COLUMBIA LIBRARIES Ohl-bMt HEALTH SCIENCES STANDARD HX00039004 l^:- THE LIBRARIES COLUMBIA UNIVERSITY 1 i 1 I 1 i 1 i i i i 1 1 1 1 1 1 1 i 1 E UuOffml[iuiifrOilfrin]ffmini^ [3 HEALTH SCIENCES LIBRARY 'i -i -f^^-^'f ■ Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/treatiseondiseasOOfind A TREATISE DISEASES OF WOMEN FOR STUDENTS AND PEACTITIONERS BY PALMER FINDLEY, B.S., M.D. PROFESSOR OF GYNECOLOGY, COLLEGE OF'&IEDICINE, STATE UNIVERSITY OF NEBRASKA; GYNECOLOGIST TO THE CLARKSON MEMORIAL HOSPITAL AND DOUGLAS COUNTY HOSPITAL; FELLOW OF THE AMERICAN GYNECOLOGICAL SOCIETY; FELLOW OP THE AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNECOLOGISTS; FELLOW OP THE CHICAGO GYNECOLOGICAL SOCIETY. ILLUSTRATED WITH 632 ENGRAVINGS IN THE TEXT AND 38 PLATES IN COLORS AND MONOCHROME LEA & FEBIGER PHILADELPHIA AND NEW YORK //v3 Entered according to the Act of Congress, in the j^ear 1913, by LEA & FEBIGER, in the office of the Librarian of Congress. All rights reserved. DEDICATED TO MY FORMER CHIEF J. CLARENCE WEBSTER WITH ALL RESPECT PREFACE This book is the natural outgrowth of the author's Diagnosis of Diseases of Women. Much that was contained in the former work has been revised, the subjects have been reclassified, and more than an equal amount of text and illustrations has been added for the purpose of making a complete text-book on the subject of diseases of women. It has been the endeavor of the author to present the subject in detail without encumbering the text with needless repetitions. With this object in view, separate chapters are devoted to the subjects of Non- operative Methods of Treatment, Hygiene and Dress, Preparation of Patient for Operation, Preparation of Operating Room, Field of Operation and Surgical Utensils, Choice of Anesthetics, Diet, Post- operative Complications and Care of Patients after Operation, and frequent references are made to these subjects throughout the text. An effort has been made to give full scope to the discussion of conservative methods of treatment, such as douches, baths, exercise, massage, diet, dress, and tampons. The author is of the opinion that the non-operative methods of treatment of diseases of women have not received their due share of consideration in text-books and in practice which they rightly deserve. The subject of diagnosis has been placed on an anatomical basis, both macroscopic and microscopic, for it is preeminently true of diseases of women that the making of a diagnosis is in large part the recognition of the morbid anatomy. There are certain subjects presented in the text which may be con- sidered as on the borderline between gynecology and obstetrics; such are surgical treatment of puerperal infection, fibroids of the uterus complicating pregnancy, prolapse of the pregnant uterus, ovarian cysts complicating pregnancy, and the immediate repair of the cervix and pelvic floor. Such subjects emphasize the illogical separation of gynecology and obstetrics. Because of their relative importance special chapters have been devoted to gonorrhea and tuberculosis in women, and a proportionately large amount of space has been allotted VI PREFACE to the discussion of fibroids of the uterus, cancer of the uterus, ovarian cysts, extra-uterine pregnancy, pelvic inflammations, lacerations of the pelvic floor, and retroversioflexion and prolapse of the uterus. The author desires to express his indebtedness to Dr. N. Sproat Heaney for his valuable assistance in proof-reading; for the service of Mr. Charles F. Bauer in preparing the illustrations, and for the generous and courteous cooperation of the Publishers. P. F. Omaha, 1913. COXTEXTS CHAPTER I Introductory: Hemorrhages from the Genital Tract The Clinical History 17 Form of Case Record 17 Address 19 Age 19 Occupation 20 Nationality 21 Social State 21 Number of Children and Miscarriages 21 General Predisposing Conditions 21 Family ffistory 21 Previous Illnesses 22 Present Complaints 22 Menstrual History 22 Hemorrhage from the Genital Tract 22 Hemorrhage from the A'ulva 22 Hemorrhage from the Vagina 23 Hemorrhage from the Cervix 23 Menstruation 23 Anatomy of Menstruating Uterus 24 Tubal Menstruation 26 Menstruation without Ovaries 26 Uterine Hemorrhage 27 Systemic Causes 27 Local Causes ■ . 28 Character of Dischai'ged Blood 33 Treatment of Uterine Hemorrhage 33 CHAPTER II Disorders Associated with ^Menstruation Amenorrhea 27 General Causes 37 Local Causes 39 ^Menstrual Xlolimina ■ . . . 40 Vicarious Menstruation 40 Diagnosis of Amenorrhea 40 ' Treatment of Amenorrhea : 41 Dysmenorrhea 42 Primary, Causes of 42 Secondary, Causes of 43 Membranous Dysmenorrhea 45 Intermenstrual Pain 47 Treatment of Dysmenorrhea 48 Backache 56 Causes 56 Static Backache and Treatment 57 Gonorrheal Arthritis 58 Treatment 58 CoccygodjTiia 58 Diastasis Recti: Enteroptosis 59 Causes 60 SjTnptoms 60 Treatment 61 viii CONTENTS CHAPTER III Leucorrhea — Sterility — The Menopause Leucorrhea: Normal Secretions of the Genital Organs 63 Clinical Grouping According to Age — Infants 63 Virgins 64 Sexual Matm-ity 64 Old Age ... , • • • 64 Odor as an Aid to Diagnosis 65 Treatment ^ 65 Sterility: Definitions 67 One-child SteriHty 67 Conditions Essential to Conception 67 Etiology 68 General Causes 68 Local Causes 69 Treatment 72 The Menopause: Premature Menopause 73 Delayed Menopause 74 Time of Appearance 74 Clinical Manifestations 75 Influence of Morbid Conditions in the Pelvis 76 Management of the Menopause 76 CHAPTER IV Examinations of the Blood — Bacteriological Examinations Examinations op the Blood 78 Morphology of Blood Cells 78 Red Cells 78 White CeUs 79 Leucocytosis of Pregnancy 80 Postpartum Leucocytosis 80 Posthemorrhagic Leucocytosis 80 Inflammatory Leucocjiiosis 81 Leucocytosis of Mahgnancy 82 Leucocytosis of Ovarian Tumors 82 Differential Count of Leucocytes . 82 Secondary Anemia 83 Bacteriological Examinations : Bacteriology of Normal Genital Tract 84 Bacteriology of Vulva and Vagina 85 Bacteriology of Uterus 86 Bacteriology of Fallopian Tubes 87 Bacteriology of Ovary 88 Bacteriology of Peritoneum and Pelvic Cellular Tissue 89 CHAPTER V General Physical Examination Preliminary Measures ' . . 90 External Abdominal Examination ." . 91 Inspection 91 Palpation 93 Percussion 97 Auscultation 99 Mensuration 99 CONTENTS ix CHAPTER VI Examination of External and Internal Genitalia Inspection of External Genitalia 100 Digital Examination of Internal Genitalia 100 Digital Examination of Vagina 100 Combined Vaginal Examination . 106 Abdominovaginal Examination 107 Palpation of Ureters thi'ough the Vagina 112 Digital Examination of the Rectum 112 Pelvimetry : 117 CHAPTER VII Instrumental Examination Vaginal Speculum 118 Vulsellum Forceps 120 Uterine Dilators 121 Uterine Sound 122 Preliminary Procedures 123 Indications 123 Contra-indications 125 Dangers 125 Uterin'e Curet 126 Indications 126 Contra-indications 127 Dangers 128 Technic 129 In Treatment 130 Exploratory Punctures and Incisions . . • 132 CHAPTER VIII Microscopic Examination op Scrapings and Excised Parts — The Diagnosis OF Expelled Membranes from the Uterus Removal op Uterine Tissue for Diagnostic Purposes 133 Test Excision from the Cervix 134 Test Curettage of the Uterus 134 Frozen Sections op Excised Pieces and Scrapings 134 Fixing the Specimens 136 Hardening and Embedding 136 Staining and Mounting . 138 Inspection of Uterus after Removal 139 The Diagnosis of Expelled Membranes from the Uterus .... 140 Membranous Dysmenorrhea 140 CHAPTER IX Ectopic or Extra-uterine Pregnancy Etiology 143 Recurrent and Multiple Ectopic Pregnancy 144 Combined Uterine and Tubal 145 Bilateral Tubal 145 X CONTENTS Classification 146 Ampullar 147 Interstitial 150 Infundibular 150 Ovarian 151 Causes of Ending of Gestation 152 Retrogressive Changes in Dead Fetus 154 Anatomic.u. Changes in Tube 154 Clinic-Uj Diagnosis 155 Subjective Signs 156 Objective Signs 156 Differential Diagnosis 158 Treatment 164 Uni-uptured Tubal Pregnancy 164 At Time of Rupture 165 Late after Rupture 167 Intraligamentary Extra-uterine Pregnancy 170 Interstitial Pregnancy 170 Advanced Extra-uterine Pregnancy 170 Combined Extra-uterine and Intra-uterine 171 Ovarian Pregnancy 171 Pregnancy in Rudimentary Horn of Uterus 171 MoRT-iLiTY OP Extra-uterine Pregnancy 172 CHAPTER X Chorioepithelioma Malignum Etiology 174 Clinical Diagnosis 175 Macroscopic Appearance 176 Microscopic Appearance 176 Malignant Degeneration of Hydatiform Mole 177 Primary Chorioepithelioma Outside of the Placental Site . . . 182 Histogenesis 184 Diagnosis 185 Treatment 186 CHAPTER XI Non-operative Methods of Treatment Hydrotherapy 188 Baths 189 Vaginal Douche 196 Intra-uterine Douche 200 Saline Injections 202 Enteroclysis 203 Hypodermoclysis 204 Intravenous Injections 205 Ice Bag 207 Hot Compresses 207 Hot-water Bag 207 Water Drinking ' . 208 Hot Air Treatment . 209 Hot Pack 210 Counterirritation 211 Tampons 211 Pelvic Massage 215 Pressure Therapy 220 Electricity 223 CONTENTS xi X-KAY Therapy 223 Swabs 225 Serum and Organotherapy . 227 CHAPTER XII Hygiene and Dress Hygiene op the School-girl 229 Physical Training in Schools 230 Public Playgrounds and Baths 230 Indoor Exercise 230 Dress 237 Corsets ■ . . 239 CHAPTER XIII Preparation of Patient for Operation Examination for Contra-indications 242 Local Treatments Preparatory to Operation 243 Preparation of the Field of Operation 244 Choice of Local or General Anesthesia 246 Local Anesthesia 247 General Anesthesia 248 Spinal Anesthesia 250 Combined Gynecological Operations 250 Diet 251 CHAPTER XIV Principles of Asepsis in Gynecology Sterilization op Field of Operation 252 Disinfection of Hands and Forearms 252 Preparation of Surgical Utensils . 254 Preparation of Gauze and Sutures 255 Preparation of Instruments 256 Sterilized Water 257 Preparation of Operating Room 257 Preparation for Operation in Private House 258 Operating Bag 260 CHAPTER XV Anomalies and Malformations of the Genital Organs Anomalies and Malformations op the Vulva 262 Absence of Vulva 262 Double Vulva 262 Atresia of Vulva 262 Infantile Vulva 263 Hypertrophy of Vulva 264 Congenital AnomaKes of Clitoris . 264 Adhesions of the Prepuce 265 Congenital Fissures of the Vulva 265 Anatomy and Malformations op the Hymen 267 Cysts of the Hymen .269 xii CONTENTS Anomalies and Malformations of the Vagina 270 Absence 270 Atresia and Stenosis 272 Double Vagina 275 Blind Pouches 276 Anomalies and Malformations of the Uterus 276 Uterus Deficiens 276 Uterus Rudimentarius 279 Uterus Foetalis 279 Uterus Unicornis 280 Uterus Septus 282 Uterus Bicornis 282 Uterus Didelphys 286 Uterus Accessorius 286 Anomalies and Malformations of the Fallopian Tubes 286 Anom.alies and Malformations op the Ovaries 286 Absence of One or Both Ovaries 286 Congenital Smallness of One or Both Ovaries 287 Supernumerarj' Ovaries 287 Congenital Largeness of One or Both Ovaries 287 CHAPTER XVI Malpositions of the Genital Organs Malpositions of the Vagin.al Walls 288 Cystocele 288 Rectocele 299 Vaginal Hernia 302 Malposition of the Uterus 305 Normal Position "... 305 Pathological Mobility 308 Pathological Fixation 308 Anteposition 309 Retroposition 310 Lateroposition 312 Elevatio Uteri 313 Torsion . '. 315 Prolapsus Uteri 315 Prolapse of the Pregnant Uterus 333 Inversion 334 Anteversion 345 Anteflexion 347 Retroversioflexion 352 Hernia 381 Malpositions of the Fallopian Tubes 382 Normal Position 382 Changes in Position 384 Malpositions of the Ov.\ries 384 Normal Position and Histology 384 Changes in Position 386 Descensus Ovarii 386 Hernia of Tube and Ovary . . : 388 CHAPTER XVII Circulatory Disturbances and Inflammations of the Genital Organs Bacteriology of the Normal Genital Tract 389 Etiology 390 General Causes 390 Local Causes 391 CONTENTS xiii CHAPTER XVIII Circulatory Disturbances and Inflammations of the Vulva and Vagina Circulatory Disturbances of the Vulva 393 Varicose Veins (Angioma Vulvae) 393 Hematoma of the Vulva 395 Edema of the Vulva 396 Gangrene of the Vulva . 396 Noma Pudendi 397 Inflammation of the Vulva 397 Vulvitis 397 Simple Catarrhal 397 Gonorrheal 398 Erysipelatous 398 Puerperal 399 Tuberculous 399 SyphiUtic 399 Diphtheritic 399 Actinomycosis 400 Treatment 404 Barthohnitis 401 Vulvitis Furimculosis 401 Pruritus Vulvae 403 Inflammation of the Vagina 406 Vaginitis (Colpitis) 406 Catarrhal 407 Ulcerative 407 Tuberculous 408 Emphysema Vaginae 408 Condylomatous 419 Senile. 409 Paravaginitis 411 Vaginismus 412 CHAPTER XIX Inflammations op the Uterus Endocervicitis (Endometritis Cervicalis) 415 Erosions of the Cervix 416 Simple 417 Papillary . . • 417 FolUcular 417 Ulcers of the Cervix 420 Decubitus 420 Tuberculous 420 Cancerous 420 Tuberculosis of the Cervix 420 Endometritis 420 CUnical Classification 421 Acute 421 Chronic . 422 Hemorrhagic 4---^ Catarrhal 422 Dysmenorrheic '±^^ Tuberculous 423 Gonorrheal 4-3 Decidual 42^ Puerperal ■ • • • 424 Postabortive 424 ExfoMative 424 Semie 425 xiv CONTENTS EXDOMETRITIS: Anatomical Classification 425 Macroscopic 426 Hj-pertrophic 426 Fungous 426 Villous 426 Pohpoid 426 ricerative . 426 Pseudodiphtheritic 426 Microscopic 427 Glandular 427 Interstitial 431 Chroxic Metritis 438 Abscess of the Uterus 438 Treatment of Inflammation of the Uterus . 434 Acute Metritis 434 Chronic Metritis 438 Endocer\'icitis 442 Erosions of the Cer\'ix 444 CILIPTER XX Circulatory Disturb.^nces, Intl-^j^imations, and Infectious Grantjlomata of Fallopi.^n Tubes and Ov.vries Circulatory Disturb.\nces in the F.u.lopian Tube 445 Causes 445 Anatomical Diagnosis 446 Clinical Diagnosis 446 Inflammations .\nd Infectious Gr.vnulomata of the Fallopi.\n Tube . 446 General Considerations 446 Classification of Salpingitis 447 Catarrhal 447 Purulent 452 Tuberculous 462 Sj-phihs of the Fallopian Tube 466 Actinomj-cosis of the Fallopian Tube 466 Parasites of the Fallopian Tube 462 Treatment of Inflammatorj' Diseases of the Tubes 467 Xon-operative Treatment 467 Conservative Operations 468 Radical Surgical Treatment 470 Operative Treatment 471 Circulatory Disturbanxes in the Ov.\ry 480 Etiolog}' 480 Anatomical Diagnosis 480 Clinical Diagnosis 482 Intlammations of the Ovary (Oophoritis, Ovaritis) 483 Acute Ovaritis 483 Chronic Ovaritis 483 Cj'stic Degeneration of the Ovaries 484 Abscess of the Ovary 489 CHAPTER XXI Peritonitis Gen'er.a^l Peritonitis ' . 493 Xon-septic, Traumatic 493 Septic 494 Postoperative 495 Puerperal 500 Gonorrheal 501 Tuberculous 502 Pel-vtc Peritonitis 503 CONTENTS ' XV CHAPTER XXII Parametritis (Pelvic Cellulitis) Acute Parametritis 510 Chronic Parametritis 512 Varicocele of the Broad Ligament 517 CHAPTER XXIII Gonorrhea in Women Historical Sketch 519 GoNOcoccus OF Neisser 519 Etiology 519 Diagnosis 522 Prognosis 527 Prophylaxis 529 Treatment 529 Gonorrhea in Children 536 CHAPTER XXIV Tuberculosis of the Genital Organs Etiology 539 1. Primary Infection 540 2. Secondary Infection 540 Tuberculosis of the Vulva and Vagina 540 Tuberculosis of the Cervix . 541 Tuberculosis of the Uterus 541 Tuberculosis of the Ovaries 541 Tuberculosis of the Fallopian Tubes 541 Tuberculous Peritonitis 544 Prognosis 544 Treatment 545 CHAPTER XXV Nutritional Disturbances of* the Genital Organs Retrogressive Tissue Changes 546 Atrophy of the Vulva (Kraurosis Vulvae) 546 Atrophy of the Vagina 549 Atrophy of the Uterus . . . , 549 Physiological Atrophy 549 Superinvolution of the Uterus 549 Atrophy of the Ovary 550 Progressive Tissue Changes 551 Elephantiasis Vulvae 551 Condyloma Acuminata 552 Hypertrophy of the Vulva 553 Hypertrophy of the Clitoris 553 Hypertrophy of the Labia 553 Hypertrophy of the Cervix 553 Supravaginal Hypertrophy 554 Infra vaginal Hypertrophy 554 Subinvolution of the Uterus ^^^ Hypertrophy of the Ovary ^^° xvi CONTENTS CHAPTER XXVI New Formations of the Vulva and Vagina New Formations of the Vulva 559 Benign Tumors of the Vulva 559 Fibroma 559 Lipoma 559 Enchondroma 559 Neui-oma 559 Sebaceous Cysts 559 Dermoid Cysts 560 Vulvar Cysts 560 Cysts of the Hjanon 560 Cancer of the Vulva 562 Sarcoma of the Vulva . 567 New Formations of the Vagina . 567 Cysts of the Vagina 567 Fibromyoma of the Vagina 569 Carcinoma of the Vagina 570 Sarcoma of the Vagina 574 Syncytioma Vaginae 574 Endothelioma of the Vagina 574 CHAPTER XXVII Fibromyoma of the Uterus Etiology 575 Histogenesis 576 Anatomical Diagnosis 577 Recurrence 584 Microscopic Diagnosis 584 Adenofibromyoma Uteri 585 Degenerations of Fibroids 586 Clinical Characteristics 591 Clinical Diagnosis 592 Differential Diagnosis 597 Effect on Neighboring Organs 604 Treatment 605 Operations for Uterine Fibroids 608 Vaginal Myomectomy 609 Vaginal Hysterotomy 612 Vaginal Celiotomy 614 Abdominal Myomectomy 617 Hysteromyomectomy 620 Vaginal 620 Abdominal 621 Fibroids Complicating Pregnancy, Labor, and Puerperium .... 630 CHAPTER XXVIII Carcinoma and Sarcoma of the Uterus Carcinoma of the Uterus . 632 Topographical Classification 632 Etiology • 632 Anatomical Diagnosis 634 Clinical Diagnosis 639 Differential Diagnosis 644 Diagnosis of Extension 651 CONTENTS xvii Carcinoma op the Uterus: Treatment 658 Operative Treatment 660 Simple Vaginal Hysterectomy 660 Byrne Method 660 Schuchardt Operation 662 Radical Abdominal Operation 665 Treatment of Cancer of Cervix Complicating Pregnancy 676 Treatment of Inoperable Cancer of Cervix 677 Treatment of Cancer of Body of Uterus 679 EndotheKoma 692 Sarcoma op the Uterus 693 Etiology 693 Anatomical Diagnosis 694 Microscopic Diagnosis , 696 Clinical Diagnosis 697 Prognosis * 697 Treatment 698 CHAPTER XXIX Tumors op the Pelvic Ligaments, Fallopian Tubes, and Vagina Tumors op the Pelvic Ligaments 699 Tumors of the Broad Ligaments 699 Tumors of the Ovarian Ligaments 699 Tumors of the Roimd Ligaments ... 700 Treatment 700 Tumors op the Fallopian Tubes ... 700 PapiUoma 700 Polyps 701 Myoma and Fibroma 701 Dermoid Cysts 701 Lipoma 701 Fibromyxoma Cystoma of the Fimbriae 701 Sarcoma , 701 Carcinoma 701 Cystic New Formations of the Fallopian Tubes 703 Hydatids of Morgagni 703 New Formations op the Ovary 703 Simple Cysts 703 Folhcular Cysts 703 Corpus Luteum Cysts 703 Tuboovarian Cysts 703 Tumors of the Ovaries 706 Carcinoma 712 Dermoid Cysts 714 Connective-tissue New Formations 715 Fibroma • 715 Myoma 715 Myxoma . . . 715 Enchondroma and Osteoma 715 Angioma and Lymphangioma 715 Sarcoma 715 EndotheHoma 717 Parovarian Cysts 718 Ovariotomy 736 Vaginal 737 Abdominal 739 Malignancy of Ovarian Tumors 742 Treatment of Ovarian Tumors Complicating Pregnancy, Labor, and the Puerperium 744 Postoperative CompUcations • • 744 Mortality. 752 Conservative Operations 753 xviii CONTENTS CHAPTER XXX Trattmatic Injuries of the Genital Organs Wounds of the Vulva and Pelvic Floor 762 Colpoperineorrhaphy 763 External Superficial Tear 763 Internal Tear and Combined External and Internal Tears (Incomplete Laceration of the Perineum) . 765 Late Repair of a Complete Rupture of the Rectovaginal Septum . . . 782 Repair of the Sphincter Ani Muscles 786 Relaxed Outlet of the Rectovaginal Septum 786 After-treatment of Plastic Operations on the Pelvic Floor . . . 788 Wounds of the Vagina 788 Acquired Stenosis and Atresia of the Vagina 790 Wounds of the Cervix 791 Immediate Repair of a Lacerated Cervix 793 Amputation of the Cervix 795 Perforating Wounds of the Uterus 797 CHAPTER XXXI Fecal and Genito-urinary Fistula Fecal Fistula 801 Rectovaginal Fistula 801 Retroperineal Fistula 804 Rectolabial Fistula 805 Enterovaginal Fistula 806 Genito-urinary Fistula 806 Urethral Fistula 806 Vesical Fistula 807 Vesicovaginal Fistula 807 Vesico-uterine Fistula 810 Vesicocervical Fistula 810 Enterovesical Fistula 811 Ureteral Fistulae 821 Ureteral Fistula at Vault of Vagina 821 Ureterocystostomy 822 Nephro-ureterectomy 823 CHAPTER XXXII Diseases of the Urinary System Diseases of the Urethra and Bladder 824 Anatomy and Physiology 825 Methods of Examination 829 Percussion .■ 829 Palpation 829 Catheter and Sound 830 Inspection 830 Urethroscopy ' . 830 Cystoscopy . 830 Malformations and Diseases of the Urethra 845 Congenital MaKormations 845 Partial or Complete Absence 845 Atresia 845 Displacement 846 CONTENTS xix Malformations and Diseases op the Urethra: Epispadias 846 Hypospadias 846 Acquired Malformations 846 Dilatation 846 Strictiire 847 Dislocations 848 Prolapse of the Urethral Mucous Membrane 848 Urethritis 848 Acute 849 Chronic 849 Newgrowths of Urethra 850 Caruncle ' . . . . 851 Fibroma 851 Carcinoma 851 Sarcoma 851 Foreign Bodies 851 Diseases of the Bladder 852 Developmental Deformities 852 Vesical Fissure 852 Double Bladder " . 853 Loculate Bladder 853 Malpositions and Malformations 853 Eversion 855 Hernia 855 Foreign Bodies 855 Cystitis 857 Hyperemia 864 New Formations 864 Myoma 864 Fibroma 865 Papilloma 865 Adenoma 865 Dermoid Cysts 866 Carcinoma • 866 Sarcoma 866 Diseases of the Ureters 869 Anatomy and Physiology 869 Methods of Examination 870 Palpation 870 Inspection 870 Catheterization 870 Examination of Urine 873 Congenital Anomalies 874 Inflammations of the Ureter 876 Obstructions of the Ureter 878 Ureteral Calculus 881 Stricture • 883 CHAPTER XXXIII Post-operative Treatment Responsibility for Complications 886 Stimulation 888 Position of Patient 889 Rehef from Pain 890 Nourishment • • 891 Evacuation of Bladder 891 Care of the Bowels 893 Apphcation of Ice to Abdomen 893 Duration of Convalescence 894 Early Rising • • cor Abdominal Supporters • °y" XX CONTENTS CHAPTER XXXrV Complications Following Operations Surgical Shock 897 Pulmonary Embolism ^y^ Ileus 903 Pneumonia ^J^o Acute Bronchitis ■ ■ ■ PosTOPERATm; Pleurisy • • • 907 Gangrene of the Lungs 908 Abscess of the Lungs 908 Pulmonary Edema 908 Local and General Infections 908 Peritonitis 909 Fermentation Fever ... 909 Septic Litoxication 910 Septicemia 910 Pyemia .... 911 Breaking of Stitches 911 PosTOPERATI^^E Hernia . 913 PoSTOPER.iTIA'E HeM.\TEMESIS 916 Retention ant) Suppression of L'rixe 917 POSTOPER.^TIVE NeUKOSES 917 Hysteria 917 Neurasthenia . 917 Insanity 917 Tymp-\nites 918 Phlebitis 920 Acute Dilatation of the Stomach 921 Vomiting 921 Postoperative Cystitis 922 Acute Nephritis 924 Traumatic Fistul-e .... 924 Ureteral Fistulse . . ' 925 Vesical Fistulse 925 Rectal Fistulse 925 Pressure Paralysis 925 Burns 925 Emphysema of the Abdomin.\l Walls 925 Poisoning by Drugs 925 Intectious and Contagious Diseases 926 Diarrhea 926 Bed-sores 926 Acid Intoxication . .* 926 Ophthalmia 927 Late Chloroform .\nd Ether Poisoning 927 Irregul.\rities of the Pulse . 927 Excessht: Pain . . 927 Variations in Body Temperature 928 Second.\ry Hemorrhage ' . . . 928 Foreign Bodies Left in the Abdominal CA\^TY after Operation . . 930 DISEASES OF WOMEN CHAPTER I THE CLINICAL HISTORY— HEMORRHAGE FROM THE GENITAL TRACT Clinical History Form of Case Record The Clinical History. — ^In the making of a diagnosis the first impor- tant step is the recording of a clinical history. A carefully recorded history has many advantages; it serves as a guide to a systematic examination, and places before the physician a detailed, logical record of the case for future reference. It is manifestly impossible always to follow a set form in case-taking, neither is it possible always to adhere to the very good general rule of taking the full history at the time of the first examination. The nervous state of the patient, together with many other factors, may preclude the taking of a complete history at the time of the first consultation, but on each occasion certain definite items may be recorded, and the history completed at a subsequent visit. It is well to begin with permitting the patient to recite her complaints without interruption. The patient becomes self-possessed, while at the same time the physician is given an opportunity to observe her general appearance, temperament, complexion, nutrition, carriage, and many other points bearing upon her case. After a time direct questions may be put to her, and as the answers are given they may be concisely placed on record. Form of Case Record. — In all text-books students are given a blank form to be filled out in the taking of a history. Such forms are of great service to the inexperienced practitioner, but for one who through long experience has acc^uired the art of case-taking they are unneces- sary and ill-adapted. The allotted space may be inadequate to suit indi- vidual requirements. The card-index system is gaining favor and is highly commendable. The author prefers his letter-head, upon which the answers to questions can be hurriedly jotted, and to which subse- quent notations can be added. This is placed in an envelope, on which 18 THE CLINICAL HISTORY is recorded the name and address. These envelopes can be filed away in alphabetical order. Notes from all subsequent examinations, copies of prescriptions, correspondence with patient and physician, can all be placed in the envelope from time to time. When visiting the patient the envelope can be placed in the pocket and referred to on the way. As a compromise between the elaborate printed forms and the blank letter-head, the following form is recommended for simplicity, accuracy, and liberal spacing: Name Address Date Patient of Dr. Address Age Occupation ■ Nationality S. M. W. Para Miscarriages Personal habits. Events following childbirths and miscarriages. Family historj-. Previous illnesses. Present complaints. Menstrual history. Uterine hemorrhage. Menstrual pain. Intermenstrual pain. Leucorrhea. General physical findings. Urinary sj^stem. IMenses began Type Quantity Duration Pain ^lenopause Urinalysis : Amount in twenty-four hours Color Reaction Albumin Total soUds Urea Sp. gr. Sugar Microscopic Physical findings in pelvis and abdomen : Abdominal wall Tender on pressure , Swellings Visceroptosis Pelvic floor. Vagina. Cervix. Uterine body. Tubes FORM OF CASE RECORD 19 Ovaries. Urethra. Bladder. Rectum. Appendix. Extragenital structures. Diagnosis. Treatment. Termination. A discussion of the different items will be of practical interest. Address. — The place of residence is inquired into, not only as a matter of business, but also to determine the possible influence of the environment upon the general health of the individual. ^Malarial districts, congested portions of the city, extremely warm or cold climates and high altitudes exercise a definite influence upon the general and local condition of a woman. Without a favorable environment it is difficult to get desired results in the treatment of many of the diseases affecting women. The local conditions may be corrected, but if the place of residence and occupa- tion are not favorable to the general well-being the results will be disappointing. This is clearly demonstrated in the speedy convales- cence of patients who pass their convalescing days far removed from home and hospital where they find rest, healthful exercises, and new associations. Age. — The special disturbances found in the various stages of life — i. e., infancy, puberty, sexual maturity, climacteric and postclimacteric — are at once suggested when the age of the patient is known. In infancy, malformations and inflammations of the lower genital tract are to be looked for; tumors, displacements, and traumatisms seldom appear. Infections rarely extend beyond the vagina. ^lore often they are limited to the vulva by the hymen, which serves as a barrier. At puberty, malformations of the genital organs are commonly first noticed through failure of the menses to appear; congenital dis- placements first cause disturbance at this time, because of the increase in the size of the uterus and the establishment of menstruation; infiammations are usually confined to the vulva, rarely extending above the hymen, while new-formations and traumatisms are seldom observed. During the period of sexual maturity all lesions of the genital organs may be found. Congenital malformations may first be observed after marriage and in childbearing. Inflammatory lesions, involving part or all of the genital tract, most often arise as the resiflt of chfldbearing, 20 THE CLINICAL HISTORY specific infection, and instrumental and digital manipulations. New- formations usually make their appearance in this period. Displace- ments and traumatisms occur as the result of childbearing and rarely arise at any other time of life. In the climacteric and postclimacteric periods all disorders have a special clinical significance. The possibility of malignancy should always be borne in mind. After seventy it is unusual for any lesion to develop. No disorder should be regarded lightly when arising at the end of the childbearing period. The onset of malignant disease is so insidious and so misleading in its clinical manifestations that no physician can afford to look lightly upon any disorder, however trivial it may seem to the patient and ph^'sician. Occupation. — Occupation is an important factor in the causation and aggravation of pelvic disorders. In young girls confined to w^ork- shops the menstrual functions are seldom perfectly established. Poor ventilation, long working hours, heavy lifting, and poor food exercise an unfavorable influence upon the development of the pelvic viscera and tend to aggravate existing maladies. On the other hand, sedentary and indolent habits are equally injurious. While it is true that occupation is essential to health, it is also true that every employment involves danger to health. This applies to those who work with . their brains as well as to those who perform manual labor. Undue exposure to heat and cold in the open air may be equally as injurious as prolonged confinement in poorly ventilated rooms. Girls who are subject to such unhygienic conditions become delicate, anemic, and suffer from various nervous disorders, and in time become unfit to assume the responsibilities of motherhood. The constant sitting position, combined with a bending forward assumed day after day and for hours at a time by girls in shops, factories, and oflBces, engenders a pelvic congestion which leads to menstrual disorders of various types. . Strassmann calls attention to the very large percentage of machine- operators who suffer from pelvic inflammation. Occupations w^hich demand prolonged standing bring their penalty in many ways. In the young girl whose pelvis is not fully developed, certain pelvic deformi- ties may result which in turn may give rise to serious trouble in future childbirths. Ivottnitz has observed the frequency of flat pelves in women who were never the subject of rickets but who began at an early age to work in weaving mills. It is a well-established fact that preexisting gynecological disorders are aggravated by long standing. Prolonged and severe exertion, early in life, leads to maladies which may make women totally unfit for wives and mothers and subject to anemic, nervous, and menstrual disorders. Overwork for one individual may not be overwork for another, but in general every woman is over- worked who toils by day in shops and factories and undertakes to perform the duties of the home in the early morning and evening hours. While we would not deny women the privilege of work, we should see to it that they do not exceed the eight-hour-day limit, that they are FORM OF CASE RECORD 21 not compelled to work Saturday afternoons and Sundays, and that every hygienic safeguard is placed about them. Women in the latter weeks of pregnancy should not be permitted to work outside the home. This, of course, is possible only by giving them compensation for the loss of w^ages incurred. No considerable improvement in the influence of industrial life upon the health of women can be looked for until health comissioners are empowered to make rigid inspection and are given the power to enforce sanitary conditions. This inspection should embrace the home, the school, the shops, and the factory. Wherever women are brought in close contact with one another, there is always a call for improvement in personal and general hygiene. Nationality. — The Jewish race is said to menstruate early and to early reach the menopause, but the author knows of no definite evidence to this effect. The Caucasian race is more subject to carcinoma, the African to fibroids. Social State. — It is well to inquire into the social state of the patient ■ — to learn whether she is single, married, or a widow. An early under- standing may forestall an embarrassing question as to the sexual relations, and may suggest possible causes for her complaints. For example, a recently married woman complaining of leucorrhea and painful urination is suspected of being infected. The fact that the patient is single or a widow should never mislead the examiner in his diagnosis; the possibility of pregnancy and venereal infection must always be excluded by the usual methods of examination, uninfluenced by the social state of the patient. While the physician must be alert to these possibilities, he should exercise great tact and caution in his inquiries. Number of Children and Miscarriages. — Frequent childbearing and mis- carriages almost certainly result in some sort of pelvic ailment. It is exceptional for a woman to give birth to several children without acquiring a pelvic lesion. Complaints dating back to a childbirth or miscarriage suggest the probable finding of an inflammatory lesion, a displacement, or a laceration. General Predisposing Conditions. — The condition of the bowels and bladder, the cardiovascular, nervous, and respiratory systems, should be carefully inquired into. Not infrequently a pelvic lesion is dependent upon a disorder of the abdominal or thoracic viscera. Dysmenorrhea, leucorrhea, uterine hemorrhage, and sterility may be directly referred to a general dis- turbance. An excitable and overwrought nervous system alone may be responsible for many of the functional disorders of the pelvic viscera. Regard for the general condition of the patient and a due appreciation of the influence of the general upon local conditions will do much toward eliminating so-called "meddlesome gynecology." Family History. — It is improbable that heredity plays an important role in the etiology of pelvic disorders. In tuberculosis, and to a lesser degree in carcinoma, the influence of heredity should not be under- 22 HEMORRHAGE FROM THE GENITAL TRACT estimated; but in the l)enif]:n tumor formations, displacements, and malformations, heredity has little or no influence. It is well to inquire carefully into the family history, but its influence should not be over- estimated. Previous Illnesses. — Acute infectious diseases, tuberculosis, and all chronic wastinj-; diseases, anemias, and long-standing lesions of the thoracic and abdominal viscera may both originate and aggravate disorder in the genital tract. General conditions have an important bearing upon the pelvic viscera, not only in aggravating the disorders, but in actually originating them. It therefore becomes imperati\-e to consider carefully all general conditions in relation to their possible bearing upon functional disturb- ances and lesions of the genitalia. Present Complaints. — The complaints of the patient will often serve as a suggestion, but a diagnosis can never be based upon subjective symptoms in the absence of a physical examination. Any or all of the pelvic disorders may exist without subjective symptoms. On the other hand, there may be serious complaints on the part of the patient in the absence of a pelvic lesion. The familiar group of symp- toms — hemorrhage, pain, leucorrhea, constipation, and backache — are common to many altogether dissimilar lesions in the pelvis. Little reliance can be placed upon the complaints of the patient, but the diagnosis must depend in great part upon the physical findings. Symp- toms, at best, are only suggestive of a possible lesion. Menstrual History. — So far the patient has been considered from the standpoint of the general practitioner. It is now necessary to consider more particularly the disorders of the genital organs. HEMORRHAGE FROM THE GENITAL TRACT Hemorrhage from the Vulva Tubal Menstruation Hemorrhage from the Vagina | Menstruation without Ovaries Hemorrhage from the Cervix Menstruation Time of Onset Frequency Quantity Anatomv of Menstruating Uterus Uterine Hemorrhage Systemic Causes Local Causes Character of Discharged Blood Treatment In diseases of women the most significant of all symptoms is hemor- rhage. While not in itself diagnostic, it is of the greatest value as an indication for an immediate and searching physical examination, both general and local. Hemorrhage from the genitalia comes from the vulva, vagina, cervix, body of the uterus, and occasionally from the tubes; never from the ovary except in the case of a tuboovarian'hema- toma discharging its contents into the uterus — a most unusual event. Hemorrhage from the Vulva. — This is the result of trauma, new- formations, ulcerations, lupus, cancroid, and rupture of varicose veins complicating pregnancy. The origin of the bleeding is recognized by direct inspection. MENSTRUATION 23 Hemorrhage from the Vagina. — This is due to causes similar to those already enumerated. An exceptional cause lies in metastatic growths of syncytium (syncytioma malignum). The bleeding site is readily disclosed by the vaginal speculum. Hemorrhage from the Cervix. — From the vaginal portion of the cervix hemorrhage follows immediately upon the delivery of the child as the result of lacerations. At the end of the childbearing period the most common cause of hemorrhage from the cervix is carcinoma. Less frequent causes are sarcoma, tuberculosis, syphilis, and erosions. Before considering the morbid conditions causing bleeding from the uterus, certain conditions which may be looked upon as a physiological uterine hemorrhage must be considered. Menstruation. — No other organism loses so much blood from the uterus as does woman. Within certain ill-defined limits this loss of blood is physiological; hence it is important to consider first of all the character of the normal menstrual act before taking up the discussion of pathological bleeding from the uterus. Time of Onset. — ^The time of onset of the menstrual function varies widely among individuals. Climate has much to do with determining the onset, and heredity has some influence. In this country Engelmann found the average age to be fourteen, in cold climates sixteen, and in warm climates nine years. Later observations made by Engelmann led him to the conclusion that early puberty is the rule in Arctic regions rather than at the equator. He observed that nutrition and habitation and a lascivious life, with early and constant mingling of the sexes, might appear to explain the early puberty of the Eskimo. Precocious Menstruation. — Precocious menstruation is a condition that occurs occasionally. The earliest case occurred in Glasgow at four days of age. Irion records a case at seven days, and the literature abounds in cases a few weeks and months of age. In nearly all these cases the genitalia were abnormally developed; there was hair on the pubis, and the breasts were often enlarged. Precocious menstruation without premature development of the menstrual organs is improbable, and when this development is not found the hemorrhage should not be regarded as catamenial unless it recurs at monthly intervals. The mother will bring to the physician a napkin marked by a red stain, and will ask whether it is possible that her child is menstruating. Such stains may be blood from a vulvovaginitis or urethritis, but are more often deposits of red urates or uric acid. City-bred girls men- struate six to twelve months earlier than girls living in the country (Williams). Frequency of the Menstrual Period. — It is often stated that the normal type is twenty-eight days, but women are rarely so regular; there is usually a variation of one or more days. Regularity in the menstrual functions adds neither strength nor grace. Women menstruate at long or short intervals without ill-effect, providing the quantity of blood lost does not materially lessen their strength. 24 HEMORRHAGE FROM THE GENITAL TRACT Quantity. — The average quantity of menstrual blood lost in a single period is estimated at from six to eight ounces — the minimum two and the maximum ten. Obviously what may be regarded as a normal quantity for one may be abnormal for another. A pletlioric, well- nourished woman may menstruate freely, for eight days without harm, while the same loss of blood in an anemic indi\idual might seriously undermine her strength. It is impractical to collect the menstrual blood ; therefore the amount of blood lost is estimated by counting the number of napkins soiled. Xo exact information is gained by this procedure because the size and quality of the napkins vary, and one woman will tolerate an over- saturated napkin, while another will scarcely permit the staining. However, no better means is at command, and by estimating the usual number at fourteen napkins in the entire period a fair estimate of the amount of blood lost during the menstrual period can be obtained. Anatomy of the Menstruating Uterus. — Kundrat and Engelmann were the first to record anatomical observations on the menstruating uterus. These observations were made on cadavers in which the endometrium of the uterine body had undergone fatty degeneration and the surface epithelium was exfoliated. Later, Williams made postmortem examinations of twelve men- struating uteri. Nine of the twelve patients died of acute infectious diseases. Like Kundrat and Engelmann, he found fatty degeneration of the mucosa of the uterine body, and stated that the entire mucosa down to the musculature was exfoliated, and that after menstruation the mucosa was regenerated from the musculature. Leopold recognized the observations of Kundrat, Engelmann, and Williams as faulty, in that the changes in the endometrium as described by them might result from the acute infections and chronic wasting diseases which were the causes of death. He carefully excluded all such cases and selected those of normal menstrual type. He failed to observe fatty degeneration of the mucosa, but agreed that the sur- face epithelium was shed in the menstrual process. He does not state how long after death the sections were made, or the method of prepar- ing the specimens. Within a few hours, certainly within twenty-four hours after death or hysterectomy', the surface epithelium undergoes degenerative changes and may be wholly lacking in microscopic sections unless the tissues are immediately fixed in formalin or some other fixing fluid. It was Moricke who first excluded the possibility of postmortem and postoperative changes in the uterus by examining scrapings from the normal menstruating uterus. He curetted and made microscopic examination of forty-five menstruating uteri in all stages of menstrua- tion. In every instance the surface epithelium was found intact. In two additional cases Lolilein reported similar findings. Westphalen also made a series of examinations of scrapings of the mucosa during the various stages of menstruation. In every case in which the mucosa was normal the entire membrane was well preserved ; MEN ST R UA TION 25 in morbid conditions of the mucosa part or all of the surface epithelium was shed. Mandle confirmed these findings. The most elaborate observations were made by Gebhard in Berlin. He not only examined scrapings, but also sections of uteri removed during the menstrual period for lesions not involving the endometrium. Stages. — He divides the anatomical changes into three stages: The Stage of Premenstrual Comjestion. — The capillaries of the mucosa are congested; a serous or serosanguineous exudate infiltrates the stroma of the mucosa, widening the intercellular spaces; later the blood leaves the capillaries and infiltrates the stroma, gravitating in the direction of least resistance — i. e., toward the uterine cavity, and forming a collection of blood beneath the surface epithelium. The Stage of Active Hemorrhage. — The blood is forced between the epithelial cells into the uterine cavity; here and there the epithelium is lifted from its bed, the continuity of the surface is broken, and bits of epithelium are accidentally broken off and carried with the menstrual flow. Blood may also find its way into the gland lumina. The Stage of Postmenstrual Involution. — The bloodvessels become less engorged; blood is no longer extravasated into the connective-tissue spaces; the blood left in the stroma is slowly absorbed; the surface epithelium lifted from its bed resumes its former place, and lost epithe- lium is rapidly regenerated from adjacent epithelial surfaces. Hitchmann and Adler divide the monthly cycle into four phases: First, the postmenstruum, which corresponds to the normal endometrium, in which the glands are small, regular, and round on cross-section, the epithelium narrow with large oval nuclei, and the connective tissue of round and spindle cells densely packed. Second, the interval in which the glands assume a corkscrew-shape, the epithelium is lengthened and contains a superabundance of protoplasm. Third, the premenstruum, in which the mucosa becomes thick and velvety, and in which three layers are distinguished, the superficial, compact, and spongy. The glands are irregularly convoluted, the epithelium is thrown into folds, and presents feathery projections. The interglandular spaces are filled with large stroma cells, not unlike decidual cells. Fourth, the phase of menstruation in which blood is noted in the stroma and on the surface, as described above. It will be observed that these histological changes are identical to those found in hypertrophic glandular endometritis, and it is altogether probable that the menstrual changes in the endometrium are often mistaken for endometritis — a fact so clearly brought out by Hitchmann and Adler. Nine hysterectomies were performed by Dr. Webster and one by the author during the various stages of menstruation. Immediately upon removal the uterus was placed in salt solution, then placed in Zenker's solution for twenty-four hours. Sections were then made from various parts of the endometrium, tubes, and cervix; they were then carried through the usual technic in preparing celloidin sections. 26 HEMORRHAGE FROM THE GEXITAL TRACT In six cases examined by the author the tubes showed no changes, and the cervix was somewhat congested. The anatomical changes char- acterizing menstruation were confined to the mucosa of the uterine body in six cases, while in the other three there were similar changes in the Fallopian tubes. These observations establish the fact of tubal menstruation. While knowledge of the physiology of menstruation is far from exact, a number of well-established facts relating to the anatomy of the menstruating uterus are known. Moricke, Mandle, Gebhard, Herzog and others ha\-e demonstrated beyond dispute that men- struation is not a shedding process, that the loss of epithelium is purely accidental and limited. Previous observations were at fault in the technic of preparing the sections, and in the selection of material which had imdergone cadaveric changes and degenerative changes common to infectious and chronic wasting diseases. Tubal Menstruation. — It has been the consensus of opinion that the Fallopian tubes do not take part in the menstrual act. A few cases have been observed in which blood collected in the tube during men- struation, but it is not proved that in these cases the blood came directly from the mucous membrane of the tube and not from the uterus. The author has observed the same histological changes during the men- strual period in the tubes and in the uterus. These changes were seen in three cases of the nine examined. From these observations the author is convinced that the Fallopian tubes menstruate in a small proportion of cases. In the three instances referred to the identical changes were found in the mucous membrane of the tube that were found in the endome- trium. The tubes were perfectly normal in every respect. J. M. Baldy, of Philadelphia, observed a complete inversion of the uterus in which the endometrium failed to bleed during the menstrual period, but at this time blood escaped from the uterine ends of either tube. J. Riddle Goffe observed blood issuing from the tubes during menstruation, and is of the opinion that the tubes occasionally menstruate. That the Fallopian tubes menstruate in a small proportion of cases would appear evident from these clinical and histological observations. Menstruation without Ovaries. — Menstruation has been know^n to appear at regular intervals and for a considerable period of time after the removal of both ovaries. The theories advanced in explanation of this phenomenon are by no means convincing. Supernumerary and Accessory Ovaries. — This will probably account for a large proportion of cases. Meriel found aberrant ovarian tissue in 4 per cent, of female bodies of all ages. These bodies varied in size from that of a millet-seed to a cherry, and were found near th6 ana- tomical ovary or remote from the parent ovary in the broad ligament, ovarian ligament, pelvic pouches, under the peritoneum, adjacent to the ureter or adherent to the omentum or intestine. Persistence of the menstrual cycle by virtue of an established "habit." UTERINE HEMORRHAGE 27 Unknown Causes. — There is strong presumptive evidence that the ovaries are not essential to menstruation; that other factors, as yet unknown, may operate in exciting the menstrual flux in the absence of the ovaries. There is much need for further investigation of the subject. Uterine Hemorrhage. — Text-books discuss menorrhagia and metror- rhagia — the former term applies to an abnormal increase in the men- strual flow, and the latter to an intermenstrual flow. These terms should be eliminated from common usage because of the impossibilit}' of distinguishing between the two in many cases. The one so often merges into the other in such a manner as to render impossible a dis- tinction between a menstrual and an intermenstrual flow. Then, too, they are dependent upon the same general causes. For the sake of simplicity and exactness, both are here included under the general head of uterine hemorrhage. Systemic Causes. — Hemorrhage from the uterus may occur as the result of general systemic disturbances in the absence of a local lesion. i^NEMiA AND Plethora. — Anemia and plethora may cause hemor- rhage — anemia by reason of the low specific gravity of the blood and its diminished coagulability, and plethora from high vascular pressure. Chlorosis is the exception among the anemias, in that the menstrual flow is lessened or absent. Anemia is commonly spoken of as the result of uterine hemorrhage, when, as a matter of fact, it is not seldom the underlying cause. The author operated upon a case diagnosticated b}' Dr. B. W. Sippy as splenic anemia, in which a perfectly normal uterus bled excessively every three weeks. Removal of the spleen resulted in a rapid restoration of the blood and the disappearance of the uterine hemorrhage. Failure to check uterine hemorrhage by ergot and curettage is frequently accounted for by failure to recognize possible general causes. Purpuric Conditions. — All purpuric conditions may be accompanied by hemorrhage from the uterus as well as from other parts of the body. Infectious Diseases. — The specific infectious diseases may be com- plicated by hemorrhage from the uterus brought about by blood and vascular changes, and acquired insufficiency of the uterine musculature. Emotion. — It is said that emotion will excite a hemorrhage from the uterus. The accuracy of this statement is doubtful; in his own experience the author has never seen the uterus bleed after a period of mental excitement in which there was not found a pathological lesion to account for the loss of blood. The mental disturbance serves only as an exciting cause of the hemorrhage, but without a pathological lesion there would be no hemorrhage. Passive Congestion. — Whatever impedes the return flow of blood from the uterus will bring about passive congestion in that organ, which in turn may result in hemorrhage. In this category may be mentioned displacements of the uterus, diseases of the heart, lungs, liver, kidney, and spleen, abdominal tumors, ascites, and, lastly, chronic constipation. Many an otherwise insignificant local lesion, such as a mucous 28 HEMORRHAGE FROM THE GENITAL TRACT polyp, would probably cause little or no bleeding were it not for the passive congestion of the pelvis brought about by such factors. Local Causes. — Subina'olution. — Subinvolution of the uterus, the result of postabortive and puerperal infection, may be regarded as the most prolific source of pelvic disorders in the female. It is the starting point of many displacements and inflammations which eventu- ate in uterine hemorrhage. The uterus is enlarged in all its diameters, and is deeply congested. Such an organ rarely maintains its position because of an increase in weight and a lack of support from the ligaments and pelvic floor, which have been stretqhed and torn in labor. The usual factors in the development of subinvolution are early rising from childbed, traumatisms in labor and infection following labor, and abortion. In this connection it is to be remembered that retained placental tissue will result in subinvolution of the uterus, and may remain organically attached to the uterus for days, months, and even years, keeping up irregular hemorrhages. The essential factor in the causation of hemorrhage from a sub- involuted uterus lies in insuflEiciency of the musculature of the myo- metrium rather than in the endometrium. Endometritis. — Endometritis is commonly recognized by the symp- toms — hemorrhage, pain, and leucorrhea. One or all of these symptoms may be absent, and the diagnosis must finally rest upon the micro- scopic examination of scrapings from the endometrium. Indeed, a posi- tive diagnosis of endometritis can be made only by the microscope. When hemorrhage exists it is usually in the form of an increase in the menstrual flow — rarely as an intermenstrual flow. Olshausen has described a lesion which he calls fungus endometritis, and bases his clinical diagnosis upon the presence of hemorrhage in the absence of pain and with little or no leucorrhea. The endometrium is greatly thickened and thrown into folds and fungous-like masses, which, under the microscope, are seen to consist of a meshwork of enlarged and greatly distended glands, with but little interglandular connective tissue. Another variety of endometritis, usually resulting in a profuse menstrual flow, is the polypoid. The author believes that hemorrhage is seldom the direct result of endometritis but rather of a deeper seated lesion; one that has engaged the attention of gynecologists in the past decade. (See Muscular Insufficiency.) Para-uterine Inflammations. — Para-uterine inflammations are usually associated with inflammation of the uterus, but may in them- selves provoke uterine bleeding. The author has repeatedly drained a pelvic abscess without curetting the uterus, and has seen the hemor- rhages from the uterus disappear with the subsidence of the parauterine exudate. Mucous Polyps. — Mucous polyps of the uterus are generally of inflammatory origin. Some authors believe them to be invariably of inflammatory origin, while all admit that they are in large part so. Polyps generally produce prof useness of the periods, though hemorrhage is not an invariable symptom, and their presence may be accidentally UTERINE HEMORRHAGE 29 discovered by the curet or after the removal of the uterus for other reasons. Uteeine Fibroids.