in the 
 comprehensive sense ordinarily implied by the word, but rather to deal directly 
 with but a section, certainly not the least important, of the subject — viz., that 
 embracing a knowledge of the preventable specific diseases. The book aims to 
 furnish information concerning the detailed management of transmissible dis- 
 eases. Incidentally there are discussed those numerous and varied factors that 
 have not only a direct bearing upon the incidence and suppression of such dis- 
 eases, but are of general sanitary importance as well. 
 
 " The work is admirable in conception and no less so in execution. It is a practical work, 
 simply and lucidly written, and it should prove a most helpful aid in that department of 
 medicine which is becoming daily of increasing importance and application — namely, prophy- 
 laxis." — l^hiladctphia Medical Journal. 
 
 " It is scientific, but not too technical ; it is as complete as our present-day knowledge of 
 hygiene and sanitation allows, and it is in harmony with the efforts of the profession, which 
 are tending more and more to methods of prtiphylaxis. For the student and for the practi- 
 tioner it is well nigh indispensable." — Medical Ne-MS, New York. 
 
CATALOGUE OF MEDICAL WORKS. ig 
 
 A TEXT-BOOK OF EMBRYOLOGY. By John C. Heisler, M. D., 
 Professor of Anatomy in the Medico-Chirurgical College, Philadelphia 
 Octavo volume of 405 pages, with 190 illustrations, 26 in colors. Cloth, 
 ^2.50 net. 
 
 Just Issued. 
 
 The facts of embryology having acquired in recent years such great interest 
 in connection with the teaching and with the proper comprehension of human 
 anatomy, it is of first importance to the student of medicine that a concise and 
 yet sutficiently full text-book upon the subject be available. It was with the 
 aim of presenting such a book that this volume was written, the author, in his 
 experience as a teacher of anatomy, having been impressed with the fact that 
 students were seriously handicapped in their study of the subject of embryology 
 by the lack of a text-book full enough to be intelligible, and yet without that 
 minuteness of detail which characterizes the larger treatises, and which so often 
 serves only to confuse and discourage the beginner. 
 
 " In short, the book is written to fill a want which has distinctly existed and which it 
 definitely meets ; commendation greater than this it is not possible to give to anything." — 
 Medical News, New York. 
 
 A MANUAL OF DISEASES OF THE EYE. By Edward Jack- 
 son, A. M., M. D., sometime Professor of Diseases of the Eye in the Phila- 
 delphia Polyclinic and College for Graduates in Medicine. l2mo, 604 
 pages, with 178 illustrations from drawings by the author. Cloth, ^2.50 net. 
 
 Just Issued. 
 
 This book is intended to meet the needs of the general practitioner of medi- 
 cine and the beginner in ophthalmology. More attention is given to the condi- 
 tions that must be met and dealt with early in ophthalmic practice than to the 
 rarer diseases and more difficult operations that may come later. 
 
 It is designed to furnish efficient aid in the actual work of dealing with dis- 
 ease, and therefore gives the place of first importance to the recognition and 
 management of the. conditions that present themselves in actual clinical work. . 
 
 LECTURES ON THE PRINCIPLES OF SURGERY. By Charles 
 B. Nancrede, M. D., LL.D., Professor of Surgery and of Clinical Surgery, 
 University of Michigan, Ann Arbor. Handsome octavo, 398 pages, illus- 
 trated. Cloth, ^2.50 net. 
 
 Just Issued. 
 
 The present book is based on the lectures delivered by Dr. Nancrede to his 
 undergraduate classes, and is intended as a text-book for students and a practi- 
 cal help for teachers. By the careful elimination of unnecessary details of 
 pathology, bacteriology, etc., which are amply provided for in other courses of 
 study, space is gained for a more extended consideration of the Principles of 
 Surgery in themselves, and of the application of these principles to methods 
 of practice. 
 
20 ^y. B. SAUNDERS' 
 
 A TEXT-BOOK OF PATHOLOGY. By Alfred Stengel, M. D., 
 Professor of Clinical Medicine in the University of Pennsylvania; Physi- 
 cian to the Philadelphia Hospital ; Physician to the Children's Hospital, 
 Philadelphia. Handsome octavo volume of 848 pages, with 362 illustra- 
 tions, many of which are in colors. Prices : Cloth, ;^4.oo net ; Half- 
 Morocco, ^5.00 net. 
 
 Second Edition. 
 
 In this work the practical application of pathological facts to clinical medicine 
 is considered more fully than is customary in works on ]3atliology. While the 
 subject of pathology is treated in the broadest way consistent with the size of 
 the book, an effort has been made to present the sul^ject from the point of view 
 of the clinician. The general relations of bacteriology to pathology are dis- 
 cussed at considerable length, as the importance of these branches deserves. It 
 will be found that the recent knowledge is fully considered, as well as older and 
 more widely-known facts. 
 
 " I consider the work abreast of modern pathology, and useful to both students and prac- 
 titioners. It presents in a concise and well-considered form the essential facts of general and 
 special pathological anatomy, with more than usual emphasis upon pathological physiology." 
 — William H. Welch, Professor of Pathology , fohns Ho/>kins University , Baltimore, Md. 
 " I regard it as the most sers'iceable text-book for students on this subject yet written by 
 an American author." — L. Hektoen, Professor of Pathology, Rush Medical College, 
 Chicago, III. 
 
 A TEXT-BOOK OF OBSTETRICS. By Barton Cooke Hirst, M.D., 
 Professor of Obstetrics in the University of Pennsylvania. Handsome oc- 
 tavo volume of 846 pages, with 618 illustrations and seven colored plates. 
 Prices: Cloth, ^5.00 net; Half-Morocco, $6.00 net. 
 
 Second Edition. 
 
 This work, which has been in course of preparation for several years, is in- 
 tended as an ideal text-book for the student no less than an advanced treatise 
 for the obstetrician and for general practitioners. It represents the very latest 
 teaching in the practice of obstetrics by a man of extended experience and 
 recognized authority. The book emphasizes especially, as a work on obstetrics 
 should, the practical side of the subject, and to this end presents an unusually 
 large collection of illustrations. A great number of these are new and original, 
 and the whole collection will form a complete atlas of obstetrical practice. 
 An extremely valuable feature of the book is the large number of refer- 
 ences to cases, authorities, sources, etc., forming, as it does, a valuable bib- 
 liography of the most recent and authoritative literature on the subject 
 of obstetrics. As already stated, this work records the wide practical ex- 
 perience of the author, which fact, combined with the brilliant presentation 
 of the subject, will doubtless render this one of the most notable books on 
 obstetrics that has yet appeared, 
 
 " The illustrations are numerous and are works of art, many of them appearing for the 
 first time. The arrangement of the subject-matter, the foot-notes, and index are beyond 
 criticism. The author's style, though condensed, is singularly clear, so that it is never 
 necessarj' to re-read a sentence in order to grasp its meaning. As a true model of what a 
 modern text-book in obstetrics should be, we feel justified in affirming that Dr. Hirst's 
 book is without a rival." — New York Medical Record. 
 
CATALOGUE OF MEDICAL WORKS. 21 
 
 A TEXT-BOOK OF THE PRACTICE OF MEDICINE. By 
 
 James M. Anders, M.D., Ph.D., LL.D., Professor of the Practice of 
 Medicine and of Clinical Medicine, Medico-Chirurgical College, Philadel- 
 phia. In one handsome octavo volume of 1292 pages, fully illustrated. 
 Cloth, ^5.50 net ; Sheep or Half-Morocco, $6.50 net. 
 
 THIRD EDITION, THOROUGHLY REVISED. 
 
 The present edition is the result of a careful and thorough revision. A few 
 new subjects have been introduced : Glandular Fever, Ether-pneumonia, Splenic 
 Anemia, Meralgia Paresthetica, and Periodic Paralysis. The affections that 
 have been substantially rewritten are: Plague, Malta Fever, Diseases of the 
 Thymus Gland, Liver Cirrhoses, and Progressive Spinal Muscular Atrophy. 
 The following articles have been extensively revised : Typhoid Fever, Yellow 
 Fever, Lobar Pneumonia, Dengue, Tuberculosis, Diabetes Mellitus, Gout, Ar- 
 thritis Deformans, Autumnal Catarrh, Diseases of the Circulatory System, more 
 particularly Hypertrophy and Dilatation of the Heart, Arteriosclerosis and 
 Thoracic Aneurysm, Pancreatic Hemorrhage, Jaundice, Acute Peritonitis, Acute 
 Yellow Atrophy, Hematoma of Dura Mater, and Scleroses of the Brain. The 
 preliminary chapter on Nervous Diseases is new, and deals with the subject of 
 localization and the various methods of investigating nervous affections. 
 
 "It is an excellent book — concise, comprehensive, thorough, and up to date. It is a 
 credit to you; but, more than that, it is a credit to the profession of Philadelphia— to us." 
 — James C. Wilson, Professor of the Practice of Medicine and Clinical Medicine, Jeffer- 
 son Medical College, Philadelphia. 
 
 " The book can be unreservedly recommended to students and practitioners as a safe, full 
 compendium of the knowledge of internal medicine of the present day ... It is a work 
 thoroughly modern in every sense." — Medical News, New York. 
 
 DISEASES OF THE STOMACH. By William W. Van Vai.zah, 
 M. D., Professor of General Medicine and Diseases of the Digestive System 
 and the Blood, New York Polyclinic; and J. Douglas Nisbet, M. D., 
 Adjunct Professor of General Medicine and Diseases of the Digestive Sys- 
 tem and the Blood, New York Polyclinic. Octavo volume of 674 pages, 
 illustrated. Cloth, ^3.50 net. 
 
 An eminently practical book, intended as a guide to the student, an aid to the 
 physician, and a contribution to scientific medicine. It aims to give a complete 
 description of the modern methods of diagnosis and treatment of diseases of the 
 stomach, and to reconstruct the pathology of the stomach in keeping with the 
 revelations of scientific research. The book is clear, practical, and complete, 
 and contains the results of the authors' investigations and of their extensive ex- 
 perience as specialists. Particular attention is given to the important subject of 
 dietetic treatment. The diet-lists are very complete, and are so arranged that 
 selections can readily be made to suit individual cases. 
 