— In general, it may be said that uterine fibroids of whatever variety can only cause hemorrhage from the uterine cavity when the tumor involves the endometrium. Fibroids rarely bleed; the hemorrhage comes from the endometrium. Sampson has made most interesting observations on the blood supply of fibroid tumors of the uterus and has drawn certain practical deductions as to the cause of hemorrhage in these cases. The veins were injected with gelatin containing ultramarine blue and the arteries with gelatin colored with Venetian red. In about half the cases the injection consisted of gelatin and bismuth for the purpose of making a;-ray examinations. By means of the arterial injections, Sampson was able to demonstrate the arterial blood suppl}^ in all but a few of the smaller tumors. In large tumors the arteries were often enlarged and apparently increased in number. Not infrequently the large tumors were more vascular than the surrounding musculature. The arterial system of the tumors appeared to be of two chief types of arrangement; there being a diffuse distribution of intrinsic vessels, extending in all directions within the tumor and a marked development of arterial trees with communicating branches and roots. The injected veins showed the tumor to be poor in veins and the endometrium rich in veins. The blood lost in uterine fibroids, accord- ing to Sampson, largely comes from the venous plexus surrounding the tumor. One or more branches of the arcuate arteries of the uterus sup- ply the tumor and are called nutrient arteries; the tumor is enveloped by these branches and penetrated by them. Arterioles in the tumor and immediately surrounding it may communicate; this Sampson believes to be a secondary development. Fibrous Polyps of Cervix. — The author has observed a number of cases of postclimacteric hemorrhage caused by fibrous polyps of the cervix. It appears that such polyps are prone to develop at this time of life. Carcinoma and Sarcoma. — One of the earliest symptoms of cancer and sarcoma of the uterus is hemorrhage. Yet these growths may be far advanced before hemorrhage or any other symptom is manifest. For this reason malignant diseases of the uterus are often not observed in time to effect a radical cure. When hemorrhage does make its appearance it is too often looked upon as an irregularity of the men- opause. The statistics in carcinoma of the uterus would he greatly bettered if all hemorrhages occurring at the time of the menopause and after this period were viewed with suspicion, and the cause sought for, rather than that all irregidarities be ascribed to the menopause. Syncytioma Malignum. — There is a malignant growth to which only a brief reference is here necessary. It is usually called syncytioma malignum, and is a malignant degeneration of placental tissue. Hemor- rhage is the earliest symptom, and it may be laid down, as a rule, 30 HEMORRHAGE FROM THE GENITAL TRACT that when an irreguhir hemorrhage follows late upon childbirth, hydatid mole, or abortion, the possibility of malignant degeneration of placental tissue must be borne in mind. The diagnosis can only be determined by an exploratory curettage and microscopic examination of the scrapings, together with a consideration of the clinical course. (See Chapter X.) Cystic Degeneration of the Ovaeies. — This is an occasional cause of uterine hemorrhage. Kelly says that hemorrhages from the uterus of ovarian origin have been known to prove fatal. On several occasions the author has checked uterine bleeding by resecting cystic ovaries without curetting the uterus or in any way directly altering its conditions. Such cysts of the ovary commonly develop from the corpus luteum. Pelvic Hematoma. — What has been said of pelvic inflammatory exudates will apply to accumulations of blood within the pelvis. When the blood is evacuated the hemorrhages from the uterus are often seen to disappear. Obstetrical Causes. — It is necessary only to refer to placenta proevia, hydatid mole, p)remat,ure detachment oj the placenta, and ectopic pregnancy as causes of uterine hemorrhage. When hemorrhage occurs during or immediately after the third stage of labor it is possible that placental tissue is retained in the uterus, or that the uterus is relaxed from fatigue and over- stretching. Improbable as it may seem, death from hemorrhage rarely follows rupture of the uterus, but it is more likely to occur from subsequent infection. Pathological Menstruation. — The persistence of menstruation during pregnancy should be regarded as a morbid condition and not as a perverted physiological type, as it is generally thought to be. The author believes that there is a pathological lesion in every instance to account for the loss of blood. Montgomery observed a case in which there was a profuse hemor- rhage at the time of the first menstrual periotl following conception. The patient learned to regard the hemorrhage as evidence of her pregnancy. Baudelocque and Deventer reported cases in which the menses only appeared during pregnancy and ceased at its termina- tion. The hemorrhage may appear at any month of pregnancy, but with greater frequency in the early months. In all such cases great caution should be exercised in the diagnosis of the cause of the hemorrhage. Before it can be regarded as menstrual blood a most searching examination must be made for the purpose of excluding such possible causes as placenta pr£evia, double uterus, fibroids, carcinoma, mucous polyps, and ectopic pregnancy. Arteriosclerosis. — Arteriosclerosis alone has been held responsible for uncontrollable uterine hemorrhage by Herman, Martin, Reinecke, and Kiistner. This cannot be wholly sustained, because in none of their cases is there a record of having excluded other possible causes UTERINE HEMORRHAGE 31 lying beyond the uterus. Reinecke and Martin performed hysterectomy in thirteen cases for the control of hemorrhage, and in all the removed uteri the arteries were found sclerosed; but they did not exclude the possibility of obstruction to the return circulation from such causes as diseases of the heart and lungs, thrombosis of the venous trunks, and portal congestion from whatever cause. The point is that in the light of twelve cases reported by von Kahlden, Popoff, Herxheimer, and Dietrich, and the one by the author, arteriosclerosis yer se is alone insufficient to cause a hemorrhagic infarction of the uterine tissues or hemorrhage into the uterine cavity. In the eight cases reported by von Kahlden the postmortem findings showed anatomical hindrances to the general circulation in every case. There was pneumonia in two of the cases, pulmonary emphysema and bronchitis in three cases, cancerous infiltration of the lungs and liver in one case, pulmonary infarcts in another, and in four of the eight cases there were cardiac lesions. In the case of Popoff there were granular nephritis and heart thrombi, pleural effusion, and infarction of the lung and brain. In Herxheimer's case there was an hypertrophied heart and thrombi in the left ventricle and right auricle, granular nephritis, and atheroma of the aorta. In the author's case, hemorrhage did not occur until there was an additional obstruction to the circulation caused by the plugging of the uterine artery. It is, therefore, not conclusively demonstrated that arteriosclerosis can in itself be the cause of uterine hemorrhage. It would appear that there must be additional causes for obstruction, such as were found in the recorded cases. In the so-called "apoplexia uteri," it is probable that the hemor- rhages are not caused by the rupture of the bloodvessels, but rather are due to capillary oozing. This would account for the hemorrhagic infiltration being so removed from the sclerosed vessels in the cases of von Kahlden. Etiology. — Respecting the etiology of arteriosclerosis of the uterine vessels and hemorrhagic infarction of the uterus, little can be said. Age varies within the limits of fifty and eighty-seven years. Pregnancy, menstruation, and inflammation of the uterus have some bearing upon the etiology. The causes of arteriosclerosis, i. e., alcoholism, chronic malaria, chronic lead poisoning, syphilis, etc., that obtain elsewhere in the body, apply likewise to the uterus. Frequency. — It is not unlikely that arteriosclerosis of the uterine arteries and hemorrhagic infarction of the uterus are often overlooked in clinical and postmortem examinations. It is probable that many cases of so-called "senile endometritis" and "hemorrhagic metritis of the menopause" are in reality hemorrhagic infarction of the uterus, and have as an underlying factor arteriosclerosis and calcareous degeneration of the uterine vessels. The fact that these cases occur in advanced years, that they may not be associated with leucorrhea, and that no cause may be found for the hemorrhages, either by clinical examination of the uterus and adnexa or microscopic examination of scrapings from the endometrium, would be strong evidence in favor 32 H.EMORRHAGE FROM THE GENITAL TRACT of the \it'\v that these cases are not infrequently hemorrhagic infarcts of the uterus and that the priman^ lesion lies in the bloodvessels. Diagnosis.— V\\\en there is no demonstrable cause for the hemorrhage the cases are usually called endometritis. If an exploratory curettage is made with negative findings, the indefinite diagnosis of metritis will probably be given, particularly when the uterus is of dense con- sistency and uniformly increased in size. It is possible that the increase in the connective tissue of the myometrium may interfere with the cir- culation, but it is altogether certain that in many cases the primary cause lies in the walls of the bloodvessels, and the hyperplasia of the uterus is secondary. It is altogether probable that arteriosclerosis of the uterine vessels may exist without sj^mptoms, and, as stated, there probably must be some additional obstruction to the return circulation in order to cause hemorrhage. This event alone is suggestive of the lesion. The clinical diagnosis is, therefore, at best uncertain. If hemorrhage occurs in the climacterium or near the time of the menopause, and no local cause for the hemorrhage can be found, either in the presence of newgrowths of the uterus and adnexa, in the position of the uterus; or in the microscopic examination of the uterine scrapings, then it is fair to .presume that arteriosclerosis of the uterine arteries exists. If, in addition to this, there is found arteriosclerosis of the peripheral arteries of the body, and there exists a disease of the viscera to account for an obstruction in the return circulation from the pelvis, then it is fair further to presume that a hemorrhagic infarction of the uterus is present, and that the uterine hemorrhages are due to a hemor- rhage into the tissues and cavity of the uterus. It is not probable that the sclerosed vessels will be found in the scrapings, because they commonly lie in the outer half of the uterine musculature. Caution must be exercised not to mistake the compressed glands for cancer nests. Syphilitic Uterine Hemorrhage. — Jaworskl mentions eight cases of obstinate uterine hemorrhage of sjqjhilitic origin. There is a sj^phi- litic angiosclerosis of the uterus marked by a hardening of the uterus which may spread to the whole organ and even to the parametric tissues. As a rule, the bloodvessels are affected and the syphilitic arteritis of tertiary syphilis may be the most prominent, and indeed it may be the only uterine change. The loss of elasticity of the uterine tissue, together with the hardening of the uterine vessels, may give rise to frequent, copious, and obstinate bleeding from the uterus, both at the menstrual period and in. any hyperemia of the uterus. He gives notes of five of his cases. In the first of these the hemorrhages had been excessive during three years, and three "cures" wdth saline baths and peat baths had done no good, nor had curetting of the uterus. At this time the man with whom the patient, an unmarried woman, cohabited came under treatment for tabes. Antisyphilitic treatment was now given the woman, with the result that the abnormal hemor- rhages altogether ceased, and the uterus became smaller and also normal in consistency. UTERINE HEMORRHAGE 33 The symptoms which suggest tertiary syphilis of the uterus are not characteristic. The most constant symptom is the occurrence of uterine hemorrhages which resist local treatment and the next in fre- quency is an olfstinate, offensive, mucopurulent discharge. The loss of blood always results in severe anemia, which may even proceed as far as cachexia. The uterus is usually increased in bulk, occasionally it is atrophic, its tissue is lacking in normal elasticity, and may be hard, sometimes almost of a cartilaginous consistency. A history of habitual abortion, usually at the same period of pregnancy, would be a great help to diagnosis. In the ulcerative forms of late syphilis of the uterus carcinoma of the uterus may be simulated. Menopause. — Finally, it may he said .thai the popular impression tliat the flow is increased in the climacterium leads to disastrous consequences. No increase in the menstrual flow at the time of the climacterium should he regarded as normal or of no clinical importance. A searching examination is imperative. Character of Discharged Blood. — The character of the discharged blood varies not only in amount, but in color and consistency; and from these characteristics something may be inferred as to the origin of the hemorrhage. The menstrual blood is usually thin and of a bright red to a dark brown color. Coagulation is hindered by the alkaline reaction of the uterine secretions. Coagulated menstrual blood is always abnormal. Coagulation of the blood may occur in endometritis, uterine fibroids, carcinoma, polyps, and abortion. When the blood is of a dark, brownish- red color it is inferred that the passage of the blood has been obstructed, giving time for coagulation within the uterine cavity. When mucus is intimately mixed with the blood it indicates an involvement of the cervix from cervical catarrh, polyp, carcinoma, or sarcoma. Blood of a syrupy consistency is supposed to have remained a long time in the uterine cavity. Tissue fibers mixed with the blood suggest the presence of degenerated newgrowths. Treatment of Uterine Hemorrhage. — In the treatment of uterine hemorrhage, the fact must not be overlooked that certain conditions remote from the pelvis may be the essential or contributing factors in the causation of uterine hemorrhages, and therefore call for systemic treatment. Anemia, plethora, purpuric conditions, diseases of the heart, lungs, kidneys, and spleen, chronic constipation, all may induce excessive bleeding at the menstrual period, and the treatment should be directed to these conditions. The treatment of uterine hemorrhage is essentially the removal of the cause and is first medicinal, second mechanical, third surgical. Medicinal Treatment. — For the control of uterine bleeding the drug p)ar excellence is ergot. The physiological effect of ergot is to produce contraction of the uterine bloodvessels and muscle fibers. Hence it is chiefly applicable to atonic conditions of the uterus associated with loss of blood. It finds its greatest applicability in the hemorrhages following abortions and labor due to relaxation of the uterine muscu- 34 HEMORRHAGE FROM THE GENITAL TRACT lature and will also promote involution of a subinvoliited uterus of recent development. Where the uterine musculature is degenerated or embarrassed by an excess of connective tissue, as in chronic metritis, ergot will have little effect in stimulating the contractions of the uterus. The fluidextract of ergot, given by mouth in 10-minim to 1-dram doses, will produce results in ten to twenty minutes. When there is need for more prompt action, ergotol in 5- to 30-minim doses may be given hypodermically. Hydrastis acts upon the bloodvessels and musculature in the same manner as ergot and may be given in equal doses alone or in com- bination with ergot. Styptol and stypticin are extolled as uterine sedatives and styptics. The author has not had as good results with these remedies as with ergot and hydrastis. They are given in 2- to 4-grain doses, three or four times daily. In the control of excessive menstruation they have some value and are also credited with ha\ing some sedative action in relieving pain. Viburnum prunifolium, in doses of ^ to 2 drams, has found favor particularly in the establishment of the normal menstrual flow. Adrenalin is said to have a controlling influence over the menses. The dose is 10 to 15 drops of a toVo solution, given four times a day. Calcium chloride may be given throughout the entire month in doses of 5 grains after each meal. During the menstrual period the same dose may be repeated at intervals of two hours. I^ — Calcii chlorid Gh'cerini Sig. — Teaspoonful three times daity. I^ — Fl. ext. ergotie Sig. — Half -teaspoonful every four hours. q. s. ad oiv 31V 20 j 120 120 Ice. oiij oj oj Calcii chlorid Ergotin Hydrastinin Div. iu caps. no. xxx. Sig. — One capsule every four to six hours. I^ — Stj-pticini gr. xl Ergotae gr- xl Div. in caps. xx. Sig. — One capsule everj'^ four hours. gi-. vn gi-. xxx gi-. iii 6} 'Bf — Hj'drastinse hydrochlorid Ergotin (^Merck) Ext. nucis vomicae Div. in caps. no. x\-. Sig. — One capsule every three hours. I^ — Desic. th\Toid . Div. in caps. no. xx. Sig. — One capsule five times daily. I^ — Ergotin 5ss Strj^chninse sulph gr. ss Ext. cannabis indica) gr. x Div. in caps. no. xxx. Sig. — One capsule every four houi's. 21592 2 592 1454 1 944 194 1032 648 UTERINE HEMORRHAGE 35 I^ — Ergotinse, Stypticini, Hydrastininse aa 5ss 2| Fiat capsulaj no. xxx. Sig.— One capsule every four to six hours. I^— Ergotin . 5ss 2| Ext. nucis vomic gr. vi 0|4 Fiat capsulse no. xxx. Sig. — One capsule every four to six hom's. • Much has been written on the use of pituitrin in the management of uterine hemorrhage of obstetrical origin, but as yet the remedy has not been extensively used in gynecological conditions. Bab has had success in the control of hemorrhages due to metritis, endometritis and pelvic inflammation. The dose was 2 or 3 c.c. of pituitrin injected subcutaneously and repeated on several successive days. The a'-rays have been effectively applied to climacteric hemorrhages of metritic origin. While employing the remedies mentioned the beneficent effect of rest must not be overlooked. Rest is the first and most essential measure to employ for the control of uterine hemorrhage. In girls who flow exces- sively it is well to enjoin rest throughout each menstrual period until the flow is regulated. This precautionary measure alone will often suffice for a cure. .Mechanical Treatment. — When the loss of blood is excessive or does not respond to medicinal treatment and rest, mechanical means must be resorted to for control of the bleeding. The following measures are in general use. Vaginal Packs. — Vaginal packs, consisting of strips of plain surgical gauze, are used to pack the vagina tightly. The packing is done through a bivalve or trivalve speculum, using a dressing forceps for the purpose. Instead of surgical gauze, lambs' wool or absorbent cotton may be used, but not so eftectively. Uterine Packs. — Uterine packs are rarely used except in postabortive and postpartum hemorrhages. Sterile gauze in long strips is packed tightly into the uterus from the fundus down. This pack is allowed to remain for forty-eight hours. Strict surgical cleanliness must be enforced in the procedure. Hot Vaginal Douches. — Hot vaginal douches are of special value in hemorrhages associated with pelvic congestion. The patient should be placed in the dorsal position. A Kelly pad or bed-pan will serve to collect the douche water. Not less than two gallons of water should be used, at a temperature of 112° to 120° F. These douches should be repeated once every four to twelve hours. Hot Intra-uterine Douches. — Hot intra-uterine douches have been used in postabortive hemorrhages, but they have a limited field of use- fulness and may do harm is dislodging emboli, in perforating the uterus, and in washing the fluid through the tubes into the abdominal cavity. Ice-bags. — Ice-bags placed over the abdomen and lumbosacral region are of service when the hemorrhages are not excessive. 36 HEMORRHAGE FROM THE GEXITAL TRACT Intra-uterine Applications. — Intra-iiterine applications of styptics are effectively used. The enclometrium is swabbed with nitric acid (C. P.) or with the perchloride of iron. Surgical Treatment. — Whatever may be the underlying cause of uterine hemorrhage the curet is the common resort with the pro- fession in general. The curet is capable of much harm and should not be used by the ignorant or the careless. The subject is fully dis- cussed on page 126, where its limitations are defined. For the treatment of uterine hemorrhage dependent upon displace- ments of the uterus, metritis, subinvolution, pelvic inflammation, cystic ovaries, extra-uterine pregnancy, incomplete abortion, fibroids, cancer, sarcoma, syncj'tioma malignum, muscular insufficiency, arterio- sclerosis, and other morbid states, the existing morbid conditions must be corrected or removed. These subjects will be discussed under their respective heads. When the patient has lost blood to the extent of creating so grave an anemia as to render an operation under anesthesia hazardous, it is well to control the hemorrhage by tentative measures until the blood is sufficiently restored to justifiy operative interference. To this end rest in bed should be enjoined, a light but nourishing diet should be given, blood tonics administered, the uterus curetted, and the vagina packed with gauze. The author has repeatedly succeeded in improving the blood at the rate of 1 per cent, a day under this treatment, and thus speedily brought the patient to a safe condition for operation. Below 40 per cent, of hemoglobin, 2,000,000 red corpuscles, and a blood pressure of 100, it is not safe to perform a major operation. Nothing short of an emergency would justify surgical interference when the blood findings are below this point. CHAPTER II DISORDERS ASSOCIATED WITH MENSTRUATION- BACKACHE— ENTEROPTOSIS DISORDERS ASSOCIATED WITH MENSTRUATION Amenorrhea Physiological Absence of Men- struation General Causes Local Causes Menstrual Molimina Vicarious Menstruation Diagnosis Treatment Pain in Pelvis during Menstrua- tion (Dysmenorrhea) Primary Secondary Membranous Dysmenorrhea Nasal Dysmenorrhea Periodic Intermenstrual Pain (Mittelschmertz) Treatment Dysmenorrhea Due to a Conical Cervix Amenorrhea. — Physiological Absence of Menstruation. — In determining the causes of amenorrhea it is well to bear in mind the physiological conditions in which the menses fail to appear. 1. Before puberty. 2. During irregular intervals at the time of the establishment of menstruation. 3. During pregnancy and a variable time in the period of lactation. 4. During the establishment of the climacterium — "dodging period." 5. After the menopause. When the menstrual flow is retarded or when the quantity is less than normal the condition is known as amenorrhea. The term may be further qualified by the words relative and absolute. By relative amenorrhea is meant a menstrual flow that is below the normal amount for the given individual. What is abnormal for one may be normal for another, depending upon the general condition of the individual. By absolute amenorrhea is meant a total suppression of the menses. The causes of amenorrhea are both general and local. General Causes. — Debilitating diseases, such as primary anemia, diabetes, Bright's disease, tuberculosis, malaria, and nervous dis- eases, are contributing factors. Chlorosis is probably the most common cause of amenorrhea in girls. In determining the cause of amenorrhea it is not enough to establish the fact of anemia, but the character of the anemia must be ascertained by an analysis of the blood, and, if possible, the underlying cause must be demonstrated. The secondary anemias are grouped according to general causes into 38 DISORDERS ASSOCIATED WITH MENSTRUATION those due to deficient nutrition and those due to increased waste. Digestive and respiratory disorders Hmit the supply of blood and oxygen essential to the proper nourishment of the body, and, indirectly, to the performance of the menstrual functions. Amenorrhea is not infrequently the first suggestion of the presence of an incipient tuberculosis. Formerly these cases were commonly regarded as chlorotic, inasmuch as the two affections present the same blood findings. Furthermore the same treatment, fresh air and abundant diet, with regulation of the bowels, is employed for both. It is encouraging to note that tuberculosis presents the more favorable prognosis, since genuine chlorosis is likely to be associated with defects in the bloodmaking organs, or with an abnormally small size of the heart and bloodvessels; conditions which cannot be remedied. Change in environment conduces to constipation, and it is observed that by regulating the bowels these amenorrheics are more readily benefited than by any other process. Hemorrhage from any part of the body, chronic diarrhea, continued suppuration, albuminuria, and the like, result in excessive waste that will bring about amenorrhea. Changes in Environmeiit. — These are often followed by amenorrhea for a variable length of time. Girls coming from foreign countries to the United States commonly experience a delay in the appearance of the menses for a variable time. Mental Shock and Anxiety. — These may cause a suppression of the menses. The fear of conception may suppress the menstrual periods, and when the fears are allayed the menses may promptly return. "Catching Cold." — This is a term in ordinary usage, implying a congestion of the pelvic ^'iscera. Part or all of the menses may be suppressed by exposure to cold immediately before and during the menstrual period. Acute Infectious Diseases. — Acute infectious diseases, including diphtheria, pneumonia, scarlet fever, and acute articular rheumatism, may be followed by a period of amenorrhea, and may result in perma- nent suppression of the menses through degenerative changes in the uterus and ovaries. Nervous Diseases. — Nervous diseases, including melancholia, various forms of insanity, and imbecility, are not infrequently responsible for amenorrhea. In many instances the amenorrhea is thought to be the exciting cause of the nervous disorders. Drug Addictions. — Morphinism is an occasional cause of amenorrhea. The same is said of alcoholism and lead poisoning. Temporary Amenorrhea. — Temporary amenorrhea is not uncommon in young women as a result of worry and anxiety, change of residence, and mode of life. In every instance the possibility of pregnancy must be borne in mind, and when it cannot be positively excluded, the patient must be kept under observation until such time as positive signs of pregnancy would be manifest. Following typhoid fever, diphtheria, scarlet fever, and other acute AMENORRHEA 39 infections the menses may not return for several months. Amenorrhea is an early accompaniment of pulmonary tuberculosis, a fact which has led to the impression among the laity that amenorrhea causes tuberculosis. Disordered Functions of the Ductless Glands. — These constitute im- portant factors in the development of amenorrhea, though as yet the problems connected with this subject are largely theoretical. When there is a lack of thyroid substance in the system, as occurs in m^'x- edema, amenorrhea is usually a symptom. In exophthalmic goitre relative amenorrhea is sometimes observed, though as a rule the menstrual flow is increased. The first symptom of Addison's disease is likely to be amenorrhea. In acromegaly, when the pituitary body is atrophied, amenorrhea is usually present as one of the earliest symptoms. Cretinism is commonly associated with amenorrhea. Local Causes. — Congenital Absence of Organs. — Congenital absence of the organs essential to menstruation, namely, the uterus and ovaries, is a rare causal factor. Hypoplasia and Atrophy. — Hypoplasia and atrophy of the organs essential to menstruation, are often accompanied by chlorosis. Here the ovaries are primarily affected. Atresia. — Retention of the menses occurs from atresia of the cervix and vagina, imperforate hymen, and tumor formations obstructing the outflow of the menstrual blood. (See Chapter XY.) Atresic conditions of the vulva, vagina, and cervix are congenital in about one-third and acquired in about two-thirds of the cases. The acquired forms are the result of gonorrheal vulvo-vaginitis and the sequelae of infectious diseases. Puerperal ulcers of the vagina and vulva may lead to atresia, as may also extensive lacerations following labor. Ill-fitting pessaries worn over a long period are occasional factors. Application of caustics to the cervix and endometrium may induce amenorrhea through atresia. Removal of Uterus and Ovaries. — Removal of the uterus or ovaries, doing away with the menstrual flow. Diseases of Genital Organs. — Diseases of the genital organs which disable and destroy the tissues essential to menstruation — i. e., metritis, endometritis, cystic degeneration of the ovaries and new-formations in the uterus and ovaries — are occasional causes of amenorrhea. Adipostity Associated with Anemia. — The fault may rest primarily in the ovaries. Amenorrhea without Apparent Cause. — ^The general and local condi- tions of an individual may appear perfectly normal in the presence of amenorrhea. Effects of Ovariotomy ox Mexstruatiox. — In this relation it is interesting to note the eft'ect of the removal of the ovaries upon men- struation. After both ovaries are removed, menstruation stops abruptly in 66 per cent, of cases. In the remaining 33 per cent., menstruation stops gradually throughout a period of one to six months. The cause of uninterrupted menstruation after double ovariotomy 40 DISORDERS ASSOCIATED WITH MENSTRUATION is explained by the presence of a supernumerary ovary or by the accidental leaving of a bit of ovarian tissue adherent to the neighboring structures. A small portion of the ovary may have been constricted off from the parent ovary by contracting bands of adhesions, and may escape notice in the removal of the ovary. The law of persistence of habit may explain an occasional case. More often a flow persists as the residt of a uterine tumor or an inflammatory lesion, and is not, strictly speaking, a menstrual flow. Menstrual Molimina. — The local and general disturbances which accom- pany the menstrual flow ?ire designated as the menstrual molimina. These disturbances are pain in the region of the ovaries, in the back, and radiating to the thighs; also flushing of the face, dizziness, palpi- tation, and headache. The duration of these symptoms varies from a few hours to the entire month. The menstrual molimina generally begin about one month after the removal of the ovaries, and extend over a period of one or two years, sometimes much longer. When the uterus alone is underdeveloped and the ovaries are sufficiently developed to functionate, there will be little or no flow of blood, but the other phenomena of menstruation which mark the con- dition known as the menstrual molimina appear at monthly intervals. Vicarious Menstruation. — Vicarious menstruation is a discharge of blood at the menstrual period from some part of the body other than the uterus. These hemorrhages may occur simultaneously with the uterine menstrual flow, or in the absence of all bleeding from the uterus. Almost all mucous and cutaneous surfaces have been known to menstruate vicariously, notably the nose, stomach, intestines, and bronchi. The urethra, bladder, throat, conjunctiva, and ears bleed less frequently. Instead of blood, other discharges ma}^ take place. Cases have been recorded of periodical diarrhea, leucorrhea, and secretions of milk from the breast. Ulcers and cicatrices have been known to bleed at the men- strual period. A nevus on the face has been known to bleed simultane- ously with the menstrual flow. The cervix was observed to menstruate by Ashton after the removal of the body of the uterus and ovaries. Diagnosis. — The diagnosis of amenorrhea is made solely upon estab- lishing the fact of the non-appearance of the menstrual flow. Such a diagnosis is of little value unless the cause of the amenorrhea is clearly established. Pregnancy must always be excluded before considering other possible causes, and in doing so it is often necessary to observe the patient for a limited period. When a patient presents herself complaining of amenorrhea, her age will suggest the possible cause. If she is about the age of puberty, the irregularities which commonly mark the establishment of the menstrual function suggest themselves; if in the period of sexual maturity, the possibility of pregnancy is uppermost in the mind; and if at a later period, the menopause is suggested. Again, if the patient has never menstruated and has advanced beyond the age of puberty a defect in the development of the sexual organs is naturally suggested. So varied are the causes of amenorrhea that without a searching AMENORRHEA 41 physical examination the diagnosis of the cause cannot be known, and without a diagnosis the treatment cannot be wisely directed, inasmuch as amenorrhea is but a symptom, and rational treatment is based upon the removal of the cause. First of all the question must be determined as to whether the amenorrhea under consideration is physiological. The questions asked are: Is it time for the establishment of puberty? Is it possible for pregnancy to exist?' Is the patient nursing a child? Is she in the dodging period of life? Has she reached the menopause? All of these questions must be settled before it is possible to pass to a consideration of the many general and local conditions which may have a direct bearing upon the existing amenorrhea. Having answered them in the negative a consideration of the systemic causes of amenorrhea is taken up. Is the patient suffering from or has she recently suffered from a debilitating disease, such as tuberculosis, malaria, nephritis, anemia, and digestive disorders ? If so, the cause of the amenorrhea may be thus explained and a rational course of general treatment is suggested. Treatment. — The habits of the individual should be investigated in reference to her mode of living and possible dissipations. If she has recently changed her residence to another climate or to some foreign country, the assumption is not out of place that in due time the men- strual periods will be reestablished. If she is addicted to the morphine habit, its correction may bring relief. If she has suffered from some mental shock or anxiety or from some nervous disorder, the treatment is best directed toward the relief of these conditions. There is a so-called functional amenorrhea in which the genital organs are apparently healthy and the general state of health is good. Such cases call for no active treatment, either local or general. The thought of these patients should be directed away from their sexual disorders, daily exercise in the open air should be insisted upon, and the excretions and diet properly regulated. Local treatments are meddlesome and cannot be productive of good. The chlorosis of young women, which is commonly associated with amenorrhea, is best treated by a judicious regulation of exercise in the open air, by prescribing a liberal diet, and by the administration of iron and arsenic. Too constant application to study should be discouraged; shorter hours in school and longer hours of rest and exercise in the open air are imperative. In severe cases it may be necessary to take the girl out of school for a time. Blaud's pill in 1- to 2-grain doses, together with 3 to 7 drops of Fowler's solution given after each meal and at bedtime and continued several months, will often effect relief. ^Vhen iron is not well borne by the mouth it may be given hypodermically in the form of ammonio-citrate of iron, I grain dissolved in ^ dram of sterile water. Laxatives are essential in regulating the bowels. 1 to 5 grains of reduced iron in pill form is a favorite method of administering iron in chlorosis. 42 DISORDERS ASSOCIATED WITH MENSTRUATION Acting on the theory that chlorosis is due to the lack of internal secretion of the ovary it would be logical to administer corpus luteum extract (Parke, Davis & Co.), given in capsules of 5 grains each after meals and at bedtime. Bandler recommends ovariin for the same purpose. Emmenagogues designed to stimulate the menstrual flow cannot be depended upon and are not recommended. There is no surgery for amenorrhea unless the obstruction to the out- flow of the menstrual blood is regarded as an example of amenorrhea. The following prescriptions are recommended by the author: I^ — Magnesii dioxid 3j 4 1 Aloin gr- iij 1 194 Fiat. pil. no. xxx. Sig. — One pill three times daily. I^ — Strychninse nitratis gr- iij 1 194 Apioline 3j 4| Fiat. caps. no. xxiv. Sig. — One capsule after meals. Pain in the Pelvis during Menstruation (Dysmenorrhea). — Pain in the pelvis is often referred to the uterus or ovaries. Of all pains in the abdomen the so-called "ovarian pain" is by far the most usual. Experience has taught that pain is referred to the ovary of the left side three times as frequently as to the right. There is no satisfactory explanation for this. It is a matter of every-day clinical experience that the pain is often referred to the left ovary when there is no apparent disease in either ovary; more than that, there may be no demonstrable lesion in the pelvis. Even more strange is the finding of the lesion in the right ovary and the pain referred to the left ovary. The author makes no attempt to explain these facts. Certain it is that reflex pains may be located in the ovary and the lesion confined to the uterus or opposite ovary. It must not be inferred from com- plaints of pain in the ovary that its structure is diseased, but such pains may well suggest possible lesions in one or more of the pelvic viscera. Such pains are particularly frequent and severe at the time of the menstrual period. This leads to the discussion of dysmenorrhea, a term often misused and little understood. Ernest Herman estimates that only 40 per cent, of women menstruate without pain, and that 10 to 20 per cent, of unmarried women are bedridden with pain during a part or all of the menstrual period. Primary Dysmenorrhea. — In determining the cause of dysmenorrhea the condition of the nervous system must first be considered. A con- dition causing pain in one individual may be unnoticed in another of more stable equilibrium. When pain in the pelvis is complained of during and between the menstrual periods and a thorough examination reveals nothing abnormal in the pelvis, it is a common habit to conclude that the fault lies in a functional derangement of the nervous system, and such vague terms as hysteria, neurasthenia, and neuroses are applied. A certain degree of pain during the menstrual period may DYSMEXORRHEA 43 be considered within normal limits, and in very nervous women such pains may become exaggerated to actual suffering. The author's opinion is that severe dysmenorrhea in the absence of pelvic abnormalities is rare. The individual becomes more and more nervous as the result of her periodic suffering. The author, therefore, is inclined to regard the general nervousness as an effect rather than a cause of the menstrual pain. The local disorder may be nothing more than a tetanic contraction of the sphincter uteri, which does not occur in the intermenstrual period. Such cases respond to dilatation of the cervix. They are also the cases which are relieved by childbearing. The explanation of the "normal" menstrual pain is probably found in the engorgement of the endometrium, which, acting as a foreign body, excites the uterus to contract; and it is these uterine contractions which occasion the pain. In many of the pathological lesions involving the pelvic viscera, the menstrual congestion is added to the already engorged tissues, and the pain is severe. It is exceptional for patho- logical lesions to exist in the uterus and adnexa without dysmenorrhea, but knowing such to be possible, and, on the other hand, knowing that pain of equal intensity may exist in the absence of a pathological lesion, it is difficult to determine how much of the pain is due to struc- tural changes and how much to an -excitable nervous system. Thus dysmenorrhea is spoken of as being idiopathic or primary when it is evident that the pain bears no relation to pathological lesions of the genitalia, and secondary when it is evident that the pain is the direct result of a morbid condition in the genital tract. Schultze suggested an explanation for dysmenorrhea occurring in young girls and young women in whom nothing abnormal was dis- covered to account for the pain. He suggests the possibility of hypo- plasia of the uterine musculature being present, and hence the uterus is unable to expel the menstrual blood as fast as it accumulates in the uterus. In this condition two sorts of pain may arise, premenstrual and menstrual, the former being due to tension in the congested uterus. In these cases pregnancy often results in a cure because of the develop- ment of the uterine musculature. Secondary Dysmenorrhea. — Secondary dysmenorrhea may be caused by all lesions of the genital tract. These may be classified under: MalderelopmenU and Malformations. — INIaldevelopments and mal- formations, which cause menstrual pain by obstructing the outflow of the menstrual blood. In this category may be included absence or atresia of the vulva, vagina, and cervix. The menstrual molimina are experienced, but without a show of blood. With the return of each monthly period the pain increases in intensity as the result of accu- mulated blood within the vagina, uterus, tubes, and, possibly, the pelvis. The obstruction may not be complete, and the retarded blood, having time to coagulate, is then expelled with cramp-like pains — the so-called "obstructive dysmenorrhea." Superinvolution of the uterus is associated with painful menstruation, the cause of which is not understood. A congenitally small uterus 44 DISORDERS ASSOCIATED WITH MENSTRUATION (infantile) is likewise associated with dysmenorrhea. In either case the explanation possibly lies in the encroachment of the tissue fibers upon the nerve filaments of the uterus. Malpositions. — Malpositions of the uterus and adnexa are less fre- quently the cause of dysmenorrhea than are the associated lesions. It is exceptional for the menstrual blood to be obstructed in its outflow by the bending or twisting of the long axis of the uterus. Pain is more often the result of complicating lesions in and about the uterus and its appendages. Fig. 1 Showing uterine pain referred to the suprapubic region and to the breast. Anteflexion of the uterus, when extreme, is almost always associated with pain. The cause of the pain in these cases is still a matter of controversy. It is not probable that the canal is obstructed by the bending of the uterus, as was formerly believed. Hyperesthesia, resulting in muscular spasms of the internal os, is a more satisfactory explanation for the obstruction. It is evident that the pain in such cases is largely neurotic in origin. Anteflexion of the uterus is said to be a frequent cause of dysmen- orrhea in virgins and nulliparous married women. In these cases it is often observed that a small sound will pass the internal os, yet there is evident mechanical obstruction to the outflow of the menstrual blood. The explanation lies in the swelling of the mucous membrane during the menstrual period, together with spasm of the sphincter above referred to. The passing sound compresses the swollen mucosa. DYSMENORRHEA 45 Inflamvmtory Diseases. — In inflammatory diseases of the uterus and adnexfe, which are more or less tender and painful in the inter- menstrual period, the suffering, is greatly intensified by the menstrual flux — -"congestive dysmenorrhea." Plugs of tenacious mucus may fill the cervical canal and obstruct the menstrual flow. New-formations. — Xew-formations, notably fibroid tumors in the genital tract, may obstruct the menstrual blood — " obstructive dysmen- orrhea." Pelvic tumors share in the menstrual congestion, and by their enlargement the pressure sjTnptoms are intensified. Fig. 2 Location of pain referred to the uterus. Membranous Dysmenorrhea. — ^Membranous dysmenorrhea is a term first applied by ]vIorgagni. In this condition there is a discharge at the menstrual period of a part or of the whole of a cast of the uterine cavity. The discharge of the membrane may occur but once or at suc- cessive menstrual periods. If it were believed that the endometrium is shed at each menstrual period, the conclusion might readily be accepted that membranous dysmenorrhea is merely an exaggeration of the normal process. The membrane may be shed as a complete triangular cast of the uterus, or may be discharged in shreds. Membranes are more frequently passed in the menstrual flow than is knowm. ^Yithout a svstematic examination of the clots expelled. 46 DISORDERS ASSOCIATED WITH MENSTRUATION such membranes will often escape notice. Sir I. Williams found mem- branes in three-fourths of his cases of dysmenorrhea and Scanzoni in two-thirds. They may be passed without pain. The possibility of monthly abortions must be borne in mind. Virgins and sterile women are most affected, though the disease is not unknown to women who have borne children. The diagnosis depends upon a careful examination of the expelled membrane. (See Chapter VIII.) Fig. 3 Showing location of ovarian pain referred to the breast, to the iliac region, and to the inner aspect of the thigh. Under the microscope a great variation in structure is seen. The membrane may resemble an hypertrophied endometrium, a decidua, or a fibrinous membrane. Accompanying the discharge of the mem- brane is intense pain. The membrane is not to be mistaken for the decidua of extra-uterine or intra-uterine pregnancy. Nasal Dysmenorrhea.^ — Fliess, in 1897, demonstrated a definite rela- tionship between the mucous membrane of the nose and the genitalia in women. He observed certain swollen and tender red spots ("genital spots") on the nasal septum and inferior turbinates. Schiff made a number of clinical observations and conclusively demonstrated that temporary relief is often afforded by cocainizing these genital spots, and that permanent relief can be afforded by the use of the cautery. Ephraim treated twenty-four cases with eight good results. These reflexes, together with the established fact of vicarious menstruation DYSMENORRHEA 47 from the nose, would appear to establish beyond a doubt an intimate relationship between the nasal and genital passages. In these cases great caution was exercised in excluding the influence of mental sug- gestion. The author is inclined to believe that the procedure is irrational and will not stand the test of time. Fig. 4 Location of pain referred to the tubes and ovaries. Periodic Intermenstrual Pain (Mittelschmertz) .— B y the term inter- menstrual pain, a condition is understood in which pain of a definite character recurs at monthly intervals between the regular menstrual periods. Very often the time is midway between menstrual periods, but may be earlier or later. Time of Occurrence. — These intermenstrual pains may begin with the establishment of the menstrual cycle, but in the majority of cases they first appear some years after puberty. They may persist through- out the entire menstrual life or may recur at regular intervals over a much shorter period. Childbearing in relation to intermenstrual pain is of significant interest. In an excellent article Heaney^ analyzed the reports of 66 1 Surg., Gyn., and Obst., October, 1910. 48 DISORDERS ASSOCIATED WITH MENSTRUATION cases, showing that the affection occurs with greatest frequency at the period of sexual maturity. There was a high percentage of steriHty; only 3 of the 66 became pregnant after the onset of intermenstrual pain and but one of these carried the child to term. In the majority of cases the intermenstrual pain began one or more years after puberty. Heaney says, "Pain is the fixed symptom and is very character- istic." The pain appears in the intermenstrual period with the same regularity as the menstrual periods. These pains are colicky in type and are more common on the left side of the pelvis. In more severe cases the pain is referred to the entire pelvic region and may radiate to one or both thighs. Leucorrhea. — While there is an accompanying vaginal discharge in many of these cases, it is not possible to establish any direct or indirect relationship between the vaginal discharge and the pain. Dysmenorrhea. — There is no direct relationship established between intermenstrual and menstrual pains. In about half the cases there are no menstrual pains. » Associated Pathological Lesions.— In a small proportion of cases the pelvic organs appear perfectly normal, while in many cases the lesions found cannot be held responsible for the pain. There is a preponderance of uterine fibroids in these cases. The belief is fre- quently expressed that the tube is the seat of the pain. Giles and Bland Sutton believed the symptom complex to be due to intermittent hydrosalpinx, the pain being due to the effort of the tube in expelling the contained fluid. Observations after operation do not support this theory. Heaney believes that " Mittelschmertz" is an abortive attempt at menstruation, having as its foundation sclerosed ovaries and uterus. Treatment. — The disease, if it may be called a disease, is not self- limited. Numerous methods of treatment, both general and local, have been suggested, and with indifferent results. Ovarian extract, thyroid extract, electricity, stem pessary, dilatation and curettage, removal of one or both appendages, all these have been tried with but an occasional good result. All that can be said is that the general condition of the patient should be improved by hygienic measures, notably rest, outdoor exercise, nourishing diet and baths, and finally, that lesions within the pelvis which may possibly account for pain should be removed. The most plausible explanation for the pain is that of Priestly, who believes the pain to be dependent upon ovulation. It is known that ovulation occurs in the intermenstrual period, and usually midway between periods, hence the suggestion that nothing short of removal of the ovary will effect a cure with any degree of certainty. ' Resort to this procedure should be taken with great deliberation, if indeed it should be countenanced. Treatment of Dysmenorrhea. — Of all the sj-mptoms complained of by women, pain is the least trustworthy, inasmuch as pain may be present without any demonstrable lesion, and, on the other hand, pain may be DYSMENORRHEA 49 absent in the presence of any of the pelvic lesions. The psychic element plays a most important role, and must always be reckoned with in estimating the significance of pain. Medical Treatment. — ^A very large proportion of women suffering from dysmenorrhea are psychoneurotics, hence the great value of psychic and hygienic treatment. In the absence of demonstrable pelvic lesions the management of this class of cases is in general as follows : Open-air exercise regulated in accordance with the patient's strength and the placing of the patient under conditions that will most agreeably absorb her attention and take her mind from her fancied ailments; the stimulating cold plunge or shower in the morning and the sedative hot bath in the evening, and finally the enjoining of rest in bed for two or three days at the onset of menstruation; all these provisions will tend to lead her out of her troubles and effect a cure. It is most important to look to the general nutrition. Many of these patients are underfed, and it will be found that they become more tolerant to suffering and indeed suffer less, as they become better nourished. They should be instructed to take a liberal mixed diet at the regular meal hours and between meals, and at bedtime should be given a glass of milk, malted milk, cocoa, or eggnog. Rest should be enjoined to suit the individual case. Not less than eight hours of sleep should be required of all, and in many instances a midday nap of one or two hours should be added. A girl suffering from severe menstrual pains should be kept quietly at home while menstruating. While suffering severe pain she should be kept in bed. As the general health improves the pain will usually lessen and more liberties may be granted. Outdoor exercise should be indulged in and encouraged for the purpose of improving the general resistance. No restrictions should be placed upon the desire for any healthful exercise. In the intervals between menstrual periods several hours a day should be devoted to such exercises. Regulation of the bowels, particularly just preceding and during the menstrual flow, is an important factor in relieving painful men- struation. The giving of saline cathartics at such times will do much in relieving pain. A hot hip bath or full tub bath, at a temperature of 110° F., taken for a half-hour at the beginning of the premenstrual symptoms, will do much to prevent the onset of pain and to promote a free menstrual flow. Great care should be exercised in preventing a chill of the body upon leaving the bath. The room should be warm, and after leaving the bath, the body should be hurriedly dried with a soft towel and wrapped in a warm, blanket and finally there should be an hour or more of rest in bed following the bath. The hot-water bag placed over the hypogastrium is usually sufficient in itself to control pain, and is a most acceptable substitute for drugs. The hot vaginal douche and hot saline rectal injections are helpful 50 DISORDERS ASSOCIATED WITH MENSTRUATION adjuncts to the hot bath. A hot mustard foot bath is a domestic remedy of some value; two teaspoonfuls of mustard are placed in a pail of hot water. ()})iates and alcoholics are seldom necessary and are capable of much harm. Many women have become addicted to opium and to alcohol by their injudicious use in controlling pain at the menstrual periods. ]\Iany of the patent remedies advertised for the cure of menstrual dis- orders contain a large percentage of alcohol. The Massachusetts State Board estimated the percentage of alcohol in Lydia Pinkham's Vege- table Compound as 20.6; in Peruna, 28.5; Pain's Celery Compound, 21; Ayer's Sarsaparilla, 26.2. When, in the judgment of the physi- cian, alcohol or opium is required the precaution should be taken to prescribe them in such a manner as to make it impossible to have the prescription refilled or for the patient to know what she is taking. The following are favorite prescriptions for the relief of menstrual pain: I^ — Aspirin 5j 41 Veronal 5j 4| — M. Ft. caps. no. xii. Sig. — One every foiu- hours. I^ — Phenacetin gr. ij 103 Salol gr. ij |03 — M. Ft. charta. Mitte tales no. vi. Sig. — One pow.der every four hours. I^ — Phenacetin gr. v 01 325 Codein gr. v o|325— M. Ft. charta. Mitte tales no. vi. Sig. — One powder and repeat in an hour. I^— Aspirin gr. iij 1 195 Phenacetin gr. iij 0|l95— M. Ft. tal. caps. no. xx. Sig. — One every three hours. ]^— Apiol gr. j 0|065— M. Ft. caps. no. xii. Sig. — One night and morning for three days before menstruation. I^ — Acetanilid gr. ij 0113 Heroinse. '. '. gr. i 01 — M. l*t. cap. no. VI. Sig. — One every two hours for three doses. I^ — Sodii bromid gr. xl 2 1 6 Hot saHn sol. (physiological) .... Oj "i M Sig. — Inject into rectum and retain. (Kelly.) I^ — Tr. opii camphorata 3j 4 Ice. Spt. chloroformi . . . . • 3ij 8 c c' Aq^menth. pip . . . q. s. ad giv 120^0! big. — One tea.spoonful as required. I^-Acetanili'd gr. ij Jl30gm. Ft.pirr'i'"'' ^^•"^' Il94gm.-M. Sig. — One pill every hour for three doses. DYSMENORRHEA 51 I^ — Ergotin gr. xxx 1 1 94 c.c. Stypticin gr. xxx 1 1 94 c.c. Div. in caps. no. xx. Sig. — One capsule every six hoiu's dm-ing menstruation. I^ — Strontii bromid 5iv 15 '52 c.c. Syrup acacise giij 90 1 c.c. Sig. — Teaspoonful in water every three hours. When pain is associated with the expulsion of blood-clots, Bandler recommends stypticin in 2-grain doses repeated several times daily. When the uterus is relaxed, as in muscular insufficiency, ergot may be given in small and repeated doses. When pain is of a congestive character the pelvis is depleted by such means as sitz baths, hot hip packs, hot vaginal douches, saline catharsis, and the application of a hot mustard plaster to the spine. A plaster three inches in width is placed on the spine from the neck to the sacrum. The following method is used in preparing the plaster: mustard is rubbed into a thick paste by adding warm water and reduced to a thick consistency by adding molasses or syrup. A piece of unstarched muslin about 24 inches long and 9 to 10 inches wide is spread through the middle third and the lateral thirds of the muslin are folded over the mustard paste. After warming the plaster it is applied the length of the spine for ten to twenty minutes and then removed. Emmet believes that dry cups are more efficacious than the mustard plaster. Four to six large tumblers may be used. They are to be placed over all tender points along the spine and left in place for fifteen minutes. SuEGiCAL Treatment. — When tentative measures fail to afford relief the final resort must be to surgical intervention. A very large proportion of cases are due to pelvic lesions which are only amenable to surgery. In order that tentative measures on the one hand and surgical measures on the other may be wisely ordered, there must be a thorough appreciation of the social, moral, and physical conditions affecting the individual. Without this understanding there can be no intelligent management of this class of cases. Dilatation of the Cervix. — The one operation that has been generally approved in the management of dysmenorrhea is dilatation of the cervix. Even when there is no known anatomical basis for the pain, the overstretching of the cervix will often eft'ect a cure. Kelly dilated 95 such cases and obtained permanent relief in 18 and great benefit in 14; 7 more were partially or completely relieved for from one to twelve years when the pain returned. It is not clear just how these results are brought about. The probable explanation is in the over- stretching of the cervix, which overcomes the spastic contractions which cause a temporary obstruction to the menstrual flow. By refer- ence to the many factors contributing to pain at the menstrual period it is apparent that dilatation of the cervix is limited in its applicability. No good can come from dilatation in many of the displacements, inflam- mations, degenerations, and new-formations of the pelvic organs. The technic of dilatation and curettage is described in Chapter VII. 52 DISORDERS ASSOCIATED WITH MENSTRUATION It would be well to discuss dilatation and curettage in the treatment of dysmenorrhea because this procedure is so frequently resorted to. Failure to effect relief is not so much ascribed to faulty technic as to a faulty diagnosis. The existence of a retrodisplacement or prolapsus of the uterus, of a subinvolution or chronic metritis, of an inflammatory Fig. 5 Conical cervix, punctiform orifice. (Pozzi.) involvement of the adnexse or of fibroid tumors, pelvic exudates or cystic ovaries, not recognized or not given due consideration, renders dilatation and curettage ineffective and often harmful. The uterus should be dilated and curetted in the presence of an existing endometritis, or of a marked anteflexion and as a sole measure DYSMENORRHEA 53 it should be employed only in the absence of other pathological lesions. When relief is afforded for a number of months or years, and pam ao-ain returns, a second dilatation and curettage will be indicated. ^Primary dysmenorrhea is relieved in many instances by dilatation of the cervix and curettage. In the absence of a pathological lesion Fig. 6 Hollowing out of the cut surfaces of the cervix. (Pozzi.) the results gained must be due to suggestion. The presence of anemia malnutritiol and neurasthenia does not necessarily -tigate ^^^^^^ the good results to be obtained from this procedure Inasmuch as t is not possible to foretell which cases will be ^-f jf^ a"^^ not, it would seem wise to subject all cases to dilatation and curettage which cannot be controlled by more tentative measures. 54 DISORDERS ASSOCIATED WITH MENSTRUATION Membranous dysmenorrhea presents a very discouraging prognosis. Curettage and the appHcation of various chemicals have been tried with Httle result. Stem Pessary. — The stem pessary has been recommended for the cure of dysmenorrhea associated with anteflexion of the uterus; but the Fig. 7 Introduction of the stitches. The commLssural stitches are drawn tight. (Pozzi.) author has no personal experience with this contrivance and does not look upon it with favor. Removal of the Ovaries. — Should apparently healthy ovaries be removed for relief from dysmenorrhea? The author has never met with a case that seemed to him to justifiy such a procedure, and he DYSMENORRHEA 55 very much questions if [the operation is ever justified under such '"^He'^ild here quote Kelly and add his personal indorsement: "(Sphorectomv, which is still, I fear, too often done for mtractable d?sr^errhea,'i; rarely, if ever justifiable. Let the younger surgeon Fig. 8 The operation finis u rlrn-n-Ti tio-ht and the leaden guards applied. ,hed. All stitches have been drawn tignc anu (Pozzi.) be assured that he may thus transform a ueurotic "jf^^t. a gloomy wreck, fitted only for an asylum^ "■'>7, f^.f jh^tfe who comes to h^afVoi'' hijL% r;;?shoSf l: ^:^^ - - -■ - 56 BACKACHE the after-state of the patient is worse than the first. It is better that ten women should continue to endure periodical suffering for which he is not responsible, than that he should cure nine and put one in an asylum." Dysmenorrhea Due to a Conical Cervix. — ^A very common cause of sterility and dysmenorrhea is said to be found in a conical cervix in which the external os is very small. This condition is an arrest of development and is commonly associated with an arrest of develop- ment of the body of the uterus (infantile uterus). The cervix is rela- tively long and is flexed forward, thereby affording additional cause for dysmenorrhea and sterility. Figs. 5, 6, 7, and 8, from an article by Pozzi,^ present the technic of the operation of Pozzi for the correction of this condition. The operation should be preceded by dilatation and curettage. Pozzi claims for this operation that he has invariably relieved dysmenor- rhea and that pregnancy has followed in more than 25 per cent, of his cases. BACKACHE Causes Treatment coccygodynia Pain in the back is so frequent a complaint of women as to. demand special consideration. Backache is not common in the young or in the aged, but occurs with great frequency between the ages of thirty and fifty. Causes. — It is a matter of common observation that the correction of pelvic disorders, notably of retrodisplacements of the uterus, does not always relieve backache. This suggests two things: (1) That uterine displacements do not, as a rule, cause backache, contrary to popular opinion, and (2) that the causes of backache are varied and oftentimes obscure. Following are the usual causes: Lumbago. — Lumbago is the result of exposure and muscular strain. The onset is usually sudden and the pain and discomfort are most distressing. The treatment consists of heat applied to the lumbar region in the form of hot-water bags, ironing the muscles with a hot iron for several minutes, massage of the lumbar muscles, rest in bed, and the administration of 10 to 20 grains of aspirin, every two to four hours, until the pain is under control, and thereafter 5 grains every two to four hours. Nervous Exhaustion. — Nervous exhaustion is almost invariably asso- ciated with backache. The pain is usually referred to the Jumbar region. Pelvic Tumors and Inflammatory Exudates. — These cause backache which may radiate to one or both thighs. Pain in the back which radiates to the thigh, suggests the probable presence of an incarcerated 1 Surg., Gyn., and Obst., August, 1909. CAUSES 57 or adherent tumor or inflammatory mass in the pelvis encroaching upon the sacral nerves. Prolapse of the Ovary. — When the ovary lies behind the uterus pain is commonly referred to the sacro-iliac joint of the respective side. The author has demonstrated this repeatedly by correcting the position of the ovary. Retroflexion of the Uterus. — Retroflexion of the uterus is a cause of backache, but not to the extent generally believed. Postoperative Backache. — Postoperative backache is a preventable complaint. It is due to strain upon the interspinous ligaments as the patient lies upon a hard operating table without pad or cushion to support the back. Furthermore, the ligaments of the sacro-iliac joints are also unduly strained by forcible abduction of the thighs with the legs in supports and the patient in the dorsal position for vaginal operations. Mobility of the Sacro-iliac Joint. — Many of the backaches are attrib- utable to luxation of the sacro-iliac joint. Static Backache. — It is now generally recognized that relaxation of the sacro-iliac joint gives rise to backache that was formerly ascribed to viterine displacements and other pelvic lesions. Albree has demon- strated the sacro-iliac joint to be a true joint which normally permits of a limited degree of motion. If, for one reason or another, the liga- ments of the joint become relaxed there will be an undue mobility of the joint with consequent pain. Reynolds and Lovett^ ascribe certain forms of chronic backache to strain upon the muscle of the back, caused by an undue effort to maintain the body balance. They endeavor to show that the centre of gravity of the body, in the erect posture, lies in front of the ankle- joints, knees, sacro-iliac joints, and most of the vertebral joints. The factors operating in the maintenance of the erect posture are chiefly the hamstrings, the glutei, and the erector spinse muscles. If for any reason the centre of gravity moves forward a strain is placed upon the posterior musculature. Authors have investigated the influence of corsets and "high-heeled shoes upon the balance of the body. A properly fitting corset should fit tightly between the trochanters and iliac crests, it should fit the hollow of the waist snugly, and above the waist it should be worn loosely. The front should be straight and without constriction at the waist line. No corset should be worn that is not comfortable; after putting on the corset as low as possible and before it is laced, the wearer should pass the hand inside and lift the abdomen, and at the same time tighten the laces from below upward. High-heeled shoes tip the body backward, and hence add to the comfort of a well-fitting corset and lessen the discomfort of a poorly fitting corset. This is so because the muscles of the back are relieved of the strain caused by the corset throwing the centre of gravity backward. Causes. — ^Meisenbach classifies the causes of relaxation of the sacro- iliac joint in women as follows: 1 Jour. Amer. Med. Assoc, March 26, 1912. 58 BACKACHE Trauinati.sms. — A blow or a fall, relaxation and strain from faulty position under anesthesia; long and rough riding on horseback or in automobiles are the tramnatic factors mentioned. General DehUity. — General debility, following wasting diseases and acute illness, such as typhoid fever; under such circumstances both joints are usually involved. Uterine Disorders. — Uterine disorders associated with pelvic con- gestion. The condition commonly follows pregnancy, particularly- a difficult labor in which high forceps are used. Neuroses. — Backache occurs in women of highly excitable tempera- ment. It is said that the periods of intermittent relaxation appear at times to cause a strain of the joint. To the author this explanation seems vague. Diagnosis. — The .r-rays are of little service in making a diagnosis of luxation of the sacro-iliac joint, but the stereoscopic radiograph is of great value. The treatment consists in the application of a plaster or celluloid jacket of steel braces, elastic webbing, etc. Such cases should be referred to the orthopedist. Gonorrheal Arthritis. — Gonorrheal arthritis affecting the sacral joints is an occasional cause of backache. Faulty Dress. — Faulty dress is responsible to a great degree for backaches complained of by women. This subject is discussed in Chapter XII. Gastro-enteroptosis. — Gastro-enteroptosis, with general relaxation of the pelvic supports, produces a feeling of heaviness in the pelvis and a weak back. Treatment. — In the management of these cases it is important to recognize the nervous element and the lack of general nutrition on the part of women complaining of backache. Without an improvement in the general state of health little good can come from correcting the local conditions. This is accomplished by giving a suitable mixed diet, by directing a systematic course of exercise within doors and outdoors, by stimulating morning baths, and by skilful massage of the muscles of the back. General tonics, notably nux vomica in 5-drop doses, increased 3 drops a day until 25 drops are taken before each meal, is recommended by Kelly. Static electricity is beneficial. The correction of pelvic lesions which contribute to backache calls for depleting treatment in pelvic inflammations, for pessaries in movable displacements of the uterus, and for surgical interference in lesions which are only amenable to surgery. Careful consideration must be given to the manner of dress and the personal habits of the individual. Coccygodynia. — Coccygodynia is a term applied to pain referred to the coccyx. Direct injury from a blow, a fall, or from the strain of labor is the usual cause. It is probable that rheumatism, especially of gonorrheal origin, plays an important part in the etiology of this affection. The disease has been called the "sitting pain," because of the dis- DIASTASIS RECTI: ENTEROPTOSIS 59 comfort and sometimes unbearable pain experienced in sitting. Walking and standing do not, as a rule, cause much discomfort. Pressure upon the cocc^'x by the examining finger either from without or through the rectum will locate the seat of pain. Defecation is often painful, and especially when there is constipation. Treatment consists in improving the general health through hygienic means, of applying the faradic current, and of massaging the cocc\tc by gentle manipulations; if these methods fail to give relief, the coccyx must be removed. In the management of coccygodynia, palliative treatment and even resection are often unsatisfactory. ]\Iassage of the coccyx is productive of the best result. The bone is held between the forefinger in the rectum and the thumb on the outside; it is then moved backward and forward and the soft parts are moved about on the bone. Immediate improve- ment will usuallv follow. Fig. 9 Demonstration of the separation of the resti inu- le- in DIASTASIS RECTI: ENTEROPTOSIS Causes Symptoms Teeatmext Patients suffering from enteroptosis commonly complain of back- ache, pain in one or both kidneys, general dragging sensations in the abdomen, dyspeptic symptoms, and general nervousness. 60 DIASTASIS RECTI: ENTEROPTOSIS On physical examination the abdominal wall is found to be relaxed, permitting of deep indentation between the widely separated recti muscles. When in the standing position the abdomen is pendulous, and on straining or coughing there is marked protrusion between the recti muscles. In these cases it is not enough to correct the relaxed and torn sup- ports of the pelvic floor. The profession is indebted to J. Clarence Fig. 10 Marked separation o( the recti muscles. The fist is buried in the gap between the separated muscles. Webster for calling attention to this important defect. The greatest point of stretching of the fascia is usually at the umbilicus, but may extend the entire length of the central line from the symphysis to the pubis. This stretching of the fascia may separate the recti muscles from two to five inches. Causes. — Childbearing is the predominating factor. This is particu- larly true when there is a succession of pregnancies. Heavy 'lifting increases the defect and malnutrition is an important predisposing factor. Fig. 11 In this scheme the abnormal separation of the recti muscles is shown, which permits a hernia-like projection of the viscera. Symptoms. — The symptoms commonly complained of are backache, dragging sensations in the abdomen, a sense of weight and insecurity in the pelvis, a feeling of fatigue on moderate exertion, dyspepsia, general nervousness, constipation, and pain in the iliac and lumbar regions. The pulsations of the aorta are often distressing. It is sometimes desirable to place the patient in the standing posture for TREATMENT 61 the purpose of inspecting the abdomen. In this position a pendulous abdomen is best inspected. The body is draped with a sheet from the hips down; the remainder of the body is stripped. The flat chest, the depressed epigastrium, the long vraist, the drooping shoulders, the general flabby muscular development, and the prominent abdomen are then noted. Fig. 12 Operation for repair of -n-eakened abdominal -svall. The drawing represents the inner edges of the separated recti muscles exposed. A, stretched and thinned linea alba; B, anterior layer of sheath of rectus; C, edge of rectus muscle exposed by opening sheath; D, skin and subcutaneous tissue. (Webster.) * I I i The drawing represents the recti muscles -with the fascia covering them drawn together and sutured by strong hnen. A, fascia form- ing anterior sheath laj^ers of rectus; B, line of juncture of the muscles and sheaths; C, skin and subcutaneous tissue. (Webster.) Treatment.— When the diastasis is of moderate degree the condi- tions mav be remedied by discarding a faulty corset, by suspending the clothing from the bust and shoulders, by systematic exercises, and the proper regulation of the diet. Abdominal supports may bring relief, but, as Webster says, they are objectionable because they produce atrophy and weakening of the trunk muscles, and they are uncomfortable to wear in hot weather. _ Technic of Operation.— Webster makes a median abdominal incision corresponding in length to the line of separation. The umbilicus may 62 DIASTASIS RECTI: ENTEROPTOSIS or may not be excised. The skin and subcutaneous fat are dissected from the underl.vmg fascia to the margins of the .separated rectf The fasca ,s then spht from beloiv upward at the attachment to The recti muscles; the muscles are dissected from the underlving fascia and are then approximated m the median line by interrupted linen s.m.res Catgut may be used to complete the approximation. When t lere fa an undue amount of redundant skin, this may be removed in a strip from either side and the margins sutured in the usual manner ^ CHAPTER III LEUCORRHEA— STERILITY— THE MENOPAUSE LEUCORRHEA NoEMAL Secretions of the Genital Organs Clinical Grouping According to Age In Infants In Virgins In Period of Sexual Maturity In Old Women Diagnosis Odor Treatment Any discharge from the vulva that is not blood is popularly called "whites" or leucorrhea. When the secretion departs from the normal in color, consistency, odor, irritability, and amount, there must exist either a functional or an organic lesion of the genital organs. Hence it is of the greatest importance to determine the character and source of the secretion. The Normal Secretions of the Genital Organs. — These are: 1. From the vulva the ordinary secretions are those of the sebaceous and sweat glands. The Bartholinean glands lying in the labia majora secrete mucus, particularly during sexual excitement. The reaction is alkaline, and the amount is scarcely noticeable. 2. The vagina does not ordinarily contain glands, but occasionally a few are found in the vault of the vagina. The vagina has essentially a skin surface, having no secretion under normal conditions. The so-called vaginal secretion is the accumulated outpour of the uterine body and cervix mixed with epithelium and bacteria. The secretion is acid in reaction as the result of the action of certain bacteria which change the alkaline secretion of the uterus to an acid reaction. 3. The secretion of the cervix is mucus. It is tenaceous and slightly alkaline in reaction. 4. The secretion of the endometrium is serous and sufficient in amount to moisten the surface; it is mildly alkaline, clear, and trans- parent. Clinical Grouping According to Age. — For clinical purposes leucor- rhea will be considered as it occurs in the various periods of life. In Infants. — In children a leucorrhea! discharge seldom arises from a point above the hymen. As a rule it is the expression of a vulvitis, which in turn is caused by soiled diapers, intestinal worms, highly acid urine, gonorrhea, masturbation, and the strumous diatheses. The vulva appears swollen and reddened, is tender, and is covered by a slimy secretion. 64 LEUCORRHEA In Virgins. — In young girls it is not unusual for a transient leucorrhea to appear from time to time. No pathological basis for the leucorrhea can be discovered further than a possible pelvic congestion. Persistent leucorrhea may be due to the same causes found in childhood. As in infants, the contributing lesion is commonly a vulvitis, and is rarely found above the hymen. The secretion is seldom sufficient to more than moisten the vulva, and rarely calls for a local examination. Anemia is always to be considered in determining the contributing factors. ti the Period of Sexual Maturity. — The secretion may come from any portion of the genital tract — from the vulva, vagina, cervix, body, and tubes. In the vast majority of cases the cause may be ascribed to gonorrhea and to labor and abortion. The most profuse leucorrhea is occasioned by gonorrheal infection. Among other causes may be mentioned instrumental and digital inspection, displacements of the uterus, passive congestion due to an interference with the return supply of blood as a result of diseases of the heart, lungs, liver, kidney, and spleen. Abdominal tumors, acute infectious diseases, and all benign and malignant new-formations of the vulva, vagina, and uterus are contributing factors to leucorrhea at this time of life. Not only the cause' but the source of the secretion must be deter- mined. Schultze devised the following method of demonstrating the source of the secretion: Following a vaginal douche of sterile water a large tampon of sterile absorbent cotton is placed against the cervix and left there for several hours. If the secretion comes from the uterus, it will collect upon the top of the tampon and can be examined for bacteria and other elements. If the secretion is mucus and in small amount, it must come from the cervix; if watery and abundant, it comes from the body of the uterus, rarely from the tubes — "hydrosalpinx profluens." It is of importance to distinguish between a hypersecretion of the endometrium and a discharge due to some pathological lesion. This is often difficult, and may be impossible. Women will often complain of a leucorrhea immediately before and after the menstrual flow. As a result of the congestion which precedes the monthly flow one or more days and continues a variable time after the cessation of the bloody flow, there is a hypersecretion of the glands sufficient to give rise to a seromucous discharge. In Old Women. — In the aged, leucorrhea has a more serious signifi- cance. The source is the vulva, vagina, and uterus. Senile vaginitis, vulvitis, and endometritis are the most common causes. In the event of unusual discharges from the genital tract of women advanced in years, whether the discharge be watery, bloody, p^urulent, or ichorous, there is always a suspicion of malignancy, and this thought is uppermost in the search for the underlying cause. Gonorrhea infect- ing the .aged rarely involves the uterus and tubes. The infection is generally limited to the vagina and urethra. The irritation of a filthy and ill-fitting pessary will occasion a vaginal discharge. TREATMENT 65 Malignant growths produce at first a watery discharge, which later becomes turbid, bloody, and foul-smelling. Cancer of the body of the uterus is more common after the menopause than is cancer of the cervix; therefore, in seeking the cause of a suspicious discharge occurring after the menopause it may be necessary to explore the uterine cavity with a curet. The discharge of a senile endometritis may simulate that of a malignant growth, and nothing short of an exploratory curettage, with a microscopic examination of the scrapings, will establish the diagnosis. Odor as an Aid to Diagnosis. — The odor of the vaginal discharge is sometimes an aid to diagnosis. The foul odor of a vaginal discharge sug- gests a rectovaginal fistula or a complete laceration of the perineum. A urinary odor to the vaginal discharge suggests a vesicovaginal fistula. The odor of a discharge from a cancerous uterus is rather characteristic but cannot be distinguished from that coming from a sloughing fibroid or decomposed placental tissue. Treatment. — ^It is manifestly unscientific to direct the treatment solely to the relief of a symptom such as leucorrhea. There is always a pathological basis which should be sought for and if possible removed. It must be borne in mind that certain general conditions may cause leucorrheal discharges; such for example are diseases of the heart, lungs, kidneys, liver, spleen, constipation, and abdominal swellings, which may create a pelvic congestion and in turn produce a hypersecretion of the uterine glands. Faulty excretions, such as are common to uremia, gout, and rheumatism, are also to be considered. The treatment in all such cases is carried out on the general principles laid down in treatises on internal medicine. In general it may be said that the effort should be made to restore the equilibrium of the general circulation by the removal of the cause of the embarrassment to the circulation, and so to regulate the diet and exercise as to promote assimilation and favor elimination. In all conditions of pelvic congestion dependent upon general causes, local depleting measures must be instituted in connection with the general treatment. These include hot douches, long continued and repeated two to four times a day, glycerin and ichthyol tampons, and free catharsis. By referring to the causes of leucorrhea as outlined, it will be apparent that the only permanent way of affording relief from these discharges lies in the removal of the cause. As temporary and palliative measures certain well-tried procedures may be adopted. These consist in cleans- ing vaginal douches, which should be taken in the recumbent position one or more times daily. Plain sterile water at a temperature of 110° F. will suffice, for this purpose. If the vaginal portion of cervix, vagina, and vulva are infected it would be well to add an antiseptic to the douche. For this purpose the author prefers formalin in solution of 1 to 2000; lysol, creolin, or bichloride of mercury will also serve the purpose. When the infection lies above the external os antiseptic douches will 66 LEUCORRHEA have little advantage over plain sterile water, inasmuch as the douche water does not reach the infected area and only serves to rid the vagina and vulva of the accumulated secretions. It is essential, however, that such infective secretions be kept clear of the vaginal and vulvar surfaces lest they in turn become infected. When the discharges ha^•e a disagreeable odor formalin is efficient. Permanganate of potassium is also a good deodorant. For the treatment of the offensive discharges from cancer of the cervix see chapter on Treat- ment of Inoperable Cancer of the Cervix. When necrotic tissue exists, as in decomposed placental tissue, sloughing fibroids, and malignant growths, the mechanical removal of the dead tissue by means of the curette and fingers is the first step in the correction of the discharges. Following this procedure, douches of hot sterile water with formalin 1 to 1000 to 1 to 2000 or permanganate of potassium 1 to 500 to 1 to 1000 may be given. Pruritus vulvae is aggravated and is often dependent upon irritating vaginal discharges. In addition to vaginal douches a dry sterile tampon of lambs' wool or a boroglycerin tampon inserted one or more times daily by the patient or nurse will prevent discharges from soiling the vulvar surface. Nearly all leucorrheal discharges are more or less dependent upon a congestion of the pelvic organs, and hence depleting measures are of the utmost value. Such are long-continued hot douches, glycerin and ichthyol tampons, and the free evacuation of the bowels. Finally, it must be again remarked that leucorrhea is but an expression of an existing lesion or physiological disturbance, and hence is not to be treated as a pathological entity, but suggests the underlying cause and calls for a searching examination. Having found the cause and effectively directed the treatment to it the leucorrhea will be relieved. The author has found little or no satisfaction in internal medication or in the application of suppositories for the relief of leucorrheal discharges. The following formulae are recommended for douche solutions : I^— Lysol 3iv 120^ Sig. — Dessertspoonful to each quart of hot water. (An antiseptic douche.) I^ — Potassii permangan oiiss lOjOO Aquse Bviij 240 1 00 Sig. — Dessertspoonful to each quart of hot water. (A deoderizing douche.) I^— Zinci sulphatis 5j 30|00 Div. in chart, no. xxx. Sig. — One powder dissolved in one quart of hot water. (An astringent douche.) I^— Aluminis giv 120:00 Div. in chart, no. xxx. One powder dissolved in one quart of hot water. (An astringent douche.) I^ — Acidi tannici oss lolOO Glycerini giv 120|00 Sig. — Two tablespoonfuls to one quart of hot water. (An astringent douche.) STERILITY 67 I^ — Liq. plumbi subacetatis §ss 15 Tinct. opii §j 30 Aquae q. s. ad §iv 120 (A sedative lotion for local application.) I^ — Zinci sulphatis . gr. viij 1518 Aquae oviij 240 1 (A sedative lotion for local application.) STERILITY Definitions | General Causes Conditions Essential to Conception ■ Local Causes Etiology Treatment Definitions. — Before entering into a discussion of the various 'causes of sterility in women the clinical significance of the term sterility and the conditions essential to conception should be clearly understood. By sterility is meant an incapacity for childbearing. This definition may be further qualified by the terms "absolute sterility" and "relative sterility." Sterility is absolute when the individual is incapable of bearing a child to the period of viability; she may conceive but habitu- ally aborts before the period of viability. Sterility is relative when childbearing is not in accordance with condition, age, and length of married life. Thus the term relative sterility may be used when three years have elapsed since the last childbirth, or when conception has not taken place within three years from date of marriage. This time limit is, of course, purely arbitrary. M. Duncan found that in one-sixth of all cases parturition occurred before the lapse of the first year after marriage, and in the second year four-sixths of all marriages were fruitful. Again, sterility may be regarded as primary and secondary: 'primary when the conditions which preclude the possibility of childbearing are primary, and secondary when after the birth of one or more children there is an acquired incapacity for childbearing. Periods of fifteen and even twenty years have intervened between successive childbirths, and this in the absence of any apparent cause for sterility. One-child Sterility. — The term one-child sterility is applied to cases in which a child is born in due time and the mother is thereafter in- capable of childbearing. The most common explanation lies in a latent gonorrheal infection which preceded the pregnancy or, more rarely, was acquired during pregnancy. Such latent infections are caused to extend from the cervix to the body of the uterus, thence to the tubes, ovaries, and pelvic peritoneum. In such an event sterility is almost the inevitable result. Other causes are lactation atrophy, puerperal non-gonorrheal infections of the uterus and its appendages, acquired displacements, lacerations, and the development of a fibroid tumor. Conditions Essential to Conception. — The conditions essential to conception are briefly enumerated as follows: 68 STERILITY 1. Deposit of semen containing living, active spermatozoa in the upper segment of the vagina. 2. Passage of the spermatozoa through the cervix into the cavity of the uterus. It is said that spermatozoa will not live longer than twelve hours in the acid secretions of the vagina; while in the uterus and tubes they commonly retain their vitality sLx to eight days. Leopold reported a ease of a woman in his clinic who had not had sexual inter- course for thirty-seven days prior to the operation, when, on abdominal section, living, active spermatozoa were found in large numbers in the fimbriated end of the tube. This case, with many other observations on women and lower animals, has led to the statement that fertilization of the ovum commonly takes place in the tube. 3. A healthy ovum must find an uninterrupted passage from the ovary, through the tube, and on into the uterine cavity. 4. The fertilized ovum must find a permanent resting-place on the endometrium until the period of viability. With these definitions of sterility and the conditions essential to conception clearly understood, it is now possible to consider the factors which tend to prevent conception. Etiology. — In seeking, the cause of sterility, not only the whole range of diseases peculiar to women must be considered, but as well the general physical and social conditions of the individual. More than this, the cause of sterility is not necessarily found in the woman ; fully one in six sterile marriages is chargeable to the husband. One marriage in ten is non-productive, and, with few exceptions, sooner or later the advice of the physician is sought. The subject is therefore of prime importance to the physician, and no condition more thoroughly taxes the skill of the general practitioner and specialist. General Causes. — In determining the cause of sterility the general conditions predisposing to sterility should first be considered, and of these age is the most important. Xo cause of sterility approaches age in extent and power. The most prolific time of life is between the ages of twenty and twenty-four. Pregnancy may occur before the menstrual period, as so often happens in India, where it is considered a sin to let pass an opportunity for conception — a sin equivalent to infanticide. Because of this belief it is customary, in such countries, to marry before puberty. ^Marriages occurring between fifteen and twenty years of age are relatively sterile as compared with those occurring between twenty and twenty-five. The explanation lies in the more mature development of the sexual organs after twenty years of age. A case is recorded where a woman gave birth to twelve children before her menstrual flow appeared. Again, it is possible for pregnancy to occur long after the cessation of the menstrual period. Trento reported a case of a woman who gave birth to a child at sixty- seven years of age. xA.braham* was one himdred years of age and Sarah ninety when their child was born. Sarah "was old and well stricken with years, and with whom it had ceased to be as it is with women" — that is, she had ceased to menstruate. Renauden reported the case of ETIOLOGY 69 a woman who was delivered of a child ten or twelve years after the cessation of the menstrual periods. So, while pregnancy is possible after the menopause, the rule is that the capacity for childbearing ceases four to six years before the cessation of the catamenia. Anemia. — Anemia, either primary or secondary to some wasting disease, such as tuberculosis, diabetes, nephritis, and malaria, is an important predisposing factor, and must always be taken into account whatever else may be found. Coiuanguinity. — JNIarriage of near relatives is said to be a cause of relative sterility, but this statement is not confirmed. G. Darwin has proved the harmlessness of marriages between cousins, and has demon- strated the fertility of such marriages. Obesity. — Obesity is undoubtedly a potent cause of sterility. That peculiar form of obesity associated with anemia especially conduces to sterility. Scanty nutrition has little or no influence. ^Yhen a woman rapidly increases in weight. she very often becomes sterile, and in such the most promising means of relieving sterility is to reduce the weight. AlcoJiolism. — Alcoholism is an indisputable factor; furthermore, the death-rate among children born of inebriate mothers is double that of temperate parentage. Sexual Instinct. — The sexual instinct evidently has some influence upon the fertility of women. While it is true that many women bear children who have never experienced sexual desire, it is the rule that women are most likely to conceive who have the greatest sexual vigor. Sexual Excess. — Sexual excess, on the other hand, conduces to sterility through the congestion and inflammation resulting from such excesses. Sexual Incompatibility. — Sexual incompatibility is an ill-defined condition that plays a role in the causation of sterility, though no explanation is offered. This recalls the childless marriage of Josephine and Napoleon and the fruitful remarriage of both. Many unhappy yet fruitful marriages disprove this theory. As a rule some other explanation for the sterility is found. Influence of Temjjerature and Climate. — The action of heat and cold in the various zones does not appear to affect fertility. Local Causes. — After this consideration of the general predisposing causes, the more tangible local factors must now be considered. Dyspareunia. — Dyspareunia is not an uncommon cause of sterility, and in every case the underlying cause of painful coition must be deter- mined. Lesions obstructing the lower genital passage, such as acquired and congenital atresia of the vulva and vagina, must be looked for, as well as overgroT\-ths of the labia and clitoris, and tumors of the vulva, vagina, and uterus, which encroach upon the lower passages. Other lesions causing pain, such as urethral caruncle, inflammatory lesions of any portion of the genital tract, inflammation of the urethra and bladder, and painful lesions of the rectum, including fissures and hemor- rhoids must also be looked for. Vaginismus without a recognizable lesion is an occasional cause of dyspareunia. It is not essential to conception that sexual union be complete. This is demonstrated by 70 STERILITY the fact that pregnancy may occur with an intact hymen and in the presence of other evident obstructions to complete sexual union. Maldeveloiyments and Malformations. — The maldevelopments and malformations of the genital organs are occasional causes of absolute sterility. The absence of any of the reproductive organs or the failure of these organs fully to develop are certain causes of sterility. A uterus partially or completely divided is not likely to become pregnant, and a septum dividing the vagina may offer an obstruction to sexual intercourse. When a woman complains of amenorrhea, or at most of a scanty, irregular flow which has persisted from a delayed puberty, it is highly presumptive that the uterus, together with the tubes and ovaries, has failed to develop beyond the infantile type. The ovaries are primarily at fault in the majority of cases, and in consequence the uterus fails to develop. While there is little encouragement in treatment of any kind, it is manifestly illogical to direct the treatment to the uterus rather than to the ovaries — a procedure akin to whipping the cart to make the horse go. The complete closure of any portion of the genital tract will result in sterility, but these conditions are rare, with the exception of closure of the tubes from inflammatory adhesions. The influence of stenosis in causing sterility is doubtless exaggerated. A congenital narrowing of the cervical canal prevents the passage of spermatozoa, but in such cases there is usually an underdevelopment of the uterus, and possibly the ovaries as well, to account for the sterility. The vagina may be too short or too narrow to retain the semen, and the cervix may be too long to allow the entrance of the spermatozoa from the vault of the vagina, where it is usually deposited. A short cervix per se is not a cause for sterility; occasionally the explanation lies in an underdevelopment of the uterus associated with a short cervix. A frequent cause of secondary sterility is superinvolution of the uterus brought about by superlactation, infection, or malnutrition. Malyositions.- — Malpositions as direct causes of sterility have been greatly overrated. Pregnancy is possible in all malpositions of the uterus with the exception of complete inversion. The underlying cause is more often in the accompanying inflammatory lesions and in dys- pareunia. Chronic endometritis and ovaritis are so commonly asso- ciated with displacements, and are such potent causes of sterility, it is fair to assume that they are most often the underlying causes. The displaced cervix is a more probable cause than is the displaced body of the uterus. The difficulty with which the semen enters the cervix when displaced forward, or to the side in backward or lateral displacement of the uterine body, will account for sterility, whereas it is difficult to conceive of the cervical canal being obstructed by the flexion of the body upon the cervix. The thick, resisting wall of the uterus will not permit of so sharp bending as to obstruct the passage of spermatozoa. Reasoning a priori, an extreme retroversion with the cervix pointing upward and forward would more likely cause sterility than would an uncomplicated retroflexion with the cervix ETIOLOGY 71 pointing downward and backward. From like reasoning, descent of the uterus, especially when associated with elongation of the cervix, as is usually the case, would be still more likely to result in sterility because of the difficulty of the semen in gaining entrance to the cervical canal. Traumatisms. — Traumatisms to the cervix and vagina not infre- quently predispose to sterility. A lacerated perineum allows of the free escape of semen from the vagina, and a lacerated cervix, followed by erosion and eversion of the cervical mucous membrane, may offer an obstruction to the semen. Rectovaginal and vesicovaginal fistulse cause sterility by the effect of the urine and feces upon the semen, by the accompanying vaginitis and the resulting dyspareunia. Cicatricial contraction of the vagina following an injury may interfere with sexual union. Pelvic Inflammation. — Pelvic inflammation is by far the most prolific source of sterility, and first among the various lesions is endometritis. The hyperplastic form of endometritis will most certainly cause sterility, and particularly when associated with profuse hemorrhages and leucor- rhea. The diseased endometrium is an unfavorable resting-place for the ovum, and the discharges play havoc with the spermatozoa. In the cervix the increased mucous secretions of endocervicitis plug the cervical canal so effectually as to prevent the entrance of the semen. Vulvovaginitis may prevent conception through perverted acid secretions and dyspareunia. Infections of the tubes destroy the cilia and often the epithelium as well, thereby hindering the progress of the ovum through the tube to the uterus. Closure of the fimbriated end of both tubes, resulting in a distention of the tube with serum, blood, or pus, will almost certainly cause permanent sterility. Yet it is of interest to know that pregnancy has followed upon the disappearance of double pyosalpinx, a fact which speaks for conservative treatment of salpingitis. A chronic inflammation or passive congestion of the ovary results in a hyperplasia of the connective tissue surrounding the follicles, in a thickening of the tunica albuginea, and in possible adhesions about the ovary. All this renders difficult or impossible the escape of ova into the tube. In pelvic cellulitis and pelvic peritonitis, constricting bands of adhe- sions may obstruct the lumen of the tube, and so displace the uterus, ovaries, and tubes as to cause sterility. An organized exudate about the ovary will prevent the ova escaping and lead to cystic degeneration of the ovary. In all these forms of infection, dyspareunia is a large factor in the causation of sterility. Neio-formations. — New-formations as causes of sterility are yet to be considered. In general, they operate through mechanical obstruction. By their presence an inflammatory reaction may develop as the prime cause of the sterility. Degeneration of the tumor leading to an irritating discharge acts in a deleterious manner upon the spermatozoa. The size of the groT\i;h is not of so much consequence as the position; a 72 STERILITY small fibroid in the ce^^'ical canal may cause complete obstruction, while pregnancy may go on to full term in subperitoneal fibroids of enormous size. Malignant growths rarely cause sterility, because the childbearing period is usually at an end before the advent of either carcinoma or sarcoma. Sterility associated with amenorrhea in the presence of an ovarian cyst suggests the possible presence of a similar involvement of the other ovary. Venereal Diseases. — Gonorrheal infection is a potent cause of sterility, but it is doubtful whether syphilis is often a cause of absolute sterility. (See chapter on Gonorrhea in Women). Treatment. — A long list of general and local conditions conduces to sterility, and hence the treatment of sterility becomes equally varied. Having by examination excluded the existence of sterility in the husband and having recognized the existence of a lesion which in itself is a satis- factory explanation for the existing sterility in the wife, it is never safe to assure the patient that its correction will permit of conception and childbearing, for the reason that there are so many associated conditions which may enter into the problem and preclude the possibility of childbearing. The most the physician can say is that if a given cause or group of causes of sterility are found to exist, removal will afford greater opportunity for childbearing. When upon examination no demonstrable cause for sterility is found and the husband is known to be potent, an exploratory abdominal incision may be justified in view of the possible finding of an unrecognized lesion, such as the matting of the fimbriae and so-called "sclerosed ovaries" (interstitial ovaritis). Primary sterility is not infrequently chargeable to an underdevelop- ment of the genital organs. There is little encouragement from any treatment, though Bumm makes claims for the galvanic current. The negative electrode is placed in the uterus and the positive on the abdo- men. A current not greater than 50 milliamperes is used and for a time not to exceed five minutes. This treatment is given twice weekly. . Dyspareunia as a cause of sterility demands serious consideration and is often amenable to treatment. When there is no evident lesion to account for an existing vaginismus, an anesthetic should be given and the vulvar outlet and vagina thoroughly stretched. Sensitive carunculse myrtiformes may be the cause of dyspareunia; these may be cauterized or excised. Urethral caruncle through its great sensitiveness may be the cause of dyspareunia and should be cauterized or excised. When a vulvovaginitis or an inflammation of the organs and tissues of the pelvis exist, long-continued antiseptic douches, together with glycerin and ichthyol tampons, may be used with eftect. Here operative measures may be resorted to for relief from an infected uterus and its appendages and from peritoneal adhesions. When the appendages are partially or wholly occluded, and when they are more or less involved in adhesions, there is little encouragement derived from any course of treatment so far as concerns sterility. In endocervicitis, when the cervical canal is plugged with mucus. THE MENOPAUSE 73 the author has known of relief from sterility by the swabbing of the cervical canal and the application of mild antiseptics. Cervical polj^ps as a potent cause of sterility demand removal. For a discussion of the treatment of uterine displacements and new- formations in their relation to sterility, see Chapter III. Lacerations of the cervix, when extensive and when accompanied by eversion and erosions, should be repaired and the pelvic floor restored when greatly relaxed and torn. An elongated cervix may be the cause of sterility and should be amputated. If hj-peracidity of the secretions in the vagina exists, 2 drams of the bicarbonate of soda may be given in a quart of water at a temperature of 110° F. This douche should precede intercourse to prevent the destruction of the spermatozoa by the acid secretions. Inasmuch as it is impossible to say that the endometrium is healthy, obscure cases of sterility are often relieved by an exploratory curettage. The practice of artificial insemination has been practised to a limited extent. While successful in a few cases it will never find general favor. THE MENOPAUSE Premature Menopause Delayed Menopause Time of Appearance Clinical Manifestations Influence on Morbid Conditions ' IN the Pelvis Management The menopause is a perfectly' natural event in the advanced years of women, and is therefore not a cause of ill health. The popular idea that the "change of life" is a critical time in a woman's life-history is quite correct, but this does not imply that the menopause per se is in any way a menace to the life of a woman. It is a critical time because the menopause marks the beginning of old age, when ill health and debility would naturally be first manifest. There are, however, certain attending phenomena which disturb the comfort and general activity of previously healthy women. This discomfort is not ill health; that is to say, it is not to be dignified by the term disease. There is a dis- inclination to mental and physical exertion. The nervous and vascular systems are more or less disturbed. Functional heart troubles, asso- ciated with forebodings of impending danger, are common experiences. Hot flashes, a sense of fulness in the head, and drowsiness are com- plained of. The memory fails from lack of concentration, and there is a marked decline in the capacity for both mental and physical work. These are the usual experiences of healthy women living under favorable circumstances as they pass through the menopause. Premature Menopause. — The menstrual flow may be permanently checked at an early age, even so early as the twenty-fourth year. The causes of premature menopause are both general and local. The general causes are those referable to the disorders of the nutritive and vascular 74 THE MENOPAUSE systems — i. e., primary and secondary anemias and general wasting diseases. Fright and sorrow are said to precipitate an early menopause. The local causes include the remo^•al of the menstrual organs, also infections, degenerations, and new-formations of the uterus and ovaries. It is interesting to observe that when healthy o^-aries have been removed, thereby bringing on the menopause abruptly, the usual derangements of the climacterium are exaggerated; whereas the removal of ovaries whose functions have been largely lost through disease causes little or no disturbance. The author has observed a woman, aged twenty years, who had not menstruated for two years. She had never suffered ill health, had no evidence of a pelvic infection or other lesion, and up to her nineteenth year had menstruated every twenty-eight days, and the amount of the menstrual flow had not varied from the normal, kt nineteen she stopped menstruating and the periods have not reappeared in the succeeding two years. On examination the uterus was about two-thirds the normal size of a matured multiparous uterus — otherwise the pelvic organs appeared normal. Delayed Menopause. — The menstrual periods may be continued far beyond the a^•erage time and without anxiety when the menstrual functions appear normal. When, however, the menses become increased in frequency and in amount it becomes imperative to inquire into the cause. The general and local causes of prolonged, morbid menstrual functions are enumerated in the section on Uterine Hemorrhage. Scanzoni believes that the prolonged menopause is often due to senile rigidity and friability of the uterine arteries, while Kisch ascribes them to softening and relaxation of the uterine tissues. Undoubtedly passive congestion of the pelvis from whatever cause may prolong the menstrual period. In the absence of all general and local causes for hemorrhage from the uterus it is possible to explain the prolonged menopause b}' the existence of vasomotor changes. Care must be taken to exclude the presence of carcinoma and all local lesions as well as the mentioned general factors before accepting such indefinite explanations as vaso- motor changes. Time of Appearance.— The average time of appearance of the change of life is from forty to fifty-five years of age. Scanzoni affirmed that any menstruation after fifty-three years of age should be regarded as pathological. Instances are not rare in which the menopause was recorded as not reached until sixty or more years of age. Tilt recorded one at seventy years of age. Currier ten at sixty to ninety-three years, and that of a nun is recorded at one hundred years of age. Pregnancy is known to occur after the establishment of the menopause. ' Piron records an abortion at the age of seventy-three. The factors influencing the time of appearance of the menopause are : Climate. — The colder the climate the later the menopause. Social State. — Sir Andrew Clark states that the menopause occurs earlier in the more civilized and cultured classes. CLINICAL MANIFESTATIONS 75 Race. — The Jews are said to reach the menopause at an earher time than the average woman of other races in the same chmate. Heredity. — It has been frequently observed that heredity has a determining influence upon the establishment of the menopause; this tendency toward an early or late menopause may persist through several generations. General and Local Diseases. — (a) Those favoring an early climacterium are: atrophy of the uterus and ovaries, superinvolution of the uterus, chronic atrophic metritis and ovaritis, postpartum hemorrhages, puerperal sepsis, and the general wasting diseases, (h) Those favoring a late climacterium are: malignant growths and fibroids of the uterus, endometritis, subinvolution of the uterus, and chronic metritis. The climacterium has an average duration of three or four years, and has been known to extend over a period of twelve years. During this time the menstrual periods commonly recur at longer and longer intervals as the flow becomes more and more scant; this is known as the "dodging period." In about one woman in seven the menses stop suddenly and per- manently. As a rule, it may be stated that an abrupt ending of the menstrual periods is due to some morbid condition, general or local. Clinical Manifestations. — The clinical manifestations of the meno- pause are most varied. They are seldom wholly absent, nor are they constantly present. As a rule, they recur at irregular intervals. The general phenomena associated with the menopause are nervous disturbances, such as irritable temperament, despondency, forgetfulness, fainting, vertigo, flashes of heat and cold, perversion of taste, loss of sexual desire, and occasionally a homicidal or suicidal tendency. The local phenomena are atrophy of the genital organs and of the breasts, and in many cases an increase in the body weight. Under normal conditions the onset of the menopause is marked by the beginning of a retrograde metamorphosis in the ovaries, tubes, uterus, vagina and vulva, and, as a rule, these changes occur in the order named, i. e., from above downward throughout the genital tract. The ovaries present a progressive thinning of the cortical zone; a gradual disappearance of ova and follicles until finally the ovary is shrunken into little more than a fibrous nodule. The Fallopian tubes lose their ciliated epithelium, the lumen is obliterated, and finally the tubes are converted into mere cords. The uterus becomes smaller in all dimen- sions, the uterine canal becomes distorted, the myometrium thins through atrophy and disappearance of the muscle fibers, the vaginal portion of the cervix is no longer in evidence, and the body of the uterus is finally resolved to a fibrous ridge or nodule. The vaginal walls become pale, dry, and glistening. Contraction is greatest at its upper portion, thereby forming an irregular funnel-shaped cavity. The external genitals lose their pad of subcutaneous fat, the hair becomes gray, and there is a general flattening and shrinking of the vulva. There are no facts to substantiate the statement that the develop- ment of skin diseases is influenced by the menopause. 