 " This is the most satisfactory work on the subject in the English language." — Chicago 
 Medical Recorder, 
 
 " The article on diet and general medication is one of the most valuable in the book, and 
 should be read by every practising physician." — New York Medical Journal. 
 
22 IV. B. SAUNDERS' 
 
 SURGICAL DIAGNOSIS AND TREATMENT. By J. W. Mac- 
 DONAi.D, M. D., Edin., !•". R. C. S., Edin., Professor of the Practice of Sur- 
 gery and of Clinical Surgery in Haniline University; Visiting Surgeon to St. 
 Barnabas' Hospital, Minneapolis, etc. Handsome octavo volume of 800 
 pages, profusely illustrated. Cloth, $5.00 net; Half-Morocco, $6.00 net. 
 This work aims in a comprehensive manner to furnish a guide in matters of 
 surgical diagnosis. It sets forth in a systematic way the necessities of examina- 
 tions and the proper methods of making them. The various portions of the 
 body are then taken up in order and the diseases and injuries thereof succinctly 
 considered and the treatment briefly indicated. Practically all the modern and 
 approved operations are described with thoroughness and clearness. The work 
 concludes with a chapter on the use of the Rontgen rays in surgery. 
 
 " The work is brimful of just the kind of practical information that is useful alike to 
 students and practitioners. It is a pleasure to commend the book because of its intrinsic 
 value to the medical practitioner." — Cincinnati Lancet-Clinic. 
 
 PATHOLOGICAL TECHNIQUE. A Practical Manual for Laboratory 
 Work in Pathology, Bacteriology, and Morbid Anatomy, with chapters on 
 Post-Mortem Technique and the Performance of Autopsies. By Frank 
 B. Mallory, A. M., M. D., Assistant Professor of Pathology, Harvard 
 University Medical School, Boston; and James H. Wright, A. M., M.D., 
 Instructor in Pathology, Harvard University Medical School, Boston. Oc- 
 tavo volume of 396 pages, handsomely illustrated. Cloth, 52.50 net. 
 This book is designed especially for practical use in pathological laboratories, 
 both as a guide to beginners and as a source of reference for the advanced. The 
 book will also meet the wants of practitioners who have opportunity to do general 
 pathological work. Besides the methods of post-mortem examinations and of 
 bacteriological and histological investigations connected with autopsies, the 
 special methods employed in clinical bacteriology and pathology have been 
 fully discussed. 
 
 " One of the most complete works on the subject, and one which should be in the library 
 of every physician who hopes to keep pace with the great advances made in pathology." — 
 jfournat of American Medical Association. 
 
 THE SURGICAL COMPLICATIONS AND SEQUELS OF TY- 
 PHOID FEVER. By Wm. W. Keen, M. D., LL.D., Professor of the 
 Principles of Surgery and of Clinical Surgery, Jefferson Medical College, 
 Philadelphia. Octavo volume of 386 pages, illustrated. Cloth, ^3.00 net. 
 This monograph is the only one in any language covering the entire subject 
 of the Surgical Complications and Sequels of Typhoid Fever. The work will 
 prove to be of importance and interest not only to the general surgeon and phy- 
 sician, but also to many s]^ecialists — laryngologists, ophthalmologists, gynecolo- 
 gists, pathologists, and bacteriologists — as the subject has an important bearing 
 upon each one of their spheres. The author's conclusions are based on reports 
 of over 1700 cases, including practically all those recorded in the last fifty years. 
 Reports of cases have been Iirought down to date, many having been added 
 while the work was in press. 
 
 " This is probably the first and only work in the English language that gives the reader a 
 clear view of what typhoid fever really is, and what it does and can do to the human organ- 
 ism. This book should be in the possession of every medical man in America." — American 
 Medico-Surgical Bulletin, 
 
CATALOGUE OF MEDICAL WORKS. 23 
 
 MODERN SURGERY, GENERAL AND OPERATIVE. By John 
 Chalmers DaCosta, M. D., Professor of Practice of Surgery and Clin- 
 ical Surgery, Jefferson Medical College, Philadelphia; Surgeon to the Phil- 
 adelphia Hospital, etc. Handsome octavo volume of 911 pages, profusely 
 illustrated. Cloth, ^4.00 net ; Half-Morocco, ^5.00 net. 
 
 Second Edition, Rewritten and Greatly Enlarged. 
 
 The remarkable success attending DaCosta's Manual of Surgery, and the 
 general favor with which it has been received, have led the author in this 
 revision to produce a complete treatise on modern surgery along the same lines 
 that made the former edition so successful. The book has been entirely re- 
 written nnd very much enlarged. The old edition has long been a favorite not 
 only with students and teachers, but also with practising physicians and sur- 
 geons, and it is believed that the present work will find an even wider field of 
 usefulness. 
 
 " We know of no small work on surgery in the English language which so well fulfils the 
 requirements of the modern student." — Medico-Chirurgical Journal, Bristol, England. 
 
 " The author has presented concisely and accurately the principles of modern surgery. 
 The book is a valuable one which can be recommended to students and is of great value to 
 the general practitioner." — American Jojirnal of the Medical Sciences. 
 
 A MANUAL OF ORTHOPEDIC SURGERY. By James E. Moore, 
 M.D., Professor of Orthopedics and Adjunct Professor of Clinical Surgery, 
 University of Minnesota, College of Medicine and Surgeiy. Octavo volume 
 of 356 pages, with 177 beautiful illustrations from photographs made spec- 
 ially for this work. Cloth, ^2.50 net. 
 
 A practical book based upon the author's experience, in which special stress 
 
 . is laid upon early diagnosis and treatment such as can be carried out by the 
 
 general practitioner. The teachings of the author are in accordance with his 
 
 belief that true conservatism is to be found in the middle course between the 
 
 surgeon who operates too frequently and the orthopedist who seldom operates. 
 
 "A very demonstrative work, every illustration of which conveys a lesson. The work is 
 a most excellent and commendable one, which we can certainly endorse with pleasure." — 
 St. Louis Medical and Surgical Journal. 
 
 ELEMENTARY BANDAGING AND SURGICAL DRESSING, 
 
 With Directions concerning the Immediate Treatment of Cases of Emer- 
 gency. For the use of Dressers and Nurses. By Walter Pye, F.R.C.S., 
 late Surgeon to St. Mary's Hospital, London. Small i2mo, with over 80 
 illustrations. Cloth, flexible covens, 75 cents net. 
 
 This little book is chiefly a condensation of those portions of Pye's " Surgical 
 Handicraft" which deal with bandaging, splinting, etc., and of those which 
 treat of the management in the first instance of cases of emergency. The 
 directions given are thoroughly practical, and the book will prove extremely use- 
 ful to students, surgical nurses, and dressers. 
 
 "The author writes well, the diagrams are clear, and the book itself is small and portable, 
 although the paper and type are good." — British Medical Journal. 
 
24 fV. B. SAUNDERS' 
 
 A TEXT-BOOK OF MATERIA MEDICA, THERAPEUTICS 
 AND PHARMACOLOGY. By George F. Butler, Ph.G., M.D., 
 rrofessor of Materia Medica and of Clinical Medicine in the College of 
 Physicians and Surgeons, Chicago; Professor of Materia Medica and 
 Therapeutics, Northwestern University, Woman's Medical School, etc 
 Octavo, 874 pages, illustrated. Cloth, $4.00 net ; Sheep, $5.00 net. 
 Third Edition, Thoroughly Revised. 
 A clear, concise, and practical text-book, adapted for permanent reference no 
 less than for the requirements of the class-room. 
 
 The recent important additions made to our knowledge of the physiological 
 action of drugs are fully discussed in the present edition. The book has been 
 thoroughly revised and many additions have been made. 
 
 " Taken as a whole, the book may fairly be considered as one of the most satisfactory of any 
 single-volume works on materia medica in the market."— y^arwa/ <y i/te American Medical 
 Association . 
 
 TUBERCULOSIS OF THE GENITO-URINARY ORGANS, 
 MALE AND FEMALE. By Nicholas Senn, M.D., Ph.D., LL.D., 
 Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical 
 College, Chicago. Handsome octavo volume of 320 pages, illustrated^ 
 Cloth, $3.00 net. 
 Tuberculosis of the male and female genito-urinary organs is such a frequent, 
 distressing, and fatal affection that a special treatise on the subject appears to 
 fill a gap in medical literature. In the present work the bacteriology of the sub- 
 ject has received due attention, the modern resources employed in the differen- 
 tial diagnosis between tubercular and other inflammatory affections are fully 
 described, and the medical and surgical therapeutics are discussed in detail. 
 
 "An important book upon nn important subject, and written by a man of mature judg- 
 ment and wide experience. The author has given us an instructive book upon one of the 
 most important subjects of the day." — Clinical Reporter. 
 
 "A work which adds another to the many obligations the profession owes the talented 
 author." — Chicago Medical Recorder. 
 
 A TEXT-BOOK OF DISEASES OF WOMEN. By Charles B. 
 Penrose, M.D., Ph.D., Professor of Gynecology in the University of 
 Pennsylvania; Surgeon to the Gynecean Hospital, Philadelphia. Octavo 
 volume of 531 pages, with 217 illustrations, nearly all from drawings made 
 for this work. Cloth, ^3.75 net. 
 
 Third Edition, Revised, 
 
 In this work, which has been written for both the student of gynecology and 
 the general practitioner, the author presents the best teaching of modern gyne- 
 cology untrammelled by antiquated theories or methods of treatment. In most 
 instances but one plan of treatment is recommended, to avoid confusing the 
 student or the physician who consults the book for practical guidance. 
 
 " I shall value very highly the copy of Penrose's ' Diseases of Women' received. I have 
 already recommended it to my class as THE BEST book." — Howard A. K.v.iaj^ , Professor 
 0/ Gynecology and Obstetrics, Johtis Hopkins University, Baltimore, Md. 
 
 " The book is to be commended without reserve, not only to the student but to the general 
 practitioner who wishes to have the latest and best modes of treatment explained with absolute 
 clearness." — Therapeutic Gazette. 
 
CATALOGUE OF MEDICAL WORKS. 25 
 
 SURGICAL PATHOLOGY AND THERAPEUTICS. By John 
 Collins Warren, M.D., LL.D., Professor of Surgery, Medical Depart- 
 ment Harvard University. Handsome octavo, 832 pages, with 136 relief 
 and lithographic illustrations, 2iZ <^f which are printed in colors. 
 
 Second Edition, 
 
 with an Appendix devoted to the Scientific Aids to Surgical Diagnosis, and 
 a series of articles on Regional Bacteriology. Cloth, ^5.00 net; Half- 
 Morocco, ;^6.oo net. 
 
 Without Exception, the Illustrations are the Best ever Seen in a 
 Work of this Kind. 
 
 "A most striking and very excellent feature of this book is its illustrations. Without ex- 
 ception, from the point of accuracy and artistic merit, they are the best ever seen in a work 
 of this kind, * * * Many of those representing microscopic pictures are so perfect in their 
 coloring and detail as almost to give the beholder the impression that he is looking down the 
 barrel of a microscope at a well-mounted section." — Annah of Surgery, Philadelphia. 
 
 " It is the handsomest specimen of book-making * * * that has ever been issued from the 
 American medical press." — Ainerican Journal of the Medicai Sciences , Philadelphia. 
 
 PATHOLOGY AND SURGICAL TREATMENT OF TUMORS. 
 
 By N. Senn, M. D., Ph. D., LL. D., Professor of Practice of Surgery and 
 of Clinical Surgery, Rush Medical College; Professor of Surgery, Chicago 
 Polyclinic ; Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, 
 St. Joseph's Hospital, Chicago. One volume of 710 pages, with 515 
 engravings, including full-page colored plates. New and enlarged Edition 
 in Preparation. 
 
 Books specially devoted to this subject are few, and in our text-books and 
 systems of surgery this part of surgical pathology is usually condensed to a de- 
 gree incompatible with its scientific and clinical importance. The author spent 
 many years in collecting the material for this work, and has taken great pains 
 to present it in a manner that should prove useful as a text-book for the student, 
 a work of reference for the practitioner, and a reliable guide for the surgeon. 
 
 " The most exhaustive of any recent book in English on this subject. It is well illus- 
 trated, and will doubtless remain as the principal monograph on the subject in our language 
 for some years. The book is handsomely illustrated and printed, .... and the author has 
 given a notable and lasting contribution to surgery." — Jotirnal of the American Medical 
 Association, Chicago, 
 
 LECTURES ON RENAL AND URINARY DISEASES. By 
 
 Robert Saundby, M. D., Edin., Fellow of the Royal College of Physicians, 
 London, and of the Royal Medico-Chirurgical Society; Physician to the 
 General Hospital. Octavo volume of 434 pages, with numerous illustra- 
 tions and 4 colored plates. Cloth, ^2.50 net. 
 
 "The volume makes a favorable impression at once. The style is clear and succinct. 
 We cannot find any part of the subject in which the views expressed are not carefully thought 
 out and fortified by evidence drawn from the most recent sources. The book may be cordially 
 recommended." — British Medical Journal. 
 
26 IV. B. SAUNDERS' 
 
 A HANDBOOK FOR NURSES. By J. K. Watson, M.D., Eiiin.. 
 
 ' Assistant IIouse-Suigeo:i, Shefliekl Royal Hospital. American Edition, 
 
 under the supervision of A. A. Stevens, A. M., M. D., Professor of 
 
 Pathology, Woman's Medical College, Philadelphia. l2mo, 413 pages, 
 
 73 illustrations. Cloth, $1.50 net. 
 
 This work aims to supply in one volume that information which so many 
 nurses at the present time are trying to extract from various medical works, and 
 10 present that information in a suitable form. Nurses must necessarily ac(|uire 
 a certain amount of medical knowledge, and the author of this book has aimed 
 judiciously to cater to this need with the object of directing the nurses' pursuit 
 of medical information in proper and legitimate channels. The book represents 
 an entirely new departure in nursing literature, insomuch as it contains useful 
 information on medical and surgical matters hitherto only to be obtained from 
 expensive works written expressly for medical men. 
 
 A NEW PRONOUNCING DICTIONARY OF MEDICINE, with 
 Phonetic Pronunciation, Accentuation, Etymology, etc. By John 
 M. Kkating, M. D., LL.D., Fellow of the College of Physicians of Phila- 
 delphia; Etlitor "Cyclopaedia of the Diseases of Children," etc.; and 
 Henry Hamilton, with the Collaboration of J. Chalmers DaCosta, 
 M. D,, and FREDERICK A. Packard, M. D. One very attractive volume 
 of over 800 pages. Second Revised Edition. Prices: Cioth, ^5.00 net ; 
 Sheep or Half-Morocco, ^6.00 net; with Denison's Patent Ready- Refer- 
 ence Index ; without patent index. Cloth, $400 net ; Sheep or Hali- 
 Morocco, ^5.00 net. 
 
 PROFESSIONAI. OPIHriOBTS. 
 
 " I am much pleased with Keating's Dictionary, and shall take pleasure in recommending 
 it to my classes." 
 
 Henkv M. Lyman, M. D., 
 Professor of Principles and Practice of Medicine^ Rush Medical College, Chicafco, III. 
 
 ' I am convinced that it wiii De a verj' valuable adjunct to my study-table, convenient in 
 size and sufficiently full for ordinary use." 
 
 C A. LiNDSLEY, M. D., 
 i-rq/essor of Theory and Practice 0/ Medicine, Medical Defit. Yale University : 
 
 Secretary Connecticut State Board 0/ Health, Neiv Haven. Conn. 
 
 AUTOBIOGRAPHY OF SAMUEL D. GROSS, M. D., Emeritus Pro- 
 fessor of Surgery in the Jefferson Medical College of Philadelphia, with 
 Reminiscences of His Times and Contemporaries. Edited by his sons, 
 Samuel W. Gross, M. D., LL.D., and A. Haller Gross, A.M., of the 
 Philadelphia Bar. Preceded by a Memoir of Dr. Gross, by the late 
 Austin Flint, M. D., LL.D. In two handsome volumes, each containing 
 over 400 pages, demy 8vo, extra cloth, gilt tops, with fine Frontispiece 
 etigraved on steel. Price per Volume, ;^2.5o net. 
 
CATALOGUE OF MEDICAL WORKS. 2/ 
 
 PRACTICAL POINTS IN "NURSING. For Nurses in Private 
 Practice. By Emily A. M. Sidney, Graduate of the Training-SchooI 
 lor Nurses, Lawrence, Mass. ; Superintendent of the Training-School for 
 iVurses, Carney Hospital, South Boston, Mass. 456 pages, handsomely 
 illustrated with 73 engravings in the text, and 9 colored and half-tone 
 Dlates. Cloth. Price, ti.l^ net 
 
 SECOND EDITION, THOROUGHLY REVISED, 
 
 In this volume the author explains, in popular language and in the shortest 
 possible form, the entire range of frivate nursing as distinguished from hospital 
 nursing, and the nurse is instructed how best to meet the various emergencies of 
 medical and surgical cases when distant from medical or surgical aid or when 
 thrown on her own resources. 
 
 t\.\\ especially valuable feature of the -work will be found in the directions to 
 the nurse how to improvise everything ordinarily needed in the sick-room, where 
 the embarrassment of the nurse, owing to the want of proper appliances, is fre- 
 quently extreme. 
 
 The work has been logically divided into the following sections : 
 
 I. The Nurse : her responsibilities, qualifications, equipment, etc. 
 II. The Sick-Room : its selection, preparation, and management. 
 Till. The Patient : duties of the nurse in medical, surgical, obstetric, a.nd gyne- 
 cologic cases. 
 IV. Nursing in Accidents and Emergencies. 
 V. Nursing in Special Medical Cases. 
 VI. Nursing of the New-born and Sick Children. 
 VII. Physiology and Descriptive Anatomy. 
 
 The Appendix contains much information m compact form that will be found 
 of great value to the nurse, including Rules for Feeding the Sick; Recipes for 
 Invalid Foods and Beverages ; Tables of Weights and Measures ; Table for 
 Computing the Date of Labor ; List of Abbreviations ; Dose-List ; and a full 
 and complete Glossary of Medical Terms and Nursing Treatment. 
 
 "This is a well-written, eminently practical volume, which covers the entire range of 
 private nursing as distinguished from hospital nursing, and instructs the nurse how best to 
 meet the various emergencies which may arise and how to prepare everything ordinarily 
 needed in the illness of her patient." — American Jo7ir7ial of Obstetrics and Diseases of 
 Women and Children, Aue., i8g6. 
 
 A TEXT-BOOK OF BACTERIOLOGY, including the Etiology and 
 Prevention of Infective Diseases and an account of Yeasts and Moulds, 
 Hsemalozoa, and Psorosperms. By Edgar M. Crookshank, M. B., Pro- 
 lessor of Comparative Pathology and Bacteriology, King's College, London. 
 A handsome octavo volume of 700 pages, with 273 engravings in the text, 
 and 22 original and colored plates. Price. ^6.50 net. 
 
 This book, though nominally a Fourth Edition of Professor Crookshank's 
 " Manual of Bacteriology," is practically a new work, the old one having 
 been reconstructed, greatly enlarged, revised throughout, and largely rewritten, 
 forming a text-book for the Bacteriological Laboratory, for Medical Ofhcers of 
 Health, and for Veterinary Insoectors. 
 
28 IV. B. SAUNDERS' 
 
 MEDICAL DIAGNOSIS. By Dr. Oswald Vierordt, Professor of 
 Medicine at the University of Heidelberg. Translated, with additions, 
 from the Fifth Enlarged German Edition, with the author's permission, by 
 Francis H. Stuart, A. M., M. D. In one handsome royal-octavo volume 
 of 600 pages. 194 fine wood-cuts in the text, many of them in colors. 
 Prices: Cloth, $4.00 net; Sheep or Half- Morocco, $5.00 net. 
 
 FOURTH AMERICAN EDITION, FROM THE FIFTH REVISED AND 
 ENLARGED GERMAN EDITION. 
 