76 THE MENOPAUSE Influence on Morbid Conditions in the Pelvis. — It will be of prac- tical interest to inquire into the influence of the menopause upon certain morbid conditions in the pelvis. A certain percentage of these lesions arises during the climacterium, while others are aggravated or are made to disappear by the advent of the change of life. Foremost among the lesions that are prone to appear in the climac- terium are malignant groT\-ths. Peculiar catarrhal forms of endometritis are known to arise at this time. Displacements of the uterus, and par- ticularly prolapsus uteri, are of common occurrence as the result of retrograde metamorphosis of the uterine supports. Fibrous polyps of the cervix are said to frequently arise subsequent to and during the climacterium and are the cause of hemorrhage — a fact which the author's experience confirms. Existing conditions in the pelvis which are aggravated by the meno- pause are displacements of the uterus due to relaxation of the uterine supports. A descensus may become converted into a complete pro- lapsus as the uterine supports relax after the menopause. On the other hand the menstrual disturbances and pressure s}Tap- toms incident to displacements of the uterus and its appendages are relieved by the suspension of menstruation and diminution in the size of the uterus. Fibroids of the uterus very often cease to grow, and not infrequently decrease in size. This is particularly true of interstitial fibroids. While favorable changes in uterine fibroids may be hoped for at the climacterium, it must be remembered that the fibroid may be transformed into a sarcoma or into other forms of degeneration which may jeopardize life. The influence of the menopause upon existing ovarian cysts is not clearly understood. The statistics of Olshausen and others show that cysts of the ovary arise more often during the period of sexual maturity and far less frequently after the climacterium. The "involuted shrunken cysts" of Rokitansky are often the direct result of the menopause, though perhaps they more often follow upon the twisting of the pedicle. Fatty degeneration of the cyst wall is especially prone to occur during and after the menopause, and this suggests the most probable cause of spontaneous rupture of ovarian cysts at this time. Management of the Menopause. — Every woman passing through the menopause should be under the guidance of a physician. This does not imply that she is necessarily in a critical condition, but the discomforts which invariably accompany the menopause can be lessened by judicious management. Furthermore, it is at this time when many of the infirmities of old age are initiated, and if recognized in their incipiency they may be forestalled. It is a deplorable fact that women in general regard the menbpause as a time of all sorts of serious events, and as a result of this popular impression, many serious conditions arising at this time are ascribed to the menopause; they are regarded as inevitable afilictions. They look forward to the establishment of the climacterium, when they wdU find relief, and thus they are deceived into serious and even fatal conditions. MANAGEMENT OF THE MENOPAUSE 77 Uterine hemorrhages and leucorrheal discharges are interpreted as a part of the usual workings of the menopause, and in this delusion the patient becomes the victim of an inoperable malignant groivth. It is of the utmost importance to look to the general state of health at this time. Medicine is of secondary importance, but fresh air, the judicious regulation of rest hours and open-air exercises, the selection of the diet, the regulation of the bowels and secretions, the employment of suitable baths, all are of prime importance. This is the fretful period of life, and as such the women who are passing through this trying period should be safeguarded as far as possible from petty annoyances, and should be placed in an environment most suited to their tempera- ment. They should be consulted as to their desires and should be gratified within all reasonable bounds. It may be advisable to recom- mend travel or some health resort or sanitarium. Thyroid Extract. — Thyroid extract has been extolled as a useful remedy in controlling the nervous symptoms associated with the menopause. In the author's hands there have been indifferent results in the admin- istration of thyroid extract, and he believes this to be the experience of most clinicians. Corpus Luteum Extract. — Corpus luteum extract is prepared in 5- grain capsules. It is a valuable remedy in controlling the disturbances incident to the removal of the ovaries, especially if given shortly after the operation and persisted in for several months in doses of 5 grains three or four times a day. The author has had most gratifying residts in these cases and never fails to prescribe it. It does not give such positive results in the natural menopause, but is of some value in a limited number of cases. CHAPTER IV exa]\iixatiox of the blood— bacteriological exa:^iixatiox EXAMINATION OF THE BLOOD ^Morphology of Blood Cells Lel-cocytosis Red Cells Differextl\l Count of Leucocytes White Cells Axemia By adopting a routine practice of making systematic examinations of the blood in all operative cases, the diagnosis has often been made more certain, the indications for operation have been more judiciously considered (not infrequently an operation has been postponed until the conditions of the blood improved), the choice of the anesthetic has hinged upon the blood findings, as has also the choice of operation, and finally, the prognosis has been influenced by repeated examinations of the blood. In routine clinical work the examinations of the blood are of no less importance than the analysis of the urine. In a large percentage of cases no additional information will be aflforded by examining the blood, but in those cases in which the responsibility is the greatest these examinations become of the highest value. Without a blood examina- tion the writer would have submitted one patient with 17 per cent, of hemoglobin to an operation for hemorrhoids, and another patient with 20 per cent, of hemoglobin to an abdominal hysterectomy for uterine fibroids. In all probability the results would have been fatal from what is called surgical shock. Rest in bed and a liberal diet brought the former case up to 35 per cent, and the latter to 78 per cent, before the operations were undertaken. It is well known how misleading mere inspection may be even in making an approximate estimate of the degree of anemia. A blood examination will often show a far greater degree of anemia than was suspected. Morphology of the Blood Cells. — Red Cells. — These cells are bicon- cave, disk-shaped bodies of a yellowish color in the fresh state. Size. — The diameter of the red cells in adults averages 3 9^0 inch and is almost constant within normal limits. In the marked anemias the diameter is more or less altered. There is little or no alteration in the mild forms of anemia. L ]\Iicrocytes are not found in normal blood. In severe t\'pes of anemia small red cells, known as microcytes, are found in varying numbers. This is especially true of pernicious anemia. MORPHOLOGY OF THE BLOOD CELLS 79 2. Megalocytes are large red cells. They may be two and one-half times the average size of red cells. They indicate a chronic anemia of severe grade. Shape. — Normal red cells are biconcave disks, but under certain impoverished conditions of the blood the margins present a serrated appearance (poikilocytes). Average Number. — The average number of red cells is 4,500,000 to 5,000,000 to the cubic millimeter. This number shows great variation in the various forms of blood diseases. Nucleated Red Cells. — Nucleated red cells are never found in adults under normal conditions. 1. Normoblasts do not differ in size from normal red cells, but contain a nucleus which occupies about one-third of the cell. They stain deeply and do not form rouleaux. In the absence of megalo- blasts they usually indicate a mild t^pe of primary or secondary anemia. 2. ^Nlegaloblasts are larger than the normal red cells and contain a large nucleus. Taken alone they certainly suggest a morbid state of the blood, but their exact significance is implied by the associated red cells. They are of greatest significance in pernicious anemia, in which they are found in large numbers, though the diagnosis max be made from the finding of a single megaloblast. AMorNT OF Hemoglobix. — It is of the utmost importance to estimate the relative amount of hemoglobin. The various anemias show great variations in this respect. White Cells (Leucocytes). — ^Iokphology. — Leucocytes are colorless bodies, varying in size and numbers of contained nuclei. As a rule they are larger than red cells. They possess ameboid movements. Five varieties are recognized: Lymphocytes. — Lymphocytes are both small and large. They have a round nucleus surrounded by a narrow rim of homogenous or reticu- lated protoplasm. Large Mononuclear Leucocytes. — They possess a coarsely reticular, vesicular nucleus surrounded by finely reticular protoplasm. The nuclei may be round, horseshoe-shape, or elongated. The cell body is usually much larger than a lymphocyte. Polynuclear Leucocytes. — Polynuclear leucocytes are larger than mononuclear leucocytes. Neutrophile granules are found in the reticu- lar protoplasm. The nuclei are elongated and may be connected by threads of chromatin. * Eosinophile Leucocytes. — Large granules are found in the protoplasm and take a deep eosin stain. The nuclei are usually bilobed. In size the cell is seldom so large as a polynuclear leucocyte. Mast-cells. — Mast-cells contain large and small basophile granules. They vary in size and in number of nuclei. Number of Leucocytes. — The number of leucocytes in a cubic millimeter may be said to vary from 7000 to 10,000 within physiological limits. The number of leucocytes is notably increased in the newborn, during pregnancy, after ingestion of food, and after active exercise. 80 EXAMIXATION OF THE BLOOD Leucocj^osis. — An increase in the number of leucocytes above that of the normal, for the particular individual under definite conditions, is known as leucocytosis. For one individual 3000 leucocytes per cubic millimeter may be normal, while for another of greater vigor 10,000 may not exceed the normal limits. x\gain, a blood-count taken shortly after a full meal or during pregnancy would naturally show an excess of leucocytes as compared with other physiological conditions. For purposes of comparison the leucocyte-count should be taken at regular intervals; these counts are best taken three or four hours after eating. In leucocytosis it is not only essential to know the number of leuco- cytes, but when the number is greatly in excess of the normal (25,000 to 80,000 to the cubic millimeter) it is also essential to make a differential count in order to distinguish a true splenic, myelogenous, or lymphatic leukeibia from a leucocytosis incident to suppuration, pneumonia, malignancy, and other morbid conditions. In the practice of gynecology and obstetrics it is seldom necessary to resort to a differential count; but it may be stated as a safe rule to follow that when the white cell count exceeds 25,000 to the cubic millimeter a differential count should be made. This rule becomes imperative when the local findings do not suggest suppuration, pneumonia, or malignancy, and when the general anemia or enlarged spleen justifies the suspicion of a primary anemia. By the aid of a leucocyte count it becomes possible to say not only that the individual is sick, but also to estimate, to a certain extent, the degree of illness, and thereby to formulate a more definite prognosis. Leucocytosis of Pregnancy. — In the early weeks of pregnancy there is little increase in the number of leucocytes, but in the latter half the number averages about 10,000 to the cubic millimeter in primiparee. It is observed that leucocytosis is not so constant in multiparse — • probably not more than 50 per cent, show an average of 10,000. Near the time of labor the physiological limit may exceed 18,000. Cabot found a leucocyte count of 25,000 to 37,000 in three normal pregnancies. Since no leucocytosis is expected before the end of the third month, a blood examination will aid but little in the diagnosis of pregnancy. In the later months of pregnancy, when the question is raised as to the differential diagnosis of pregnancy from other pelvic and abdominal swellings, leucocytosis will give little clue because in almost all of these conditions it is expected that the leucocyte count will be high. Postpartum Leucocytosis. — After childbirth, when conditions are perfectly normal, the number of white cells gradually diminishes and usually returns to that of the non-pregnant state in about two weeks. When much blood has been lost, or when there have been excessive lacerations or infection in the pelvis or breast, the usual diminution in white cells is interrupted. After-pains are said to retard the gradual diminution of the leucocytes. Pathological Leucocytosis. — Posthemorrhagic Leucocytosis. — By experi- mental and clinical observations it is known that immediately after a severe acute hemorrhage there is an initial diminution in the number LEUCOCYTOSIS 81 of leiicoc}-tes. Very soon a rapid increase in the number of white cells takes place. Within a few hours this leucoc\i;osis may reach 45,000, and it has been known to go as high as 62,000. In three or four days the leucocytosis gradually recedes, but seldom returns to the normal in less than a month. Leucocytosis is usually proportionate to the amount of blood lost and to the acuteness of the attack. Xo such condition is observed in chronic hemorrhages. The author has failed to observe leucocytosis in large but long-standing collections of blood in the pelvis from ruptured tubal pregnancy. The increase in the number of leucoc\i:es immediatelv following upon a postpartum hemorrhage is great m proportion to the amount of blood lost. This is due to the contributing influence of pregnancy, which in itself causes leucocytosis to a variable degree. The leucocytosis disappears long before the number of red cells returns to the normal. It is difficult to explain the absence of leucocytosis in occasional cases of acute hemorrhages; the explanation probably lies in the lowered resistance of the individual. Inflammatory Leucocytosis. — It is a rule, to which there are few exceptions, that the number of white cells is increased above the phy- siological limit in septic infections, whether localized or general. This leucocytosis is proportionate to the virulence of the infection and to the resistance of the individual — not to the amount of exudate. A large pelvic abscess of long standing, containing no virulent microorganisms and weH walled oft' by firm adhesions, very frequently causes no leuco- cytosis. The greater the resistance of the individual the greater will be the leucocytosis. That is to say, an individual with poor resistance and a virulent infection, may have no greater leucocytosis than an individual with high tissue resistance and a less virulent infection. It is observed that so long as the shock of an operation lasts, leucocytosis does not appear, but just in proportion to the reaction of the patient from shock there is a development of leucocytosis, showing that with- out reaction of the tissues leucocytosis will not occur. A purulent exudate usually produces a higher degree of leucocytosis than does a serous exudate, for the reason that the infection is more virulent. While it is possible for a fever to exist without an increase in the number of white cells, it is true that when the fever is solely dependent upon the infection, the leucocytosis will rise and fall with the temperature. "When the individual becomes overwhelmed with sepsis the tissues fail to react, and hence leucocytosis fails to appear. The number of white cells increases in proportion to the reaction of the patient from the septic influences, and therefore may be regarded as a favorable omen rather than as evidence of increased infection. In a large number of observations on acute and subacute cases in which pus was confined to the tube, ovary, appendix, broad ligament, or cul- de-sac, the leucocj-tosis usually ranged between 12,000 and 19,000, the maximum being 24,000. In long-standing pus tubes, in which the con- tents were sterile, the number of leucocytes did not exceed the normal. It is therefore seen that leucocytosis is not a constant factor in the 6 82 EXAMINATION OF THE BLOOD presence of pus, but is directly proportionate to the \'irulence of the infection and the resistance of the tissues. The white count is therefore of no little value in determining the virulence of infection. In the presence of pus localized in the pelvis the determination of an accom- panying leucocytosis will lead to early interference and will at least suggest the advisability of establishing drainage through the vagina rather than through an abdominal incision. Tuberculous pus causes no leucocytosis, and gonorrheal plis only a moderate increase in the number of leucocytes. This is explained on the theory of greater tolerance and less power of absorption of the peritoneum for these bacteria and their toxins. Repeated leucocyte counts are of special value when taken in con- junction with the pulse and temperature. By combining these obser- vations it is possible to make a fairly accurate diagnosis of the presence of pus and to judge something of the virulence of the infection. In pelvic exudates, leucocytosis is a valuable indication for operative interference; the more chronic the case the greater the value. In subacute and chronic cases, with little or no rise in temperature and a leucocytosis of 12,000 to 18,000, pus is almost certainly present. Leucocytosis of Malignancy. — In general it is said that the blood changes are proportionate to the degree of malignancy. The more rapid the growth aiid the greater the metastasis the more advanced the leucocytosis. In cancer of the uterus, vagina, and vulva the associated hemorrhages and infections, if acute and great, contribute to the leucocytosis. The resisting power of the individual also influences the degree of leucocytosis. The effects of sarcoma upon the blood are of the same sort, but are said to be of a greater degree than in car- cinoma. In thirteen of the author's cases of malignancy there was no leucocytosis in eight. The highest white count was 16,000. Blood examinations will, therefore, aid little or not at all in the diagnosis of malignancy. The author has not observed that leucocytosis is more marked in sarcoma than in cancer; in the two cases observed the white count did not exceed 10,000. Leucocytosis in Ovarian Tumors. — In ovarian tumors there may be an increase in the leucocyte count. This is particularly true if the pedicle is twisted and if there is irritation of the peritoneum. The leucocyte count does not aid in determining the malignancy of an ovarian tumor, but when the red cells are diminished there is a sug- gestion of possible malignancy.. Differential Count of Leucocytes. — Pus may be present in the absence of any increase in number of the leucocytes. Such cases will, as a rule, show an increase in the polymorphonuclear leucocytes to ove'r 80 per cent. In certain chronic abscess formations, both the qualitative and quantitative estimates m.ay fail to suggest the presence of pus — these cases are exceptional. In the hands of an expert laboratory worker the quantitative count is of great value in selected cases, but for the ordinary clinician it is of little or no value because of its technical difficulties. ANEMIA 83 Anemia. — It is of the greatest importance for the obstetrician and gynecologist to accurately diagnosticate both primary and secondary anemias. Primary and secondary anemias are not infrequent causes of amenorrhea, menorrhagia, sterility, and abortion, and hence the recognition of the extent and variety of anemia has a very special value in diagnosis. Too often the physician assumes that the disorder is a local one when in reality it is a general blood affection. It becomes imperative to know the degree of anemia before resorting to a major operation. The individual's general appearance is not a safe guide. In the cases already referred to, the one with 20 per cent, of hemo- globin and the other with 17 per cent, did not appear to be nearly so anemic, and without a blood examination, would have been operated without knowledge of the great danger. When the history points to a primary anemia a differential blood count must be made. By cover-slip preparations and properly selected stains, chlorosis, pernicious anemia, and the leukemias are recognized. This, together with the estimate of the number of red and white cells and the percentage of hemoglobin, constitutes an exact diagnosis. Secondary Anemia. — Secondary anemia is the result of some definite cause, such as digestive disturbances, infection, and hemorrhage. In the mildest forms it is manifested merely by diminution in the size of the red cells and a corresponding decrease in the amount of hemo- globin. The number of red cells may not be lessened. Again, the red cells may assume irregular shapes and sizes (poikilocytes, microcytes, macrocytes) . A still greater degree of anemia is manifested by a decrease in the number of red cells as well- as by alteration in their shape and size. As an indication of the most advanced type of secondary anemia, there are added to the alterations in the shape and size of the red cells and to the decrease in their number, certain regenerative changes in the red cells. Nucleated red cells are found — normoblasts, micro- blasts, megaloblasts. During the preparation of this chapter the author had under observation a seventeen-year-old girl who had but 10 per cent, of hemoglobin and 1,200,000 red cells as the result of uterine hemorrhages caused by a fibroid tumor. In high degrees of anemia, where operative interference is indicated for relief from a pelvic dis- order, the exact degree of anemia is determined before resorting to the operation. It will be of interest to inquire as to the degree of anemia which would contra-indicate an operation. Each case must be a law unto itself. There are many things to consider : The urgency of the indication for operative interference, which may be very great in septic conditions and hemorrhage; the general condition of the patient excluding the anemia; and finally the nature of the operation, particularly as to the duration of the anesthesia required. The author has curetted and packed the uterus under chloro- form anesthesia, where there was only 20 per cent, of hemoglobin; this was done for the purpose of controlling the hemorrhage until the blood could be built up to a point that would justify an abdominal 84 BA CTERIOLOGICA L EX A MIX A TIOX hysterectomy for the removal of a uterhie fibroid. When pus can be drained through the vagina or the uterus curetted for the relief of hemorrhage it would be Avise to dispense Avith anesthesia, when possible, if the blood is very low. In general it may be said that there should be no protracted operation with the hemoglobin below 40 per cent, and the red cell count less than 2,000,000. There are exceptions to this rule, but all such cases must necessarilv be hazardous. BACTERIOLOGICAL EXAIVQNATION Bacteriology of Normal Genital Bacteriology of Fallopian Tubes Tract Bacteriology of Ovary Bacteriology of Vulva and Vagina Bacteriology of Peritoneum and Bacteriology of Uterus Pelvic Cellular Tissue While the range of bacteriology in diseases of women is comparatively limited, the value of bacteriological examinations in selected cases cannot be oA'erestimated. By these examinations it is possible to arrive at the diagnosis of the essential cause of the infection and to determine whether the pus is sterile or virulent, and, having done so, the prognosis is made with more certainty and the method of treatment is more intelligently decided upon. The pathogenic organisms commonly found in the genital tract are the staphylococcus pyogenes albus and aureus, streptococcus pyogenes, gonococcus, colon bacillus, tubercle bacillus, bacillus lanceo- latus, and typhoid bacillus. Pathogenic microorganisms less frequently found in the genital tract are the bacillus aerogenes capsulatus, pneumococcus, diphtheria bacillus, tetanus bacillus, bacillus pyo- cyaneus, anaerobic putrefactive bacteria, streptococcus of erysipelas, and the streptothrix actinomyces. There is great confusion in the literature regarding the relative frequency with which these organisms are found. Indeed, it is not possible to make any definite statement as to their relative frequency. The reader is referred to special works on bacteriology for detailed descriptions of the micro5rganisms common to the genital tract. The author will attempt only a clinical consideration of the subject from a diagnostic point of \ie\v. Bacteriology of the Normal Genital Tract. — The upper genital tract — i. e., cervix, uterine body, tubes, and ovaries — is free from all forms of microorganisms under normal conditions. Much difference of opinion exists as to the bacteriology of the vagina in health. That numerous bacteria are found in the healthy A'agina is generally recog- nized, but to what extent, if any, these microorganisms are pathogenic is an unsettled question. Numerous observations have been made to determine this question. Kronig, Menge, and Whitridge Williams carefully excluded the possibility of contamination, and agreed, from extended observations, that pathogenic organisms could not long exist BACTERIOLOGY OF THE VULVA AND VAGINA 85 in the healthy vagina. Their experiments were largely carried out during pregnancy. These authors ascribe to the vaginal secretion an antiseptic action which is more pronounced during pregnancy. The vulva is rich in pathogenic as well as non-pathogenic microorganisms. This accounts for the readiness with which the vagina is contaminated. It is of interest to know that the intact vaginal and vulvar surface will not admit of infection. In order that infection of these surfaces be possible, there must be an atrium for infection acquired by direct injury, maceration of the epithelium from profuse irritating secretions, the development of malignant growths, or lastly, the devitalization and desquamation of the epithelium incident to old age. Not so with the delicate surface epithelium of the uterus and tubes. Here the infection is readily engrafted upon the healthy surface. Not infre- quently an infection acquired per vaginam will primarily attack the endometrium and later the vaginal surface when the epithelial covering has been macerated by the uterine secretion. Bacteriology of the Vulva and Vagina. — Undoubtedly various patho- genic and non-pathogenic microorganisms exist from time to time in the vulva and vagina. That they do not more frequently cause infec- tion is due to the fact that the vulva and vagina are so well protected by stratified squamous epithelium. In infancy and old age, when the epithelium has not the resisting power found in mature life, the vulva and vagina are more susceptible to infections and especially to gonorrhea. In the newborn the vagina is free from microorganisms, but a variety of germs may enter soon after birth. It is agreed upon by all observers that pathogenic bacteria lose their virulence as they approach the cervix. This fact is due, in all probability, to the presence of lactic acid, which in turn is the product of an acid-forming microorganism discovered by Doderlein. This organism offers a restraining and often a prohibitive influence upon pathogenic organisms, thereby preventing the infection of the upper genital tract unless the organisms are carried there by hands and instruments. Certain organisms, particularly the gonococcus and streptococcus, may travel to the uterus, notwithstanding the bacillus of Doderlein. J. Whitridge Williams made a study of the bacteria in the vagina of ninety-two pregnant women and came to the following conclusions: "1. We agree with Kronig that the vaginal secretion of pregnant women does not contain the usual pyogenic cocci, having found the staphylococcus epidermidis albus only twice in ninety-two cases, but never the streptococcus pyogenes or the streptococcus aureus or albus. "2. The discrepancy in the results of the various investigators is due to the technique by which the secretion is obtained. "3. As the vagina does not contain pyogenic cocci, infection from them is impossible, and when they are found in the puerperal uterus, they have been introduced from without. " 4. The gonococcus is occasionally found in the vaginal secretion, and during the puerperium may extend from the cervix into the uterus and tubes. 86 BACTERIOLOGICAL EXAMINATION " 5. It is possible, but not yet demonstrated, that in very rare instances the vagina may contain bacteria, which may give rise to sapremia and putrefactive endometritis l)y auto-infection. " G. Death from puerperal infection is probably always due to infection from without, and is usually the result of neglect of aseptic precautions on the part of the physician and nurse. "All infections of the vulva and vagina are mixed infections. The gonococcus, tubercle bacillus, diphtheria bacillus, staphylococcus, and streptococcus never exist alone, though they may so dominate in numbers and clinical phenomena as to be regarded as an isolated infection." Gonococcus Infection. — This type of infection is rarely primary during the period of sexual maturity, but in infancy and in old age when the epithelium offers less resistance, primary vulvovaginitis is relatively frequent. The gonococcus is often found in the secretions of the vagina and vulva and occasionally when the secretion is not purulent. The Bartholinean gland, or rather the outlet of the gland, is the most frequent point of attack in the vulva. It is said that the gonococcus never invades the deeper ramifications of the gland. Here, as else- where, the infection is mixed. Tubercle Bacillus Infection. — This is rarely a primary infection. As a rule, the infection is secondary to that of the uterus; more rarely to the vulva, bladder, or rectum. Direct infection is possible, as is also infection through the blood. Diphtheria Bacillus Infection. — ^This is commonly a puerperal infection conveyed directly to an injured tissue. The author has seen but one such case. This one responded promptly to the antitoxin of diphtheria. The nurse in attendance acquired a diphtheritic sore throat from the patient. Aerogenous Infection. — This infection is manifested by the formation of small subepithelial cysts containing gas (emphysematous vaginitis). The infection is usually associated with pregnancy. Bacteriology of the Uterus. — Under normal conditions the uterus is at all times free from microorganisms, both pathogenic and non-patho- genic. The normal cervical secretion is said to possess a germicidal power. Even in chronic inflammation of the uterus, bacteria are rarely demonstrated. Uterine infections are identical with those of the tube and are classified either as mixed or specific. It is highly probable that all uterine infections are mixed. The so-called specific infections are those in which a certain pathogenic microorganism (streptococcus, gonococcus, tubercle bacillus) predominates. According to Sinclair the causes of immunity from infection of the cervix are: 1. Alkaline reaction of the cervical secretion. 2. Small caliber of the cervix. 3. Increased muscular power in the walls of the cervix. 4. The downward stream of the cervical secretion. 5. Germicidal quality of the cervical secretion. BACTERIOLOGY OF THE FALLOPIAN TUBES 87 Bacteriology of the Fallopian Tubes. — Under normal conditions no microorganisms exist in the tubes. Few bacteriological examinations have been made from catarrhal salpingitis, and the results are not definite. In the purulent forms of salpingitis a large number of observers have made careful observations. Frank T. Andrews/ in writing of the causes of salpingitis, has presented a valuable series of statistics collected from 28 sources. The following table was constructed bj^ Andrews : In a total of 684 observations the following percentages were found : Sterile 55.0 per cent. Only saprophytes 6.0 per cent. Gonococcus 22. 5 per cent. Staphylococcus and streptococcus 12.0 per cent. Pneumococcus 2.0 per cent. Bacillus con communis 2.5 per cent. Gonococcus. — The gonococcus of Xeisser was found 155 times in 308 cases in which microorganisms were demonstrated. Without doubt a large proportion of the sterile tubes was originally infected by the gonococcus. The gonococcus frequently escapes detection because it disappears early from the pus contents of the tubes, and it is extremely difficult to recognize the gonococcus in the wall of the tube, though they have been known to exist many years. In 36 cases of gonorrheal salpingitis, other bacteria were found in 5. Streptococcus and Staphylococcus. — ^These two microorganisms are con- sidered together, first, because they so commonly coexist, and, second, because their anatomical effects are much the same. Their virulence in the tube is variable. Pneumococcus of Frankel. — The pneumococcus infections of the tube, which have been reported, bear no relation to pneumonia. The infec- tion of the tube is probably acquired in these cases by direct extension from the lower genital tract. Bacillus Coli Communis. — This infection is very often mixed, the colon infection being usually secondary to other forms. In the majority of cases the presence of the colon bacillus implies adhesions binding the tube to the bowel, though, as stated by Andrews^ the infection may extend through the bowel wall, along the peritoneum to a non- adherent tube, or may travel up through the genital tract. Typhoid Bacillus. — Xo direct connection has been traced between typhoid infection of the tube and typhoid fever, though it is possible that the typhoid bacillus may exist in tissues years after an attack of typhoid fever. Saprophytic Bacteria. — Xon-pathogenic bacteria of the saprophytic order are not infrequently found in salpingitis. Infectious Granulomata.— Of the infectious granulomata, tuberculosis ranks first in frequency and in clinical importance. 1 American Journal of Obstetrics, February, 1904. 88 BACTERIOLOGICAL EXAMINATION Tuhercuhsis. — In a total of 100 cases of pyosalpinx collected by Andrews, 10 per cent, were tuberculous. The tubes are usually the primary seat of genital tuberculosis — 57 out of G7 cases (JMeyer). On the other hand, Orthmann states that primary tubal tuberculosis occurs in 18 per cent, of genital tuberculosis in women; this in a series of 168 cases. Secondary tubal tuberculosis is relatively common, and is most often acquired through the blood. Syphilis. — Syphilis is rarely identified in the tube. Undoubtedly syphilitic lesions of the tube are common to general syphilitic infec- tion, but it is difficult to identify them as such. But three cases are recorded. Adinomiicosis. — Actinomycosis of the tube is a great rarity. Bacteriology of the Ovary, — Infections of the ovary are almost with- out exception secondary to tubal infection, and hence the bacteriology of ovarian abscesses is in most part identical with that of purulent salpingitis. Primary ovarian abscesses are exceedingly rare, though the possibility of infection travelling to the ovary by way of the blood- lymph channels or directly through the genital tract without visible effects until the ovary is reached, cannot be denied. Sutton says that primary ovarian abscesses are always tuberculous. This statement is not verified by experience. Martin collected 55 cases of ovarian abscesses from the literature, and of this number 35 contained bacteria, the remaining 20 were sterile. The gonococcus and the bacillus coli communis were the most frequently found. Staphylococci streptococci, pneumococci, and the typhoid bacillus were relatively infrequent. The rule that bilateral infection of the appendages speaks for gonorrhea and unilateral involvement for puerperal infection has many exceptions. Suppurating ovarian cysts have been discussed by Cumston. Dermoid cysts are particularly susceptible to infection and the development of abscesses. The organisms which have been mentioned have been found in these cysts. Inasmuch as suppurating cysts are almost invari- ably adherent to the bowel, the colon bacillus is of common occurrence, but more often as a secondary infection. The size of the abscess is no criterion of the virulence of the pus. Fraisse removed a cj'st containing fifteen liters of sterile pus. Such abscesses at one time undoubtedly contained either pathogenic or saprophytic organisms. The periodic congestion of the ovary and rupture of the Graafian follicles, together with the tendency of the ovary to the formation of new^growths and to torsion of the pedicle, render the ovary peculiarly susceptible to infection. Streptococcus and Staphylococcus. — These infections are common; they frequently follow upon labor and abortion. The virulence of the infec- tion and the resistance of the individual determine the clinical picture. The lesion in the ovary is but a part of the more general infection of the lower genital tract and occurs at intervals of days weeks, and months subsequent to the initial infection. Gonococcus. — This infection doubtless ranks first in point of frequency. Reymond affirms that the gonococcus always attacks the surface of BACTERIOLOGY OF THE PERITONEUM 89 the ovary, and is never found in the pus of an ovarian abscess. The gonococcus can enter the substance of the ovary through the blood and lymph channels and through the follicles and corpora lutea. Bacillus Coli Communis. — This is said to never occur in the absence of adhesions binding the ovary to the bowel. The infection is conse- quently mixed in the majority of cases. It is probable that the infection travels also through the genital tract to the ovary. Pneumococcus. — This form of infection has been recorded by several observers. A pure culture of the pneumococcus has been obtained from the pus in the abscess. In none of the cases was there a recent history of pneumonia. Tubercle Bacillus. — This infection is by no means so infrequent as the early writers would have us believe. Miliary tubercles are observed by the microscope in ovaries that appeared perfectly normal. Primary infection of the ovary is most unusual. The infection is almost invariably secondary, but it is not always possible to determine the initial point of infection. It is generally believed that the tubes are the primary seat in the majority of cases. Schottlander believes the peritoneum to be the primary source of the infection, but does not exclude the tubes as a possible source. It is, of course, possible for the tubercle bacillus to pass from the vagina by way of the uterus and tubes to the ovary, or from the vagina through the broad ligaments to the hilum of the ovary. In general miliary tuberculosis the ovary is especially liable to be attacked by way of the blood. In 48 cases of ovarian tuberculosis Orthmann traced the infection to the tubes in 26 and to the peritoneum in 22. Bacteriology of the Peritoneum and Pelvic Cellular Tissue. — The involvement of the peritoneal and cellular tissues of the pelvis is almost invariably secondary to infections of the uterus, tubes, ovaries, cervix, vagina, bladder, or rectum. The bacteriology of pelvic cellulitis and peritonitis is therefore that of vaginitis, metritis, salpingoovaritis, cystitis, and proctitis. In puerperal infection the streptococcus and staphylococcus are about equally liable to infect the pelvic cellular tissue and peritoneum. Not so with the gonococcus and tubercle bacillus, which attack by preference the peritoneum. The colon bacillus and tubercle bacillus doubtless very frequently pass througli the bowel to the peritoneum and cellular tissue, though with these organisms, as with all others, the usual avenue of infection is the genital tract. CHAPTER V GENERAL PHYSICAL EXAMLXATIOX— EXA:\nXATIOX OF EXTERXAL AXD IXTERNAL GEXITALS GENERAL PHYSICAL EXAMINATION Preliminary ^Measures : Percussion External Abdominal Ex.\mination i Auscultation Inspection I ' Mensuration Palpation I Preliminary Measures. — After the history has been taken, the next st^p is to determine by a general physical examination the possible bearing which some remote affection may have upon the pelvic organs. Giving attention more particularly to the abdomen and pelvis, the following outline will serve to indicate the methods to be employed in a systematic and thorough physical examination, as well as the order in which practical experience has sanctioned their usage. N^o invariable order can be adopted; circumstances will alter the general routine; but it is well to follow a definite method of pro- cedure as closely as possible. The habit of making a systematic routine examination will not infrequently eliminate many errors in diagnosis. The examiner will not likely be content with any single, explanation for the patient's complaint, but will seek farther for other possible lesions. The writer recalls a case in which hemorrhage was the symptom complained of. On physical examination an interstitial fibroid was discovered. This was believed to explain the hemorrhage, and a hysterectomy was performed. Li the cavity of the uterus was a cauliflower carcinoma, which had not been suspected. The examina- tion had not been complete; when a single cause for the hemorrhage was discovered no further search was made. Had a more conservative operation been performed and the uterus not removed, the more serious of the lesions would have been overlooked. !!> learn from such experi- ences that ice should not be content with the finding of a single cause for a given ymptom, but shoidd search for cdl possible cavses, inasjuvch as two or more morbid conditions may contribute to the symptom. In making a physical examination care should be taken not to injure the structure examined; and the examiner should always endeavor to avoid inflicting pain. The more skilled the examiner the more careful and gentle he is. A vaginal examination may cause great discomfort, and serious damage may be done to an inflamed mucous membrane EXTERNAL ABDOMINAL EXAMINATION 91 or malignant growth. As the result of a bimanual examination roughly made, not only much suffering may be caused, but cysts may be ruptured, abscesses may break into the peritoneal cavity, the gestation sac of an ectopic pregnancy may be ruptured, adhesions may be torn, and in the use of the sound, curet, and speculum, serious and even fatal injuries may be sustained. While an exact diagnosis is desired in the first examination, it is seldom absolutely necessary and is frequently impossible. Certain procedures, such as catheterizing the ureters, must often be postponed for a subsequent examination. It is seldom necessary to make an examination during the menstrual period. It is not only objectionable to the patient, but at this time the pelvic viscera are congested, and there is an added risk of injury. During the menstrual period the cervix is softened and somewhat patulous, and for this reason Simpson has advised the exploration of the uterine cavity during menstruation for the detection of foreign growths. The added risk of infection and injury would seem to con- tra-indicate such a practice. The intermenstrual period is therefore chosen for local examinations and treatments, for the reasons that the conditions then found are more nearly normal and there is less risk of injury. Furthermore, it is best to make the examination at a time when the patient is in a condition the nearest possible to the normal. To this end the exami- nation should not be made immediately after a full meal, or when for any reason the patient is exhausted and nervou'. Whenever possible the patient should be examined on a table in a good light. Whatever the table used it should be of convenient width and length to permit the patient to assume any desired position. It should be so placed as to be approached by the examiner from all sides, and should be of convenient height to allow him to proceed without assuming an unnatural and strained attitude. Fig. 14 shows a correct table for the making of examinations and operations. This table was designed by Dr. L. E. Schmidt, of Chicago, and has the special advantage of directing the buttocks well over the edge of the table, thereby favoring instrumental examinations of the bladder, vagina, and rectum. Frequently a patient must be examined on a bed or couch. The author does not favor the examining chair because of its formidable appearance, its cumbersome weight, and the inconvenience with which the position of the patient is changed. External Abdominal Examination. — Inspection. — It is well to expose the abdomen by removing the corset and all constriction about the waist. A sheet should cover the upper portion of the trunk to the waist line; another sheet should cover the lower extremities and hips, as seen in Fig. 15. The chief value of inspection is to determine abnormalities in the contour of the abdomen. Among the points to be observed are the size of the abdomen, its form, the site of a convexity or depression, the laxity or tension of the abdominal wall, the retraction or protrusion 92 Q EN ERA L PH YSICA L EX A MIX A TIOX of the umbilicus, the presence of Hnea albicantes, pigmentations, (hstended veins, hernia, skin diseases, peristaltic movements of the intestine, pulsations of the aorta as seen through the thin abdominal Examiaiag table. (Schmidt.) Fig. 15 Position for abdominal examination. < Oh s Ti ^ CD '^ +j ■Jl t^ £. ■^, -^ i3) ^ ^ C -' C ^ O o ^ CO m CO S ^ ^ tw 'C ,, •i:; 0) 3 ^ r-" +J Cl-H 0) ^ (D C £1 03 -d ^ ^ '^ >. ^ ■^ CO !^ & ^ ^ "i-l tj d ,„ « ^ Jii c; T3- 2 ^ *^ a f s- ti CO ^ in the eontour of the abdomen produced by t\Tapany, ascitic fluid, tumors, and thick parietes are readily recognized by a competent observer. In a thick, fatty abdominal wall the abdomen is flattened and the flanks protrude and sag downward when the patient lies on her back. Great transverse folds are formed. (See Plate I.j Free ascites, with the patient in the dorsal position, causes a bulging in the flanks and a flattening of the anterior abdominal wall. With change in position of the patient the contour of the abdomen is altered. (See Plate II.j In ovarian cysts the abdomen is irregularly ovoid. In the A'ery large cysts, or where the pedicle is long and the cyst is freely movable, the abdomen may be evenly distended. When tKe abdominal wall is thin and the cyst large and multilocular, it is sometimes possible to see the irregular elevations through the abdominal wall. (See Plate III ) Large uterine fibroids may e\enly distend the abdomen, but more frequently cause an irregtilar protuberance. fSee Plates IV and V.j In interstitial fibroids the abdominal enlargement is inclined to be more median than in ovarian cysts. (See Plate IV.j In excessive distention of the abdomen the skin is white and shiny, and often streaked with irregular red lines. Additional information may be gained by watching the movements of the abdominal wall. The excursions of the abdominal wall are restricted during respiration by the presence of painful lesions within the abdomen, such as peritonitis, circumscribed abscesses of the abdomi- nal viscera, intestinal obstruction, and intraperitoneal hemorrhages. Large abdominal tumors also inhibit the excursions of the abdominal wall over the region occupied by the tumor. Tumors of the upper abdomen, if not firmly adherent, will usually move with the respirations, while pelvic tumors are not affected by the respiratory movements. Inspection is of assistance in recognizing the presence of a living fetus in utero. The active fetal moA'ements may be seen and the intermittent contractions of the pregnant uterus are discernible. In intestinal obstruction the peristaltic wave may be seen to pass in the direction of the distended gut. Pigmentation of the skin in the median line of the abdomen suggests a previous pregnancy, as do also strise. Palpation. — The abdomen is best palpated with the patient in the dorsal position. The head and chest, if elevated, will diminish the field of exploration. When it is desired to note the effect of change in position upon the abdominal contents, the erect, the knee-elbow, or the lateral position may be assumed. Preliminary to all abdominal and pelvic examinations, the bladder and rectum must be empty and all constricting bands of clothing removed. The examiner's hands should be warm and the finger nails cut short. Both hands should be used. They should be laid gently upon the abdomen, with steady and firm pressure, avoiding all sudden 94 GENERAL PHYSICAL EXAMINATION and unexpected movements. The patient should be instructed to breathe cinietly, with the mouth open. Her attention may be drawn froni the examination by asking questions concerning some other portion of her body. In this manner, with the abdominal walls thin and relaxed, it may be possible to palpate the projecting vertebrae, the posterior wall of the pelvis, the promontory of the sacrum, and the pulsating aorta. Thick and tense abdominal walls may prevent satisfactory palpation of the abdomen, thereby necessitating an anesthetic. Very often, by care and patience, the tendency to contract the abdominal walls may be overcome Avithout resorting to anesthesia. Remember that it is possible to do harm by rupturing collections of blood, cysts, and abscesses, and by exciting a limited or latent inflammation to extend to surrounding structures. Fig. 16 Palpation of the colon. For couA-enience of description the abdomen may be divided into quadrants (Fig. 17). These are named respectively the right upper, the left upper, the right lower, and the left lower' quadrants. Before determining the nature of a swelling, it is necessary to identify it either as growing from the pelvis or from the abdomen, and to demonstrate its relation to the viscera and to the abdomin'al wall. It is well to follow a routine system, beginning below and proceeding upward. If the preliminary step of emptying the bladder and bowels is taken there should be no confusion with a fecal tumor and distended bladder. Sensitiveness, tension, thickness, and consistency of the abdominal wall are noted by systematically palpating symmetrical Eh < p^ m U) ^ t5 u5 r; ^ CO fl (S Cfl G >3 o 0) ^ rj -ij S Cm '&^ 03 tTI > r^ .M & 5 m ^ "'3 U5 •-1 C a -ci ^ CO ^ H > < P. PALPATION 95 parts and comparing them. Xo considerable pressure need be exerted in determining these facts. "When sensitiveness is found nervous irri- tabiHty and inflammation should be carefully distinguished. When deep pressure is tolerated in the presence of superficial tenderness, inflammation can be almost surely excluded. All tumors of the abdominal wall move with the wall, and may be lifted up with it. The connection of a tumor wdth the skin is recognized by inability to lift the skin apart from the tumor. Fig. 17 pper Right Quadrant Lower Right Quadrant Upper Left^; Quadrant Lower Left Quadrant Diagram of the areas into -which the abdomen mav be divided. All intraperitoneal tumors and viscera move with respiration; the nearer the diaphragm the greater the excursions. If the organ or tumor is adherent or is incarcerated the excursions will be limited. These isochronous, respiratory movements are readily recognized by the hand, and under favorable conditions may be recognized by inspection. An organ or tumor lying underneath the peritoneum, if protruding into the peritoneal cavity, may be affected by respiratory movements. Such, for example, may be the case with a movable kidney or a pedunculated 96 GENERAL PHYSICAL EXAMINATION Fia. IS Demonstrating the thickness of the abdomen. Fig. 19 Showing position of various organs. G.BL, gall-bladder; Spl., spleen; K, kidney; Vr., ureter; T-0, tube and ovary; Ut., uterus; BL, bladder. > < PERCUSSION 97 subserous fibroid. All tumors arising in the pelvis tend to grow upward. The contour of the swelling and its consistency are determined by palpation. It is important to recognize periodical alterations in consistency in connection with the differential diagnosis between pelvic or abdominal swellings and a pregnant uterus. No swelling other than a pregnant uterus contracts intermittently. The softening of a tumor speaks for a degenerative process. When the swelling is deep-seated or the abdominal wall thick and tense, it may be impossible to determine the consistency and contour of the swelling. Fluctuation is best detected by percussion associated with palpation, and when elicited speaks for the presence of fluid. The readiness of response to impulse, indicates to some extent the consistency of the fluid. The examiner is often at a loss to decide whether or not fluid is present. Tense cysts may not fluctuate, and, on the other hand, soft tumors may appear to fluctuate. The connection of the swelling with other tumors and viscera may be determined by palpation. The exact location of the tumor is noted, and by palpation is often traced to a particular organ. By changing the position of the patient, additional information may be obtained regarding the attachment of the swelling. Spencer Wells has pointed out that non-adherent-, pedunculated tumors of the pelvis gravitate into the abdominal cavity when the knee-chest position is assumed. Percussion. — The abdomen is best percussed with the patient in the dorsal position. When it is desired to demonstrate by percussion the change in position of a tumor or fluid, the patient may assume any required position. Since the normal percussion tone of the abdomen differs according to the contents of the stomach and bowels, the results obtained by percussion are not altogether reliable. The normal range of motion in the abdominal and pelvic viscera also adds to the uncertainty of the conclusions arrived at by percussion. Furthermore, it is impossible to compare the percussion note on corresponding sides as is done in percussing the chest. Percussion is to be regarded as an auxiliary to palpation. In proceeding it is well to go over the entire abdomen in a systematic manner. If firm pressure is made by the fingers the intestines, unless adherent, will be pushed aside, and the underlying organ or tumor can be directly percussed. Percussion is of the greatest value in demon- strating the presence or absence of intestine lying in front of the organ or tumor. All other conditions are better elicited by palpation. In ascites the dull percussion note of the fluid is found in the most dependent portion of the abdomen, and the tympanitic note of the intes- tine is found above the fluid. When the mesentery is short or the bowel fixed by adhesions, the above findings are not elicited. If gas does not distend the intestine, or if fecal matter fills the intestine, the tympanitic note is not elicited in contrast to the dull note of the fluid. When the ascitic fluid greatly distends the abdomen there may be no change in 98 GEXERAL PHYSICAL EXAMIXATION Fig. 20 Breaking the fat wave in percussing for fluid in the atdomen. Fig. 21 Demonstrating the percussion wave in abdominal ascites MENSURATION 99 the area of dulness. When there is a small amount of ascitic fluid the intestine may float to the side of the abdomen and give a tympanitic note together with fluctuation. When an ovarian cyst distends the abdomen the percussion note is dull in front and the tympanitic note of the intestine is found low in the flanks. Auscultation. — This is of little value except in the diagnosis of pregnancy, but should be a part of the routine examination in all abdominal swellings which resemble pregnancy. Other than the sounds referable to the fetus, the placenta, and the pregnant uterus, there may be heard over the abdomen the maternal heart tones, pulsations of the aorta, murmurs of abdominal aneurysms, gurgling of gas in the bowel and stomach, and the friction sounds caused by the rubbing together of rough surfaces. The patient should be in the dorsal position, with the legs sufficiently flexed to relax the abdominal walls, yet not to the extent of interfering with the examination. The ear or stethoscope may be employed, preferably the latter. The uterine bruit is not to be mistaken for the bruit that is heard in about 50 per cent, of uterine tumors and occasionally in ovarian cysts. A similar bruit has been heard over the tumors of the liver, spleen, and the retroperitoneal spaces. No such sound has been heard over tumors of the kidney. Mensuration. — This is of some importance in the diagnosis of ab- dominal swellings. It finds its greatest service in obstetric practice. It is a fairly precise means of determining the rate of growth of an abdominal swelling. Exact measurements are difficult, because of the variable degree of distention of the intestine and the shifting of the abdominal tumor. There must be a convexity of the abdomen; otherwise, comparative measurements would be of no value. An ordinary tape-measure will answer the purpose. The measure- ments to be taken are: the greatest circumference, the circumference at the level of the umbilicus, the distance from the ensiform cartilage to the pubis, from the umbilicus to the anterior superior spine of the ilium on either side, and the distance from the linea alba to the spine of the vertebrae. It is important for the purpose of comparison that the same position be assumed in making subsequent measurements. CHAPTER VI EXAISIIXATIOX OF EXTERNAL AND INTERNAL GENITALIA Inspection of External Genitals Digital Examination of Internal Genitals Digital Examination of Vagina Abdominovaginal Examination Palpation of Ureters through Vagina Digital Examination of Rectum Combined ^^aginal Examination ; Pelvimetry Inspection of the External Genitals. — The routine practice of inspect- ing the external genitals is unnecessary, and should be discountenanced. AVhen required the Sims position or the ordinary lithotomy position is assumed. The sheet is drawn about the lower extremities and tucked about the vulva in such a manner as to make the least possible exposure. The labia are held apart by the thumb and index finger for the inspection of the vestibule, urethral opening, hymen, and the perineum. When gonorrhea is suspected the urethra and Bartholinean glands should be inspected. When these structures are infected, and par- ticularly if pus can be expressed from the urethra, the diagnosis of gonorrheal infection amounts to a moral certainty. Recent injuries should be inspected, but long-standing injuries to the pelvic floor can be detected and a fair estimate of their extent gained from the sense of touch alone. ]Malformations, pigmentations, varices, edema, and all the new- formations should be examined by direct inspection. Digital Examination of the Internal Genitals. — The hidden position of the internal genitals makes it necessary to examine them through one or more of the natural openings — i. e., rectum, bladder, and vagina. Lentil the end of the eighteenth century the vaginal route was the only one used for such examinations. Little progress was made in the diagnosis of diseases of the internal genital organs untU combined methods of examination were introduced by M.' Puzos, in the eighteenth century, and revived and elaborated by Sir James Y. Simpson. The combined examination is the only means of determining the size, position, consistency, mobility, sensitiveness, and relative positions of the pelvic organs. Digital Examination of the Vagina. — This is made with the patient in the Sims or lithotomy position, and rarely in the erect or knee-chest position. When the bare hand is used it should be scrubbed with soap and water and disinfected with lysol. The best lubricant for the ex- amining finger is scented green soap. Vaseline is not desirable, because DIGITAL EXAMIXATIOX OF THE VAGIXA 101 Fig. 22 Patient prepared for inspection and vaginal examination in the office. Fig. 23 Patient prepart-d lur inspection and vaginal examination. Hips drawn to the end of the couch and feet resting on stools. 