 In this work, as in no other hitherto published, are given full and accurate 
 explanations of the phenomena observed at the bedside. It is distinctly a clin- 
 ical work by a master teacher, characterized by thoroughness, fulness, and accu- 
 racy. It is a mine of information upon the points that are so often passed over 
 without explanation. Especial attention has been given to the germ-theory as a 
 factor in the origin of disease. 
 
 The present edition of this highly successful work has been translated from 
 the fifth German edition. Many alterations have been made throughout the 
 book, but especially in the sections on Gastric Digestion and the Nervous System. 
 
 It will be found that all the qualities which served to make the earlier editions 
 so acceptable have been developed with the evolution of the work to its present 
 form. 
 
 THE PICTORIAL ATLAS OF SKIN DISEASES AND SYPHI- 
 LITIC AFFECTIONS. (American Edition.) Translation from 
 the French. Edited by J. J. Pringle, M. B., F. R. C. P., Assistant Phy- 
 sician to, and Physician to the department for Diseases of the Skin at, the 
 Middlesex Hospital, London. Photo-lithochromes from the famous models 
 of dermatological and syphilitic cases in the Museum of the Saint-Louis 
 Hospital, Paris, with explanatory wood-cuts and letter-press. In 12 Parts, 
 at $3.00 per Part. 
 
 " Of all the atlases of skin diseases which have been published in recent years, the present 
 one promises to be of greatest interest and value, especially from the standpoint of the 
 general practitioner." — American Medico-Surgical Bulletin, Feb. 22, 1896. 
 
 "The introduction of explanatory wood-cuts in the text is a novel and most important 
 feature which greatly furthers the easier understanding of the excellent plates, than which 
 nothing, we venture to say, has been seen better in point of correctness, beauty, and general 
 merit." — Neiv York Medical Journal, Feb. 15, 1896. 
 
 " An interesting feature of the Atlas is the descriptive text, which is written for each picture 
 by the physician who treated the ca-se or at whose instigation the models have been made. 
 We predict for this truly beautiful work a large circulation in all parts of the medical world 
 where the names St. Louis and Baretta have preceded it." — Medical Record, N. Y., Feb. i, 
 1896. 
 
 A TEXT-BOOK OF MECHANO-THERAPY (MASSAGE AND 
 MEDICAL GYMNASTICS). By Axel V. Grafstrom, B. Sc, 
 M. D., late Lieutenant in the Royal Swedish Army; late House Physi- 
 cian, City Hospital, Blackwell's Island, New York. i2mo, 139 pages, 
 illustrated. Cloth, ^i. 00 net. 
 
CATALOGUE OF MEDICAL WORKS. 2g 
 
 DISEASES OF THE EYE. A Hand-Book of Ophthalmic Prac- 
 tice. By G. E. DE SCHWEINITZ, M. D., Professor of Ophthalmology in 
 the Jefferson Medical College, Philadelphia, etc. A handsome royal- 
 octavo volume of 696 pages, with 255 fine illustrations, many of which are 
 original, and 2 chromo-lithographic plates. Prices : Cloth, ^4.00 net ; 
 Sheep or Half-Morocco, ^5.00 net. 
 
 THIRD EDITION, THOROUGHLY REVISED. 
 
 In the third edilion of this text-book, destined, it is hoped, to meet the favor- 
 able reception which has been accorded to its predecessors, the work has been 
 revised thoroughly, and much new matter has been introduced. Particular 
 attention has been given to the important relations which micro-organisms bear 
 to many ocular diseases. A number of special paragraphs on new subjects have 
 been introduced, and certain articles, including a portion of the chapter on 
 Operations, have been largely rewritten, or at least materially changed. A 
 number of new illustrations have been added. The Appendix contains a full 
 description of the method of determining the corneal astigmatism with the 
 ophthalmometer of Javal and Schiotz, and the rotation of the eyes with the 
 tropometer of Stevens. 
 
 "A work that will meet the requirements not only of the specialist, but of the general 
 practitioner in a rare degree. I am satisfied that unusual success awaits it." 
 
 William Pepper, M. D. 
 Provost and Professor of Theory and Practice of Medicine and Clinical Medicine 
 in the University of Pennsylvania. 
 
 "A clearly written, comprehensive manual. . . . One which we can commend to students 
 as a reliable text-book, written with an evident knowledge of the wants of those entering upon 
 the study of this special branch of medical science." — British Medical Journal. 
 
 " It is hardly too much to say that for the student and practitioner beginning the study of 
 Ophthalmology, it is the best single volume at present published." — Medical News. 
 
 " It is a very useful, satisfactory, and safe guide for the student and the practitioner, and 
 one of the best works of this scope in the English language." — Annals of Ophthalmology. 
 
 DISEASES OF WOMEN. By J. Bland Sutton, F.R. C. S., Assistant 
 Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital, London ; 
 and Arthur E. Giles, M. D., B. Sc, Lond., F. R.C. S., Edin., Assistant 
 Surgeon to Chelsea Hospital, London. 436 pages, handsomely illustrated. 
 Cloth, ^2.50 net. 
 
 The authors have placed in the hands of the physician and student a concise 
 yet comprehensive guide to the study of gynecology in its most modern develop- 
 ment. It has been their aim to relate facts and describe methods belonging to 
 the science and art of gynecology in a way that will prove useful to students for 
 examination purposes, and which will also enable the general physician to prac- 
 tice this important department of surgery with advantage to his patients and with 
 satisfaction to himself. 
 
 " The book is very well prepared, and is certain to be well received by the medical public." 
 — British Medical Journal. 
 
 "The text has been carefully prepared. Nothing essential has been omitted, and its 
 teachings are those recommended by the leading authorities of the Aa.y."—Journal of the 
 American Medical Association, 
 
30 m: £. SAUNDEk^'^ 
 
 TEXT-BOOK UPON THE PATHOGENIC BACTERIA, bpt-.- 
 cially written for Students of Medicine. By Joseph McFarland. 
 M. D., Professor of Pathology and Bacteriology in the Medico-Chirurgical 
 College of Philadelphia, etc. 497 pages, finely illustrated. Price, Cloth, 
 52.50 net. 
 
 SECOND EDITION, REVISED AND GREATLY ENLARGED. 
 The work is intended to be a text-book for tlic medical student and for the 
 practitioner who has had no recent laboratory training \\\ this department of medi- 
 cal science. Tlie instructions given as to needed ai)])aratus, cultures, stainings, 
 microscopic examinations, etc. are ample for the student's needs, and will aflbrd 
 to the physician much information that will interest and prolit him relative to a 
 subject which modern science shows to go far in explaining the etiology ot many 
 diseased conditions. 
 
 In this second edition the work has been brought up to date in all depart- 
 ments of the subject, and numerous additions have been made to the technique 
 in the endeavor to make the book fulfil the double purpose of a systematic work 
 upon bacteria and a laboratory guiae. 
 
 " It is excellently adapted for the medical students and practitioners for whom it is avowedly 
 written. . . . The descriptions given are accurate and readable, and the book should prove 
 useful to those for whom it is written. — London Lancet, Aug. 29, 1891). 
 
 " The author has sncceded admirably in presenting the essential details of bacteriological 
 technics, together with a judiciously chosen summary of our present knowledge of pathogenic 
 bacteria. . . . The work, we think, should have a wide circulation among English-speaking 
 students of medicine." — N. Y. Medical Journal, April 4, 1896. 
 
 " The book will be found of considerable use by medical men who have not had a special 
 bacteriological training, and who desire to understand this important branch of medical 
 science." — Edinburgh Medical Journal, July, i8y£. 
 
 LABORATORY GUIDE FOR THE BACTERIOLOGIST. By 
 
 Langdon Frothingham, M. D. V., Assistant in Bacteriology and Veteri- 
 nary Science, Sheffield Scientific School. Yale University. Illustrated. 
 Price, Clotn, 75 cents. 
 
 The technical methods involved in bacteria-culture, methods of staining, ana 
 microscopical study are fully described and arranged as simply and concisely as 
 possible. The book is especially intended for use in laboratory woric 
 
 " It is a convenient and useful little work, and will more than repay the outlay necessary 
 for its purchase in the saving of time which would otherwise be consumed in looking up trie 
 various points of technique so clearly and concisely laid down in its pages." — Jinierican ikea.- 
 Surg. Bulleiin. 
 
 FEEDING IN EARLY INFANCY. By Arthur V. Meigs, M. D. 
 Bound in limp cloth; flush edges. Price, 25 cents net. 
 
 Synopsis : Analyses of Milk — Importance of the Subject of Feeding in Early 
 Infancy — Proportion of Casein and Sugar in Human Milk — Time to Begin Arti- 
 ficial Feeding of Infants — Amount of Food to be Administered at Each Feed- 
 ing — Intervals between Feedings — Increase in Amount of Food at Different 
 Periods of Infant Development — Unsuitableness of Condensed Milk as a Sub- 
 stitute for Mother's Milk — Objections to Sterilization or " Pasteurization " erf 
 Milk — Advances made in the Method of Artificial Feeding of Infants. 
 
CATALOGUE OF MEDICAL WORKS. 3I 
 
 MATERIA MEDICA FOR NURSES. By Emily A. M, Stoney, 
 
 Graduate of the Training-school for Nurses, Lawrence, Mass. ; late 
 Superintendent of the Training-school for Nurses, Carney Ilosijital, South 
 Boston, Mass. Handsome octavo, 300 pages. Cloth, ^1.50 net. 
 
 The present book differs from other similar works in several features, all of 
 which are introduced to render it more practical and generally useful. The 
 general plan of contents follows the lines laid down in training-schools for 
 nurses, but the book contains much useful matter not usually included in works 
 of this character, such as Poison-emergencies, Ready Dose-list, Weights and 
 Measures, etc., as well as a Glossary, defining all the terms in Materia Medica, 
 and describing all the latest drugs and remedies, which have been generally 
 neglected by other books of the kind. 
 