102 EXAMINATION OF EXTERNAL AND INTERNAL GENITALIA of the odor from the secretions, which cHngs to the fingers in spite^ of vigorous scrubbing. In an ordinary digital examination of the vagina it is unnecessary to expose the vulva; the examination may be made in a perfectly satisfactory manner under cover of a sheet. It should be the invariable practice of physicians to wear a thin rubber glove or finger-cot (Fig. 26) in making vaginal and rectal exami- nations. This is done not only as a matter of cleanliness in preventing septic infection of the genital organs, but as well to prevent infection of the examining finger. A well-known authority on skin and venereal Fig. 24 Vaginal cxaminutiou with two fingers. iStep 1. The perineum i.s forrilily depressed by the palmar surface of the middle finger, thereby increasing the vaginal outlet. diseases has informed the author that an average of one physician a week came to his office with a syphilitic infection acquired in making examinations. This appalling statement should make the examiner very cautious. The attitude of the examiner should be carefully considered. Fig. 27 shows the correct position, though the table is somewhat high for convenience and efficiency. The examiner stands at the end of the table; one foot rests upon a low stool; the elbow of the examining arm rests upon the knee, thereby permitting free motion in the forearm and hand. DIGITAL EXAMINATION OF THE VAGINA 103 Choice of Hand. — The choice of hand will depend in part upon the comparative utility of the two hands, but more upon the habit acquired. Fig. 25 Vaginal examination with two fingers. Step 2. Index finger is inserted above the middle finger and into the vaginal outlet. FULL SIZE Finger-cot worn on the index finger. 104 EXAMINATION OF EXTERNAL AND INTERNAL GENITALIA As a general thino;, the right side of the pelvis is best palpated with the right hand, and the left side with the left hand. In the early experience of the examiner it is best to cultivate the sense of touch in a single hand, and in later years, as there are opportunities for more experience, either hand may be used, with equal expertness. Fig. 27 Combined vaginal examination. _ Number of Fi7igers. —When two fingers can be introduced without discomfort to the patient, the two will be found more effective than one. In order that the fingers may be introduced with the least possible annoyance to the patient, the labia are separated by the thumb and index finger. The middle finger of the opposite hand is inserted into DIGITAL EXAMINATION OF THE VAGINA 105 the vulvar opening, with the palmar surface restmg upon the Pjmeum Firm pressure is made by the finger upon the permeum. The vulvar Xt^ftherebv deepened, and into it the index finger can be readily ll^^rted (F^^^ t;o fingers are now passed into the vagma, Fig. 28 Lithotomy position. Fig. 29 Knee-chest position. ^.aking firm pressure upon the V^^^f^^ P^^^ upon the clitoris and urethra (I'lg. 2o). When tne n „ inserted the palm of the hand is turned "PJ^ten et al'^le outlet is small, the mucosa sensitive, or the hjmen 106 EXAMINATION OF EXTERNAL AND INTERNAL GENITALIA fins^er should be employed. When pain is caused by inserting the finger it is well to ask the patient to bear down while the finger is being introduced. Fig. 30 Inspection of the vagina and cervix -with patient in the knee-chest position. The following conditions are determined by a simple vaginal exami- nation: the size, form, and position of the vulva, vagina, and vaginal portion of the cervix; the condition of the hymen, whether present or absent, perforate or imperforate; the integrity of the pelvic floor; the presence of newgrowths in the vulva, vagina, and vaginal portion of the cervix; sensitiveness and fulness in the vault of the vagina and the capacity of the pelvic outlet. The knee-chest position is especially advantageous when it is desired to do away with intra-abdominal pressure for the purpose of permitting the uterus and freely movable pelvic tumors to rise out of tjie small pelvis. The erect position is practised chiefly in determining the degree of prolapsus of the uterus. After concluding the examination the finger is withdrawn and the secretion on the finger inspected. The Combined Vaginal Examination (Bimanual). — Bishop says: "The secrets of success in bimanuel examinations are: a warm hand, a gentle ABDOMINOVAGINAL EXAMINATION 107 Fig. 31 touch, and patience. Any hurry is fatal." The advantages of a com- bined examination over a simple vaginal or rectal examination are evident. The combined method may be regarded as the most valu- able of all physical explorations of the pelvis. Various combinations may be utilized, they being designated as abdominovaginal, abdomino- rectal, abdominovesical, abdomino- vesicovaginal, abdominovesico, and rectovaginal. As a preliminary step to the exami- nation, the bladder and rectum are emptied, all clothing is made loose about the waist, and the patient placed in the lithotomy position. Abdominovaginal Examination. — In order that this method of examination be properly performed, the vagina must be patent and its walls relaxed. Furthermore, it is essential that the abdominal walls be sufficiently thin and relaxed to permit of depression. When there is much fat in the ab- dominal wall, a pendulous abdomen, or tenderness and pain on pressure, little or nothing can be accomplished by this method without the aid of an anesthetic. In extreme elongation of the vagina, and when there is an excessive deposit of fat in the external genitals and thighs, it may be impos- sible to palpate high in the vault of the vagina. The bimanual examination is best performed in the lithotomy or dorsal position, with the thighs slightly flexed. Little can be gained from such an examination with the patient in the erect or knee-chest position. The side positions, while awkward and ill-adapted for general use, are of special service in testing the mobility of the pelvic viscera and tumors. All that has been said in describing the digital examination of the vagina concerning the choice of hands, the use of one or two fingers, and the manner of introduction of the fingers, will apply to the com- bined method of examination. The function of the hand upon the abdomen is to steady the pelvic organs while being palpated by the fingers in the vagina. A complete outlining of the pelvic viscera by the external hand is not possible, consequently light pressure is all that is required, and has the advantage of not exciting the abdominal Erect position. 108 EXAMINATION OF EXTERNAL AND INTERNAL GENITALIA muscles to contract. The tips of the fingers are directed toward the ensiform cartiUige and gradually made to compress the abdominal wall at a variable point above the symphysis pubis. With a thin, flaccid abdominal wall, in the absence of large swellings, the external and internal fingers may be approximated in front of the uterus with only the vaginal wall, the bladder, and the abdominal wall intervening. Under most favorable conditions the fingers may be similarly approxi- mated behind the uterus. Lifting the uterus forward and upward by Fig. 32 Back view of Sims' position. Fig. 33 V'i %fs'f|f| Front view of Sims' position. the finger in the vagina, the uterus may be palpated over the entire surface of its body, and at the same time the vaginal and supravaginal surface of the cervix may be outlined by the finger in the vagina. In anteversion of the uterus the anterior surface of the uterine body is best palpated by the finger in the vagina, and the posterior surface by the external fingers. In retroversioflexion the posterior surface of the uterus is best palpated by the finger in the vagina and the anterior surface by the external fingers. When the uterine body is enlarged it ABDOMINOVAGINAL EXAMINATION 109 may be readily outlined in the combined examination without elevating the uterus by pressure from below. Under favorable conditions it is possible to determine the position of the uterus, its size, form, sensitiveness, consistency, and mobility. No manipulating should be done until the position of the uterus is determined, and this is largely accomplished by vaginal touch. Pressure by the examining fingers may correct or exaggerate a malposition of the uterus. A preliminary vaginal examination will serve to eliminate such errors. For details of the method of examination in displacements of the uterus see Chapter X^'I. Fig. 34 Sims' position. Perineum retracted by an assistant. Only under unusually favorable conditions can a normal tube be outlined in a bimanual examination. If the abdominal walls are thick and tense an anesthetic will be required. The uterus is first located by the abdominovaginal examination. From the horn of the uterus the hand, passing outward toward the sides of the pelvis, should follow the tube a variable distance. The normal tube is made to roll under the examining finger like a cord. It appears to be about the size of a slate-pencil. At the fimbriated extremity the wall is so thin that it is impossible, under normal con- ditions, to palpate it. When the uterus is in retroposition, or when no EXAMINATION OF EXTERNAL AND INTERNAL GENITALIA Fio. 35 Abdominovaginal examination Fig. 36 Proper attitude of the hand in making a vaginal examination with two fingers. ABDOMIXOVAGIXAL EXAMIXATION 111 the tubes have fallen behind the uterus, or when the uterus and tubes are in their normal position and the vagina is small and sensitive, the recto-abdominal method of examination is preferable. In the unmar- ried, with the hymen intact, a recto-abdominal examination should be made. ^Mien the tubes lie beyond easy reach of the examining finger, traction upon the cervix with vulsella forceps should be made by an assistant, while the recto-abdominal or vagino-abdominal method is carried out. Can a sound be passed into the tubes? Undoubtedly the sound has been passed into diseased tubes, but it is questionable whether the normal tube has ever been sounded. It is certain that the procedure should never be attempted for fear of penetrating the uterus The normal ovaries are palpated with difficulty, and are recognized by their position, size, form, and sensitiveness. The ovarian ligament is seldom felt. In seeking the ovary, the bladder and rectum should be empty, and all constricting clothing removed from the waist. An anesthetic is not always required, but is helpful in all eases and indispensable in many. The patient is placed in the lithotomy position. The abdominovaginal method is usually chosen. If the vagina is short, resisting, or sensitive to pressure, or if the hymen is intact, it will be advisable to make a recto-abdominal examination. AYhen the ovary lies behind the uterus it may be better palpated through the rectum. As a matter of routine, it is advisable first to locate the uterus, then to follow from the horn of the uterus along the course of the tube to the ovary. The right ovary is best detected by the fingers of the right hand and the left ovary by the fingers of the left hand. It is not, as a rule, necessary to change hands; either the right or the left hand will suffice in most cases for the examination of both ovaries. The pelvic peritoneum and cellular tissue should be explored as far as possible to discover undue sensitiveness, cicatricial contractions, inflammatory exudates, tumor formations, and collections of blood. The rectum on its anterior wall may be explored through the vagina and something learned of its sensitiveness, of inflammatory infiltrations, foreign growths, and fistulous openings, but the rectovaginal method of examination is more satisfactory. The base of the bladder and ureters may be palpated through the anterior vaginal wall. Tumors, calculi, inflammatory infiltrations, new- growths, and tenderness, from whatever cause, can be determined with some degree of satisfaction. A rough estimate of the capacity and deformity of the bony pelvis can be made by the combined method. The abdominovaginal examination is of greatest service in the differ- ential diagnosis of pelvic tumors. By the combined method their size, form, consistency, rate of growth, mobility, and relation to other structures are determined. AYhen the tumor is large and in the abdominal cavitv the method of Schultze may be employed with 112 EXAMISATIOX OF EXTERNAL AND INTERNAL GENITALIA advantao-e In addition to the customary bimanual examination an assistant" draws the abdominal tumor upward while traction is made upon the cervix with a vulsellum forceps. (See Plate \11.) The tumor mav so closely press upon the uterus or be so closely adherent to it that a line of distinction between the two cannot be recocrnized hv the examining finger. The variations m consistency and forn^, togeth'er with the use of the uterine sound, may determine the relations. Swellings of the tubes and ovaries when small can be differ- entiated from the uterus; but later, as they increase in size and become displaced liehind or to the side of the uterus, they are recognized with difficult \-. Likewise, pelvic exudates may blend intimately with the uterus. ' FrequentJN' bodies which are apparently immovable in one position may be movable in another. Examination under narcosis has many ad\'antages. Kelly lays down the following rules for the use of anesthesia in the diagnosis of diseases of women: 1. ^Yhen doubt exists after the ordinary bimanual examination. 2. When a patient comes to a specialist after having had treatment for a long time at other hands without improvement. 3. In all cases of pelvic peritonitis involving one or both ovaries or tubes without producing any gross tumor, the anesthetic will aid much in determining the extent of the disease. 4. Always in unmarried women. Nitrous oxide will serve admirably in the majority of- cases. When the examination must be prolonged, as in the use of the cystoscope or curet, either chloroform or ether is often necessary. It should be a rule, to which there are no exceptions, that after the paiient is asleep and before the operation is begun a thorough bimanual examin- ation should be made. Under anesthesia a higher point may be reached by inmginating the pelvic floor . This is accomplished by making firm pressure upon the vulva and perineum with the examining hand. In so doing a gain of one to two and a half inches may be made. Additional pressure may be made by supporting the elbow of the examining arm against the hip and throwing the weight of the body against the arm. Palpation of the Ureters through the Vagina. — When the abdominal walls are relaxed and thin and when there is relaxation of the vaginal walls it may be possible to palpate a thickened ureter for about two inches upward from the base of the bladder. The landmark for the pelvic portion of the ureter is at the brim of the pelvis, at a point just outside the sacro-iliac joint and internal iliac artery. When there is a suspicion of tuberculosis of the urogenital tract an effort should always be made to palpate the ureter. Digital Examination of the Rectum. — In point of efficiency, digital examination of the rectum and, through the rectum, of the pelvic structures ranks next to the vaginal method, and in some conditions is to be preferred. In all difficult and obscure vaginal examinations a rectal or rectovaginal examination should be made. PLATE VII Palpation of the Pedicle of an Ovarian Cyst. Two fingers are inserted into the rectum and the opposite hand over the abdomen. An assistant makes traction upon the cervix with a vulsella forceps while a third assistant Rrasps the cyst with both hands and draws it upward. In this manner the pedicle is put Spon the stretch and can be engaged between the fingers m the rectum and those on the abdomen. DIGITAL EXAMINATION OF THE RECTUM 113 Fig. 37 Inspection of the anus. Fig. 38 X-^^A, Abdominoreotal e.xamination. 114 EXAMINATION OF EXTERNAL AND INTERNAL GENITALIA The Simple Rectal Touch.-^Xhen for any reason a digital examina- tion of the vagina cannot or should not be made, the mternal genital organs must be examined per rectum. This method is most useful in cono-enital or acquired absence of the vagina, a narrow, shallow vagina, inversion of the uterus, ^'aginismus, and in virgins with an intact hymen A rectal examination is of special advantage, not onl>- when the vagmai examination is precluded, but in all lesions in the rectovaginal space. ' The position of the patient should be the lithotomy, knee-elbow or the Sims. In passing the finger into the rectum the tonicity ot the sphincter is noted. Fissures, polyps, hemorrhoids, and new-tor- mations are detected. Through the anterior wall of the rectum are felt the posterior vaginal wall, the cervix, and part or all ot the pos- terior surface of the uterus, the base of the broad ligaments, frequently the tubes and ovaries when enlarged and prolapsed, and the uterosacral Fig. 39 Digital examination of the rectum. ligaments. Through the posterior wall of the rectum are felt the sacrum and cocc^-x. Because of the thinner and more distensible bowel wall, the structures occupying the posterior segment of the uterus are more easily reached through the rectum than through the posterior vaginal vault. The cervix projecting backward is not to be mistaken for the body of the uterus. Ahdominoredal Examination {Bimanual).— This method is-carried out in general as is the abdominovaginal examination. In virgins with an intact hymen it is the method of choice. All conditions recog- nized by a simple rectal examination are more clearly palpated by the combined method. The examination may be embarrassed by coils of intestine wedged into the cul-de-sac of Douglas. When such difficulties exist and the bowels are not adherent, they may be displaced by placing the patient Fig. 40 Rectal examination with traction upon the cen-ix by a vulselltun forceps. Fig. 41 Abdominovaginorectal examination. The right hand depresses the abdomen, the thumb of the left hand is inserted into the vagina, and the index finger into the rectum. 116 EXAMINATION OF EXTERNAL AND INTERNAL GENITALIA in the knee-chest position. A Sims specuhim is inserted into the bowel, allowing the air to rush in and balloon the rectum, when the bowel will fall forward out of the cul-de-sac. The patient is then placed m the dorsal position and the examination continued. Fig. 42 Vesicorectal examination. A sound is passed into the bladder and the index finger into the rectum. In this manner the presence or absence of the uterus is determined. Traction upon the Uterus in the Abdominorectal Exaimination by a vulsellum forceps will greatly facilitate the examination when the uterus lies either too far forward or too high to be readily reached by the finger in the rectum. At the same time pressure may be made from above downward and backward upon the uterus. The vulsellum forceps are held by an assistant while the operator makes the examination. No great amount of force should be applied to the uterus for fear of tearing adhesions. ^ • u i Ahdominovaginoredal Emminations. — This is a most serviceable method of examination. ^Yhile effective, it is unpleasant to patient and physician. The finger should never be withdrawn from the vagina and inserted into the rectum without cleansing. Digital examination of the bladder, either simple or combined ^yith vaginal and abdominal methods (abdominovesical, abdominovesico- PELVIMETRY 117 vaginal), will not be considered. These methods have been replaced by others that are more efficient and less objectionable. Pelvimetry.— It is seldom that pelvic measurements are taken of a gynecological case. This is but an evidence of the illogical separation of obstetrics and gynecology. Not a few of the pelvic lesions are the result of deformities of the bony pelvis. For a detailed description of the deformities of the pelvis and their measurements, the reader should refer to text-books on obstetrics. For practical purposes the measure- ments between the anterior superior spines of the ilium, between the trochanters, between the widest points in the crest of the ilium, and Baudelocque's diameters are all that are required. CHAPTER VII INSTRUINIENTAI. EXAMINATION Vaginal Speculum VuLSELLUM Forceps Uterine Dilators Uterine Sound Preliminarj'' Procedures Indications Contraindications Dangers Uterine Curet Indications Contraindications Dangers Technic In Treatment Exploratory Punctures and Inci- sions Vaginal Speculum. — For direct inspection of the vagina the speculum is used both in diagnosis and treatment. For diagnostic purposes it has a limited field of usefulness; digital exploration will alone serve the purpose in a large proportion of cases. The lithotomy position is the one of choice. The rectum and bladder must be emptied. Before introducing the speculum a digital examina- tion of the vagina should be made to locate the cervix for the purpose of knowing the proper direction in which to introduce the speculum in exposing the cervix. The varieties of specula in common use are the Sims, Simons, bivalve, and tubular. Sims' speculum is used with best advantage in the lateral position of Sims. The vaginal outlet is spread open by the thumb and index finger of the left hand, while the right hand introduces the speculum. The blade is passed between the fingers spreading the vulva, and is allowed to glide over the perineum into the vault of the vagina. With the placing of the speculum the air rushes into the vagina and balloons it. In this manner a direct inspection of the vaginal mucosa is made possible. Firm and steady traction is made backward upon the perineum in exposing the cervix. The Sims speculum was originally used in the knee-elbow position, but is now almost invariably used in the Sims or left lateral posture. When the vagina is deep and the walls relaxed, in addition to the speculum, it is essential to use some sort of a depressor with which to expose the cervix by holding the Avails of the vagina apart. When the cervix is directed backward and is not readijy exposed to view it may be hooked by a tenaculum and drawn forward. Such manipulations must only be carried out under the guidance of the eye or finger, for fear of hooking the vaginal wall instead of the cervix. Simon's speculum is a device not unlike that of Sims', having a single spoon instead of two. It has an advantage over Sims' speculum in that there is no second handle to interfere with the manipulation of the instrument. VAGINAL SPECULUM 119 A combination of spoons of various shapes and sizes adjusted to separate handles has been devised by Bozeman and others. For the purpose of exposing the cervix the lateral walls of the vagina may require retraction. The bivalve speculum is in general use, though inferior in every respect to the Sims and Simons. Cusco's lateral modification is simple and easily manipulated. The instrument consists of two blades, taking the form of a beak. The articulated outer end is manipulated by a screw which spreads the valves to an acute angle. It is closed and inserted by its smaller diameter, and when inserted the instrument is Fig. 43 Insertion of the bivalve speculum. Labia held apart by the fingers of the left hand. turned so that the screw points toward the perineum. As the blades are separated they distend the vagina, and the cervLx engages between the blades.' The great objection to this instrument is that the anterior and posterior walls of the vagina are obscured by the blades, and the traction upon the vaginal walls separates the lips of the cervix to an unnatural degree. The one great advantage is the fact that it is a self-retaining speculum, requiring no assistant to hold it. In withdrawing the instrument care must be exercised for fear of catching folds of the mucous membrane; the instrument must be withdrawn slowly and the screw gradually loosened as the speculum is retracted. 120 INSTRUMENT A L EX A MINA TION The tubular speculum is seldom used. It is made of metal, wood, celluloid, glass, or vulcanite, and may be introduced in the lithotomy, knee-chest, or vSims' position. It can only expose the cervix, and this is done with difficulty. The self -retaining- speculum, composed of a spoon-like blade and a weighted handle, will be found of the greatest service in making an exploratory curettage and in excising pieces from the cervix. Currier's weighted self-retaining speculum with two adjustable blades is an admirable device. Inspection of the cervix by artificial light (through a bivalve speculum.) Too much emphasis cannot be placed upon the necessity for surgical cleanliness in the use of vaginal specula. Some operators who scrupulously sterilize all instruments to be introduced into the uterus carelessly use a speculum after little or no cleansing. Gonorrheal infection ma}- be transmitted in this manner. To fail to sterilize the vaginal speculum before using is criminal negligence. Vulsellum Forceps.— Traction upon the cervix is made with the vulsellum forceps. When the uterus and its attachments are in a normal position the cervix can be drawn almost to the vulvar outlet. Little or no pain is caused by the grasp of the forceps upon the cervix. UTERINE DILATORS 121 A vaginal speculum need not necessarily be used in grasping the cervix with the vulsellum forceps; the finger may be used as a guide, but this procedure demands great caution and experience. As an aid to diagnosis the vulsellum forceps is used to make traction upon the uterus, bringing it and adjoining structures within easier reach of the examining finger in the vagina or rectum. In determining the relation of large tumors and swellings to the .uterus, it is of advantage to steady the uterus by making traction downward upon the cervix. The forceps is held by an assistant while the examiner manipulates the tumor. If tumor and uterus move together there must be an intimate connection between the two. In differentiating an erosion from an eversion of the cervix the two lips of the cervix are grasped by the vulsellum forceps and the lacerated edges approximated. If the red surface disappears an eversion is diagnosticated; if there still remains a red zone about the external OS an erosion must be present. In removing sections from the cervix for diagnostic purposes the cervix is grasped by the vulsellum forceps. Forcible traction upon the cervix is not without danger. It is pos- sible to rupture the peritoneum and to tear through adhesions. Acute inflammatory lesions of the pelvis are absolute contraindications to the use of the vulsellum forceps lest the inflammation be excited to further extension. In the pregnant uterus severe hemorrhage may be brought on by the application of the forceps. In removing the vulsellum forceps care must be exercised for fear of injuring the cervix or wounding the patient. Superficial sutures of catgut or a vaginal pack of iodoform gauze may be placed if hemor- rhage is severe. Uterine Dilators. — For the purpose of exploring the uterine cavity with the finger and curet the cervix must be dilated. Hegar's or Kelly's dilators are recommended for general use. By them the cervix is symmetrically dilated, with a minimum amount of trauma. The vaginal speculum should always be used to expose the cervix. The anterior lip of the cervix is grasped by a vulsellum forceps. The dilators are sterilized by boiling, and lubricated with sterilized glycerin or boroglycerin. Beginning with a size that can easily be passed through the cervical canal, one after another of the sounds is passed until the cervix will admit the index finger. The utmost care must be exercised in passing the dilators for fear of losing control of the instrument and accidentally forcing it through the uterine wall. To eliminate this danger the depth and direction of the uterus should first be ascertained by the sound. The dilators are then grasped by the thumb and index finger at a point about one inch short of the length of the uterus. Instruments of divulsion, such as Palmer's, Goodell's, and Ellinger's, are commonly used in America. Only moderate force should be applied in dilating with these instruments for fear of tearing the cervix. They do not find favor in Europe because of this frequent accident. 122 INSTRUMENTA L EX A MINA TION Tents are now seldom used. They are not only slow and uncertain in their action, but are a source of danger from infection. They are made of sea-tangle, sponge, and tupelo. Fig. 45 Laminaria tent. Dilatation of the cervix with a laminaria tent. Fig. 46 Cervix dilated with a Hegar bougie Uterine Sound.— Aetius speaks of using the sound to measure the length of the vagina. Sir James Y. Simpson introduced the modern sound as a material aid in the diagnosis of lesions involving the uterus. UTERINE SOUND 123 Fig. 47 Simpson does not deny that the sound was used for exploration and measurements of the uterus long before his time. Certain it is that Wierus used the sound for like purposes as early as 1637. Beginning with the indorsement of Simpson and up to the present time, the sound has been used too freely and not without harm. Since the bimanual method of ex- amination has been largely practised, the use of the sound has been materially restricted. It is seldom necessary to pass the sound in the consultation room. The bimanual examination will usually suffice. In the construction of a uterine sound there are certain requirements. This instrument should be made of a flexible metal, preferably of copper, and nickel plated; the distal end should be rounded and knob-like; the handle should be flat and grooved on one side only. Beginning two and one-half inches from the distal end the sound should be graduated every half-inch for the purpose of measuring the depth of the uterine cavity. Preliminary Procedures. — Before the sound is passed certain precautionary measures are necessary. First, there must be surgical cleanliness in the preparation of the field of operation, the instruments, and the hands of the operator. Second, a bimanual exami- nation should be made to determine, if possible, the position of the uterus. By adhering to these pre- liminary precautions the dangers of infection and perforation are minimized. The most convenient position is the lithotomy, though it is possible to introduce the sound with the patient in the lateral or knee-chest position. Indications for the Use. — Esiimaiing the Depth of the Uterine Cavity. — The depth of the uterine cavity is accurately measured by the sound. Its average nor- mal depth is two and a half inches in a nullipara of mature years, and this is increased about one-half inch in the multipara. (a) The depth of the uterine cavity is lessened in acquired and congenital atrophy, atresia of the uterus, inversion of the fundus, and in new-forma- tions encroaching upon the cavity of the uterus. (6) The depth of the uterine cavity is increased in pregnancy, subinvolution, elongation of the cervix, endometritis, metritis, and newgrowths of the uterus. The Direction of the Uterine Canal. — This is often changed from the normal by newgrowths in and about the uterus, by senile involution, by inflammatory contraction, and by displacements of the uterus from whatever cause. As stated above, it is always wise to precede the Simpson's graduated sound. 124 INSTRUMENTAL EXAMINATION Fig. 48 First step. The sound is guided to the external os along the palmar - i:: ;■ ■ > i t speculum is used. The patient is in the dorsal position. ' I'x tiugiT uF the Fig. 49 Second step. The sound is passed slowly into the uterine ca\dty. The direction taken by the sound is carefully noted. The patient is in the dorsal position. UTERINE SOUND 125 passage of the sound by a preliminary bimanual examination. If the relation of the body to the cervix is determined, the sound is curved at the proper angle before it is introduced. By so doing there is less danger of puncturing the uterus. Stenosis and Atresia of the Uterine Canal. — These lesions can be definitely determined by the sound. Apparent stenosis at the point of flexion is often made to disappear by traction upon the cervix with vulsellum forceps. Irregularities of the Mucosa. — If not too small and soft, they may be detected by the sound. Such irregularities are submucous fibroids, polyps, malignant groT\-ths, and retained placental tissue. When possible it is always preferable to use the finger rather than the sound. The Thickness of the Uterine Wall. — By passing the sound into the uterus and having one hand over the abdomen and the fingers of the other hand in the rectum, it is possible, under favorable conditions, to make a fair estimate of the thickness of the uterine wall. Contra-indications to the Use of the Sound. — Menstruation. — Though not an absolute contra-indication, it is better to delay the procedure until the intermenstrual period. Pregnancy. — Pregnancy is an absolute contraindication to the pas- sage of the sound. While the sound has been passed into a gravid uterus without interrupting pregnancy, it is never justifiable to pass the sound when there is a possibility of pregnancy. Malignant Growths. — ^Malignant groT\-ths, while not an absolute contraindication, are to be regarded as a source of danger and demand very cautious use of the sound for fear of exciting hemorrhage and perforating the uterus. Acute Pelvic Inflammation. — Acute pelvic inflammation is a con- traindication to the use of the sound as well as to all manipulations of the pelvic viscera. Dangers. — Infection of the Uterus. — This may be caused either by an unclean instrument or by carrying the infection from the lower genital tract. Forcible and careless manipulations injure the delicate mucosa, thereby producing an atrium for infection. Because of the danger of infection the custom of passing the sound in the routine office practice is condemned. Perforation of the Uterus. — This accident may happen to the most cautious operator. The uterine wall may be so soft as to ofter no perceptible resistance to the passage of the sound into the peritoneal cavity. Such softening may be due to infection, malignant infiltration, or pregnancy. Hemorrhage. — Hemorrhage may be alarming in the case of malignant growths of the uterus, hydatid mole, and incomplete abortion. Pelvic Inflammation. — Pelvic infiammation may be occasioned by the passage of a sound into the uterus. This is seldom the case in the absence of a preexisting infection. It is a dangerous practice to test the mobility of the uterus by means 126 INSTRUMENTAL EXAMINATION of the sound. The bimanual examination, with or without anesthesia, should afford all needed information, and with far less risk. Uterine Curet. — The fact that the uterine curet is universally used speaks for its utility; but, as with many of the great and useful things of life, it is also capable of harm in the hands of the incompetent. The use and abuse of the uterine curet is a subject that should engage the careful consideration of the general practitioner far more than many of the more pretentious problems in the treatment of diseases of women, because the curet is the most used and the most abused instrument in the armamentarium of the gynecologist, and, the author might add, of the general practitioner as well. Fig, 50 Blake's curet. Fig. 51 Boldt's double curet. Indications. — The indications for the use of the uterine curet in the diagnosis of the diseases of women are as follows: The uterine curet in diagnosis may be used in any of the lesions within the uterine cavity and involving the endometrium. Endometritis. First in order of clinical importance and frequency is endometritis. An excessive menstrual flow and a so-called leucorrheal discharge from the uterus, together with a history of infection, generally suffice for a clinical diagnosis of endometritis; but a posi- tive diagnosis — one that amounts to a scientific certainty — can only be made by a microscopic examination of scrapings removed by the curet. All of the clinical signs of endometritis may be present without inflammator}^ changes in the endometrium, and, on the other hand, endometritis ma}' be present to a marked degree in the absence of any clinical evidence. It is never justifiable to curet the uterus for the purpose of differentiating between the various anatomical forms of endometritis, but rather to determine the fact of endometritis and to exclude other possible lesions, such as * retained placental tissue and carcinoma. It is a matter of little concern whether the lesion is a hypertrophic or a hyperplastic, a fungous or a polypoid endometritis. It is the possibiHty of the presence of endometritis and not 'the ques- tion of the particular anatomical variety that is of practical clinical importance. Retained Products of Conception. — These may remain attached to the uterus for years, giving rise to hemorrhage and leucorrhea, the cause of which can only be demonstrated by exploring the uterine cavity. In all such cases the finger, if possible, should be used in CONTRAINDICATIONS 127 locating and removing the retained fetal tissue. Shortly after abortion and labor, curetting is rarely justifiable because of the dangers involved. The author's preference is for the Emmet curet forceps as a substitute for the usual form of curet. Fig. 52 Emmet curet-forceps. Submucous Fibroid. — The firm, rounded bulging of a submucous fibroid is sometimes demonstrated by means of the curet. Maligncmt Growths. — Malignant growths of the endometrium can only be diagnosticated in the early stage by microscopic examinations of scrapings. There may be no symptoms, or merely those common to endometritis, and this is even possible in cases far advanced. In the author's experience the systematic examination of uterine scrapings has frequently brought to light an unsuspected malignant growth, and that which has passed clinically for malignancy has been demon- strated to be endometritis or retained placental tissue. Syncytioma malignum — i. e., a malignant degeneration of placental tissue — is a rare finding, but because of its rapid spread and fatal issue an early diagnosis is imperative. When an unaccountable hemor- rhage from the uterus occurs weeks or months after labor or abortion, and particularly after the expulsion of a hydatid mole, an exploratory curettage is demanded, and a microscopic examination should be made in view of the possible finding of malignant changes in the placental remains. There is no more important and certainly no more satisfactory procedure in all the range of diagnosis than the differential diagnosis of uterine scrapings. A sharp line cannot always be drawn between the benign and tlie malignant, but in the hands of a competent observer such failures are unusual. In the diagnosis of ectopic pregnancy it is sometimes advisable to curet the uterus to determine the presence of decidual tissue. Great caution must be exercised for fear of rupturing the gestation sac. Contra-indications. — Menstruation. — Menstruation is not an absolute contra-indication, but it is seldom that the procedure cannot be delayed until the menstrual period Is passed. Pregnancy. — The possibility of pregnancy must be positively excluded. When doubt exists after a thorough examination it is always well to await developments for a month or more. A good rule to follow is to never use the curet in cases of delaj^ed menstruation when pregnancy is at all possible. 128 INSTRVMEXTAL EXAMIXATIOX Acute and Subacuie Pelvic Inflammations. — These are contraindica- tions because of the danger of extending the infection. It is always wise to wait until the pelvic inflammation has subsided before curetting. Distended tubes and ovaries are liable to rupture. Xo harm is likely to result if the contained matter is serum, but if pus escapes the con- sequences may be disastrous. Dangers. — The dangers involved in curettage are by no means trivial. The curet is a formidable instrument, and curettage is not to be regarded as a minor operation and without attending dangers. Septic Infections. — ^As with all operations, there is the risk of septic infection through a wounded surface. The likelihood of infection is not great when the uterus is firmly contracted; but in the puerperal uterus, with large venous sinuses and possible infection already existing therein, all the conditions are present which favor a woimd infection. Hemorrhage. — Hemorrhage is an unlooked-for complication, yet in puerperal and malignant cases the loss of blood may be alarming and fatal. Inflammatory Exacerbations. — The danger of exciting an acute ex- acerbation of a preexisting pelvic inflammation is always imminent. Perforation. — Perforation of the uterus by the curet is an accident that may happen to the most skilled and cautious surgeon. The author ventures the assertion that not an operator of large experience has escaped this misfortune. The statements frequently made that the per- foration is of little consequence are not substantiated. In a puerperal infected uterus the uterine wall may offer no more resistance to the curet than woidd blotting paper; the instrimient passes through the wall, apparently meeting no resistance. In dealing with a puerperal uterus the only safeguard lies in discarding the curet, both the dull and the sharp. The fingers, placental forceps, and douche are all sufficient, save in very exceptional cases. Not only is the finger less likely to perforate the uterus, but by the finger the placental site is located and the adherent placenta remo^'ed, leaving the remaining uterine surface intact, as it should be. Nature has thrown out a barrier in the decidua in the form of leucoc\'tes or phagocytes, the so-called "protective zone," that t\i11 resist the invasion of microorganisms if it is possible for anything to do so. The curet would but tear away this protective wall and allow a direct invasion of the venous sinuses by the septic organisms. Removal of Decidua. — The remo\'al oi the decidua down to the musculature is a possible danger when the curet is used. With the finger this accident will not occur. From the decidua the new endome- trium is regenerated, and if completely scraped away there will be left in its place a permanent scar surface, rendering the woman sterile and a sufferer. The same result, though to a lesser degree, may follow too vigorous scraping of the non-puerperal uterus. The grating of the instrument is a sign that the mucosa is removed down to the deeper and firmer layers, and it is time to stop lest the entire mucosa be removed. TECHNJC OF OPERATION OF CURETTAGE 129 Technic of Operation, — The following is an outline of the technic of curettage: 1. Anesthesia, preferably ether or nitrous oxide and oxigen. 2. Shaving and sterilization of the vulva and vagina. 3. Dilatation of the cervix with Hegar's bougies or an instrument of divulsion. Fig. 53 Graduated bougies are used for the dilatation of the cervix. This method is preferable to that shown in Fig. 54. 4. Cautious introduction of a curet to one of the uterine horns and deliberately sweeping downward as far as the internal os. Passing by successive sweeps along the posterior wall to the opposite horn, then to the side and in front to the original point of attack, making sure that no furrows or patches are left by again going over the surface in a similar manner. All upward movements of the curet should be per- formed with caution for fear of perforating the uterus. 5. As a routine practice the author would recommend swabbing the uterus with full strength formalin. 6. No uterine pack is recommended unless the uterus is relaxed and bleeding freely. A sterile vaginal tampon should be inserted against the cervix for twenty-four hours, then removed, and 1 per cent, lysol douches or formalin (1 to 2000) should be given daily for a week. 7. Rest in bed should be enjoined for a period of four or more days. 9 130 1 NS TR UMEN TA L EX A MINA TION 8. No escharotics should be used. The sharp curet should be em- ployed in all cases, with the exception of a puerperal uterus, which should never be scraped. (See Figs. 53 to 56.) Fig. 54 Cen'ix is exposed by a self-retaining speculum and grasped at its anterior lip by a vulseUum forceps. Traction is made upon the cervix as it is dilated by an instrument of divulsion. Patient in dorsal position. The Uterine Curet in Treatment. — There is no instrument so universally misused as the uterine curet. It has been applied for the relief of almost every pelvic disorder, because no accurate diagnosis was made. Pelvic pain, leucorrhea, uterine hemorrhage, backache, sterility, one and all, have been made the object for the indiscriminate use of the curet. The fact is, there is but a limited field of usefulness for the curet in the treatment of diseases of women. Indications. — Following are the therapeutic indications: Control of Uterine Hemorrhage. — Whatever the cause of uterine hemorrhage may be, whether it is due to endometritis, cancer, fibroids, muscular insufficiency of the uterus, polyps, sarcoma, syncytioma malignum, etc., the bleeding can usually be checked for a time at least by thorouglily scraping the uterus. The control of uterine hemorrhage is the one great therapeutic function of the curet. Leucorrhea. — ^\^Tien there is no infection of the uterus the leucorrheal discharges can be controlled in part by scraping the uterus, but the Fig. 55 Curettage of the uterus. Fig. .56 Curetted surface is s-n-abbed -n-ith pure formalin. 132 INSTRUMENTAL EXAMINATION opportunity will rarely arise for its use in this particular. The uterus should- never he curetted in the presence of a purulent discharge, because the scraping of an infected uterus leads to extension of the infection to the deeper structures in the uterine wall and to the tubes. Because of the great importance of this dictum the author repeats, Never curette an infected uterus! Inoperable Cancer of the Uterus. — When the disease has gone beyond hope of radical cure the hemorrhages and other discharges may be controlled for a time by scraping away all friable tissue. Exploratory Punctures and Incisions. — An exploratory puncture is occasionally resorted to for the purpose of completing the diagnosis. When a conjoined examination fails to determine the nature of a pelvic tumor, aspiration is an essential aid to the diagnosis. Collections of blood, pus, and serum in the tubes, ovaries, and pelvic tissues often cannot be diagnosticated with certainty until the contents are procured either by aspiration or by incision. Furthermore, the character of the obtained fluid may not be recognized until submitted to a chemical, microscopic, and bacteriological examination. It is a growing con- viction that an exploratory incision afi'ords better results and is less dangerous than is aspiration. This is particularly true of abdominal explorations. It is a matter of common experience that pus and blood cannot always be withdrawn from the pelvis through an aspirating needle. Fig. 57 Exploratory syringe. The instrument and field of operation must be rendered perfectly sterile. When surgical principles are carried out no harm should follow either procedure. Exploratory incisions are of value not only in determining the character of the contained fluids in the pelvis, but the procedure has a much wider range of usefulness. Indeed, it may he truly said that every abdominal incision is in a sense exploratory. The abdomiiial surgeon very often encounters unsuspected groioths and adhesions, and, for this reason, one who is not master of any condition that may unexpectedly arise, should not undertake to open the abdominal cavity. CHAPTER VIII MICROSCOPIC EXAMINATION OF SCRAPINGS AND EXCISED PARTS— DIAGNOSIS OF EXPELLED MEMBRANES FROM THE UTERUS MICROSCOPIC EXAMINATION OF SCRAPINGS AND EXCISED PARTS Removal op Uterine Tissue for Diagnostic Purposes Test Excision from the Cervix Test Curettage of the Uterus Frozen Specimens of Excised Pieces AND Scrapings Fixing the Specimens Hardening and Embedding Method of Staining and Mounting Sections Inspection of Uterus after Re- moval The microscope is indispensable in the diagnosis of diseases of women. The microscopic examination of scrapings and excised pieces constitutes one of the most important and gratifying means of deter- mining the character of lesions involving the cervix and endometrium. Bimanual examination alone will determine many of the affections of the pelvic viscera; inspection of the vagina and vaginal portion of the cervix through a speculum will afford much information; direct palpation of the cervical canal and cavity of the uterus will add much knowledge of the extent and character of the lesions involving these surfaces; the clinical symptoms are important in the consideration, but a positive diagnosis, one that admits of no reasonable doubt, is often reserved until a microscopic examination of scrapings and excised pieces has been made. Very often the microscope serves to verify a clinical diagnosis, but in not a few cases a previously unsuspected condition is brought to light by a microscopic examination of scrapings from the endometrium and excised pieces from the vaginal portion of the cervix. The author does not claim that the microscope is an infallible means of making a diagnosis. These are cases in which the diagnosis remains in question after all means — the microscope included — have been exhausted. When a clinical diagnosis of cancer is made the suspected tissue should not be scraped unless preparations are made for a radical operation. This rule should be enforced because of the danger of disseminating a cancerous growth by means of the curet. Removal of Uterine Tissue for Diagnostic Purposes. — In all cases, unless contraindicated, a general anesthetic is advisable. Cocaine may be used as a local anesthetic in excising pieces from the cervix. 134 MICROSCOPIC EXAMIXATIOX OF SCRAPIXGS When the tissue is soft and friable, as in carcinoma, no local or general anesthetic may be required. It is not necessary to shave the vuh'a. Init by ^(Tubbing and douching the field of operation is made clean. The position assumed by the patient may be the Sims or lithotomy. If the former, the Sims or Simon speculum is used; if the latter, the Simon or self-retaining speculum is preferred. The self-retaining speculum is especially advantageous because no assistant is needed. Test Excision from the Cervix. — ^After grasping the anterior iip of the cervix by the vulsellum forceps a small wedge is cut from the cervix by angular scissors. In selecting a portion for excision an effort should be made to include in the removed piece a part of the healthy together with the diseased tissue for the purpose of studying the transition stages. Hemorrhage is controlled by a gauze pack, or, when necessary, by the placing of absorbable sutures. Test Curettage of the Uterus. — The cervix is dilated sufficiently to admit a moderate-sized curet. The instrument is passed, under control of the eye, by the aid of a Sims or Simon speculum. The patient is in the Sims or lithotomy position. In order that no portion of the endometrium escape the curet, the uterus should be scraped systematically and thoroughly, beginning at one horn and sweeping deliberately down to the internal os, passing in this manner over the entire inner surface of the uterus, taking care that no portion of the endometrium be missed. Before the blood has time to coagulate firmly the scrapings are first washed in cold running water and then removed to a 4 per cent, solution of formalin. Allowing them to lie long in water causes maceration. All particles in the scrapings are to be carefully preserved, so that if necessary the entire specimen may be examined. Frozen Specimens of Excised Pieces and Scrapings. — When an immediate diagnosis is required the freezing method may be employed with fairly satisfactory results. It occasionally happens that the examination of excised pieces and scrapings will determine the question of a more radical procedure. If for reason of expediency or added risk from a second anesthetic it becomes necessary to proceed without delay, frozen sections may be prepared and diagnosticated while the patient is being prepared for a radical operation. Xot more than twenty minutes are required for the examination. The following is the method employed in Johns Hopkins Hospital by Cullen: (a) Place the frozen section in 5 per cent, aqueous solution of formalin for from three to five minutes. (&) Leave in 50 per cent, alcohol one minute. (c) In absolute alcohol one minute. (d) Wash out in water. (e) Stain in hematoxj-lin two minutes. (/) Decolorize in acid alcohol. FROZEN SPECIMENS OF EXCISED PIECES AND SCRAPINGS 135 (({) Rinse in water. (A) Stain with eosin. (^) Transfer to 95 per cent, alcohol. (j) Pass through absolute alcohol, then through creosote or oil of cloves, and mount in Canada balsam. Fig. 58 Bardeen CO2 freezing microtome. This microtome is an improved pattern after designs by Professor C. R. Bardeen, of Johns Hopkins University, and is a most excellent instrument for regular patho- logical and other demonstrations. It is indispensable for clinical work when stained sections of morbid tissues are required within a few minutes of the beginning of an operation in order that the surgeon may determine his mode of procedure. It freezes almost instantaneously regardless of room, tempera- ture, or humidity, and at very small expense. The temperature of the object to be frozen is, within limits, under the control of the operator. The freezing chamber contains a spiral passage through which the expanding CO2 passes, securing the maximum freezing power. The knife sUdes on glass guides. The finest feed is twenty microns. The microtome may be attached directly to a CO2 cylinder. While the freezing method has an important place in connection with the operating room, the sections are not eminently satisfactory, for the reason that only small sections can be made and differentiating stains cannot be used. When an immediate diagnosis is not required (and this is true in the majority of instances) the celloidin or paraffin methods are preferred. 