 ESSENTIALS OF ANATOMY AND MANUAL OF PRACTI"^ 
 
 CAL DISSECTION, containing " Hints on Dissection." By Charle.s 
 B. Nancrede, M. D., Professor of Surgery and Clinical Surgery in the 
 University of Michigan, Ann Arbor ; Corresponding Member of the Royal 
 Academy of Medicine, Rome, Italy; late Surgeon Jefferson Medical Col- 
 lege, etc. Fourth and revised edition. lost 8vo, over 500 pages, with 
 handsome full -page lithographic plates in colors, and over 200 illustrations. 
 Price : Extra Cloth or Oilcloth for the dissection-room, ^2.00 net. 
 
 Neither pains nor expense nas been spared to make this work the most ex- 
 haustive yet concise Student's Manual of Anatomy and Dissection ever pub- 
 lished, either in America or in Europe. 
 
 The colored plates are designed to aid the student in dissecting the muscles 
 arteries, veins, and nerves. The wood-cuts have all been specially drawn ancj 
 engraved, and an Appendix added containing 60 illustrations representing the 
 structure of the entire human skeleton, the whole being based on the eleventh 
 edition of Gray's Anatomy^ 
 
 A MANUAL OF PRACTICE OF MEDICINE. By A. A. Stevens, 
 A. M., M. D., Instructor in Physical Diagnosis in the University of Penn- 
 sylvania, and Professor of Pathology in the Woman's Medical College of 
 Pennsylvania. Specially intended for students preparing for graduation 
 and hospital examinations. Post 8vo, 519 pages. Numerous illustrations 
 and selected formulae. Price, bound in flexible leather, ^2.00 net. 
 
 FIFTH EDITION, REVISED AND ENLARGED. 
 
 Contributions to tlie science ot medicine have poured in so rapidly during the 
 last quarter of a century that it is well-nigh impossible for the student, with the 
 limited time at his disposal, to master elaborate treatises or to cull from them 
 that knowledge which is absolutely essential. From an extended experience m 
 teaching, the author has been enabled, by classification, to group allied symp- 
 toms, and by the judicious elimination of theories and redundant explanations 
 to brmg vvithir. r. '""mDaratively small compass a complete outline of the prac« 
 tice ot medicme. 
 
32 IV. B. SAUNDERS 
 
 MANUAL OF MATERIA MEDICA AND THERAPEUTICS. 
 
 By A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the 
 University of Pennsylvania, and Professor of Pathology in the Woman's 
 Medical College of Pennsylvania. 445 pages. Price, bound in flexible 
 leather, $2.25. 
 
 SECOND EDITION, REVISED. 
 
 This wholly new volume, which is based on the last edition of the Pharma- 
 copoeia, comprehends the following sections : Physiological Action of Drugs ; 
 Drugs; Remedial Measures other than Drugs; Applied Therapeutics; Incom- 
 patibility in Prescriptions; Table of Doses; Index of Drugs; and Index of 
 Diseases; the treatment being elucidated by more than two hundred formulae. 
 
 " The author is to be congratulated upon having presented the medical student with as 
 accurate a manual of therapeutics as it is possible to prepare." — Tlierapeutic Gazette. 
 
 " Far superior to most of its class ; in fact, it is very good. Moreover, the book is reliable 
 and accurate." — A^e^u York Medical Journal. 
 
 " The author has faithfully presented modern therapeutics in a comprehensive work, . . . 
 and it will be found a reliable guide." — University Medical Magazine. 
 
 NOTES ON THE NEWER REMEDIES: their Therapeutic Ap- 
 plications and Modes of Administration. By David Cerna, M. D., 
 Ph. D., Demonstrator of and Lecturer on Experimental Therapeutics in 
 the University of Pennsylvania. Post-octavo, 253 pages. Price, j?l.25. 
 
 SECOND EDITION, RE-WRITTEN AND GREATLY ENLARGED. 
 
 The work takes up in alphabetical order all the newer remedies, giving their 
 physical properties, solubility, therapeutic applications, administration, and 
 chemical formula. 
 
 It thus forms a very valuable addition to the various works on therapeutics 
 now in existence. 
 
 Chemists are so multiplying compounds, that, if each compound is to be thor- 
 oughly studied, investigations must be carried far enough to determine the prac- 
 tical importance of the new agents. 
 
 "Especially valuable because of its completeness, its accuracy, its systematic consider- 
 ation of the properties and therapy of many remedies of which doctors generally know but 
 little, expressed in a brief yet terse manner." — Chicago Clinical Review. 
 
 TEMPERATURE CHART. Prepared by D. T. Laine, M. D. Size 
 8x 13^ inches. Price, per pad of 25 charts, 50 cents. 
 
 A conveniently arranged chart for recording Temperature, with columns for 
 daily amounts of Urinary and Fecal Excretions, Food, Remarks, etc. On the 
 back of each chart is given in full the method of Brand in the treatment of 
 Typhoid Fever. 
 
CATALOGUE OF MEDICAL WORKS. 33 
 
 A TEXT-BOOK OF HISTOLOGY, DESCRIPTIVE AND PRAC- 
 TICAL. For the Use of Students. By Arthur Ci.akkson, M. B., 
 C. M., Edin., formerly Demonstrator of Physiology iii the Owen's College, 
 Manchester; late Demonstrator of Physiology in the Yorkshire College, 
 Leeds. Large 8vo, 554 pages, with 22 engravings in the text, and 174 
 beautifully colored original illustrations. Price, strongly bound in Cloth, 
 $4.00 net. 
 
 The purpose of the writer in this work has been to furnish the student of His- 
 tology, in one volume, with both the descriptive and the practical part of the 
 science. The first two chapters are devoted to the consideration of the general 
 methods of Histology ; subsequently, in each chapter, the structure of the tissue 
 or organ is first systematically described, the student is then taken tutorially over 
 the specimens illustrating it, and, finally, an appendix affords a short note of the 
 methods of preparation. 
 
 " The work must be considered a valuable addition to the list of available text-books, and 
 is to be highly recommended." — New York Medical Journal. 
 
 " One of the best works for students we have ever noticed. We predict that the book will 
 attain a well-deserved popularity among our students." — Chicago Medical Recorder. 
 
 THE PATHOLOGY AND TREATMENT OF SEXUAL IM- 
 POTENCE. By Victor G. Vecki, M. D. ' From the second Ger- 
 man edition, revised and rewritten. Demi-octavo, about 300 pages. 
 Cloth, ^2.00 net. 
 
 The subject of impotence has but seldom been treated in this country in the 
 truly scientific spirit that it deserves, and this volume will come to many as a 
 revelation of the possibilities of therapeusis in this important field. Dr. Vetki's 
 work has long been favorably known, and the German book has received the 
 highest consideration. This edition is more than a mere translation, for, although 
 based on the German edition, it has been entirely rewritten by the author in 
 English. 
 
 " The work can be recommended as a scholarly treatise on its subject, and it can be read 
 with advantage by many practitioners,"— yo?<r««/ of the American Medical Association. 
 
 THE TREATMENT OF PELVIC INFLAMMATIONS 
 THROUGH THE VAGINA. By W. R. Pryor, M. D., Pro- 
 fessor of Gynecology in the New York Polycliiiic. i2mo, 248 pages, 
 handsomely illustrated. Cloth, |2.oo net. 
 
 In this book the author directs the attention of the general practitioner to a 
 surgical treatment of the pelvic diseases of women. There exists the utmost 
 confusion in the profession regarding the most successful methods of treating 
 pelvic inflammations ; and inasmuch as inflammatory lesions constitute the ma- 
 jority of all pelvic diseases, the subject is an important one. It has been the 
 endeavor of the author to put down every little detail, no matter how insig- 
 nificant, which might be of service. 
 
34 ' PF. B. SAUNDERS' 
 
 DISEASES OF WOMEN. By Henry J. Garrigues, A.M., M. D., 
 Professur of Gynecology in the New York Scliool of Clinical Medicine; 
 Gynecologist to St. Mark's Hospital and to the German Dispensary, New ' 
 York City. In one handsome octavo volume of 728 pages, illustrated by 
 335 engravings and colored plates. Prices: Cloth, ^4.00 net; Sheep or 
 Half-Morocco, ^5.00 net. 
 
 A PRACTICAL work on gynecology for the use of students and practitioners, 
 written in a terse and concise manner. The importance of a thorough know- 
 ledge of the anatomy of the female pelvic organs has been fully recognized by 
 the author, and considerable space has been devoted to the subject. The chap- 
 ters on Operations and on Treatment are thoroughly modern, and are based 
 upon the large hospital and private practice of the author. The text is eluci- 
 dated by a large number of illustrations and colored plates, many of them being 
 original, and forming a complete atlas for studying embryology and the anatomy 
 of \)\Q. female genitalia, besides exemplifying, whenever needed, morbid condi« 
 tions, instruments, apparatus, and operations. 
 
 Second Edition, Thoroughly Revised. 
 
 The first edition of this work rnet with a most appreciative reception by the 
 medical press and profession both in this country and abroad, and was adopted 
 as a text-book or recommended as a book of reference by nearly one /ittndred 
 colleges in the United States and Canada. The author has availed himself of 
 the opportunity afforded by this revision to embody the latest approved advances 
 in the treatment employed in this important branch of Medicine. He has also 
 more extensively expressed his own opinion on the comparative value of the 
 different methods of treatment employed. 
 
 "One of the best text-books for students and practitioners which has been published in 
 the English language ; it is condensed, clear, and comprehensive. The profound learning 
 and great clinical experience of the distinguished author find expression in this book in a 
 most attractive and instructive form. Yoiuig practitioners, to whom experienced consultants 
 may not be available, will find in this book invaluable counsel and help." 
 
 Thad. a. Reamy, M. D., LL.D., 
 Prq/essar of Clinical Gynecology, Medical College of Ohio ; Gynecologist to the Good 
 Samaritan and Cincinnati Hospitals. 
 
 A SYLLABUS OF GYNECOLOGY, arranged in conformity with 
 "An American Text-Book of Gynecology." By J. W. Long, M. D., 
 Professor of Diseases of Women and Children, Medical College of Vir- 
 ginia, etc. Price, Cloth (interleaved), ^i.oo net. 
 
 Based upon the teaching and methods laid down in the larger work, this will 
 not only be useful as a supplementary volume, but to those who do not already 
 posses? the text-book it will also have an independent value as an aid to the 
 practitioner in gynecological work, and to the student as a guide in the lecture- 
 room, as the subject is presented in a manner at once systematic, clear, succinct, 
 pod practical. 
 
CATALOGUE OF MEDICAL WORKS. 35 
 
 THE AMERICAN POCKET MEDICAL DICTIONARY. Edited 
 by W. A. Newman Borland, M. D., Assistant Obstetrician to the Hospital 
 of the University of Pennsylvania; Fellow of the American Academy of 
 Medicine. Containing the pronunciation and definition of all the principal 
 words used in medicine and the kindred sciences, with 64 extensive tables. 
 Handsomely bound in flexible leather, limp, with gold edges and patent 
 thumb index. Price, ;^l.oo net ; with thumb index, ^1.25 net. 
 
 SECOND EDITION, REVISED. 
 
 This is the ideal pocket lexicon. It is an absolutely new book, and not a re- 
 vision of any old work. It is complete, defining all the terms of modern medi- 
 cine and forming an unusually complete vocabulary. It gives the pronunciation 
 of all the terms. It makes a special feature of the newer words neglected by 
 other dictionaries. It contains a wealth of anatomical tables of special value to 
 students. It forms a handy volume, indispensable to every medical man. 
 
 SAUNDERS' POCKET MEDICAL FORMULARY. By William 
 
 M. Powell, M. D., Attending Physician to the Mercer House for Invalid 
 Women at Atlantic City. Containing 1800 Formulae, selected from several 
 hundred of the best-known authorities. Forming a handsome and con- 
 venient pocket companion of nearly 300 printed pages, with blank leaves 
 for Additions ; with an Appendix containing Posological Table, Formulse 
 and Doses for Hypodermatic Medication, Poisons and their Antidotes, 
 Diameters of the Pemale Pelvis and Foetal Head, Obstetrical Table, Diet 
 List for Various Diseases, Materials and Drugs used in Antiseptic Surgery, 
 Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables 
 of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- 
 somely bound in morocco, with side index, wallet, and flap. Price, ^1.75 
 net. 
 
 FIFTH EDITION, THOROUGHLY REVISED. 
 
 " This little book, that can be conveniently carried in the pocket, contains an immense 
 amount of material. It is very useful, and as the name of the author of each prescription is 
 giveUjis unusually reliable." — New York Medical Record. 
 
 A COMPENDIUM OF INSANITY. By John B. Chapin, M.D., LL.D., 
 Physician-in-Chief, Pennsylvania Hospital for the Insane; late Physician- 
 Superintendent ofthe Willard State Hospital, New York ; Honorary Mem- 
 ber of the Medico-Psychological Society of Great Britain, of the Society of 
 Mental Medicine of Belgium. l2mo, 234 pages, illust. Cloth, ^1.25 net. 
 
 The author has given, in a condensed and concise form, a compendium of 
 Diseases of the Mind, for the convenient use and aid of physicians and students. 
 It contains a clear, concise statement of the clinical aspects of the various ab- 
 normal mental conditions, with directions as to the most approved methods of 
 managing and treating the insane. 
 
 " The practical parts of Dr. Chapin's book are what constitute its distinctive merit. We 
 desire especially, however, to call attention to the fact that in the subject of the therapeutics 
 of insanity the work is exceedingly valuable. The author has made a distinct addition to the 
 literature of his specialty." — Philadelphia Medical Journal. 
 
36 ty. B. SAUNDERS' 
 
 AN OPERATION BLANK, with Lists of Instruments, etc. re- 
 , quired in Various Operations. Prepared by W. W. Kp;en, M. D., 
 LL.D., Professor of Principles of Surgery in the Jefferson Medical Col- 
 lege, Philadelphia. Price per Pad, containing Blanks for fifty operations, 
 50 cents net. 
 
 SECOND EDITION, REVISED FORM. 
 
 A convenient blank, suitable for all operations, giving complete instructions 
 regarding necessary preparation of patient, etc., with a full list of dressings and 
 medicines to be employed. 
 
 On the back of each blank is a list of instruments used — viz. general instru 
 ments, etc., required for all operations ; and special instruments for surgery of 
 the brain and spine, mouth and throat, abdomen, rectum, male and female 
 genito-urinary organs, the bones, etc. 
 
 The whole forming a neat pad, ananged for hanging on the wall of a sur- 
 geon's office or in the hospital operating-room. 
 
 " Will serve a useful purpose for the surgeon in reminding him of the details of prepa- 
 ration for the patient and the room as well as for the instruments, dressings, and antiseptics 
 needed " — Netu York Medical Record 
 
 " Covers about all that can be needed in any operation." — American Lancet. 
 
 " The plan is a capital one." — Boston Medical and Surgical Journal. 
 
 LABORATORY EXERCISES IN BOTANY. By Edson S. Bastin, 
 M. A., Professor of Materia Medica and Botany in the Philadelphia Col- 
 lege of Pharmacy. Octavo volume of 536 pages, 87 full-page plates. Price, 
 Cloth, ^2.50. 
 
 This work is intended for the beginner and the advanced student, and it fully 
 covers the structure of flowering plants, roots, ordinary stems, rhizomes, tubers, 
 bulbs, leaves, flowers, fruits, and seeds. Parlicular attention is given to the gross 
 and microscopical structure of plants, and to those used in medicine. Illustra- 
 tions have freely been used to elucidate the text, and a complete index to facil- 
 itate reference has been added. 
 
 " There is no work like it in the pharmaceutical or botanical literature of this country, and 
 we predict for it a wide circulation." — American yournal of Pharmacy. 
 
 DIET IN SICKNESS AND IN HEALTH. By Mrs. Ernest Hart, 
 formerly Student of the Faculty of Medicine of Paris and of the London 
 School of Medicine for Women ; with an Introduction by Sir Henry 
 Thompson, F. R. C. S., M. D., London. 220 pages; illustrated. Price, 
 Cloth, $1.50. 
 
 Useful to those who have to nurse, feed, and prescribe for the sick. In 
 each case the accepted causation of the disease and the reasons for the special 
 diet prescribed are briefly described. Medical men will find the dietaries and 
 recipes practically useful, and likely to save ihem trouble in directing the dietetic 
 treatment of patients. 
 
CATALOGUE OF MEDICAL WORKS. 37 
 
 A MANUAL OF PHYSIOLOGY, with Practical Exercises. For 
 
 Students and Practitioners. By G. N. Stewart, M. A., M. D., D. Sc, 
 
 lately Examiner in Physiology, University of Aberdeen, and of the New 
 
 Museums, Cambridge University ; Professor of Physiology in the Western 
 
 Reserve University, Cleveland, Ohio. Handsome octavo volume of 848 
 
 pages, with 300 illustrations in the text, and 5 colored plates. Price, Cloth, 
 
 ^3.75 net. 
 
 THIRD EDITION, REVISED. 
 
 " It will make its way by sheer force of merit, and amply deserves to do so. It is one oj 
 the very best English text-books on the subject." — London Lancet. 
 
 " Of the many text-books of physiology published, we do not know of one that so nearly 
 conies up to the ideal as does Professor Stewart's volume." — British Medical Journal. 
 
 ESSENTIALS OF PHYSICAL DIAGNOSIS OF THE THORAX. 
 
 By Arthur M. Corwin, A. M., M. D., Demonstrator of Physical Diagno- 
 sis in the Rush Medical College, Chicago; Attending Physician to the 
 Central Free Dispensary, Department of Rhinology, Laryngology, and 
 Diseases of the Chest. 219 pages. Illustrated. Cloth, flexible covers. 
 Price, $1.25 net. 
 
 THIRD EDITION, THOROUGHLY REVISED AND ENLARGED. 
 SYLLABUS OF OBSTETRICAL LECTURES in the Medical 
 Department, University of Pennsylvania. By Richard C. Norris, 
 A. M., M. D., Lecturer on Clinical and Operative Obstetrics, University 
 of Pennsylvania. Third edition, thoroughly revised and enlarged. Crown 
 8vo. Price, Cloth, interleaved for notes, ^2.00 net. 
 
 " This work is so far superior to others on the same subject that we take pleasure in call- 
 ing attention briefly to its excellent features. It covers the subject thoroughly, and will 
 prove invaluable both to the student and the practitioner. The author has introduced a 
 number of valuable hints which would only occur to one who was himself an experienced 
 teacher of obstetrics. The subject-matter is clear, forcible, and modern. We are especially 
 pleased with the portion devoted to the practical duties of the accoucheur, care of the child, 
 etc. The paragraphs on antiseptics are admirable; there is no doubtful tone in the direc- 
 tions given. No details are regarded as unimportant; no minor matters omitted. We ven- 
 ture to say that even the old practitioner will find useful hints in this direction which he can- 
 not afford to despise." — Neiv York Medical Record. 
 
 A SYLLABUS OF LECTURES ON THE PRACTICE OF SUR- 
 GERY, arranged in conformity with «' An American Text-Book 
 of Surgery." By N. Senn, M. D., Ph. D., Professor of Surgery in Rush 
 Medical College, Chicago, and in the Chicago Polyclinic. Price, ;^2.00. 
 
 This work by so eminent an author, himself one of the contributors to 
 " An American Text-Book of Surgery," will prove of exceptional value to 
 the advanced student who has adopted that work as his text-book. It is not 
 only the syllabus of an unrivalled course of surgical practice, but it is also an 
 epitome of or supplement to the larger work. 
 
 " The author has evidently spared no pains in making his Syllabus thoroughly comprehen- 
 sive, and has added new matter and alluded to the most recent authors and operations. Full 
 references are also given to all requisite details of surgical anatomy and pathology."— .SriVff* 
 Medical Journal, London. 
 
38 W. B. SAUNDERS' 
 
 THE CARE OF THE BABY. By J. P. Crozer Griffith, M. D., 
 Clinical Professor of Diseases of Children, University of Pennsylvania; 
 Physician to the Children's Hospital, Philadelphia, etc. 404 pages, with 
 67 illustrations in the text, and 5 phitcs. i2mo. Price, $l.So. 
 
 SECOND EDITION, REVISED. 
 
 A reliable guide not only for mothers, but also for medical students and 
 practitioners whose opportunities for observing children have been limited. 
 