136 MICROSCOPIC EXAMINATION OF SCRAPINGS Fixing the Specimens. — Zenker's Fluid. — Zenker's fluid (IMiiller's fluid, 100 per cent.; bichloride, 5 per cent., and, shortly before using, the addition of 5 per cent, of glacial acetic acid) is an excellent fixing fluid, preserving the blood in its natural color. After fixing in Zenker's for twenty-four hours the section is placed in cold running water for twenty-four hours or in a weak iodine solution for a like time. The section is then ready for hardening in alcohol. No better fixing fluid can be used when time will permit. It is often well to place the entire uterus in Zenker's fluid for a week or more before cutting sections from it. Fig. 59 Ether or rhigolene freezing attachment. This attachnaent consists of a cylindrical freezing stage upon which the object to be frozen is placed and against which a very fine spray of ether or rhigolene as desired is projected by a delicate atomizer operated by the bulb air-pump shown in the illustration. The rapid evaporation of the fluid abstracts sufficient heat from the object to freeze it in a short time. There is always, however, an excess of fluid which does not evaporate, and this is drained back into a bottle and used again. This freezer is applicable to the automatic laboratory, medium laboratory, student, table, and demonstration microtomes. Alcohol. — Alcohol as a fixing agent is objectionable because of the shrinkage of the tissues. \\Tien it is desired to examine for micro- organisms, alcohol is of special value. Formalin, — Formalin may be used in a 2 to 4 per cent, solution. It is objected to because of the difficulty in cutting the musculature. Hardening and Embedding. — When it is desired to prepare the section hurriedly, a small piece is placed immediately in ^absolute alcohol and changed three or four times in twenty-four to thirty-six hours, when it is ready for embedding. When an additional day or two can be taken, better sections are made by running the pieces through successive strengths of alcohol, changing every two to twelve hours through 70, 80, and 90 per cent, and absolute alcohol. It is now necessary to embed the section in a substance that will HARDENING AND EMBEDDING 137 permeate the tissue, fill up all spaces, and give support to the section while being cut and mounted. The embedding of a specimen in celloidin follows upon the harden- ing process. For general purposes the celloidin method is preferred. From absolute alcohol the section is placed in equal parts of sulphuric ether and absolute alcohol for from six to twenty-four hours, depending upon the size of the section. Next the section is transferred to a dilute solution of celloidin in ether for from six to twenty-four hours; it is then placed in a thick solution of celloidin in ether for an equal time, when it is ready to mount upon a cork for sectioning. After blocking the specimen on wood or cork it is allowed to fix firmly in the open air or under a bell-jar, and is then placed in 70 per cent, alcohol for an hour or more. The section is now ready for cutting and mounting. Fig. 60 The student microtome. This is intended for individual and laboratory use when a mechanical microtome at small cost is required. It is extremely simple, yet very accurate in construction. This is one of the few models which have remained practically unchanged, showing that it is adapted for its work. The stand is one solid piece of metal. The knife block is as heavy as is consistent with the size of the instrument. The feed arrangement is carried in a metal stirrup attached permanently to the front of the stand, and consists of an accurately cut micrometer screw having a pitch of 0.5 mm., with a graduated head divided to 100 parts, each graduation, therefore, having a value of 5 microns. The object clamp is adjustable in two planes, and can be set for paraffin or celloidin cutting. The embedding of sjjecimens in paraffin is an excellent method for general laboratory purposes, but is somewhat complicated for private laboratory use. When the tissues are soft and small, as in scrapings, ideal sections are prepared by this method. For serial sections no other method can be employed. After thoroughly dehydrating the tissue the specimen is immersed in a solution of zylol and paraffin, or in chloroform and paraffin, for from two to twenty-four hours, and is kept at a uniform temperature of 37° C. Next the specimen is im- mersed in melted paraffin for a like time and kept at a temperature 138 MICROSCOPIC EXAMIXATIOX OF SCRAPINGS of 4S° to 50° C. It is then removed to a cool place and is quickly solidified in the paraffin, after which it is blocked out with a knife and mounted on a cork for cutting. Method of Staining and Mounting Sections. — Celloidin Sections. — For all practical purposes the hematoxylin-eosin stain is most satis- factory. After cutting the sections and immersing them in water for a few moments the following method is adopted: Lines of incision in opening the uterus after hysterectomy. 1. Stain in hematoxylin one to two minutes. 2. Decolorize in acid alcohol. 3. Immerse in weak ammonium-water until the blue color returns. 4. Immerse in water to remove the ammonium. 5. Counter-stain in eosin from ten to thirty seconds 6. Immerse in 75 per cent, alcohol two minutes. 7. Absolute alcohol one minute. 8. Clear in creosote or oil of cloves. 9. Mount in Canada balsam. Paraffin Sections.^ — After cutting the sections they are carefully transferred to a shallow basin of warm water, on which they spread in thin ribbons. The water must not be hot enough to melt the paraffin, INSPECTION OF THE UTERUS AFTER REMOVAL 139 but merely sufficiently so to unfold the sections and spread them out smoothly. A glass slide is held underneath the sections, and they are made to float upon the slide. The slide is then withdrawn from the water, the water drained off from the slide, when it is placed for several hours on the top of an oven or radiator, where the moisture is thor- oughly driven from the slide and the section firmly fixed. The paraffin is dissolved in zylol or cliloroform (by which the section is "cleared"), and from this point on the staining is carried out in the usual manner. The uterine cavity exposed. Inspection of the Uterus after Removal. — In order that a satisfactory examination may be made of the uterus after its removal, the operator should handle and mutilate the specimen as little as possible. The introduction of swabs, probes, and curets injures the endometrium and leads to false observations. Fig. 61 shows the method of opening the uterus. The body of the uterus is grasped by the left hand. Two incisions are made, as shown in Fig. 61 and the uterus is spread open in such a manner that the entire mucosa will be exposed (Fig. 62). Before the uterus is opened it is always well to fix it in Zenker's fluid for several days. The structures are thereby less disturbed in their relations. The color, consistency, outline, and measurements are all to be noted and recorded. Foreign growths and abnormalities are described in detail. 140 DIAGNOSIS OF EXPELLED MEMBRANES FROM THE UTERUS THE DIAGNOSIS OF EXPELLED MEMBRANES FROM THE UTERUS The physician will be called upon to determine the nature of a mem- brane or mass spontaneously expelled from the uterus. Here the microscope is indispensable to a positive diagnosis. It is of prime importance to determine, first, whether or not the membrane is organ- ized. If on placing the membrane in cold water it becomes friable and disintegrates it is unorganized. Under the microscope a fibrinous structure is seen, in the meshes of which are blood cells in all stages of disintegration. Calcareous concretions may be expelled sponta- neously or removed by the curet. They probably come from calcareous deposits in mucous polyps or submucous fibroids. Cast from uterine cavity in exfoliative endometritis, membranous dysmenorrliea, natural size. (After Costa.) Of the organized structures the following will be considered: the decidua of intra-uterine pregnancy, the decidua of extra-uterine preg- nancy, the decidua of menstruation, and the vesicles of hydatiform mole. Membranous Dysmenorrhea (Exfoliative Endometritis). — Because of the occurrence of menstruation accompanied by a discharged mem- brane and great pain the condition is spoken of as membranous dys- menorrhea; but since the discharged membrane does not resemble that of the uterine mucosa during menstruation, but does closely resemble interstitial exudative endometritis, a better term to employ would be exfoliative endometritis. This does not imply that the lesion is necessarily inflammatory in origin, inasmuch as there are no known facts to substantiate such an assertion. Nothing definite is known of the cause of this lesion. MEMBRANOUS DYSMENORRHEA 141 The first clinical observations were made in 1723 by Morgagni. When the existence of pregnancy can be excluded beyond all possible doubt a clinical diagnosis is made. When there is any possibility of pregnancy a positive diagnosis can only be made by a microscopic examination of the discharged membrane, and even here difficulties will arise because of the presence of large connective-tissue cells resembling decidual cells. Fig. 64 Aborted ovum. Decidua and ovum complete, o. i., corresponds to the decidua situated at the OS internum; t t, to the decidua situated at the openings of the tubes. (Jewett.) Macroscopic Examination. — The membrane rarely appears as a com- plete cast of the uterus. In form it is triangular, presenting an opening at each angle — i. e., the internal os and the uterine ends of the Fallopian tubes. The outer surface is shaggy and of a dull gray color; it is some- times overlaid with a coagulum of blood. Opening the sac, nothing is found within to suggest fetal remains. The inner surface is smooth and presents numerous small openings which represent the mouths of glands. The membrane is 1 to 3 mm. thick. Microscopic Examination. — In general the membrane may be said to resemble exudative interstitial endometritis. The surface epithe- 142 DIAGNOSIS OF EXPELLED MEMBRANES FROM THE UTERUS lium may be intact or partially or wholly lost. The glands are irregularly compressed and widely separated. A rather characteristic feature is the zigzag course of the glands. The stroma is more or less crowded with small round cells. In the lower strata are frequently seen large connective-tissue cells which closely resemble decidual cells. The presence of these cells sometimes makes it diflfjcult and at times impossible to distinguish the membrane from the decidua of pregnancy. C. Ruge called attention to the fact that decidual cells are not evidences of pregnancy ; that these cells are found in occasional forms of endometritis. In exfoliative endometritis these connective-tissue cells are less uniformly enlarged than in the decidua of pregnancy, and upon this fact the diagnosis must largely be based. The Diagnosis of Expelled Membranes Clinical features. Macro- scopic findings. Micro- scopic findings. Decidua of intra-uterine pregnancy. Symptoms and signs of preg- nancy; hemorrhage and pain accompanying the discharged membrane; no extra-uterine pelvic tumor. Thiclj shreds with shaggy sur- face, or smooth, glistening membrane. Surface epithelium. Glands. Stroma. Vessels. Fetal tissue. Seldom pres- ent. Compressed above, widely dilated and very irregular below; epithe- lium flattened. Typical de- cidual cells. Very widely dilated; walls composed of endothelium; no muscula- ture. Chorionic villi! amnion. Decidua of extra-uterine pregnancy. Symptoms and signs of pregnancy; often irregu- lar hemorrhage and pain accompanying the dis- charged membrane; ex- tra-uterine pelvic tumor. Rough fibrous membrane; no villous structures; ir- regularities on inner sur- face. Flattened; may be want- ing. Changes similar to intra- uterine pregnancy, though less marked. Decidual cells not so large; more intercellular substance. Less widened blood spaces. Absent. Decidua of menstruation. No evidence of pregnancy; no extra-uterine pelvic tumor. Unorganized. Fibrinous structure, external sur- face smooth, internal sur- face rough. Absent. Absent. Fibrinous network. Absent. Absent. Oroanized. Triangular cast of uterus, or bits of membrane; surface smooth with sieve-like depressions. Cylindrical, rarely flattened or lost. Zigzag in their course; epithelium cylindrical. Round-cell infiltration; protoplasm of cells in- creased. As found in endometritis. Decidual cells are hypertwphied connective-tissue cells. There are causes of hypertrophy of these cells other than pregnancy, and hence it is that decidual cells are not jJathognomonic of pregnancy. The only posi- tive evidence of pregnancy in discharged membranes is the presence of chorionic villi. CHAPTER IX ECTOPIC OR EXTRA-UTERINE PREGNANCY^ Etiology Differential Diagnosis Recurrent and Multiple Ectopic Treatment Pregnancy Unruptured Tubal Pregnancy Combined Uterine and Tubal At Time of Rupture Bilateral Tubal Late after Rupture Classification j Intraligamentary Extra-uterine Ampullar ' Pregnancj^ Interstitial Interstitial Pregnane}^ Infundibular Advanced Extra-uterine Preg- Ovarian ! nancy Causes of Ending of Gestation I Combined Extra-uterine and Iiitra- Retrogressive Changes in Dead Fetus Anatomical Changes in Tube Clinical Diagnosis Subjective Signs Objective Signs uterine Pregnancy Ovarian Pregnancy Pregnane}^ in Rudimentary Horn of Uterus Mortality of Extra-uterine Preg- nancy Etiology. — Predisposing Causes. — 1. INIechanieal interference with the passage of the o\'um through the tube from — (a) Tumors in and about the tube — i. e., mucous polyps, ovarian and parovarian cysts. (b) Persistence of the fetal type — small himen and convoluted course of the tube. (c) Peritoneal bands constricting the tube and drawing it out of position. (rf) Congenital anomalies in development, namely, diverticuli and rudimentary fimbriae. (e) Malpositions of the tube, either congenital or acquired. 2. Loss of cilia and epithelium through inflammation. Gonorrhea has been mentioned by Gottschalk, Braun-Fernwald, and Bandler as a frequent forerunner of tubal pregnancy. Tuberculous and puerperal infections of the tube play a less important but by no means insignificant role. Erich Opitz detected signs of inflammation in all of his 2.3 cases. Essential Cause. — While the conditions above enumerated are fre- quently present, it is a matter of common observation that tubal pregnancy may occur in an apparently normal tube. Webster affirms that in ectopic pregnancy there is a genetic reaction 1 The author acknowledges his indebtedness to J. Clarence Webster, from whose monograph on Ectopic Pregnane}' much of the material in this chapter on the classification and diagnosis has been taken. 144 ECTOPIC OR EXTRA-UTERINE PREGNANCY in the tube which is essential to the implantation and development of the ovum in the tube, as truly as a similar genetic reaction in the uterus is essential to uterine gestation. This genetic reaction consists in the formation of decidual tissue. It is claimed by Webster that a decidua, however limited, is always found in the pregnant tube. With- out a decidua the ovum would find no abiding place in the tube, even in the presence of predisposing causes. In the event of a decidual formation in the tube the predisposing causes serve to obstruct the passage of the ovum, and make possible the implantation of the ovum in the tube rather than in the uterus. Ectopic gestation in a blind accessory fimbriated extremity of the right tube. (Jewett.) Ectopic pregnancy may occur at any time during the period of sexual maturity, but its greatest frequency is between the ages of thirty and forty. It is stated that a long period of sterility predisposes to ectopic pregnancy, probably because of the existence of one or more of the predisposing causes. Tubal gestation occurs five times as frequently in multiparse as in primiparse — a fact which may again be explained on the ground of the development of the predisposing causes. Recurrent and Multiple Ectopic Pregnancy. — Recurrence of Tubal Pregnancy in the Same Tube or in the Opposite Tube. — Occasionally there are reports of cases in which a second, third, or even fourth preg- nancy has occurred in the same tube or has occurred alternately in both tubes. In a case of Grandin the second pregnancy was recognized only two months subsequent to the first tubal pregnancy. H. C. Hindler reported a case recurring in the stump of a tube that had been pre- viously amputated for tubal pregnancy. MULTIPLE ECTOPIC PREGNANCIES 145 Multiple Ectopic Pregnancies. — There may be twin pregnancies in one tube, in both tubes, or in the uterus and one tube. Again, the uterus and both tubes may each contain an ovum. Fig. 66 Tubal abortion on right side; hematosalpinx on left side, the result of a tubal pregnancy one year previous. The uterus is reconstructed. Dr. Richard R. Smith reported 170 cases of ectopic pregnancy which recurred one or more times; four of these cases were his own. The author has had but one such case. The fact that the opposite tube may subsequently become pregnant after the removal of a pregnant tube is no argument in favor of removing a healthy tube in the presence of a pregnancy in the opposite tube. Smith finds less than 4 per cent, of recurrences in the opposite tube. Hindler reported a case recurring in the stump of a tube that was previously removed for tubal pregnancy. Combined Uterine and Tubal Pregnancy. — Hanna found 69 cases of tubal pregnancy associated with uterine pregnancy. Vilkin reported 68 cases in literature, in 20 of which both fetuses approached maturity. Simpson reviewed the history of 113 cases, and added one of his own. He gives the following classification: Class 1. The woman becomes pregnant while carrying the dead products of an ectopic gestation. Class 2. The ectopic and uterine gestation are both living at the same time. (o) Ectopic gestation precedes the uterine. (6) Ectopic gestation follows the uterine. (c) Ectopic and uterine gestation occur coincidently. Bilateral Tubal Pregnancy. — A review of the literature on ectopic gestation discloses the records of a large number of cases in which pregnancy has occurred in the same tube or in the opposite tube. Almost as frequent are the references to combined tubal pregnancy and uterine pregnancy. Several cases of twin pregnancy in a single tube and one of triplets are recorded. The author has been able to find 10 146 ECTOPIC OR EXTRA-UTERINE PREGXANCY records of 28 cases of bilateral tubal pregnancy, but in the majority of these cases the proofs are by no means conclusive. Bland Sutton quotes Parry as follows: "Twin conceptions are much more frequent in extra-uterine than they are in normal gestation (four to one). It is a striking fact, however, that both children are rarely developed in the same locality. In a large majority of these tubal conceptions one ovum finds its way into the interior of the uterus, while the other is arrested at some point in its descent. This fact has led Professor Barnes to believe that twin conception is one cause of extra-uterine pregnancy." Bland Sutton fails to concur in the views of Parry. In reviewing the reports of cases of bilateral tubal pregnancy, it is evident that in some the products of conception were of simultaneous development; in others it is equally clear that the development of the two ova was not of the same period, and in the majority of cases there was no conclusive evidence on this point. Fig. 67 Bilateral tubal pregnancy (coincident development). Right tubal abortion, left tubal rupture. (Flndlej'.) Of the 28 cases reported as examples of bilateral tubal pregnancy, but 8 are unquestioned. Of the 20 cases of doubtful identity, the clinical diagnosis was not supported by the macroscopic and microscopic findings of fetal structures in the two tubes. In the case (Fig. 67) which was reported by the author^ there was the escape of the ovum and blood through the abdominal end of the left tube and of its twin, through a rent in the ampulla of the right tube. Placental tissue, decidua, and chorionic villi were found in both tubes, but neither fetus was discernible. Both ovaries were cystic and were bound by adhesions to neighboring structures. In the right ovary was a fresh corpus luteum. Classification. — In nearly three-fourths of the cases the ovum develops in the ampullary portion of the tube and with about equal frequency in the interstitial and fimbriated portions. 1 Surgery, Gynecology, and Obstetrics, July, 1910. AMPULLAR TUBAL PREGNANCY 147 Ampullar Tubal Pregnancy. — -The gestation begins in the ampullar end of the tube. Ampullar tubal pregnancy may persist as such, or the gestation sac may rupture from the tube. Persistent. — In rare instances the gestation in the ampulla may go to full term. The gestation sac is pedunculated, movable, incar- cerated, or fixed by adhesions. When confined to the pelvis the uterus and ovary are crowded to the opposite side; when large and lying in the abdominal cavity the uterus may not be displaced. As a rule, the gestation sac lies at the side of or behind the uterus, rarely between the bladder and uterus. Adhesions may firmly bind the tube, uterus, and ovary together. Fig. 68 Ectopic pregnancj- located in the uterine end of the tube. This might be called a tubo-interstitial pregnancy, inasmuch as the uterus formed a part of the gestation sac. The pregnancy had advanced about eight weeks. Rupture had not occurred. (Specimen reconstructed.) Rupture. — Rupture may occur early. The most likely exit is between the layers of the broad ligament, though not infrequently it ruptures into the free peritoneal cavity. Intraligamentary Gestation. — The ovum escapes through the lower segment of the tube between the layers of the broad ligament. Here the ovum may perish or go on to full development. Rupture usually takes place not later than the fourteenth week. The escape of the fetus and blood may be gradual or abrupt. The process may be so gradual that no general disturbance will be caused, and, on the other hand, the fetus and blood may be discharged in such a manner as to occasion profound shock. As the gestation sac enlarges the layers of the broad ligament are separated, the pelvic viscera are pushed to one side, the peritoneum is stripped from the bladder, uterus, rectum, and pelvic wall. Later, as the gestation sac increases in size, it burrows beneath the parietal and visceral peritoneum, crowding the viscera forward and to the opposite side. The placenta may remain attached to the tube or escape with the fetus between the lavers of the broad ligament and become attached 148 ECTOPIC OR EXTRA-UTERINE PREGNANCY to any of the raw surfaces. The tube may be stretched out over the gestation sac as a mere ridge. Rupture into the peritoneal cavity may take place at any time after the escape of the ovum and blood between the layers of the broad ligament. The danger to life in such an event is imminent, and immediate surgical interference is imperative. Fig. 69 Schematic drawing showing locations of ectopic pregnancy, a, interstitial; 6, ampullary; c, infundibular; d, tuboovarian; e, ovarian. Fig. 70 Left Fallopian tube with ectopic gestation in diverticulum, a, a, gestation sac coinmunicating with diverticulum. (Jewett.) Tuboperitoneal Gestation. — In tuboperitoneal gestation the placenta remains in the tube and the fetus escapes into the peritoneal cavity. The probability of such a condition was long held impossible. The first authentic case reported was that of Croom. Webster made sectional, dissectional, and microscopic studies of the case, and proved PLATE VI 11 Secondary Abdominal Pregnancy at Eight Months, Primarily Tubal. The primary attachment of the placenta is plainly discernible at the original tubal site. After rupture the placenta grew and became attached to a large surface on the anterior abdominal wall. The child was delivered through a retrouterine vaginal incision. (Jewett.) AMPULLAR TUBAL PREGXAXCY U9 the existence of tuboperitoneal gestation beyond dispute. AYebster holds that it is as yet improved that a fetus can escape into the peritoneal cavity free of its investing membranes and then develop to full term; he doubts the probability of such an occurrence. Furthermore, it is as yet unproved that the early complete ovum can escape into the peritoneal cavity and then go on to develop. As stated by Webster, it is inconceivable that a villous-covered o\'um can escape into the peritoneal cavity and there await the development of intervillous blood spaces. Gestation may terminate by rupture of the tube and escape of blood into the free peritoneal cavity. The amount of blood lost may be insignificant and occasion no constitutional effects; while, again, the blood may instantly escape in such large amounts as to jeopardize the life of the mother and fetus unless surgical intervention is prompt. The consequences to the mother are, therefore, dependent upon the extent of the tear, the rapidity with which the blood is allowed to escape, Primarj- intraperitoneal rupture; fifth week. Tube completely ruptured, a, o^-um still slightlj- adherent to its original site. (Jewett.) and, finally, upon timely surgical interference. The fetus may plug the opening and prevent the escape of much blood, or the blood may escape at intervals and eventually assume large proportions without seriously depressing the patient. (See Plate ATIL) Interrupted hemorrhage may also be due to contraction and retraction of the tube and bloodvessels. Though the quantity of blood lost in interrupted hemorrhages may be equally as great as in the immediate escape of blood, the effect upon the mother is far less serious. The later in pregnancy the rupture occurs the more serious the consequences, because of the unusual size of the rent, the failure of the muscular vrall to retract, the presence of large blood sinuses, and the failure on the part of the fetus to be absorbed. Prior to the end of the second month, if rupture takes place, the hemorrhage will usually not be great, and the fetus will almost cer- tainly be absorbed. Paipture has been known as early as the second week. The time of greatest frequency for rupture to occur is from 150 ECTOPIC OR EXTRA-UTERIXE PREGNANCY the sixth to the fourteenth week. The greatest number rupture in the second month. The escaped blood accumulates in the most dependent portion of the pelvic cavity. There it is rapidly coagulated, and is later absorbed, suppurates, or is organized. Fritsch says there is no case of pelvic hematocele in which ectopic pregnancy can be positively ruled out; while, on the other hand, such authorities as Kober and Freund have reported cases. It is unusual for acute peritonitis to follow the development of a hematocele, though it is the rule for peritoneal adhesions to form about the mass of escaped blood. Tubal abortion. A large intraperitoneal hemorrhage occurred in the second month of pregnancy. The tube is dark red and larger than a man's thumb. From the abdominal end of the tube a blood coagulum is seen to escape. Interstitial Tubal Pregnancy. — In this form the portion of the tube lying within the uterine wall encloses the gestation sac. This is an unusual location. There may be tubo-uterine pregnane^', in which the ovum lies partly within the interstitial portion of the tube, and partly within the uterine cavity. Again, the ovum may first develop within the interstitial portion of the tube, and later be expelled into the cavity of the uterus ("tubal abortion"). The gestation sac forms a part of the uterine tumor, and lies within the attachment of the round ligament — all other forms of tubal pregnancy lie external to the round ligament. Interstitial pregnancy may go on to full term; the fetus may die at any period of its development, or, finally, rupture of the tube may permit the ovum to escape into the uterine cavity between the layers of the broad ligament or directly into the peritoneal cavity. In any event, the resulting hemorrhage may be fatal. Infundibular Tubal Pregnancy. — The ovum is found in the infundibu- lum. This is an unusual condition. The behavior is similar to that of ampullar pregnancy. The tube is likely to adhere to surrounding structures, and by adhering to the ovary a tuboovarian pregnancy becomes possible. OVARIAN PREGNANCY 151 Ovarian Pregnancy. — Contrary to earlier conceived notions primary ovarian pregnancy does exist. Two cases of ovarian pregnancy are reported by Webster. About 20 cases are now on record. Fig. 73 Interstitial pregnancy. (Sutton.) Fig. 74 Amnion Partially separated placenta. Ulerine [i cavitj -ervix Interstitial pregnancy. (Bumm.) 152 ECTOPIC OR EXTRA-UTERINE PREGNANCY Williams collected 13 positive and 22 probable cases from the literature. Eleven of this number progressed to full term, which suggests that the ovary is more capable of accommodating the grow- ing ovum than is the tube. No definite decidua was found in any of the cases. The ovum advanced to full term or died in situ in a minority of the cases. Rupture with escape of blood and fetus was the rule. Causes of Ending of Gestation. — The Formation of a Hematoma. — The accumulated blood destroys the life of the fetus. Rupture of the tube has been known to occur after the death of the fetus (Braun- Fernwald). The growth of the placenta subsequent to the death of the fetus is the probable cause of rupture. The lower the attach- ment of the placenta the greater the hemorrhage, and hence the greater the likelihood that the life of the fetus will be destroyed. The escaped blood, if large in amount, may undermine the perito- neum, and sometimes encircles the uterus and rectum and displaces the uterus. Coagulation of the blood is rapid, and eventually com- plete absorption of the clots or the organization of the clots into adhesions follows, unless, perchance, the escaped blood suppurates and forms a pelvic abscess. Fig. 75 Ampullar tubal pregnancy. Fetus surrounded by a blood coagulum. Suppuration. — This event is usually late in its occurrence. It is unusual for an acute abscess to follow a hematoma of the pelvis. The more intimate the relation to the bowel the greater the liability of the escaped blood to suppurate. If the abscess is not opened by surgical means it may become absorbed, but will more probably find its way to a hollow viscus or externally through the vagina or PLATE rX Fig, 1 Fig. 2 f Ovarian Pregnancy. CW'ebster.j TUBAL ABORTION 153 abdominal wall. Parry reports a case in which rupture occurred thirty-two years after the formation of an abscess. Twelve cases are recorded in which the fetus was discharged through the bowel. Tubal Abortion. — By tubal abortion is meant the escape of the ovum through the fimbriated end of the tube into the peritoneal cavity. This implies that the tube must be patent at its fimbriated end. Accord- ing to Dobberts, tubal abortion is three to four times as frequent as rupture of the tube. All authorities agree that it is much more frequent Fig. 76 Intraligamentary rupture of a tubal pregnancy. Rupture at the isthmus, with escape of the fetus. (Jewett.) than rupture of the tube. The contractions of the tube expel the ovum, forcing it in the direction of least resistance. The nearer the attachment of the ovum to the fimbriated end of the tube the greater the likelihood of abortion. Hemorrhage is rarely considerable. The author removed two gallons of blood from the peritoneal cavity as the result of tubal abortion. All that has been said of tubo-abdominal gestation in reference to the fate of the mother and ovum applies to tubal abortion, though with less force. The hemorrhage is rarely so 154 ECTOPIC OR EXTRA-UTERINE PREGNANCY great and the fetus is usually absorbed. Hence the mother may and indeed often does suffer but little (Fig. 72). Formation of a Mole. — The fetus dies and is preserved in its entirety, forming a fleshy mole. The death of the ovum is caused by an escape of blood into the fetal membranes. At first the mass appears like a fresh, firm, blood-clot. Later it organizes and becomes paler as the blood absorbs. The Formation of an Adipocere, a Lithopedion or Mummy. — When the fetus is far advanced in its development it is liable to one of these formations. Retrogressive Changes in a Dead Fetus. — Mummification. — Mum- mification is a process of desiccation in which the water is extracted from the fetus. In addition a deposit of earthy salts is often super- imposed. Calcification. — In calcification the fetal membranes and placenta and rarely the superficial parts of the fetus are permeated and incrusted with lime salts. A dense incrustation is seldom formed. It is not un- common for an adhesive peritonitis to develop about the lithopedion. The petrified ovum may remain in the tube, in the peritoneal cavity, or between the layers of the broad ligament for years without creating serious disturbance. Well-formed children may be born while the parent still carries a lithopedion. Adipocere Formation. — In adipocere formation the ovum is converted into a soap-like mass. Calcareous deposits may be found in the fetal structure. Gangrene of the Fetus. — Gangrene of the fetus may result, and if surgical interference is not instituted, death from septic infection and peritonitis will probably follow. Anatomical Changes in the Tube.— Mucous Membrane.— In the tubal mucosa decidual changes are always to be found (Webster). This view is not universally accepted. Webster has never failed to demonstrate a decidua in the tube, but finds great variation in the location and extent of the development. The early specimens show this so-called genetic reaction more clearly than do the advanced cases. The decidua may be confined to a narrow ring about the tube. It is, therefore, not strange that conflicting statements are made concerning the presence of a decidua in the tube, for, it is often necessary to make sections from various portions of the tube. Asin uterine pregnancy, so in the tube, a decidua vera, reflexa, and serotina are usually found. The decidua vera is composed of -a spongy and compact layer, as in uterine pregnancy. In the compacta the decidual cells are closely packed together, while in the spongy layer they are separated by gland-like spaces formed by mucous folds. In later months the distinction between the compact and spongy layers is lost. In the earlier stages the surface epithelium remains intact, but as time goes on the cilia are lost, the surface cells become flattened, and, finally, wholly disappear. As in the endometrium, the decidual cells are derived from the connective tissue of the mucosa. They are PLATE X Fig. 1 Hematoma of the Left Broad Ligament Lying Close to the Uterus. Fig. 2 Hematoma of the Left Broad Ligament and Extending in Front of the Cervix to tlie Right Side of the Uterus. PLATE XI Hematoma of both Broad Ligaments Extending in Front of the Uterus. Fig. 2 Hemiatoma of both Broad Ligaments Connected Behind the Uterus. THE CLIXICAL DIAGXOSIS 155 essentially greatly enlarged connective-tissue cells, and show great variation in size and form. In far-advanced cases these cells become elongated into a fibrous structure and lose their decidual character. The decidua serotina, that portion of the decidua kno-uTi as the placental site, is relatively larger than the serotina of the pregnant uterus. The decidua reflexa may or may not be present. Some authorities disclaim its existence. According to Webster, the ttibe lumen may be so small that the ovum, pressing upon the wall of the ttibe, makes the formation of a decidua reflexa impossible. On the other hand, the tube lumen may be exceptionally large, in which case a complete reflexa may be formed. As the ovum develops the reflexa becomes thin and early disappears. Beyond the attachment of the OA'iim the tubal mucosa may not suffer change; occasionally, however, decidual changes are recognized throughout the entire mucosa of the tube. As the ovum enlarges and fills the tube, the surface epithelium is compressed and wholly disappears; so, also, with the decidua. The. muscular wall of the tube varies in thickness in different sections and in the various stages of pregnancy. In the early months the musculature thickens through h^'pertrophy. In the later months pressiu^e and stretching of the musculature may cause aU traces of muscle fibers to disappear. The peritoneal covering of the tube is stretched by the growing o\'um and inflammatory adhesions may form about the tube. Regarding the fetal membranes, there is little that differs from the membranes of normal uterine gestation. The Clinical Diagnosis. — Huggins believes that a diagnosis should be made in SO per cent, of unrtiptiu-ed cases provided the physician is called in time. To achieve this it is necessary that the p^e^dous his- tory, as well as the present complaints of the patient, be very care- fully considered. Consideration of the History. — The examiner should go back years into the history for the discovery of symptoms suggestive of tubal infection. These s^Tnptoms may ha^'e been pronounced at one time or they may have been mild from the beginning. A history of a latent gonorrhea in the husband may be the flrst suggestion of a possible ttibal involvement in the wife. A period of sterility is presumptive evidence of tubal involvement. When the patient has had a perfectly normal menstrual history and at examination presents definite irregu- larities, such as delayed onset of the menstrual periods or excessive and possibly painful periods, a suspicion of ectopic pregnancy is awakened. Again, when the menstrual period has been missed for from one to three weeks and then begins with pain in the hj-pogastriimi, the possible presence of ectopic pregnancy should be considered. The clinical diagnosis of ectopic pregnancy is made, first, by estab- lishing the fact of pregnancy, and, second, by locating the gestation sac. The subjective signs are of value in establishing the fact of 150) ECTOPIC OR EXTRA-UTERINE PREGNANCY pregnancy, but the location of the gestation sac can only be determined by a physical examination. Subjective Signs. — The subjective signs may not differ materially from those of uterine pregnancy of a similar age. In the early weeks of an ectopic gestation the patient is seldom aware of any unusual complications, while in the later months the symptoms rarely conform to those of normal pregnancy, and give rise to feelings of apprehension on the part of the patient. Not so with the physical signs; these are to be differentiated from the normal from the earliest time. Cessation of Menstruation. — This occurs in about one-half of the cases. The hemorrhage, when present, comes from the endometrium. Morning Sickness. — Morning sickness occurs at about the same time and to about the same extent as in uterine pregnancy. Nervous Phenomena.- — Nervous phenomena, such as ringing in the ears and despondency, are likely to be more marked than in normal uterine gestation. Periodic Colicky Pains.- — Periodic colicky pains are unlike anything that should occur in normal uterine pregnancy. It is this incident that commonly first attracts the patient's attention to her condition. These pains are said to be due to the contractions of the uterus and pregnant tube. In character they are intermittent and cramping, and are located in the region of the uterus and affected tube. During these pains rupture of the gestation sac may occur. Objective Signs. — The objective signs differ essentially from those of uterine gestation. Mammary Glands. — The mammary glands do not often show the marked changes accompanying uterine pregnancy. The areola is poorly marked and the secretion of colostrum is scant. Discoloration of the Vulva and Vagina, Softening of the Vaginal Portion of the Cervix, and Comi^ressibility of the Lower Uterine Segment. — These may all be present, but seldom to the degree found in uterine gestation. Active Fetal Movements. — Active fetal movements may be recognized earlier and with greater ease than in uterine pregnancy, provided the fetus lies in close proximity to the abdominal wall. Later on the movements may be readily seen through the parietes. Intermittent Uterine Contraction. — Intermittent uterine contractions are often present, though not to the degree found in uterine pregnancy. Direct Palpation. — Direct palpation of the fetal parts may be very difficult and obscure, or very easy, depending upon the relation- of the fetus to the abdominal wall. Auscultation. — (a) Fetal heart tones are heard with varying degrees of distinctness, depending upon the development of the fetus, its relation to the abdominal wall and upon the thickness of the latter. (6) The fetal souffle is rarely heard, and only in the latter half of preg- nancy, (c) The placental souflfle is rarely heard after the third month, and only on the side occupied by the gestation sac. OBJECTIVE SIGNS 157 The Rate of Growth, Form, Position, and Consistency of the Uterus. — These vary considerably from that of uterine gestation. While the uterus almost always enlarges, it never attains a greater size than that of a four months' pregnant uterus, and does not enlarge regularly and progressively as does the gravid uterus. The nearer the gestation sac is to the uterus the larger the uterus develops. Cases are recorded in which the uterus did not develop, but these are exceedingly rare. The general contour of the uterus differs somewhat from that of the normal pregnant uterus. It retains much the same form as does the non-pregnant uterus. The transverse diameter is proportionately less, and there is no shortening of the cervix in advanced cases. The uterus seldom lies in the median line, but is usually crowded to one side by the gravid tube. In consistency the uterus changes, but not to the degree found in uterine gestation. Discharge of the Uterine Decidua. — The discharge of the uterine decidua is an event peculiar to ectopic pregnancy. Part or all of the uterine decidua may be expelled at any time during the course of an ectopic pregnancy. As a rule, the decidua is expelled piecemeal, rarely in its entirety. Much blood may accompany the discharged decidua and completely mask the accompanying fragments. When ectopic pregnancy is suspected the escaped blood should be carefully preserved by the nurse for the inspection of the physician. Histologically, the uterine decidua of ectopic pregnancy does not differ essentially from that of uterine gestation, the distinguishing feature being the absence of fetal structures. Spurious Labor. — At full term pains not unlike those of labor come on and constitute what is known as spurious labor. These pains may occur weeks before the end of full term, and, on the other hand, may altogether fail or be delayed one or more months beyond full term. The pains commonly continue a number of hours, as in normal labor, but have been known to persist for a week and longer. They vary in intensity and location; often they are severe and located in the side of the pelvis. A bloody discharge appears shortly after the onset of the pain, and with it there is usually a discharge of decidual membrane. The amount of blood lost may be alarming. Following spurious labor the fetus always dies, the liquor amnii becomes absorbed, the gestation sac contracts, and the fetus under- goes changes previously referred to, namely, mummification, litho- pedion, gangrene, or adipocere formations. Intraperitoneal Hemorrhage. — An intraperitoneal hemorrhage should be suspected when a woman in the childbearing age experiences a sudden and severe abdominal pain with the appearance of extreme anemia and faintness. As the pallor increases the pulse becomes increasingly rapid and compressible and may become imperceptible, the respirations are sighing, restlessness develops, and the temper- ature becomes subnormal. The abdomen may become somewhat distended and tender, with more or less rigidit}-. Death may follow 158 ECTOPIC OR EXTRA-UTERINE PREGNANCY within a few hours or the bleeding may be checked spontaneously and the patient recover. Bimanuol Examination. — An anesthetic will be found of immense advantage in making a bimanual examination, but should not be given if the patient is greatly depressed. Great variations are observed in the local findings of ectopic pregnancy. Vessels may be felt to pulsate in the vaginal vault, particularly on the side of the gestation sac. The vagina may be displaced and misshaped by the gestation sac and accumulated blood above. The vaginal walls may bulge at the sides and behind the uterus, and the vagina may be pushed far to one side. The uterus is almost invariably displaced by the tumor mass. The most common displacement is forward and upward, because of the frequency with which the blood collects in the pouch of Douglas, The uterus is elongated, but is never so broad as in uterine gestation of a similar period of development. Its consistency is firmer than in uterine pregnancy, the lower uterine segment is not well-marked, and the cervix is not shortened. The pregnant tube is not unlike the inflammatory swellings of the tube. AYithout other evidences of pregnancy it would be impossible to say, with assurance, that the tube is pregnant and not distended with blood, pus, or serum. As in sactosalpinx, the pregnant tube commonly lies low at the side of or behind the uterus. In interstitial pregnancy the gestation sac forms with the uterus a single mass, distinguished by a more elastic consistency when con- trasted with the firmer uterine tissue. Exploratory Vaginal Incision. — Exploratory vaginal incision has been practised by Grandin and Spinelli as a last resort in the making of the diagnosis. If an exploratory vaginal incision reveals the pres- ence of an ectopic pregnancy it is advised that the operation should immediately follow. Exploratory Abdominal Incision. — Through an abdominal incision an accurate diagnosis can be made and the operation completed without delay. Differential Diagnosis. — Diagnosis from Pregnancy in a Retroverted Uterus. — As the gestation sac of an ectopic pregnancy frequently lies behind the uterus, and since in the early months the size, form, and consistency of the uterus of an ectopic pregnancy do not differ widely from that of intra-uterine pregnancy, confusion is likely to arise. Here an examination under anesthesia is of the greatest value in locating the uterus and in clearly outlining it apart from any mass outside. In an ectopic pregnancy lying in the retro-uterine space the uterus lies well forward, and by its form and consistency can usually be outlined apart from the gestation sac. The anatomical distinctions between the pregnant uterus and the uterus of an ectopic pregnancy are to be borne in mind. In uterine pregnancy the uterus is more elastic and soft, the lower uterine segment is clearly defined, and the transverse diameter is relatively increased. The possibility of a com- bined uterine and extra-uterine gestation should be borne in mind. DIFFERENTIAL DIAGNOSIS 159 Uterine Pregnancy Complicated with a Tubal or Ovarian Swelling may easily be confused with ectopic pregnancy. The difficulties are increased when the uterus is enlarged through inflammation (chronic metritis) . Such a uterus, when gravid, will not have the usual elasticity and softness of a normal pregnant uterus. On the other hand, the abdominal wall and uterine musculature may be so thin as to give the impression that the fetus lies outside the uterus. In the first trimester the physical examination of the uterus alone can only serve to sug- gest the possibility of pregnancy. When from the size, position, con- sistency, and contour of the uterus pregnancy is suspected, the next step is to determine whether the adnexse are enlarged from pregnancy, infection, or a new-formation. The history must be carefully con- sidered, with special reference on the one hand to pregnancy and on the other to infection. The pregnant tube is usually of softer consist- ency and less tender than is an inflammatory swelling. More confusing still is the occasional occurrence of a tubal pregnancy implanted upon an inflammatory swelling of the tube. Here, and indeed in all cases, the history will be of the greatest value in making the differential diagnosis. The unilateral involvement of the tube is evidence in favor of tubal pregnancy, though bilateral tubal pregnancy is possible and unilateral involvement of the tube and ovary is common. A pregnant tube is not so likely to be fixed by adhesions as is an inflammatory swelling of the tube, and tenderness is not so great. As a last resort, when a diagnosis is imperative, a sound may be passed into the uterus, or if there is evidence to support the belief that an abortion has occurred, the uterus may be curetted and a microscopic examination made of the scrapings. If decidua and fetal tissue are found in the scrapings the pregnancy must have been intra- uterine. The fact that no decidua is found is not conclusive evidence that tubal pregnancy cannot possibly be present, because it is possible that the decidua was previously expelled. This occurred in a case reported by Tanneus. Diagnosis from Pelvic Exudate, Especially When following upon an Abortion. — A period of amenorrhea may be interrupted by uterine hemorrhage, without the recognition of fetal structures in the escaped blood. From such a history the examining physician is unable to decide whether it was a uterine abortion or a ruptured tubal pregnancy. If an examination is not made until some time has elapsed, and a mass is found in the pelvis, the question arises as to whether this mass is due to an inflammatory exudate or to a gestation sac and the escaped blood of a ruptured ectopic pregnancy. If an inflammatory exudate, the history should point to a pelvic infection following the abortion, to a rise of temperature, and to pain in the pelvis. The mass should be firmly fixed and tender. In ectopic pregnancy there is less tenderness and pain, and the general symptoms of sepsis are not present unless the mass has become infected. A very good general rule is that in a pelvic abscess the fever and high pulse-rate precede IGO ECTOPIC OR EXTRA-UTERIXE PREGNAXCY the development of the pehic exudate, while in ectopic pregnancy there is no fever or rise of pulse-rate before the de^•elopment of the tumor. Furthermore, with the de^-elopment of the inflammatory exudate the general symptoms of infection increase, while with the sudden appear- ance of an escaped mass following upon the rupture of a gravid tube the temperature is likely to become subnormal and be later followed by a moderate rise of temperature. Finally, an exploratory puncture or incision through the vaginal wall will determine the true nature of the swelling. If a pelvic abscess develops it may not be possible to determine whether it was derived from an inflammatory exudate or from a secondary infection of an ectopic pregnancy. In the removal of the puSj fetal tissue may or may not be discovered either by the naked eye or by the microscope. The presence of blood-clots in the pus is highly suggestive of tubal pregnancy. Diagnosis from Pregnancy in a Bicomate Uterus. — Pregnancy in a bicornate uterus may closely resemble an ectopic pregnancy. The diagnosis may be clarified by the discovery of a septum in the vagina or cervix. It is seldom possible to palpate the round ligament, but if it is found attached external to the gestation sac the pregnancy is either interstitial or in a horn of a malformed uterus; if the round liga- ment lies internal to the gestation sac a bicornate pregnancy is excluded. Diagnosis from Pregnancy in a Rudimentary Horn. — Pregnancy in a rudimentary horn cannot be distinguished from tubal pregnancy before opening the abdominal cavity. It is then recognized by finding the insertion of the round ligament external to the gestation sac. Diagnosis from Ovarian Tumors. — Ovarian tumors may be difficult to distinguish from an ectopic pregnancy. In ovarian tumors the breasts may enlarge and secrete colostrum, and there may be morning sickness and amenorrhea. With the aid of an anesthetic a bimanual examination should determine the diagnosis. As a rule the uterus can be clearly outlined distinct from the ovarian tumor, and is found not to differ from the normal non-gravid uterus. Rupture of an ovarian cyst may suggest a possible rupture of an ectopic pregnancy. The absence of a history of pregnancy, the pres- ence of a long-standing tumor, and the absence of changes in the uterus suggestive of pregnancy, including a decidua, should suffice for the making of a diagnosis. Torsion of the pedicle of an ovarian cyst may give rise to pain and symptoms of internal hemorrhage not unlike those of a ruptured. ectopic pregnancy. A consideration of the points referred to under rupture of an ovarian cyst should serve in excluding rupture of an ectopic pregnancy. An ovarian tumor complicating pregnancy is at times confusing in the diagnosis. The shape, size, and consistency of the uterus, as a rule, serve in determining the presence of a uterine pregnancy. The great improbability of a tubal pregnancy complicating a uterine pregnancy, together with the usual signs of an ovarian cyst, generally clears up DIFFERENTIAL DIAGNOSIS 161 the diagnosis. If the cyst is large it will be observed that there is an absence of ballottement, of fetal heart tones, and of fetal movements in what is suspected of being a gestation sac. Diagnosis from Fibromyoma of the Uteras. — Fibromyoma of the uterus can scarcely be mistaken for ectopic pregnancy. There is an absence of a history of pregnancy, and the uterus shows none of the characteristic changes. The tumor is of long standing, which together with its firm consistency and the close relation of the uterus to the tumor mass, should leave little doubt as to the diagnosis. An explor- atory curettage of the uterus will fail to find decidual tissue. Fig. 77 Left tubal pregnancy operated on five months after signs of life had disappeared. The superior surface of the left tube is still visible on the surface of the sac. The left ovary was visible only as a bluish flattened patch apparently forming a part of the sac wall. The sac developed between the folds of the mesosalpinx and mesosigmoid. The patient was suffering from uterine hemorrhage, but had never been seriously ill. There had never been signs of rupture, and the whole sac was dissected intact from, the cornua of the uterus. (Jewett.) Diagnosis from Malignant Diseases of the Pelvis. — ]\Ialignant disease of the pelvis, by its irregular outline, may suggest an ectopic preg- nancy, and the more so when it occurs in the "dodging period." The absence of the signs of pregnancy and the presence of general signs of malignancy should exclude the possiblity of ectopic pregnancy. Diagnosis from Pelvic Hematoma and Hematocele. — Pelvic hematoma and hematocele not due to ectopic pregnancy are exceedingly rare. Causes other than ectopic pregnancy resulting in the formation of a 11 162 ECTOPIC OR EXTRA-UTERINE PREGNANCY hematoma or hematocele are obstructions to the outflow of the men- strual blood, rupture of varicose veins in the broad ligaments, and rup- ture of an ovarian cyst and of the uterus. In determining the origin of the blood mass the first and most important step is the consideration of pregnancy. In long-standing cases of hematoma and hematocele following upon the rupture of an ectopic pregnancy it may be impos- sible to find any evidence of pregnancy either in the tube or in the uterus. Diagnosis from Acute Abdominal Affections, — Of all acute abdominal affections in woman, ruptured ectopic pregnancy is the most important ■ from a gynecological point of view. There are a number of acute affections of the abdominal organs which have very similar clinical manifestations, and it is imperative that a diagnosis be made at the earliest possible moment in order that proper surgical measures may be instituted. The importance of differentiating these various lesions will justify a thorough consideration. The following acute abdominal affections may simulate ectopic pregnancy: 1. Appendicitis. 