 " The whole book is characterized by rare good sense, and is evidently written by a mas. 
 ter hand. It can be read with benefit not only by mothers, but by medical students and by 
 any practitioners who have not had large opportunities for observing chWdrtn."— American 
 jfournal of Obstetrics. 
 
 THE NURSE'S DICTIONARY of Medical Terms and Nursing 
 Treatment, containing Definitions of the Principal Medical and Nursing 
 Terms, Abbreviations, and Physiological Names, and Descriptions of the 
 Instruments, Drugs, Diseases, Accidents, Treatments, Operations, Foods, 
 Appliances, etc. encountered in the ward or the sick-room. By Honnor 
 Morten, author of " How to Become a Nurse," " Sketches of Hospital 
 Life," etc. i6mo, 140 pages. Price, Cloth, ^i.oo. 
 
 This little volume is intended for use merely as a small reference-book which 
 can be consulted at the bedside or in the ward. It gives sufiRcient explanation 
 to the nurse to enable her to comprehend a case until she has leisure to look up 
 larger and fuller works on the subject. 
 
 DIET LISTS AND SICK-ROOM DIETARY. By Jerome B. Thomas, 
 M. D., Visiting Physicia-n to the Home for Friendless Women and Children 
 and to the Newsboys' Home ; Assistant Visiting Physician to the Kings 
 County Hospital; Assistant Bacteriologist, Brooklyn Health Department. 
 Price, Cloth, ;S!l.50 (Send for specimen List.) 
 
 One hundred and sixty detachable (perforated) diet lists for Albuminuria, 
 Anaemia and Debility, Constipation, Diabetes, Diarrhoea, Dyspepsia, Fevers, 
 Gout or Uric- Acid Diathesis, Obesity, and Tuberculosis. Also forty detachable 
 sheets of Sick-Room Dietary, containing full instructions for preparation of 
 easily-digested foods necessary for invalids. Each list is numbered only, the 
 disease for which it is to be used in no case being mentioned, an index key 
 being reserved for the physician's private use. 
 
 DIETS FOR INFANTS AND CHILDREN IN HEALTH AND 
 IN DISEASE. By Louis Starr, M. D., Editor of "An American 
 Text-Book of the Diseases of Children." 230 blanks (pocket-book size), 
 perforated and neatly bound in flexible morocco. Price, $1.25 net. 
 
 The first series of blanks are prepared for the first seven months of infant 
 life; each blank indicates the ingredients, but not the quantities, of the food, 
 the latter directions being left for the physician. After the seventh month, 
 modifications being less necessary, the diet lists are printed in full. Formula 
 im tne preparation of diluents and foods are appended. 
 
CATALOGUE OF MEDICAL WORKS. 39 
 
 HOW TO EXAMINE FOR LIFE INSURANCE. By John M. 
 Keating, M. D., Fellow of the College of Physicians and Surgeons of 
 Philadelphia; Vice-President of the American Psediatric vSociety; Ex- 
 President of the Association of Life Insurance Medical Directors. Royal 
 8vo, 211 pages, with two large half-tone illustrations, and a plate prepared 
 by Dr. McClellan from special dissections ; also, numerous cuts to elucidate 
 the text. Third edition. Price, Cloth, ^2.00 net. 
 
 " This is by far the most useful book v/hich has yet appeared on insurance examination, a 
 subject of growing interest and importance. Not the least valuable portion uf the volume is 
 Part II., which consists of instructions issued to their examining physicians by twenty-four 
 representative companies of this country. As the proofs of these instructions were corrected 
 by the directors of the companies, they form the latest instructions obtainable. If for these 
 alone, the book should be at the right hand of every physician interMtcd in this special branch 
 of medical science." — -The Medical News, Philadelphia. 
 
 NURSING: ITS PRINCIPLES AND PRACTICE. By Isabel 
 
 Adams Hampton, Graduate of the New York Training School for 
 Nurses attached to Bellevue Hospital; Superintendent of Nurses and 
 Principal of the Training School for Nurses, Johns Hopkins Hospital, 
 Baltimore, Md. ; late Superintendent of Nurses, Illinois Training School 
 for Nurses, Chicago, 111. In one very handsome i2mo volume of 512 
 pages, illustrated. Price, Cloth, ^2.00 net. 
 
 SECOND EDITION, REVISED AND ENLARGED. 
 
 This original work on the important subject of nursing is at once comprehensive 
 and systematic. It is written in a clear, accurate, and readable style, suitable 
 alike to the student and the lay reader. Such a work has long been a desidera- 
 tum with those entrusted with the management of hospitals and the instruction of 
 nurses in training-schools. It is also of especial value to the graduated nurse 
 who desires to acquire a practical working knowledge of the care of the sick 
 and the hygiene of the sick-room. 
 
 OBSTETRIC ACCIDENTS, EMERGENCIES, AND OPERA- 
 TIONS. By L. Ch. Boisliniere, M. D., late Emeritus Professor of 
 Obstetrics in the St. Louis Medical College. 381 pages, handsomely illus- 
 trated. Price, ^2.00 net. 
 
 , " For the use of the practitioner who, when away from home, has not the 
 opportunity of consulting a library or of calling a friend in consultation. He 
 then, being thrown upon his own resources, will find this book of benefit in 
 guiding and assisting him in emergencies." 
 
 INFANT'S WEIGHT CHART, Designed by J. P. Crozer Grjffzth, 
 M. D., Clinical Professor of Diseases of Children in the University of Peniv 
 sylvania. 25 charts in each pad. Price per pad, 50 cents net. 
 
 A convenient blank for keeping a record of the child's weight during the first 
 two years of life. Printed on each chart is a curve repi'esenting the average weight 
 of a healthy infant, so that any deviation from the normal can readily be detected. 
 
Saunders' 
 New Series 
 OF Manuals 
 
 for Students 
 and 
 Practitioners. 
 
 THAT there exists a need for thoroughly reliable hand-books on the leading 
 branches of Medicine and Surgery is a fact amply demonstrated by the 
 favor with which the SAUNDERS NEW SERIES OF MANUALS have been 
 received by medical students and practitioners and by the Medical Press. 
 These manuals are not merely condensations from present literature, but 
 are ably written by well-known authors and practitioners, most of them being 
 teachers in representative American colleges. Each volume is concisely and 
 authoritatively written and exhaustive in detail, without being encumbered 
 with the introduction of " cases," which so largely expand the ordinary text- 
 book. These manuals will therefore form an admirable collection of advanced 
 lectures, useful alike to the medical student and the practitioner : to the latter, 
 too busy to search through page after page of elaborate treatises for what he 
 wants to know, they will prove of inestimable value ; to the former they will 
 afford safe guides to the essential points of study. 
 
 The SAUNDERS NEW SERIES OK MANUALS are conceded to be 
 superior to any similar books now on the market. No other manuals afford so 
 much information in such a concise and available form. A liberal expenditure 
 has enabled the publisher to render the mechanical portion of the work worthy 
 of the high literary standard attained by these books. 
 
 Any of these Manuals will be mailed on receipt of price (see next page 
 for List). 
 
SAUNDERS' NEW SERIES OF MANUALS. 
 
 VOLUMES PUBLISHED. 
 
 PHYSIOLOGY. By Joseph Howard Raymond, A. M , M. D., Professor 
 of Physiology and Hygiene and Lecturer on Gynecology in the Long 
 Island College Hospital, etc. Price, ^1.25 net. 
 
 SURGERY, General and Operative. By John Chalmers DaCosta, 
 M.D., Professor of Practice of Surgery and Clinical Surgery, Jefferson 
 Medical College, Philadelphia. Second edition, revised and greatly en- 
 larged. Octavo, 911 pages, 386 illustrations. Cloth, ^4.00 net; Half- 
 Morocco, ^5.00 net. 
 
 DOSE-BOOK AND MANUAL OF PRESCRIPTION-WRITING. 
 
 By E. Q. Thornton, M. D., Demonstrator of Therapeutics, Jefferson 
 Medical College, Philadelphia. Price, ^1.25 net. 
 
 MEDICAL JURISPRUDENCE. By Henry C. Chapman, M. D., Pro- 
 fessor of Institutes of Medicine and Medical Jurisprudence in the Jeffer- 
 son Medical College of Philadelphia, etc Price, ^1.50 net. 
 
 SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's 
 Hospital and to the German Poliklinik ; Instructor in Surgery, New York 
 Post-Graduate Medical School, etc. Price, ^1.25 net. 
 
 MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct 
 Professor of Anatomy and Demonstrator of Anatomy, Medical Department 
 of the New York University, etc. Price, S2.50 net. 
 
 SYPHILIS AND THE VENEREAL DISEASES. By James 
 Nevins Hyde, M.D., Professor of Skin and Venereal Diseases, and 
 Frank H. Montgomery, M. D., Lecturer on Dermatology and Genito- 
 urinary Diseases in Rush Medical College, Chicago. Price, $2.50 net. 
 
 PRACTICE OF MEDICINE. By George Roe Lockwood, M. D., 
 Professor of Practice in the Woman's Medical College of the Nevir York 
 Infirmaiy, etc. Price, ^2.50 net. 
 
 OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant Demon- 
 strator of Obstetrics, University of Pennsylvania; Chief of Gynecological 
 Dispensary, Pennsylvania Hospital. Price, ^2.50 net. 
 
 DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant 
 Surgeon to the Middlesex Hospital, and Surgeon to the Chelsea Hospital 
 for Women, London ; and Arthur E. Giles, M. D., B. Sc. Lond., F. R. C. S. 
 Edin., Assistant Surgeon to the Chelsea Hospital for Women, London. 436 
 pages, handsomely illustrated. Price, ^2.50 net. 
 
 IN PREPARATION. 
 
 NERVOUS DISEASES. By Charles W. Burr, M. D., Clinical Profes- 
 sor of Nervous Diseases, Medico-Chirurgical College, Philadelphia, etc. 
 
 *** There will be published in the same series, at short intervals, carefully prepared works 
 on various subjects, by prominent specialists. 
 
SAUNDERS' QUESTION COMPENDS. 
 
 Amuiged in Qiiestiou and Answer Form. 
 
 THE LATEST, MOST COMPLETE, and BEST ILLUSTRATED 
 SERIES OF COMPENDS EVER ISSUED. 
 