2. Intestinal colic. 3. Renal colic. 4. Hepatic colic. 5. Internal hernia. 6. Acute pancreatitis. 7. Movable kidney. 8. Rupture of a gastric or duodenal ulcer. In differentiating these conditions consideration must be given, first, to the previous history, then to the present complaints, and finall}^ to the physical examination. Appendicitis. — Appendicitis in its onset and in its further course may very closely simulate a ruptured tubal pregnancy, but in appen- dicitis there are none of the general and local signs of pregnancy. There is often a history of previous attacks, with intervals of complete or partial freedom from pain and intestinal disorder. The distress is almost always confined to the right side, while in ectopic pregnancy it is often referred to the median line or left side. In both of these conditions the pain appears suddenly, and ma,y be intense; in ectopic pregnancy it may be momentary, while in appen- dicitis it usually persists throughout the attack. The sudden pallor and collapse frequently following immediately upon the rupture of a tubal pregnancy never occur in appendicitis. It is at this time that a most suggestive sign appears — i. e., uterine hemorrhage accompanied by a discharge of decidual membrane. In such an event there can be no further consideration of appendicitis. Much dependence is placed upon the finding of an enlarged soft uterus and an irregular mass attached to it at the side or lying behind the uterus. When doubt exists, the uterus may be explored with a curet and the scrapings examined for decidual tissue. DIFFERENTIAL DIAGNOSIS 163 In intraperitoneal hemorrhages from rupture of the gestation sac the abdomen may be distended, firm, and tender, and this may be associated with nausea, vomiting, rise of temperature, and leucocy- tosis. Here the diagnosis must rely almost wholly upon the previous history. Intestinal Colic. — Intestinal colic begins with griping abdominal pains, vomiting, and diarrhea. This may lead on to collapse. Often a cause for the intestinal colic can be elicited. Lead colic is rarely seen in women. The blue line on the gums, constipation, and colicky pains about the umbilicus found in a patient working with lead will fix the diagnosis of lead colic. Renal Colic. — Renal colic should not be difficult to diagnosticate from rupture of an ectopic pregnancy. When occurring during the course of a uterine pregnancy, renal colic may excite suspicion of a ruptured tubal pregnancy. In renal colic the pain is severe and increasing, it is sharp and radiates to the groin and thigh. Vomiting, sudden rise of temperature, cold sweats, and collapse are frequent accompaniments. Watching the urine closely, blood will be seen to appear, though the microscope may be required to detect it. All urine voided should be searched for the stone. These events, in the absence of an extra-uterine pelvic mass, will serve for a diagnosis. A history of previous attacks will be highly suggestive. It is possible that the presence and location of the stone can be determined by means of the .r-ray. Hepatic Colic. — Hepatic colic frequently arises after the childbearing period. When associated with pregnancy the rupture of an ectopic pregnancy would naturally be suggested. Flatulent dyspepsia has usually been a more or less constant complaint. Pain is referred to the right hypochondrium, epigastrium, right shoulder, and back. Associated with this is epigastric tenderness, nausea, and vomiting. If the stone passes into the common bile duct there will probably be jaundice, clay-colored stools, and bile in the urine. The gall-bladder may be distended and tender. If gallstones are passed by the bowel or seen by the a:-ray the diagnosis is established. There is little in such a history to suggest rupture of an ectopic gestation sac, and yet mistakes have been made. Internal Hernia. — Internal hernia usually begins with pain, which may be severe or slight, and even absent. Vomiting is often the earliest sign, and this becomes stercoraceous. There is no gas or fecal matter passed by the bowel. Indican is present in the urine in large quantities. None of the symptoms points to the pelvis, and a vaginal examination excludes the possibility of ectopic pregnancy. Acute Pancreatitis. — Acute pancreatitis is frequently regarded as an aggravated form of indigestion until the patient is seized with severe pain in the epigastrium, repeated vomiting, and collapse. The epi- gastrium is tender on pressure, though there is no distention. Collapse may follow upon persistent vomiting. There is little possibility of mistaking such a condition for ectopic pregnancy, though the abdominal pain, vomiting, and collapse occurring in a woman of the childbearing 1G4 ECTOPIC OR EXTRA-UTERINE PREGNAXCY period should first of all suggest an abnormal condition of pregnancy and call for an immediate physical examination. Movable Kidney. — ^Movable kidney is seldom associated with such intense pain and shock as to become a serious, acute abdominal affection. The pain is usually referred to the right h\-pochondrium, and may be associated with vomiting and shock. Palpating a firm, tender, kidney- shaped tumor in the right lumbar or iliac space and the ability to readily force this tumor beneath the right costal arch will determine the diagnosis. A history of previous lesser pains and a dragging sensa- tion coming on in the right hypochondrium shortly after rising, together with relief upon lying down, will suggest the diagnosis. Rupture of Gastric or Duodenal Ulcer. — Rupture of a gastric or duodenal ulcer will almost always occur after a meal and upon exertion. There is a previous history of anemia and indigestion in nearly all cases. The vomiting of blood and the occurrence of gastric pains are frequent events. The history and a pelvic examination will exclude ectopic pregnancy. Treatment. — Extra-uterine pregnancy is one of the most formidable of surgical emergencies and in the majority of instances calls for early surgical interference in the interest of the mother. The observations of Werth ha^'e an important bearing upon the treatment of extra-uterine pregnancy. He has shown that after the death of the fetus, either before or after the escape of the ovum from the tube, the chorionic epithelium (Langhans' cells and syncytium) may continue to proliferate and to invade maternal bloodvessels in the wall of the tube, thereby inducing hemorrhages. Furthermore, a par- tial abortion, where the ovum has partly escaped from the fimbriated end of the tube, may occasion repeated hemorrhages as was well illustrated in one of the author's cases. These facts speak for the uncertainty of tentative treatment. Unruptured Tubal Pregnancy. — The only safe rtde to adopt in the interest of the mother is to remove the imruptured gestation sac at the earliest possible moment. ^Mien the pregnancy is far advanced, delay may be ^countenanced in the interest of the child, but only with full understanding of the dangers involved. As soon as an unruptured tubal pregnancy is recognized, or diag- nosticated with a reasonable degree of certainty, the patient must be put to rest and no time lost in the preparations for operation. The question of the advisability of removing the patient to a hospital must be determined by the conditions governing the patient. If the distance is not too great, the means of transportation such as will permit of moving the patient with all possible care and the general resistance of the patient is sufficient for the task, it would seem advisable to convey the patient to a hospital where her interests can be best safeguarded. However, it is best to operate in the home if to move the patient entails great risk. In the removal of the gestation sac the abdominal route should be chosen. TREAT MEXT 165 \Yhen the fetus and its membranes are located at the outer end of the tube and can be removed without sacrificing the tube, some authorities have advised conservatism. ^Miile such a procedure is theoretically conse^vati^■e, there is always the question of possible infection and hemorrhage on the one hand and of the leaving of a disabled and offending tube on the other. It is the author's preference to remove the entire tube together with the ovum. The anatomical findings present so many variations that it is quite impossible to describe a technic which wUl be of universal application. The general principles are as follows: A median abdominal incision is made of a length sufficient to deliver the gestation sac and its contents intact; adhesions binding the gestation sac to surrounding structures are broken up, taking care not to break the gestation sac; the tube and its contents are removed en masse; all bleeding vessels are firmly secured and the raAv surfaces covered with peritoneum. In the absence of sepsis and oozing surfaces the abdomen is closed without drainage. When drainage is established it is best to make an opening through the cul-de-sac of Douglas into the vagina, and through this to carry the end of a roll of antiseptic gauze, leaving the remaining portion of the gauze snugly packed into the space previorsy' occupied by the pregnant tube; the- abdominal incision is then closed. The drainage is left about forty-eight hours, when it is removed through the vagina. As a precautionary measure against the occurrence of hemorrhage while removing the tube, it is weU to ligate or clamp the ovarian vessels near the uterine cornua and between the fimbriated end of the tube and brim of the pelvis. Having secured these vessels the tube or tube and ovary may be removed by excising the uterine end of the tube from the coinua, then with the scissors cutting along the lower circumference of the tube throughout its entire length; thus completely removing the tube from its attach- ments and leaving the cut edges of the broad ligament to be whipped over with a running suture of Xo. 1 plain catgut. The ovary or any part of it should not be sacrificed unless diseased. After the tube is removed, all bleeding points controlled by ligatures and the raw surfaces cx)vered by peritoneum, the surgeon proceeds to correct, as far as possible, all associated lesions in the abdomen: In nearly all instances the position of the uterus must be corrected; this is usually accomplished by Ioo])ing the round ligaments behind the fundus. At the Time of Rupture. — "When a case is seen at the time of rupture the following questions present themselves: Is immediate operation indicated? Is an immediate operation imperative? Will the patient be in better condition for operation after a variable period of rest and stimulation? These questions can only be determined after carefully considering all conditions pertaining to the physical condition of the patient and the preparedness of the stirgeon for operation. The essen- tial principles underlying the solution of the problem are as follows: As a general proposition all cases seen near the time of rupture or 166 ECTOPIC OR EXTRA-UTERIXE PREGXAXCY abortion of the tube call for early but not immediate operation. This is imperative in view of the great dangers of secondary hemorrhage which may prove fatal, and of ill health which often results from too long delay. While it is true that the primary hemorrhage is seldom fatal, it is equally true that there is no possibility of predicting the possible occurrence of secondary hemorrhage, much less the time of its occurrence and the possible consequences. Hence the inadvisability of unnecessary delay after the onset of hemorrhage. When the patient is found in a state of great depression delay may be countenanced. This the author has done in three instances where a large amount of blood had escaped into the abdominal cavity and the patients were profoundly depressed. Xo time was lost in making ready for operation, but while the preparations were being made the patients were stimulated and carefully watched. They responded readily to stimulation and were carried safely through the period of depression before the operation was undertaken. Had they not so readily responded they would have been operated upon without delay and without general anesthesia. The author is in accord with Pro- chownick, who concludes that early operative interference in these cases is the best and most certain form of conservatism. In 50 lapa- rotomies performed by Prochownick good results were obtained in 41, and in 18 vaginal incisions, 12 complete recoveries ensued. Of the cases treated expectantly some were satisfactorily relieved, but the majority failed to attain good health. Out of 39 laparotomies, 21 (53 per cent.) subsequently became pregnant, while in those treated expectantly 50 per cent, became pregnant. In this connection it is of interest to note the advice of Werth, who councils immediate surgical intervention regardless of the degree of shock. He argues that the operation is short, that the anesthetic is given sparingly, if at all, and that he has observed the pulse to improve immediately after these operations. ^^^len the rupture is recent it would seem wise to always choose the abdominal route in preference to the vaginal. By doing this the affected tube can be dealt with and there is a minimum risk of hemor- rhage. In one of the author's cases, in which vaginal drainage was established, an intraperitoneal hemorrhage was excited by the manip- ulations and was all but fatal. In an operation by Schauta, of Vienna, which the author witnessed, the vaginal incision and drainage were hurriedly followed by an abdominal incision for the control of an intraperitoneal hemorrhage. As soon as the abdomen is opened, if there is no fresh bleeding, the escaped blood is removed with swabs and the tube together with the ovum are removed as described above. If there is fresh hemorrhage at the time of operation there should be no loss of time in controlling the uterine and ovarian arteries with clamp or ligature. The abdominal incision should be long enough to permit of ready access to the field of operation. The escaped blood may mask the condition, and if new blood is being constantly added to that which has escaped, the operator should not attempt to cleanse the field of operation before removing T RE ATM EXT 167 the tube, but should grasp the uterus with his hand. With this as a starting point he should pass the hand on either side until the preg- nant tube is recognized; this is grasped, freed of its adhesions, and pulled into view. A clamp is then placed on either side of the gesta- tion sac to control the ovarian arteries. The escaped blood is then removed with swabs and the operation proceeds as already described. \Mien there is great depression too much time should not be con- sumed in the various niceties of the peritoneal toilet and in correcting other conditions within the abdomen. At the meeting of the American Gynecological Society in 1912 there was a symposium on the management of intra-abdominal hemorrhage in tubal pregnancy. From the discussion the following deductions are presented as an expression of the opinion of the society: 1. Neither undue haste nor }'et unnecessary delay should be practised in dealing with these cases, because not more than 5 per cent, die from hemorrhage, and, on the other hand, too long delay in interference may lead to permanent disabilities. 2. An immediate operation does not contribute largely to shock if done skilfully. The added depression as the result of the operation can usually be eliminated by the timely administration of salt solution and other stimulants. 3. The conclusions drawn from a comparison of cases operated immediately with those operated at a much later date are liable to be misleading in that the former group presents a greater number of serious cases. 4. In the hands of the unskilled and when the surroundings are unfavorable to good surgery the deferred operation is preferred, with the exception of the few cases which faU to react under stimulation. 5. No definite rule can be adopted for the management of aU cases. It is the business of the surgeon to immediately prepare for operation while restorative measures are being applied. If the patient reacts the operation may be delayed; if she does not react, no time should be lost in opening the abdomen. After Rupture. — When the case is seen late after rupture the question of tentative treatment may be justly considered. Unquestionably, cases of ruptured tubal pregnancy frec{uently resolve themselves into a perfectly normal state and may require no surgical intervention. However, it is not possible in any given case to predict such a result with certainty. There is always the possible danger of some untoward event which may jeopardize the life and health of the patient. It is for such reasons that tentative treatment for ruptured tubal pregnancy should not long be entertained, and only so when the patient is under close observation. The dangers arising out of the escaped blood and gestation sac are discussed on page 166. Managemext of Exd Stages. — The management of the end stages of ruptured tubal pregnancy are here briefly outlined: Formation of a Hematoma. — If a blood mass is found in the pelvis, and the history points to its existence for some time, it is not wise to 1G8 ECTOPIC OR EXTRA-UTERINE PREGNANCY council further delay. The likelihood of an indefinite delay in the absorption of the escaped blood, or of the development of a pelvic abscess, or, what is more likely, of the formation of pelvic adhesions, speak for the evacuation of the escaped blood without untlue delay. If the escaped blood can be readily reached through a vaginal incision this route should be preferred to the abdominal. Vaginal drainage is only applicable to old cases in which there is little danger of exciting fresh hemorrhage. The disadvantage of vaginal drainage in such cases is apparent. It is not possible to deal carefully with adhesions to coils of bowel nor to be as conservative with the ovary as by the abdominal route, and it is never possible to say with assurance that the placental tissue has wholly escaped from the tube. As long as the chorion remains in the tube there is danger of secondary hemorrhage from the continued growth of the epithelium of the chorion into the bloodvessels of the tube wall. For these reasons some authorities advise operating through the abdomen when infection of the blood mass can be excluded. Before establishing drainage the position, size, and relation of the hematoma to the pelvic organs must be clearly defined by a bimanual examination under anesthesia. The cervix is grasped with a vulsellum forceps and traction is made by an assistant downward and forward. The posterior wall of the vagina is grasped about one inch from the cervix by a long rat-tooth tissue forceps, and with long sharp-pointed scissors the vaginal wall is incised laterally immediately behind the cervix for a distance of one inch. The index-finger is then inserted into the incision and in the direction of the blood mass. In some instances the finger cannot be forced into the hematoma and long blunt forceps or scissors are directed in advance of the finger. This is a dangerous procedure and should be carried out with great caution. When the clotted blood makes its appearance through the incision the wound is carefully spread with the fingers to permit free drainage. With the fingers or with small swabs the blood-clots are wholly removed. Then follows the packing of the cavity and vagina with a long strip of iodo- form gauze. No sutures or ligatures are required. If irrigation of the cavity is made it should be done under low pressure and with sterile normal salt solution at a temperature of 110° to 114° F. The author has operated upon ten cases in this manner, and in every instance a perfect result was obtained without suppuration. In two of the cases a second and in one a third drainage with irrigation was necessary because of the untimely closure of the incision. The after-treatment of these cases consists in enjoining rest in bed until such time as the cavity has closed, which rarely exceeds four weeks; of removing the pack forty-eight hours after its insertion, to be followed by an antiseptic vaginal douche; to give such stimulation as may be required, and to nourish the patient in every possible way. The possible development of adhesions subsequent to the closure of the cavity occupied by the blood must not be disregarded, and when noted they are to be dealt with by the application of hot vaginal TREATMENT 169 douches, glycerin and icthyol tampons, and pelvic massage according to the principles laid down. See Chapter XI. Suppuration. — ^When the escaped blood becomes converted into an abscess no time should be lost in draining the abscess through the vagina. The author recently performed an operation in which not only a pelvic abscess developed out of a ruptured tubal pregnancy, but a general suppurative peritonitis followed. After draining such a pelvic abscess, great caution must be exercised in all the manipulations for fear of breaking down the protective wall of adhesions which safeguards the general peritoneal cavity. Too vigorous manipulations with swabs, fingers and instruments within the abscess cavity have been responsible for the development of general peritonitis. The irrigation of the abscess cavity at the time of the operation should also be condemned for the same reason. After the abscess has been drained it is the author's custom to pack the cavity and the vagina with a single long strip of iodoform gauze. These strips are usually removed thirty-six to forty-eight hours after the operation and a vaginal douche of formalin, 1 to 4000, given at low pressure. Subsequently, if the drainage is not good, as evidenced by increased pain in the pelvis, rise of pulse-rate and temperature, the original incision may be spread with forceps or fingers, and the cavity irrigated with sterile normal salt solution. If an accumulation of pus is detected in the pelvis which will empty by this method alone, it should be opened by the finger or by advancing forceps, and possibly again packed with gauze. There should be no thought of opening the abdominal cavity so long as the pus is confined to the pelvis and can be drained through the vagina. There is time enough for an abdominal section after the pus is well drained, and the acute stage of the pelvic inflammation has long passed. Happily, in many cases there is no need of a subsequent abdominal section. Secondary Hemorrhage. — When there has been a secondary hemor- rhage no time should be lost in performing an abdominal section. Vaginal incision is not countenanced in view of the possibility of having to contend with an uncontrollable hemorrhage. Delay in interfering is likewise inadvisable, for it is assumed that a third and possible fatal hemorrhage may ensue. Growth of Fetus after Rupture. — If the escaped mass of blood and ovum slowly increases in size and it is thought highly probable that the fetus is living, the proper procedure is to open the abdominal cavity and remove the tube and escaped mass. In exceptional cases it may be demonstrated by the examination that the ovum lies within the broad ligament. In such an event a vaginal section would be the method of choice. The precaution, however, should be taken to pre- pare previously for an abdominal section in view of possible failure to complete the operation through a vaginal incision. While the vaginal route has been chosen for the removal of advanced 170 ECTOPIC OR EXTRA-UTERIXE PREGNANCY extra-uterine gestation the difBciilties are great and should only be chosen in preference to the abdominal route when there is suppuration. Treatment of Intraligamentary Extra-uterine Pregnancy. — When the diagnosis is made in advance of the operation an extraperitoneal route should be chosen; this should be by the vagina or immediately above Poupart's ligament, depending upon the location of the gestation sac. If the sac is located low in the pelvis the vaginal route is chosen, if high upon the anterior wall, the incision should be made immediately above Poupart's ligament. Unless far advanced in pregnancy one of these routes should be chosen even after an abdominal incision has been made and the gestation found lying extraperitoneal. Treatment of Interstitial Pregnancy. — Kelly advises the making of a gentle effort to open the sac wall into the uterine cavity by dilating the cervix and using a sound. Such a procedure would seem to be very uncertain and hazardous. The difficulties involved in accurately locating the gestation sac in the horn of the uterus before making an abdominal incision are great, and it would seem to the author that in view of the opportunities for infection the greatest safety lies in favor of excismg the gestation sac and tube from the uterus through an abdominal incision. Treatment of Advanced Extra-uterine Pregnancy. — Xo consideration should be given the child prior to the period of viability. The dangers attending the presence of a living fetus within the abdomen, but not resident in the uterus, are of such a serious nature as to brook no delay in its removal. After the period of viability the question may justly arise as to the advisability of allowing pregnancy to advance to near term in the interest of the child. The author very much questions the wisdom of such a course. A living and well-developed child is occasionally delivered through the abdomen, but such instances are very rare. It is far more likely that the mother's life will be jeopardized in the effort, or that the life of the child will not be saved. Too often such babies are poorly developed and survive for only a short time. At all events, if such an expectant course is to be pursued in the latter half of pregnancy, it should be by the expressed wish of the mother and friends after a full understanding of the attending dangers. Throughout this period of watchful expectancy the patient must always be under masterly control, with conditions such as will permit of immediate surgical intervention should occasion arise. When the ectopic pregnancy is advanced into the second semester it is of the highest importance to determine the life or death of the fetus. Upon this decision will depend the disposition that will be made of the placenta. If the fetus is living the removal of the placenta together with the fetus becomes a dangerous procedure, because of the accompanying hemorrhage. In the presence of a dead fetus the placental sinuses are plugged with coagula and no serious hemorrhage is antici- pated in its removal. In the majority of cases the life or death of the fetus is not determined before opening the abdomen. TREATMENT 171 If the fetus is dead it should be removed together with the placenta. If the fetus is living and the placenta is so attached to the uterus, broad ligaments or tubal wall that the bloodvessels leading to the placenta may be securely ligated, the placenta may be removed along w4th the fetus. If not so attached the cord is ligated and severed close to the placenta, the fetus removed, and an iodoform gauze pack carried down upon the placenta. This gauze pack is removed at the end of forty-eight hours and the placenta left to be discharged piecemeal through the wound or removed en masse at the end of the forty-eight hours. In such cases there is always the danger of hemorrhage from the placental site, and the infection of the placental mass prolongs the convalescence and may lead to a fatal issue. Whenever possible it is a wise precaution to ligate the ovarian and uterine vessels on the affected side. The greatest care must be exercised in securing by ligatures all bleeding vessels and in maintaining the strictest precautions against infection. As far as possible the general peritoneal cavity must be protected against possible contamination. This is done by walling off the peri- toneal cavity with sterile packs of gauze while the operation is in progress, and when the placenta is left, by stitching the amniotic sac to the peritoneum of the abdominal incision. Because of the great danger of secondary hemorrhage and sepsis it would be hazardous to close the abdominal incision after removing the fetus, leaving the placenta to be absorbed. If extensive adhesions exist they are carefully separated, and if the raw surfaces cannot be well covered with peritoneum or thor- oughly charred with a thermocautery it may be well to establish drainage. This is best done by carrying the end of a long strip of iodoform gauze through the cul-de-sac into the vagina and packing the pelvis. Treatment of Combined Extra-uterine and Intra-uterine Pregnancy. — Many cases have been reported in which a lithopedeon of long standing has remained in the peritoneal cavity without disturbing subsequent uterine pregnancies. They have been known, however, to necessitate the induction of abortion and to obstruct labor at full term. When the tubal pregnancy is active at the time of uterine pregnancy the indication for interference is imperative. W^hile an effort shoidd be made to save the child in utero, the presence of a tubal pregnancy brooks no delay. The rule is to deal with the tubal pregnancy along the lines already laid down and to prevent, if possible, the interruption of the uterine pregnancy. It is always hazardous to attempt an immediate delivery of the fetus in utero. Treatment of Ovarian Pregnancy. — This does not differ essentially from that of tubal pregnancy. Treatment of Pregnancy in a Rudimentary Horn of the Uterus. — The operation does not differ essentially from that described for tubal 172 ECTOPIC OR EXTRA-UTERINE PREGNANCY pregnancy. As a rule the rudimentary horn has a well-marked pedicle which is dealt with as is the uterine end of the tube. Fig. 7,S A case of ovarian pregnancy. A, stroma of ovary; B, cut edge of attachment; C, placental tissue; D, seat of rupture. (Banks, in Jour, of Obst. and Gyn. of British Empire, April, 1912.) Mortality of Extra-uterine Pregnancy. — In 22 cases of tubal preg- nancy the author has had 2 fatalities; 1 a ruptured tubal pregnancy which was not seen until a general suppurative peritonitis had developed, and an intraligamentary pregnancy ruptured into the general peritoneal cavity with the escape of a large amount of blood. Death resulted from surgical shock. The 20 cases which recovered were of the following varieties: early unruptured tubal pregnancies, 4; early tubal abortions, 3; early intraperitoneal ruptures, 7; early intra- ligamentary ruptures of the pregnant tube, 6. In all the cases both the tube and the gestation sac were removed. The ovary of the affected side was saved in more than half the cases. Schauta reported 241 cases not operated in which there was 'a mor- tality of 68.8 per cent. In the Johns Hopkins Hospital there were 139 cases reported by Kelly, of which 6 died. It will be of interest to note a comparison of the results in the conservative and radical methods of treatment of extra-uterine pregnancy. Von Scanzoni treated 56 cases of early rupture of the tube by the expectant treatment and operated in 63 additional cases. Those treated MORTALITY OF EXTRA-UTERINE PREGNANCY 173 expectantly were dismissed on an average of fourteen days earlier than were those on whom a laparotomy was performed. It must be borne in mind that the depression in these cases was not as great as it was in those on whom laparotomies were performed, and hence the period of convalescence would naturally not be so long. It must also be borne in mind that Scanzoni has not taken into account the disabilities that accrue from unremoved pelvic hematomas, meaning by them principally the adhesions which commonly develop in and about the site of a hematoma. Prochownick argues for early operative interference in all of these cases. He affirms that the majority of his cases treated on the expectant plan kept on ailing, whereas those on whom an abdominal or vaginal section was performed gave better remote results. In 50 laparotomies 41 gave good results and in 18 vaginal incisions 12 made good recoveries. The following statistics speak for the good results in operated cases of ruptured tubal pregnancy with encapsulated escaped blood: Schauta 82 cases with 2 deaths Ktistner 72 cases with 1 death Fehling 130 cases with 3 deaths Kronig 63 cases with death Total 347 6 Formad, formerly coroner's physician in Philadelphia, found hemor- rhage due to ruptured tubal pregnancy the cause of death 35 times in 3500 autopsies. CHAPTER X CHORIOEPITHELIOMA MALIGNUM Etiology Clinical Diagnosis Macroscopic Appearance Microscopic Appearance Malignant Degeneration of Hyda- TiFORM Mole Primary Chorioepithelioma Out- side OF the Placental Tissue Histogenesis Diagnosis Treatment From the fact that the histogenesis of this newgrowth has, until recently, been little understood, a number of names have been assigned to it. It was called deciduoma malignum, because it was believed to be a malignant proliferation of the decidua. Sarcomachoriocellulare was a name suggested, on the theory that the essential cell structures were of mesoblastic origin. On the other hand, the name carcinoma syncytiale was proposed, because of the supposed epithelial character of the growth . The term chorioepithelioma malignum more accurately expresses the true histogenesis of the growth, for it is now generally conceded that the growth is derived from the epithelial elements of the chorion and not from the decidua. (See Plate XII.) This tumor formation was first described by Sanger, in 1888, before the Obstetrical Society of Leipzig. Sanger believed the growth to be a malignant proliferation of the decidua, and classified it as a sarcoma. L. Fraenkel was first to demonstrate the origin of the growth in the epithelium of the chorion. He classified the tumor as a carcinoma. The present knowledge of the histogenesis and histology of chorio- epithelioma malignum is largely due to Marchand's important work on this subject. He demonstrated that both the syncytium and Langhans' cells take part in the formation of the newgrowth, and hence the fetal origin of the tumor, though occupying maternal tissues. Peters demonstrated the true genesis of the epithelial layers of the chorion, Langhans' layer, and syncytium in his observations on an ovum estimated to be five to six days old.' He has demonstrated to the satisfaction of most observers that both the syncytium and Lang- hans' layers are derived from the ectoderm or trophoblast and that they are histogenetically identical. Holding to this view of the his- togenesis of Langhans' layer and the syncytium a more intelligent discussion of the histology of the growth is possible. Etiology.— In the author's analysis of 210 cases of hydatiform mole, he found that 16 per cent, became malignant. It is stated that from 40 to 53 per cent, of chorioepithelioma malignum cases follow the expulsion of a hydatiform mole, 25 to 35 per cent, follow upon abortions, and 20 to 25 per cent, follow upon full-term labors. Briguel collected X [J < O) s: a 'E o >> ETIOLOGY 175 181 cases of syncytioma malignum, in which 46 were preceded by normal labors, 55 by abortion, 76 by hydatid mole, and 4 by tubal pregnancy. Tubal pregnancy has given rise to chorioepithelioma malignum in 13 reported cases. All were fatal save the one reported by Albert. It is seen that hydatid mole is particularly likely to undergo malignant degeneration. The time a hydatiform mole remains in utero has no influence upon the development of a malignant growth; there is the same liability to malignant transformation in the early as in the later moles. In 124 cases collected by Ladinski the average age of the patients was thirty-two years — the extreme ages seventeen and fifty-five years. The greatest number occurred between twenty-seven and thirty-three years of age. In 90 cases collected by the same author the average number of children born was 4.2. The time of the development of the growth in the placental site in relation to the expulsion of a hydatid mole, an abortion, or a full-term labor is two weeks to four and a half years. Clinical Diagnosis. — The diagnosis must be based upon both clinical and histological investigations. There is almost invariably a history of pregnancy and the expulsion of a hydatiform mole, an undeveloped fetus, or a full-term fetus, weeks, months, and even years before the appearance of a malignant growth. The earliest symptom is hemorrhage. The loss of blood increases in amount and frequency, and very early causes profound anemia. The usual means employed to check hemorrhage fail utterly, and may increase the flow. Persistent hemorrhage following upon an abortion or hydatid mole is suggestive of syncytioma. In curettage, the procedure must sometimes be abandoned because of the alarming hemorrhage. A dirty, watery discharge occurs, together with and in the intervals between hemorrhages. Later this discharge assumes a foul odor. Pain is not a notable symptom. When present it is usually referred to the thighs and sacral region. Cachexia is an early development, following closely upon anemia. Loss of weight and strength is extreme. Symptoms referable to metastasis are early present — so early as to be characteristic of the disease. In order of frequency metastatic growths are found in the lungs, vagina, liver, spleen, kidneys, ovaries, intestines, brain, broad ligament, pleura, lymphatic glands, pancreas, heart, stomach, and lymph glands of the pelvis. It is unusual for the metastatic growths to spread by way of the lymph glands, as is com- mon with carcinoma. The cellular elements are, as a rule, conveyed by the blood stream, and in this respect behave like a sarcoma. Fever of a low grade is commonly present, and may reach 104° F. The pulse is correspondingly rapid and feeble. These clinical signs are very significant, but alone they are not sufficient. The macroscopic and microscopic features of the growth must be considered before a diagnosis can be made with certainty. 176 CHORIOEPITHELIOMA MALIGNUM Macroscopic Appearance. — The macroscopic appearances of the growth are generally characteristic. The uterus is almost always enlarged, and is commonly described as soft. In advanced cases there may be irregularities on the outer surface as well as on the inner. The cervix is usually patulous to the index finger, and in the cavity of the uterus may be felt a soft, brain-like mass, friable, and bleeding profusely when handled. To the naked eye this soft mass resembles at times placental tissue, and at other times a vascular sarcoma. The color of the growth is mottled red, varying from a bright to a dark shade. Necrosis early develops. The primary growth is not always confined to the uterus. Cases have been recorded in which the uterus remained free and a chorioepithelioma malignum developed in the vagina, lung, kidney, liver, brain, and spleen. (Vide infra.) Microscopic Appearance. — The microscope is indispensable in deter- mining the true character of the growth. Under the microscope a rapidly proliferating structure is recognized. It is composed of syn- cytium and Langhans' cells, which invade the uterine tissue in a most typical manner, and are early conveyed to distant portions of the body by way of the blood-stream. After the expulsion of a hydatid mole the uterus should be explored by the finger to detect and remove any retained placental tissue. Two weeks later the uterus should be curetted and the scrapings examined microscopically. If Langhans' cells and the syncytium are found to be proliferating in the decidua, the uterus should be removed without delay. In every abortion or full-time labor, when an unaccountable hemorrhage follows weeks and months afterward, an exploratory curettage should be done, in view of the possible finding of malignant placental tissue. The microscopic picture is that of strands of protoplasmic masses, with nuclei and vacuoles forming a reticular structure. Polynuclear giant cells of syncytium are found in the network. The histological character of these growths differs widely. Two chief classes are recognized by Marchand: The typical and atypical. Typical Form. — ^The typical form assumes the character of the chorionic epithelium in the early placenta, in that it presents a prolific growth of syncytium in a more or less established manner, together with a rather definite proportion of Langhans' cells. Not only may the epithelial elements be present in fairly definite proportions, but the entire villus, composed as it is of stroma and overlying epithelium, may be found in the tumor growth. In short, there are found in the chorioepitheliomatous growths all the elements of the placenta which are found in the early stages of pregnancy, and the arrangement of these elements is not unlike that of the normal placenta. Atypical Form. — The atypical form presents a remarkable variation in its cellular structure and in the arrangement of its cells. The gen- eral arrangement of the elements in the normal placenta is lacking. The shapes of the individual cells alone suggest placental tissue, and in this there are great variations. Some have been composed wholly of MALIGNANT DEGENERATION OF HYDATIFORM MOLE 177 syncytium, others wholly of Langhans' cells. There is such variation in structure that at times it is impossible to distinguish Langhans' cells from syncytium. A feature worthy of special remark is the large quantity of blood in the primary and secondary growths. The blood lies between the cell elements and bathes them as in the case of the normal placenta, only here an exaggerated condition is found. A further analogy between the chorioepitheliomatous growths and the normal placenta is the peculiar relation between the epithelial cells and blood fibrin. In both conditions fibrin layers are found between individual cells and groups of cells. The syncytial cells penetrate vessel walls, blood is liberated, and, as a consequence, thrombi are formed in the bloodvessels, and there is a hemorrhagic infiltration of surrounding tissues with the formation of fibrin. Fresh hemorrhages add to the mass by extending the blood-spaces, and in this manner the rapid growth of the tumor is explained. The metastatic growths resemble the primary tumor. Fig. 79 ,.r"^-idi &._ "•;.ed and why the growth at times becomes malignant are unsolved problems. Diagnosis. — From a study of reported cases it is observed that the clinical diagnosis of primary chorioepithelioma has only been made in the cases in which the lesion could be directly inspected — i. e., in the vagina, labium, and cervix. They were recognized by their character- istic rounded shape and bluish color, their tendency to bleed freely, and by the absence of uterine hemorrhage, together with negative findings in the uterus, after exploring with the finger and curet. The clinical diagnosis was at all times confirmed by microscopic examinations of portions of excised or curetted tissue. Without the microscope a positive diagnosis is not possible. Tumors lying in hidden portions of the body — e. g., kidney, liver, 186 CHORIOEPITHELIOMA M ALIGN UM and lung — were not diagnosticated with certainty without a post- mortem examination. When the case did not end fatally it was not possible to say that the growth was malignant, from the fact that the macroscopic and microscopic findings in these growths were in no way diagnostic of malignancy. The ages at time of operation were twenty to fifty years. Twelve of the seventeen cases in which the age was recorded occurred between thirty-five and forty-one years of age. Among these there is one case in which a hydatiform mole was in utero at the time of the appearance of the symptoms and primary growth. In another case there was a two months' fetus in utero. In three cases the tumor followed incomplete abortions; in three others the abortions were complete, and seven cases had had normal labors. In all cases in which there were vaginal or cervical tumors, hemor- rhage was the symptom which led to the detection of the growth. In exceptional cases a foul-smelling vaginal discharge followed the appearance of the hemorrhage. From the fact that these growths are so frequentl}^ located in the vagina, and that hemorrhage is an early and constant symptom, suspicion should always be aroused by the occurrence of bleeding from the vagina during the course of pregnancy after the expulsion of a hydatiform mole, an abortion, or labor. If on inspection such a tumor is found it should be excised, and if on microscopic examination chorionic epithelium is found an exploratory curettage of the uterus should be made. The microscopic findings in the scrapings, however, cannot be depended upon in determining the malignancy; hence, because of these present limitations, it would appear to be advisable to make a complete extirpation of the uterus when syncytial tissue is found in the scrapings. The cases which have recovered after the removal of the vaginal growth without hys- terectomy do not, as far as present knowledge goes, justify leaving the uterus unless, by an exploratory curettage, the uterus is found free from all chorionic epithelium. The relation of hydatiform mole to chorioepithelioma malignum is discussed on page 177. The diagnosis of the malignant character of a chorioepithelioma cannot be based upon the macroscopic or microscopic appearances of the growth, nor will the presence of metastatic growths confirm the diagnosis. The histological and naked-eye appearances are the same in the benign as in the malignant forms, and metastatic growths have been known to disappear spontaneously. The ultimate clinical course must therefore be depended upon for the diagnosis of malignancy. Treatment. — The treatment consists in the removal of the entire uterus and its appendages at the earliest possible moment. The high mortality in cases following labor at term is very striking. CHAPTER XI NON-OPERATIVE :METH0DS OF TREATMENT Hydrotherapy Hot Air Treatment Hot Pack Counter-irritatiox Tampons Pelvic Massage Pressure Therapy Electricity X-RAY Therapy Swabs Serum and Organotherapy Prior to the days of antisepsis and asepsis, operations were performed for the relief of only a limited number of the diseases peculiar to women and these were practically confined to the plastic operations upon the cervix, vagina, and perineum. Even these operations did not meet with general favor because of the dangers involved from hemorrhage and infection, and the small percentage of satisfactory results. At such a time it was but natural that relief should be sought in more conservative ways. Accordingly the profession seriously dis- cussed the value of electricity, massage, internal medication, etc., for relief from ailments which are now regarded as preeminently surgical. The explanation for these measures lay not only in the shortcomings of surgery, but, in part, in the lack of knowledge of the pathology of intrapelvic lesions. As a logical sequence, diagnosis and treatment had no rational scientific basis. The advent of antiseptic surgery ultimately made possible the explo- ration of the pelvic cavity with comparative safety, thereby affording abundant opportunities for the study of these lesions. An operative furore was created, which for a time so possessed the profession that non-operative means of relieving the ailments of women were almost wholly lost sight of. Organs were sacrified, partly in ignorance, partly for greed of gain. Happily, at no time were these extreme practices universally com- mended; there were always weighty voices raised to challenge the practices of the rash, the vicious, and the ignorant. Having applied non-operative methods to all but the exclusion of the operative, and later the operative to the nearly universal annihila- tion of the non-operative, the profession has come to the position of true conservatism. The limitations of non-operative therapy are now appreciated, and it is accorded its rightful place in the treatment of diseases of w^omen. Similarly surgery now has its limitations; the one is not employed to the exclusion of the other but, hand in hand, they work for good. General and local treatments are made to accomplish what siu-gery 188 NON-OPERATIVE METHODS OF TREATMENT has failed to do in selected cases. ]\Iore often they are used as a fore- runner and accompaniment of surgery, and as a means of obtaining a better result subsequent to operation. The author believes in the inestimable value of so-called local treat- ments, not only as an aid to surgery, but also in many instances as the only method required to obtain the desired result. Everything depends upon the intelligent application of the treatments. As often practised they are of no value and are more meddlesome than useful. In order that their full value may be understood and their limitations be clearly defined, the author deems it necessary to present a detailed description of the technic, and a comprehensive discussion of the indications and contraindications for all non-operative, therapeutic measures applied to diseases of women. They are worthy of more generous recognition than has heretofore been accorded to them in text-books and monographs. The physician who is most successful in the treatment of diseases peculiar to women will give due consideration to all conditions — phj'sical, social, and moral — which influence the life of women, and he must not lose sight of the fact that gynecology is an integral part of the general medical science. Hence it follows that the genital organs of women are not a law unto themselves, but are subject to the laws which govern the body in general. HYDROTHERAPY Baths Ice-bag Vaginal Douche ' Hot Compresses Intra-uterine Douche Saline Injections Enteroclysis HjT)odermoclysis Intravenous Hot-water Bag Water Drinking Baruch says: "A somewhat extensive experience has convinced me that, although water is a simple remedy and so easily applied that anyone seems justified in using it, I must insist, with full consciousness of the import of my words, that no remedy in the entire materia medica demands as clear judgment and as much knowledge of the patient's condition as does the application of water." The value of water as a remedial agent is not fully appreciated, because the physiological action of water is not generally understood by the profession. Hydrotherapy, accordingly, is not applied with that discriminating sense which brings desired results. Water is one of the most valuable therapeutic agents in the treatment of diseases of women, but the laws of hydrotherapy must be understood if they are to be applied successfully. The physiological action of water applied to the surface of the body or to the vagina and bowel produces a mechanical HYDROTHERAPY 189 effect upon the tissues with which it comes in contact, and upon the nerves and vessels supplying these structures. The direct impact of the water cleanses the surface or cavity and stimulates the peripheral vasomotor nerves, thereby producing a primary effect of stimulation in proportion to the force of impact and to the degree of heat or cold. If the application is long continued the effect of stimulation gives place to that of relaxation. If the area involved is of considerable extent the general vascular system will be influenced in the same manner as are the vessels in the tissues directly affected. By stimulating the general circulation, the nutrition and secretions of the body are influenced; thus, a general as well as a local reaction is obtained which contributes to the general well-being. Fig. 83 A modern bath. Baths. — By the application of hot or cold water to the surface of the body, both the vasomotor nerves and the muscular fibers are stimulated. In this respect cold produces the same effect as heat, differing only in degree. The degree of heat or cold and the duration of the application determine the effect upon the tissues as to whether the reaction will be short or long, great or little. This period of reaction is in two stages, (1) of stimulation, (2) of relaxation. In the first stage the bloodvessels are constricted, hence the supply of blood is lessened in the tissues directly affected; in the 190 NON-OPERATIVE METHODS OF TREATMENT second stage the walls of the bloodvessels are relaxed, thereby increasing the blood-supply to the parts immediately affected. It is estimated that the cutaneous bloodvessels are capable of accommodating 60 per cent, of the blood of the body, hence baths have much to do in controlling the distribution of the blood. Temperature. — The temperature of the water is a most essential factor in the successful application of the bath. By regulating the temperature it is possible to obtain a stimulating or relaxing eft'ect and to accomplish the effect quickly or slowly according to the degree of temperature. The effect of cold upon the respiration is that of stimulation. The respiratory act is deepened, thus oxidation is increased and an excess of carbon dioxide is thrown off. By stimulating the heart and contracting the peripheral bloodvessels the blood tension is heightened. Cold baths at daily intervals, when properly administered, will tend to increase the general nutrition; to promote secretions and excretions and in time to improve the functional activity and structural develop- ment of the body. The primary effect of moderate degrees of heat is mildly stimulating and the secondary effect is that of relaxation. The primary effect of high degrees of heat is at first stimulating then relaxing. Duration. — A bath or douche of short duration, whether hot or cold, is stimulating, and in proportion to the degree of heat or cold. With the continuance of the bath the stage of relaxation comes and con- tinues in proportion to the degree of heat or cold, to the duration of the bath and to the physical resistance of the individual. The Position of the Patient. — The position of the patient while taking the bath or douche has much to do with the results. (See page 197.) Rest and Friction after the Bath. — When a stimulating effect is desired the bath should be followed by friction of the body with a coarse towel, and should be both preceded and followed by systematic exercise to promote the circulation and thus favor a prompt reaction. Sedative baths should be followed by rest and the body should be dried with a soft towel without friction. The idiosyncrasies and state of health of the individual must be considered in the enforcement of these rules. A short cold bath and to a lesser degree a short hot bath are stimulating. Blood is first forced to the deeper parts of the body; the respirations are deepened. This in turn stimulates the heart and thereby increases the blood supply to the body. In this manner the tissues are better nourished and all functions of organs are more active. All this leads to a heightened power of resistance to morbid processes. If the tissues react promptly to the stimulating effects of the bath there is a general invigoration of the whole body, and this is increased by friction of the body and exercise. Time for Taking a Bath. — As a rule a stimulating bath should be taken in the morning upon rising and a sedative bath in the evening before retiring. HYDROTHERAPY 191 Varieties of Baths. — Sponge Bath. — The sponge bath has a stimulating effect if taken hot, cold, or alternating. The hot sponge bath is seldom employed. In the cold sponge bath there is a stimulating action. After exercise it is invigorating and refreshing. The temperature of the bath-ranges from 50° to 70° F. It is best taken standing in a bath-tub. When the individual is not accustomed to cold baths it would be well to begin with a temperature of 70° to 80° F. and gradually lower the temperature to 50° F. Occasionally the alternating sponge bath is recommended for its stimulating qualities. Two basins are placed side by side in a bath- tub, one filled with water at 110° the other at 50° F. Standing in the bath-tub the individual quickly alternates from one basin to the other, using a sponge. Vigorous friction with a coarse towel should follow the sponge bath, after which some light exercise should be indulged in, such as walking briskly. Sponging in Bed. — When for any reason the patient cannot stand throughout the bath she may be sponged in bed. She lies upon a rubber sheet and is covered by a woollen blanket. The body should be kept covered during the bath, so far as possible. Equal parts of alcohol and water are applied at a temperature of 70° to 75°. Fig. 84 .