 Now the Standard Authorities in Medical Literature 
 
 students and Practitioners in every City of the United 
 States and Canada. 
 
 THE REASON WHY. 
 
 They are the advance guard of " Student's Helps " — that DO help; they are 
 the leaders in their special line, well and authoritatively wj-itten by able men, 
 who, as teachers in the large colleges, knozv exactly what is wanted by a student 
 preparing for his examinations. The judgment exercised in the selection of 
 authors is fully demonstrated by their professional elevation. Chosen from the 
 ranks of Demonstrators, Quiz-masters, and Assistants, most of them have be- 
 come Professors and Lecturers in their respective colleges. 
 
 Each book is of convenient size (5x7 inches), containing on an average 250 
 pages, profusely illustrated, and elegantly printed in clear, readable type, on 
 fine paper. 
 
 The entire series, numbering tvventy.four subjects, has been kept thoroughly 
 revised and enlarged when necessary, many of them being in their fourth and 
 fifth editions. 
 
 TO SUM UP. 
 
 Although there are numerous other Quizzes, Manuals, Aids, etc. in the mar- 
 ket, none of them approach the " Blue Series of Question Compends;" and 
 the claim is made for the following points of excellence : 
 
 1. Professional distinction and reputation of authors. 
 
 2. Conciseness, clearness, and soundness of treatment. 
 
 3. Size of type and quality of paper and binding. 
 
 %* Any of these Compends will be mailed on receipt of price (see next 
 
 page for List). 
 
 42 
 
SAUNDERS* QUESTION-COMPEND SERIES. 
 
 Price, Cloth, $J.OO per copy, except when otherwise noted. 
 
 1. ESSENTIALS OF PHYSIOLOGY. 4th edition. Illustrated. Revised and enlarged. 
 
 By H. A. Hare, M. D. (Price, JSloo net.) 
 
 2. ESSENTIALS OF SURGERY. 7th editfon, with a chapter on Appendicitis, go illus- 
 
 trations. By Edward Martin, M. D. (Price, ;jSi.oo net ) 
 
 3. ESSENTIALS OF ANATOMY. 6th edition, thoroughly revised, i.si illustrations. 
 
 By Charles B. Nancrede, M. D. (Price, $1.00 net.) 
 
 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. 
 
 5th edition, revised, with an Appendix. By Lawrence, Wolff, M. D. (^i.oo net.) 
 
 5. ESSENTIALS OF OBSTETRICS. 4th edition, revised and enlarged. 75 illustra- 
 
 tions. By W. Easterly Ashton, M. D. 
 
 6. ESSENTIALS OF PATHOLOGY AND- MORBID ANATOMY. 7th thousand. 
 
 46 illustrations. By C. E. Armand Semple, M. D. 
 
 7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE. 
 
 SCRIPTION-WRITING. 5th edition. By Henry Morris, M. D. 
 
 8. g. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M. D. 
 
 An Appendix on Urine Examin ation. Illustrated. By Lawrence Wolff, M. D. 
 3d edition, enlarged by some 300 Essential Formulae, selected from eminent authori- 
 ties, by Wm. M. Powell, M. D. (Double number, price J2.00.) 
 
 10. ESSENTIALS OF GYN.ffiCOLOGY. 4th edition, revised. With 62 illustrations. 
 
 By Edwin B. Cragin, M. D. 
 
 11. ESSENTIALS OF DISEASES OF THE SKIN. 4th edition, revised and enlarged. 
 
 71 letter-press cuts and 15 half-tone illustrations. By Henry W. Stelwagon, M.D. 
 (Price, $1.00 net.) 
 
 12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL 
 
 DISEASES. 2d edition, revised and enlarged. 78 illustrations. By Edward 
 Martin, M. D. 
 
 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 
 
 130 illustrations. By C. E. Armand Semple, M. D. 
 
 14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. 124 
 
 illustrations. 2d edition, revised. By Edward Jackson, M. D., and E. Baldwin 
 Glkason, M. D. 
 
 15. ESSENTIALS OF DISEASES OF CHILDREN, ad edition. By William M 
 
 Powell, M. D. 
 
 16. ESSENTIALS OF EXAMINATION OF URINE. Colored " Vogel Scale," 
 
 and numerous illustrations. By Lawrence Wolff, M.D. (Price, 75 cents.) 
 
 17. ESSENTIALS OF DIAGNOSIS. 2d edition, thoroughly revised. 60 illustrations. 
 
 By S. SoLis-CoHEN, M. D., and A. A. Eshner, M. D. (Price, ^i.oo net.) 
 
 i8. ESSENTIALS OF PRACTICE OF PHARMACY. 2d edition, revised. By L. 
 E. Sayre. 
 
 20. ESSENTIALS OF BACTERIOLOGY. 3d edition. 82 illustrations. By M. V. 
 
 Ball, M.D. 
 
 21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. 48 illustrations. 
 
 3d edition, revised. By John C. Shaw, M. D. 
 
 22. ESSENTIALS OF MEDICAL PHYSICS. 155 illustrations. 2d edition, revised. 
 
 By Fred J. Brockway, M. D. (Price, gi.oo net.) 
 
 23. ESSENTIALS OF MEDICAL ELECTRICITY. 65 illustrations. By David D. 
 
 Stewart, M. D., and Edward S. Lawrance, M. D. 
 
 24. ESSENTIALS OF DISEASES OF THE EAR. 114 illustrations. 2d edition, re- 
 
 vised and enlarged. By E. Baldwin Gleason, M. D. 
 
Some of the Books in Preparation for 
 Publication during 1900. 
 
 AMERICAN Text=Book of Pa= 
 thology. 
 
 Edited by LuDViG Hektoen, M.D., Pro- 
 fessor of Pathology, Rush Medical College, 
 Chicago; and David Riesman, M.D., De- 
 monstrator of Pathological Histology, Uni- 
 versity of Pennsylvania. 
 
 AMERICAN Text=Bookof Legal 
 Medicine and Toxicology. 
 
 Edited by Frederick Peterson, M.D., 
 Chief of Clinic, Nervous Department, College 
 of Physicians and Surgeons, New York City; 
 and Walter S. Haines, M.D., Professor of 
 Chemistry, Pharmacy, and Toxicology, Rush 
 Medical College, Chicago. 
 
 BECK— Fractures. 
 
 By Carl Reck, M.D., Professor of Surgery 
 in the N. Y. School of Clinical Medicine. 
 
 BOHM, DAVIDOFF, and HU= 
 BER-A Text=Bookof Human 
 Histology. 
 
 Including Microscopic Technic. liy 
 
 Dr a a. Bohm and Dr. M. von Davidoff, 
 of the Anatomical Institute of Munich, and 
 G. C. Huber,M.D., Junior Professor of Anat- 
 omy and Histology, University of Michigan, 
 Ann Arbor. 
 
 EiCHHORST— A Text=Book of 
 the Practice of Medicine. 
 
 liy Dr. Hekman Eichhorst, Professor of 
 Special Pathology and Therapeutics and Di- 
 rector of the Medical Clinic, University of 
 Zurich. Translated and edited by Augustus 
 A. EsHNER, M.D , Professor of Clinical 
 Medicine in the Philadelphia Polyclinic. 
 
 FRIEDRICH — Rhinology, La= 
 ryngology, and Otology in 
 their Relations to General 
 Medicine. 
 
 By Dr. E. P. Friedrich, of the Univer- 
 sity of Leipsig. 
 
 LEVY AND KLEMPERER — 
 The Elements of Clinical Bac= 
 teriology. 
 
 By Dr. Ernst Levy, Professor in the 
 University of Strassburg, and Dr. Felix 
 Klemperer, Privat-Docent in the Univer- 
 sity of Strassburg. Translated and edited 
 by Augustus A. Eshner, M.D., Professor 
 of Clinical Medicine in the Philadelphia Poly- 
 clinic. Just Ready. Cloth, ^2.50 net. 
 
 McFARLAND— A Text=Book of 
 Pathology. 
 
 By Joseph McFarland, M.D., Professor 
 of Pathology and Bacteriology, Medico-Chi- 
 rurgical College, Philadelphia. 
 
 OGDEN — Clinical Examination 
 of the Urine. 
 
 By J. Bergen Ogdrn, M.D., Assistant in 
 Chemistry, Harvard Medical School. 
 
 PYLE— A Manual of Personaf 
 Hygiene. 
 
 Edited by Walter L. Pvle, M.D., Assis- 
 tant Surgeon to Wills" Eye Hospital, Philada. 
 
 SCUDDER— The Treatment of 
 Fractures. 
 
 By Charles L. Scudder, M.D. .Assistant 
 in Clinical and Operative Surgery, Harvard 
 University. 
 
 SENN— Practical Surgery. 
 
 By Nicholas Senn, M.D., Ph.D., LL.D., 
 Professor of the Practice of Surgery and of 
 Clinical Surgery, Rush Medical College, Chi- 
 cago. Octavo volume of about 800 pages, 
 profusely illustrated. 
 
 The Pathology and Treatment 
 of Tumors. 
 
 By Nicholas Senn, M.D., Ph.D., LL.D., 
 Professor of the Practice of Surgery and of 
 Clinical Surgery, Rush Medical College, Chi- 
 cago. A New and Thoroughly Revised Edi- 
 tion in preparation. 
 
 STENGEL AND WHITE — The 
 Blood in its Clinical and Patho= 
 logical Relations. 
 
 By Alfred Stengel, M.D., Professor of 
 Clinical Medicine, University of Pennsyl- 
 vania; and C. Y. White, M.D., Instruc- 
 tor in Clinical Medicine, University of Penn- 
 sylvania. 
 
 STEVENS— The Physical Diag= 
 nosis of Diseases of the Chest. 
 
 By A. A. Stevens, A.M., M.D., Lecturer 
 on Terminology, and Instructor in Physical 
 Diagnosis, University of Pennsylvania. 
 
 STONE Y — Surgical Technique 
 for Nurses. 
 
 By Emily A. M. Stoney, late Superin- 
 tendent of the Training Schools for Nurses, 
 Carney Hospital, South Boston, Mass. 
 
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