^ Portable tub. Showee Bath. — The action of the cold shower is stimulating. For convenience, the adjustable shower bath with a rubber sheet attach- ment is preferred. This can be arranged to overhang the bath-tub with little expense. A less expensive apparatus consists of an adjustable spray attached to the spigot of the bath-tub by a flexible tube several feet in length. In the absence of suitable plumbing, such as pray may be attached to a fountain syringe. With such an apparatus the patient may stand in a tub. The force of the spray as well as the temperature of the water determine the stimulating; effect of the bath. The colder the water 192 XOX-OPERATIRE METHODS OF TREATMENT and the greater the force the more rapid and more pronounced the reaction. As ^\ith the sponge bath so with the shower, the water may be cold or graduated from lukewarm to cold; again, it may be alternating from hot to cold. The spray is directed first to the shoulders, then to the chest, back, abdomen, and extremities, and should not, as a rule, exceed thirty seconds in time, and should never be prolonged bevond two or three minutes. Fig. So Shower bath. As with all cold baths, the shower bath is best taken in the morning after light exercise, and should be followed by rubbing with a coarse towel. The graduated shower bath should begin at about S0° F., and the temperature lowered 2° each day until 50° F. are reached. The alternating spray begins at 100° to 114° F. and abruptly changes to 50° to 70° F. The R^lf Bath.— The tub is filled with water sufficient to cover half the body, with the patient in the recumbent position. The bath may be hot or cold according to the indication. The same precautions should be taken as in the other varieties of baths. If a stimulating effect is desired the temperature of the water may be fixed at 80° F.; in HYDROTHERAPY 193 this the patient lies for a few minutes, then rises for a short cold shower and vigorous friction of the body. If a sedative effect is desired the temperature of the water should be about 80° F., and the duration of the bath twenty to thirty minutes, after which the body is dried with a soft towel, without friction. The body is then "^Tapped in a woollen blanket or bath robe. It would be well for the patient to lie on a couch or bed for a half hour or more after such a bath. The Full Tub Bath. — The full tub bath may be stimulating or sedative according to the temperature of the water and the length of the application. The prolonged hot tub bath is sedative, and should not be preceded by exercise. It is best taken at bedtime and should not be followed by vigorous rubbing or exercise. The temperature of the hot bath ranges from 100° to 114° F., and the duration is ten to thirty minutes, according to the reaction of the individual and the effect required. Long hot baths frequently repeated are debilitating. The hotter the bath the quicker and the more pronounced the reaction. The warm tub bath at 75° to 90° F. is sedative in its effect but the reaction comes slowly. It is subject to the same regulations as the hot bath. The Cold Tub Bath. — With the water at 50° F. .the bath is decidedly stimulating. In order that the reaction will not be delayed it should be preceded by sufficient exercise to stimulate the circulation. As with all cold baths it is best taken in the morning upon rising, and should be followed by vigorous rubbing with a coarse towel. The duration of the plunge should not exceed thirty seconds unless the individual is very vigorous. Depression will follow a prolonged cold bath. Chill, languor, or drowsiness coming on after the bath are contra-indications. Old age is a contra-indication, as is arteriosclerosis and other evidences of senility. The Sitz Bath. — Sitz baths are applied to the pelvis and its contents; they operate upon this region of the body as does a full bath upon the general system. They are giA^en cold, hot, or graduated. Cold Sitz Baths. — Cold sitz baths are given at a temperature of 50° to 75° F. They are seldom employed and are of little value. Their duration should not exceed one to five minutes, after which the body should be quickly dried, and a rest of a half hour or more should be enjoined. • The cold sitz bath is indicated in amenorrhea not dependent upon pregnancy, in lactation atrophy of the uterus, in muscular insufficiency of the uterus causing hemorrhage and leucorrhea, and in subinvolution, passive congestion, and chronic inflammation of the uterus. The contra-indications are pregnancy, menstruation, acute pelvic inflammation, and spastic conditions of the bladder. Prolonged Hot Sitz Bath. — The prolonged hot sitz bath is of value in relieving congestion and in favoring the absorption of pelvic exudates. Hot sitz baths are usually taken at bedtime, and have a sedative 13 194 NON-OPERATIVE METHODS OF TREATMENT effect on the tissues directly affected. The temperature of the water ranges from 110° to 114° F., and is continued from twenty to thirty minutes. The graduated sitz baths begin at a temperature of about 100° F., and cold water is added until the patient begins to feel chilly, when she is removed from the bath, dried, and placed in bed between warm blankets. The effect is slightly stimulating. Sea Bath. — Sea bathing is very beneficial on account of its stimu- lating effects, if taken judiciously. The benefit derived does not depend solely upon the effect of the water. The change of scene, diet, and air are most helpful; these factors, together with the cool plunges and the invigorating effects of the surf, act as a tonic to the general system. If prolonged the effect may be exhaustion, hence the temptation to remain long in the water must be resisted. As soon as the sense of chilliness is felt the bath must be discontinued and the body rubbed with a coarse towel. These baths should only be taken in the sunshine, when the reaction will be more prompt. They are of special value because of the attending muscular exertion. It is well to take a brisk walk on the beach before and after the bath. Salt Baths. — The addition of two five-pound packages of sea salt to the cold tub bath adds to the stimulating effects of the bath; furthermore, sea salt added to the hot tub bath augments the sedative effect. The Turkish Bath. — To equip the home with a turkish bath requires a specially constructed apparatus. A cabinet may be made of a steel frame covered with a double layer of rubber sheeting. In the top is an opening through which the head protrudes. Enclosed within the cabinet is a stool on which the patient sits, and under this stool is placed an alcohol lamp or gas stove. The cabinet should be heated for ten minutes before the patient enters it. The hot-air bath should continue ten to twenty minutes, and imme- diately upon leaving the cabinet the patient should be given a hot shower bath at a temperature of 100° to 110° F., this to be followed by a cold shower of 50° to 75° F., and, finally, there should be vigorous rubbing of the body with a coarse towel, after which the patient is wrapped in a blanket and placed on a couch for a half-hour or more. Water should be drunk freely both before and during the bath. Free perspiration is usually excited within ten minutes of the begin- ning of the bath. If throbbing of the head occurs or the pulse reaches 120 to the minute the bath must be discontinued. A cold cloth, to the head will add to the comfort of the patient. The Russian Bath. — The apparatus and general technic of the bath is the same as in the Turkish bath, with the exception that a kettle filled with water is placed over the stove to generate steam. The Sheet Bath. — A muslin sheet is wrung out in iced water and wrapped about the body. With a wet towel the attendant slaps the body vigorously. Sharp, quick strokes are kept up for from two to five minutes. The sheet is then removed and the skin vigorously rubbed HYDROTHERAPY 195 with a coarse towel. The patient is then placed in bed, WTapped in a blanket. Such a bath is stimulating in its effects, and is best given in the morning. Bathing during the Menstrual Period. — There is no reason why a woman who is in the habit of taking daily baths should be deprived of them while menstruating. A menstruating woman in good health will suffer no ill eft'ects from a hot or cold bath provided certain precautions are taken, and it may be said of all women that their personal comfort and general health will be the better if such daily baths are taken during the menstrual period. The rules of hygiene demand that a daily tepid bath (80° to 90° F.) be taken throughout the menstrual period. Women should be cautioned against the dangers of chilling the body during and following the bath. Sea-bathing, for this reason, is dangerous. The Nauheim Bath. — The stimulating effect of a bath may be aug- mented and made more agreeable by the addition of certain chemical substances. In this manner a pronounced reaction is eff'ected which alters the distribution of the blood so that the congestion of internal organs is relieved. The number of red blood cells is increased in the circulating blood, the tone of the tissues, including the heart, is increased, and by stimulating the trophic central nervous system the general tissue metabolism is increased. By adding to the bath water a chemical stimulus the eff'ect is most agreeable and prompt. The addition of salt augments the stimulating qualities, and because of this the individual will take the bath at a lower temperature. The Xauheim bath consists of a bath containing salt, calcium chloride, and carbonic acid gas, in var^dng proportions. The temperature of the bath varies from 80° to 95° F., and should be continued five to twenty minutes. Kt the beginning of the treatments there should be added to the tub of water 3 to 5 pounds of sea salt, 2 to 4 ounces of calcium chloride, and one-half box of triton salts. After each third or fourth bath a little more of each salt should be added if the patient responds well to the baths. The temperature of the bath which begins at 75° F. is gradually lowered to 85° F., provided the change is agree- able to the patient. xAfter the bath the body is gently dried with warm towels, a hot drink of milk or tea is taken, and the patient lies down for a rest of an hour or two. It will be seen that these baths are eminently stimulating, and as such are applied to individuals suft'ering from chlorosis with accompany- ing amenorrhea, faulty development of the genitalia, subinvolution of the uterus, and all lesions of the pelvic organs which are associated with pelvic congestion, such as chronic metritis, pelvic cellulitis, and salpingitis. They are also said to add tone to relaxed pelvic and abdomi- nal organs as seen in general visceroptosis. Neurasthenic conditions are favorably influenced by these baths. The nervous manifestations of the change of life are greatly relieved by the judicious application of these baths. It is imperative that they should be given under the direction of the physician, because the reaction of the individual 196 NON-OPERATIVE METHODS OF TREATMENT depends upon the strength of the baths, upon their temperature and duration. The Therapeutic Application of Baths. — Sedative Bath (Hot). — The relaxing effect of a prolonged warm bath has been noted. It follows that such a bath would be applicable to nervous and excitable indi- viduals, to insomnia, to spastic dysmenorrhea, to the various nervous manifestations of the climacteric, and to pelvic congestion from whatever cause. They are best given in the evening just before retiring, and should be followed by a drink of hot milk or hot lemonade. Stimulating Bath {Cold). — Inasmuch as the cold bath is stimulating to the vasomotor nerves, to the superficial muscles, and indirectly quickens the general circulation, driving the blood to internal organs, thereby stimulating the functions, of these organs, it follows that the Fig. 86 Vaginal douche. Patient lying upon her back. The vagina is distended. cold stimulating bath is of special value in neurasthenic states, in general malnutrition, chlorosis and other forms of anemia, in amenor- rheics, especially when associated with chlorosis and in visceroptosis with relaxation of the supports to the pelvic organs. The bath is best given in the morning, and should be followed by brisk rubbing, with a coarse towel and moderate exercise if the condition of the patient will permit. The Vaginal Douche. — One of the most valuable agencies in the treatment of diseases of women is the vaginal douche. Like the bath its modus operandi is not generally understood, and when wrongly applied is capable of doing harm, but when rightly applied the vaginal douche acts as a stimulant to the vasomotor nerves and to the uterine musculature. As a cleansing agency it is indispensable, and as a means HYDROTHERAPY ' 197 of conveying certain remedies to the vagina and vaginal portion of the cervix it is of service. Physiological Action. — The physiological action depends upon the manner of its application. The posture of the patient and the duration and temperature of the douche are all essential factors in obtaining the desired results. Posture. — For all purposes the recumbent posture is essential in order that the fluid may come in direct contact with the vault of the vagina and cervix and indirectly with the pelvic structures. Fig. 87 \ Kelly pad. The position should be such as to permit the patient to lie in comfort, without exertion, and without fear of soiling the bed or couch. The complaint is frequenth' made that hot douches are exhausting; the explanation usually lies in a faulty posture. Lying upon an uncom- fortable douche-pan that is repeatedly oA'erfilling, requiring its removal from time to time in the process of the douche, is a source of annoyance, and is exhausting. A small spout placed at the upper end of a metallic douche-pan, to which a rubber tube is attached, will serve to carry the douche water from the pan to a bucket at the side of the bed. If the bed is firm, a Kelly pad will serve as a substitute for the douche-pan. For cleansing purposes an ordinary rubber douche bag, holding four quarts, will serve the purpose, but when the douche must be long 198 NON-OPERATIVE METHODS OF TREATMENT continued it is advisable to provide a receptacle holding two to four gallons of water. For this purpose the author usually has a galvan- ized zinc or tin bucket made. It has a capacity of four gallons; a small spout is attached near the bottom, to which a rubber tubing is attached. With such a contrivance and the bed-pan already described a prolonged douche can be given without discomfort to the patient and without exhausting her strength. Fig. 88 Vaginal douche. The reservoir should not be placed higher than four feet above the hips; if pain is caused by the impact of the douche water it should be lowered. A light woollen blanket is thrown over the patient while she is taking HYDROTHERAPY 199 the douche and the temperature of the room should be maintained at 75° to 80° F. Temperature. — The temperature of the douche water is an important factor and largely governs the effect of the douche. A temperature of 110° to 120° F. is well borne. Cold douches are injurious and cannot be too strongly condemned. The pernicious habit of taking cold douches to prevent conception and to delay the menstrual period is productive of much harm in creating a pelvic congestion. Cold douches have been recommended for chronic metritis (Skutsch), for prolapsus uteri, hyperemia uteri, and climacteric hemorrhages (Kisch), but the author cannot indorse these suggestions. Duration. — The duration of the douche is second only in importance to the temperature. A hot douche of short duration (three to five minutes) stimulates the vasomotor nerves and the uterine musculature. In so doing the vaginal cavity is not only cleansed but the uterus is made to contract and the bloodvessels of the pelvis are constricted, thereby raising the blood pressure. With the hot douche prolonged for a period of ten to twenty minutes the uterine musculature relaxes, the caliber of the vessels widens, and congestion is relieved. From this action of the hot douche it is seen that hemorrhages from the uterus are best controlled by a short, hot douche; the effect is due to uterine contraction. Leucorrheal discharges arising from the uterus are influenced in like manner. The great purpose of the short, hot douche is the cleansing of the vagina. The prolonged hot douche is a most efficient means of relieving pelvic congestion, wherever located within the pelvis, and in favoring the absorption of inflammatory exudates. Time of Application. — The time of application will depend upon the indication as well as upon convenience. When given for cleansing purposes the amount and character of the secretions will determine the quantity and frequency of the douche. When the discharge is profuse, irritating, and odorous, the douche should be repeated two or more times daily, but otherwise a single morning douche will suffice. The judicious employment of cleansing vaginal douches will largely prevent the irritating effects of uterine discharges and the development of vulvovaginitis in the presence of a discharge from an infected uterus. It must be borne in mind that hot douches too freely given macerate the vaginal and vulvar epithelium and render the underlying tissues susceptible to infection. In the presence of a pelvic congestion or an inflammatory exudate in the pelvis the hot douche should not only be prolonged ten to twenty minutes, but in order that the effect may be continuous these douches should be repeated every four to eight hours. The duration of the treatment depends solely upon the results obtained. As long as there is an active congestion the douches must be given at frequent intervals, but as the congestion subsides the inter- vals between douches are lengthened, but the duration of the douche 200 NON-OPERATIVE METHODS OF TREATMENT is not shortened. It is not only desired that rehef be given for the time being, but that the results may be permanent; hence the douches must be persisted in so long as there is any evidence of the preexisting lesion. Medicated Vaginal Douche. — Antiseptic solutions are frequently applied, but their value is, as a rule, uncertain. The vast majority of infections are located above the external os and hence cannot be reached by the douche. In such cases the vaginal douche is of no value as an antiseptic agent and serves solely the purpose of cleansing the vagina and in relieving the congestion of the structures lying above the vagina, hence sterile water is just as effective as an antiseptic solution; the effect is thermic, not chemic. It is only when the vaginal and vulvar tissues are infected that the antiseptic douche possesses special virtues; such instances are relatively rare. It is therefore seen that antiseptic vaginal douches have little advantage over aseptic douches. When the discharge has a foul odor, as is the case with advanced cancer, permanganate of potassium or formalin will serve to correct the odor. All sorts of antiseptics have been used. The author's preference is for formalin, 1 to 2000 to 1 to 4000. It is an effective deodorizer and antiseptic; the author employs it as a vaginal douche to the exclusion of all other antiseptics. Fig. 89 Intra-uterine douche. The douche point is directed to the cervix by passing along the palmar surface of the finger. Intra-uterine Douche.^ — The intra-uterine douche has a limited field of usefulness, and is capable of much harm as compared with the HYDROTHERAPY 201 vaginal douche. Indeed, in the author's judgment there is no great indication for intra-uterine douches in gynecological practice; it is largely an obstetrical procedure, and in obstetrical practice it has its limitations. Fig. 90 Intra-uterine douche. Limitations. — It is of little value in gynecological practice because foreign particles can be dislodged from the cavity of the uterus by means of the swab, fingers, curet, and forceps, and medicinal agencies can be applied to the endometrium more effectively and with greater safety by means of the swab. In intra-uterine douches there is always the danger of forcing fluids from the uterus into the tubes and on to the peritoneum. This danger is particularly imminent in the puerperal uterus. Physiological Action. — The action of the hot intra-uterine douche is stimulating if given over a short period; it stimulates the vasomotor nerves, the vessel walls, and the uterine musculature. It also serves to cleanse the uterine cavity. "\ATien long continued the effect is to relax the uterine musculature and the walls of the bloodvessels. The apparatus differs from that of the vaginal douche only in the douche point, which is longer and is provided with a return flow. Technic. — The technic of an intra-uterine douche is as follows: The patient is placed upon a table or firm couch or bed. If she is weak, every means should be employed to conserve her strength; 202 NON-OPERATIVE METHODS OF TREATMENT she should he lengthwise of the bed, and a Kelly pad or bed-pan with an exit spout should be placed under the hips. If it is possible to move her without exhausting her strength or causing pain, it is better to place her crosswdse of the bed with the hips well to the margin of the bed. The feet of the patient may rest upon two chairs placed at the side of the bed. The vulva should be washed with green soap and sterile water followed by lysol or creolin solution or painted with 3 per cent, tincture of iodine solution. A sterile bivalve speculum is inserted into the vagina and the cervix exposed to view. A sterile reservoir, holding two to four quarts of sterile normal salt solution, or a mild antiseptic such as formalin 1 to 4000 or bichloride of mercury 1 to 4000 is placed about two feet about the level of the hips. This reservoir is provided with a sterile rubber tubing and glass or metallic douche point. The temperature of the douche solution ranges from 110° to 120° F., which is accurately determined by a bath thermometer. Under direct inspection the douche point is guided through the cervix into the cavity of the uterus. Before introducing the douche point into the uterus a slow stream' of solution should be allowed to flow in order that all air may be expelled. The solution is then allowed to flow into the uterine cavity at a low pressure, taking care that there is a free return flow. Fig. 91 Leonard's uterine douche. While giving the douche, chilling of the body should be avoided by providing a warm temperature for the room and a covering of blankets for the patient. i\.fter completing the douche the external genitals are dried and the patient is placed comfortably in bed. If iodine is used to disinfect the vulva it is well to remove the iodine in part by bathing the painted surface with alcohol; this will avoid subsequent irritation. The virtue of the intra-uterine douche lies largely in its mechanical and thermic effects; therefore sterile water or normal salt solution will be less dangerous and perhaps equally as effective as antiseptics. When, however, antiseptic solutions are given they should be greatly attenuated because of the absorbing power of the uterus and the danger of forcing the solution into the peritoneal cavity through the Fallopian tubes. Saline Injections. — The injection of a sterile physiological solution of salt into the circulation of the blood is recognized as one of the most HYDROTHERAPY 203 valuable therapeutic agencies at the command of the physician. As a non-operative, life-saving agency, normal salt solution has no equal. General Indications. — Normal salt solution finds its greatest indication in the treatment of shock from loss of blood. It is also of great value in the treatment of renal insufficiency, general sepsis, and in uncontrol- lable vomiting following operations, and as a routine procedure after prolonged operations for the purpose of relieving depression and quenching the thirst. For fear of increasing the blood pressure, normal salt injections should not be given in postoperative hemorrhages until the bleeding vessels are secured. The choice of the method of its administration is governed by the urgency of the indication. When prompt action is demanded intra- venous injections should be employed. When there is less urgency, hypodermoclysis is the method of choice; and when the depression is but slight, the diminution in the secretions of the kidney not alarming, or the loss of blood not great, enterocylsis is preferred unless contra- indicated by conditions of the bowel, such as obstruction, recent oper- ations upon the lower bowel, and injuries to the bowel wall acquired in operation. Enteroclysis. — Technic. — The reservoir for containing the solution may be a rubber bag holding two to four quarts or a graduated glass receptacle. To the reservoir is attached a rubber tube several feet in length, on the end of which is a rectal douche point made of glass or hard rubber. This apparatus is sterilized by boiling in water or by placing in an instrument sterilizer. A sterile thermometer should be provided by which the temperature of the solution may be accurately measured. Quantity of the Solution. — One to two quarts of sterile normal salt solution are placed in the reservoir at a temperature of 110° F. If additional stimulation is indicated a half-ounce of whisky or brandy may be added to the salt solution. Half and half of salt solution and black coffee is an effective enema. Rapidity of Administration. — The urgency of the indication and the absorbing power of the bowel will govern the rapidity of the administration. As a rule one to two pints of the solution are injected into the bowel four to six times in twenty-four hours throughout the period of de- pression, and the time allotted to each injection will range from five to fifteen minutes. When the reaction has set in, as indicated by the increase in the volume of the pulse and the added quantity of urine secreted, the interval between the injections should be gradually increased. The continuous injections of normal salt solution in the bowel are of special value when there is profound shock from loss of blood or grave and progressive general sepsis. The technic consists in elevating the foot of the bed and hips to an angle to 20 to 30 degrees; the rectal tube is inserted high in the colon; the reservoir is placed at a 204 NON-OPERATIVE METHODS OF TREATMENT Fig. 92 low level to provide but little pressure in order that the solution may enter the bowel slowly. An hour should be consumed in the injection of a single pint of the solution. These injections should not be permitted to embarrass the heart action by increasing the vascular tension beyond the ability of the heart to propel the blood current. Such an event is particularly imminent when there is faulty elimi- nation from the kidneys, bowel and skin. Several degrees of temperature are lost in the passage of the solution through the tube, hence the necessity of keeping the solution in the reservoir at about 114° F. When not contra-indicated these continuous, irriga- tions may be prolonged over many hours and even for a day or two. Sooner or later there is likely to develop an irritable condition of the bowel, in which event the injections must be discontinued and hypodermoclysis substituted if the condition of the patient demands it. Hypodermoclysis. — Apparatus. — The apparatus is identical to that used in enteroclysis with the sub- stitution of an aspirating needle for a rectal tube. Preparation of the Field of Operation. — Surgical principles are to be applied to the preparation of the field of operation. The part to be injected should be thoroughly cleansed with green soap and sterile water, dried with sterile gauze and finally scrubbed with alcohol. A more convenient method of sterili- zation is the painting of the field with tincture of iodine. After com- pleting the injection the puncture is sealed with collodion and sterile cotton. Temperature. — ^The temperature of the injected solution should be 112° F.; this will favor rapid absorption and a prompt reaction. Quantity. — The quantity of the solution injected should not exceed one pint and may be repeated once in four to six hours until the reaction is well established. From fifteen to thirty minutes should be consumed in the injection of a single pint. Massage. — Massage of the injected area will favor the absorption of the solution and may be carried on throughout the process of injection. Technic. — The point of injection should be at the seat of an abundance of loose connective tissue, preferably in the breast, the midaxillary line three inches below the axilla, or in the lumbar region. The author has never employed local anesthesia before the injection, because the introduction of the aspirating needle causes little more pain than the hypodermic needle. When a local anesthetic is desired a 2 per cent, solution of the hydrochlorate of cocaine or freezing with ethyl chloride may be employed. The reservoir, tubing, and aspirating needle must be rendered sterile HYDROTHERAPY 205 by boiling. A known quantity of sterile salt solution is placed in the reservoir, and an assistant is instructed to hold the reservoir about six feet above the level of the field of operation. The operator allows the solution to flow while holding the tubing and needle upright to expel the air and the water which has cooled in the tube. With the solution running, the needle is thrust obliquely through the skin into the subcutaneous connective tissue, taking care that it does not enter the muscles. As the solution infiltrates the connective tissue spaces the skin is raised and stretched. If the solution is not readily Fig. 93 Administration of normal salt solution. absorbed, gentle massage of the infiltrated area will hasten the absorp- tion. The temperature of the solution in the reservoir should be kept at 112° F. by the addition from time to time of a hot solution. When the desired amount has been injected the needle is quickly withdrawn, a finger is placed over the puncture in the skin to prevent the escape of the fluid until the wound is dressed with sterile cotton and collodion or sterile gauze and adhesive straps. Intravenous Injection. — Indications. — This method of administration of normal salt solution is practically limited to cases demanding an 206 XOX~OPERATIVE METHODS OF TREATMENT immediate reaction. When there has been great loss of blood, the lowered blood pressure may prevent the absorption of the salt solution from the bowel and subcutaneous connective tissue, and demand the introduction of the solution directly into the blood stream. In septicemia and uremia, when the blood pressure is high, it may be advisable to perform venesection for the removal of a quantity of blood, and to follow the withdrawal of the blood by the introduction of an equal or greater quantity of normal salt solution. Apparatus. — The apparatus required in intravenous injections con- sists of a graduated glass reservoir, a thermometer, a rubber tubing several feet in length to which is attached a Shober cannula. In addition to these instruments there will be required a scalpel, a pair of small sharp pointed, straight scissors, tissue forceps, two small curved needles, a needle holder, and No. 2 plain catgut. All instruments, as well as the hands of the operator, must be rendered sterile by the usual methods. Local Anesthesia. — A 2 per cent, solution of cocaine may be injected at the point of incision. This should render the operation painless. Technic. — The operation consists in bandaging the arm tightly above the elbow. An incision of three-quarters of an inch in length will suffice for the exposure of the vein. A careful dissection of the vein is then made, freeing it for a distance of about one inch. The vein is ligated with catgut at the lower extremity of the incision. A second ligature is passed about the vein three-quarters of an inch above the lower ligature, but is not tied until the vein is opened and the cannula is in place. The vein wall is grasped with a tissue forceps at a point midway between the ligatures and snipped obliquely upward, making an opening large enough to introduce a cannula into the lumen of the vein. Before introducing the cannula the air and cooled water in the tube should be allowed to flow out. The vein is then tied snugl}' over the cannula. The compression above the elbow is removed, and the solution is permitted to flow into the vein. When the required amount of solution has been injected a third ligature is passed above the second to secure the proximal end of the vein; the second ligature is cut and removed and the cannula withdrawn. The incision in the skin is then closed with silk, linen, or horse-hair, and the wound dressed in a sterile bandage. Quantity. — The quantity of fluid injected varies from one to four pints and may be repeated in two or more hours. As a rule the injection is not repeated but is reinforced by hypodermoclysis or enteroclysis. Temperature.— The temperature of the solution in the reservoir should be kept at 105° F. This should be accm-ately measured by a thermometer kept immersed in the solution in the reservoir. The weaker the pulse the lower should the reservoir be held in giving the injection for fear of introducing the solution too rapidly into the circulation. HYDROTHERAPY 207 Ice-bag. — A rubber ice-bag is partly filled with cracked ice. This is placed in direct contact with the surface of the body. If the intense cold causes discomfort it may be wrapped in muslin. When the ice has melted the bag should be refilled. Simpson recommends the application of the ice-bag to the abdomen after all abdominal operations. He believes that it will prevent the development of peritonitis to a degree and will have a decided influence in allaying a preexisting inflammation. Application of ice-bags to abdomen. Hot Compresses. — The continuous apphcation of heat, either by means of a compress or water-bag, will have a sedative effect, and is, therefore, much used in the relief of pain from whatever cause. Compresses are made of several layers of flannel or sterile gauze wrung out in hot water. To retain the heat the compress is covered with oil silk or a rubber sheet. A hammock may be made of a towel with sticks at either end. In this device the clothes are wrung by a twisting process. Hot-water Bag. — A rubber bag containing one to four quarts of hot water, when applied to the surface of the body, will produce an effect upon the tissues with which it comes in contact that varies with the degree of temperature and the time of application. In a general way it may be said that the hot-water bottle produces the same effect upon the vasomotor nerves, bloodvessels, and muscular tissues as does the hot vaginal douche; it is at first, temporarily stimulating; second, relaxing or sedative. 208 NON-OPERATIVE METHODS OF TREATMENT Water Drinking. — Water is not sufficiently appreciated as a remedial agent in various modes of application ; this is particularly true of water taken into the stomach. Physiological Action. — The physiological effect of drinking water depends upon the quantity of water ingested and the degree of tem- perature. The physiological action of water taken into the stomach is varied. When taken in large quantities it flushes the system by diluting the blood, raising the arterial tension, and promoting the excretions from the body, thus carrying away the waste stuffs from the body through the natural channels — the kidneys, bowels, and skin. The peristaltic activity of the intestines is increased, the skin and kidneys secrete more freely, and the lungs are made more active in throwing off carbonic oxide gas and in taking in oxygen. Not only is the elimination of the waste stuffs of the blood favored, but also those which are deposited in the tissues are taken up by the lymph- and blood-streams and are excreted. The temperature of the water when taken into the stomach, and the quality and quantity of the water determine the physiological effect. Heat and cold, when applied internally by the drinking of water, have the same effect as when they are applied externally in the form of a bath. It necessarily follows that the amount of water ingested will produce effects that are analogous to the bath, so far as concerns the length of application. Pure water is the first requisite. That it should be free of pathogenic germs is generally admitted, but there are other qualities which are almost equally important. Water may contain certain organic and mineral substances which are injurious to the body. Mineral salts in water are not essential to the physical economy; sufficient salts are obtained from the foodstuffs. The function of drinking water is in part to absorb from the tissues certain mineral salts, rather than to carry salts to them. It therefore holds that the purer the water ingested, the greater will be its power of absorption. Water free from mineral salts possesses great power of absorption, and conversely a water surcharged with mineral salts not only fails to absorb salts from the tissues but may actually add to these salts. Lime salts in drinking water account to ^ degree for the calcareous deposits found within the body, which inhibit the functions of the blood- vessels and the organs they supply. A good filter, kept clean, will eliminate microorganisms from the water, but will not remove the soluble mineral salts. For this reason distilled water becomes the safest and best of drinking waters. The quantity of water which an individual in good health should drink depends upon the body weight, the activity of the individual, and the temperature. The average quantity is one or two quarts a day. No large quantity should be taken with the meals because the secretions of the stomach become diluted, thereby interfering with digestion. Water should be drunk freely between meals, at bedtime. HOT-AIR TREATMENT 209 and upon rising in the morning. Hot water is an aid to digestion when taken before meals. Cold water retards digestion, and should never be taken immediately before, during, or shortly after the ingestion of food. HOT-AIR TREATMENT Physiological Action ; Technic Indications and Contraindications i The author has had but a limited experience in the use of hot air as a remedial agent and the following description is largelj^ based upon the experience of others. Physiological Action. — ^An active hyperemia is produced. With a properly applied apparatus this action is not confined to the superficial bloodvessels but extends to the deeper structures. At the beginning of the application, when the temperature is high, there is a temporary contraction of the bloodvessels which is soon followed by dilatation. According to Bier this arterial hyperemia provides nourishment for the tissues, favors the carrying away of waste stuffs, and stimulates the regenerative functions of the tissues to a degree that will fortify the tissues against the invasion of microorganisms. Indications and Contra-indications. — Pregnancy is an absolute contra- indication to the application of heat to the degree required to obtain a physiological reaction. Fever is also said to be a contra-indication and so are advanced affections of the lungs and incompetent heart action. The method is recommended for all chronic non-suppurative inflam- matory exudates. The application of hot air is also recommended in chronic metritis and lactation atrophy of the uterus, especially when associated with edema. The very nature of these lesions suggests the limitations of this form of treatment. Little can be expected from any remedy in the manage- ment of such lesions. Hot-air therapy is effective not so much in the correction of morbid anatomical conditions as in bringing about relief from pain associated with chronic inflammatory lesions. This relief may persist for many hours after application, and by repeated applications the pain becomes less in frequency and in severity. The relief from pain is particularly observed when an edematous infiltration is a contributing factor. Technic. — The application of hot air to the vagina is impracticable. To obtain the required degree of heat would cause pain and a superficial inflammatory reaction. The method is therefore confined to the skin surface of the abdomen and pelvis. Before proceeding with the treatment all contra-indications must be excluded. The duration of the treatment should not exceed twenty minutes in the beginning and may be gradually increased to an hour. A^TLen there is a tendency to faintness a cold cloth may be placed on the head. 14 210 NON-OPERATIVE METHODS OF TREATMENT After the treatment rest in bed for at least a half-hour should be enjoined. The frequency with which the treatments are repeated will be governed by the individual case. The degree of heat should at first not exceed 200° F., and later it may gradually be raised to 250° F. The temperature and pulse should be taken at intervals during the application, and a physical examination of the affected area should be made to ascertain the effects of the treatment and to detect any existing complications "at the earliest possible time. The treatment may be combined with massage and pressure therapy with good results. The author has adopted the electric heater of Gellhorn (Fig. 95) with gratifying results. Application of dry heat (electric). HOT PACK One of the most effective means of quieting a nervous patient is to wrap the body in a sheet wrung out in water at a temperature of 50° to 70° F. Several woollen blankets are then wrapped snugly about the body. In a few minutes the body will begin to perspire freely and often the patient falls into a quiet sleep. This bath has been found of great value in treating maniacal patients. TAMPONS 211 COUNTER-IRRITATION Cantharides Plaster Mustard Plaster In pelvic inflammation considerable relief from pain may result from the application of counter-irritants over the seat of pain. It is of interest to note that Morris has called attention to the two points of tenderness located over the lumbar ganglia, about one inch below and to either side of the umbilicus. Pressure over these points in the presence of a chronic pelvic inflammation will elicit more or less tender- ness. If these areas of tenderness are painted with tincture of iodine, or if a mustard or cantharides plaster is applied, much relief may be afforded. In this manner much of the pain incident to the menstrual period in the course of a pelvic inflammation may be controlled. Cantharides Plaster. — In applying a cantharides plaster the skin is first cleansed with soap and water, then dried, and smeared with vaseline. Over an area about two inches in diameter on either side is applied a cantharides plaster. This is held in place by two cross-strips of adhesive plaster for six to eight hours until blisters appear. The plaster is then removed, the blisters opened in a cleanly manner, and a zinc ointment applied to the blistered surface. Over this is placed a pad of sterile gauze, held in place by adhesive straps. The surface is dressed daily until all signs of irritation have disappeared. Collodium cantharidations (60 per cent.) may be applied with a camel's-hair brush. Mustard Plaster. — To prepare a mustard plaster use half and half black mustard and flaxseed meal or flour. If white mustard is used it should be used in the proportion of three of mustard to one of flour or flaxseed meal. These are applied hot for a half hour. If a longer application is desired the proportion of mustard is lessened. TAMPONS No one form of topical treatments in diseases of women is so generally employed as tampons. When applied intelligently they are of great value, but in so doing there must be a very clear conception of their indications and of the manner of their application, otherwise they are productive of no good and may do positive harm. Indications. — The indications for tamponade of the vagina are: 1. Hemorrhage. 2. Pelvic inflammations and congestion. 3. Drainage. 4. Protection against infection. 5. Uterine support. Hemorrhage. — For the immediate control of hemorrhage from the uterus and vagina, resort may be had to the vaginal tampon. This 212 NON-OPERATIVE METHODS OF TREATMENT measure may suffice for temporary or permanent control of the bleeding, depending upon the seat of the hemorrhage, its cause, and its severity. When the bleeding comes from large vessels in the cervix or vagina, or when the hemorrhage comes from within the uterus and is severe, failure is likely to ensue. However, until more effective means can be employed, tightly packed vaginal tampons should be resorted to. Form of Tamponade. — Vaginal Tampons. — Tampons when tightly packed in the vagina will control bleeding from the vaginal walls, and will be effective in moderate hemorrhages from the cervix and cavity of the uterus. Whenever a bleeding vessel can be isolated it should be secured by a ligature or transfixed by a suture. Intra-uterine Tampons. — Xo other method is so effective in the control of bleeding from the uterus into the uterine cavity. It may be stated, as a general rule, that the uterus should be tamponed after all intra-uterine operations whenever there is a possibility of post- operative hemorrhage. Curettement for conditions such as endometritis is not included in this category. Technic. — ^The best material for intra-uterine and vaginal tampons used for the purpose of controlling hemorrhage is sterile, plain, or iodo- form gauze. Strips two to four inches in width, several plies in thickness and of sufficient length to pack the uterus and vagina tightly, are preferred. When the uterine cavity is to be packed a thorough sterilization of the vulva and vagina should precede the packing. The patient is placed crosswise of the bed in the dorsal position and every precaution is taken to protect the gauze from contamination. A bivalve speculum is introduced through which the cervix is grasped by a tenaculum. The end of the gauze strip is then conveyed to the fundus of the uterus by means of a dressing forceps or sound. This must be done with caution for fear of perforating the uterine wall. The cavity of the uterus is gently but firmly packed from above downward until the entire cavity, including that of the cervix, is filled. ]More than this the vagina should be firmly packed and a T-binder adjusted over a sterile vulvar pad. When the vagina alone is to be packed for the control of hemorrhage the same aseptic precautions must be exer- cised, and the packing should be done through a vaginal speculum. The gauze, as a rule, should be removed by the end of forty-eight hours, and if the hemorrhage still continues fresh gauze may be inserted. Inflammation and Congestion. — Tampons have a therapeutic value in all stages of pelvic inflammation and congestion. As a vehicle for the introduction of medicaments the vaginal tampon has a large range of application. It provides the only practical and effective means of applying remedies to the vaginal walls and overlying structures. But few remedies have been accepted as being of very special thera- peutic value; such are ichthyol, formalin, iodine, mercurial ointments, gylcerin and certain combinations of glycerin, notably boroglycerin and borolyptol. Glycerin and ichthyol are the most generally used TAMPONS 213 Fig. 96 of these remedies. Glycerin withdraws serum from the tissues, and in this manner the tissues of the pelvis are depleted; connective-tissue spaces are emptied of serous exudates, serous elements are withdrawn from pus cavities and the engorged lymph and bloodvessels are relieved. To accomplish this large quantities of glycerin must be used. The vagina should be loosely packed with tampons of sterile cotton or gauze in glycerin. The time required for the application of the glycerin may be stated at six to eight hours. They should then be removed lest they become a source of irritation. The amount of serum that is extracted from the tissues in this way is often astonishing. As a valuable adjunct to glycerin, ichthyol may be added in the proportion of seven part of ichthyol to ninety-three parts of glycerin. It is claimed for ichthyol that it is somewhat antiseptic and analgesic and an absorbent of cellular elements. These properties in conjunction with the glycerin, which only withdraws the watery elements, makes the combi- nation most effective. Ichthyol is gen- erally accepted as a valuable remedy in the treatment of pelvic inflammations, and especially when combined with gly- cerin in the proportions given. It is indorsed almost uniformly by practical workers in the field of gynecology. Exu- dates are absorbed by the liberal appli- cation of ichthyol and glycerin — this applies to serous, purulent, and cellular exudates alike. Under this treatment the author has seen large pelvic exudates disappear and pus accumulation absorb. In one case of bilateral pyosalpinx the tubes were not only reduced to their normal size,but pregnancy followed in the course of a vear and terminated unevent- fully. The uterus and appendages, enlarged from congestion, are reduced in size and rendered less sensitive. Excessive bloody and leucorrheal dis- charges are lessened by depleting the engorged lymph and bloodvessels. Menstruation is rendered less painful by relieving the congestion. It is therefore evident that local depleting treatment by means of tampons is worthy of the serious consideration of surgeons. In not a few cases these treatments, combined with prolonged hot douches, and the regulation of the bowels, diet, and exercise, will effect a cure that is impossible by other means. They are valuable adjuncts to surgery both as a preliminary measure and as a postoperative means of restoring the integrity of the tissues. The surgeon is seldom justified in interfering surgically during the acute stage of a pelvic inflammation unless there is an accumulation of pus that can be drained through the vagina. By first depleting -c^y Vaginal tampon of lambs' wool. 214 NON-OPERATIVE METHODS OF TREATMENT the tissues the acute inflammatory reaction is allayed, exudates are ab- sorbed and the need for surgical intervention may be averted; organs are safeguarded which have been sacrificed without these preliminary measures. Postoperative exudates in and about the genital organs demand consideration, otherwise the results will be disappointing. Such exudates may be made to disappear by the treatment outlined. To remove a diseased endometrium and leave a congested uterus affords little or no permanent relief; a healthy endometrium cannot be expected to form, and the congested uterus will remain a disturbing element; hence the value of depleting treatment as a postoperative measure. The author cannot agree with Dudley, who says that the therapeutic value of medicated tampons is overestimated. While it is true that they are too often misapplied, it is even more true that their therapeutic value is not fully appreciated. The former statement applies particu- larly to the general practitioner, the latter to the general surgeon. For subacute and chronic vaginitis the vagina may be loosely packed with strips of sterile gauze saturated with a solution of formalin, 1 part ; glycerin, 400 parts; water, 2000 parts. For specific ulcers of the cervix and vagina, tampons of sterile cotton or gauze may be smeared with mercurial ointment. Duration of Application. — No tampon should be left in the vagina longer than twenty-four hours. The accumulated secretions of the uterus become a source of irritation, hence the tampons should be removed within twenty-four hours and a vaginal douche given. Frequency of Application. — No set rule can be established for the frequency of application of uterine and vaginal tampons. Each case must be a law unto itself. When tampons are used for depleting purposes they should be inserted at least every other day. During the acute stage of a pelvic inflammation they should be applied daily. The patient should remain in bed while the tampons are in place, otherwise much of the solution will be lost. For this reason such treatments given in the office are of little value. Twenty-four to forty-eight hours is the limit of time for the appli- cation of intra-uterine tampons, and it is seldom advisable to repeat the application. There is always the danger of conveying infection to the uterus by tamponing the uterine cavity, and for this reason their application should be as limited as possible. For the control of hemorrhage, vaginal and intra-uterine tampons are allowed to remain no longer than is demanded for fear that the accumulated blood may undergo decomposition and infection. When removed a vaginal douche should be given. Drainage. — Some operators drain the uterus with a strip of sterile gauze after curettage. To the author this procedure has never seemed necessary or advisable, because the uterus, in itself, constitutes an ideal drain. PELVIC MASSAGE 215 Protection against Infection. — After all intra-uterine operations it is advisable to pack the vagina with sterile or iodoform gauze as a precaution against possible infection of the wound within the uterus. Such dressings should not be left longer than forty-eight hours. Fig. 97 Insertion of a tampon ol' lanil Support to the Uterus. — Vaginal tampons of sterile lambs' wool are of service in uterine displacements when for any reason a pessary cannot be worn, and operative interference is not permissible. For example, the vagina may not tolerate a pessary, or a uterus and its appendages may be so tender that they do not permit the w^earing of a pessary because of pain and the likelihood of exciting an acute inflammatory reaction. Tampons for this purpose are only temporary expedients, and should soon be replaced by the pessary or by operative intervention. PELVIC MASSAGE Physiological Action Indications contra-indications Technic This therapeutic measure has found little favor in America, although in Sweden, from whence it emanated, and in Germany and France, 216 NON-OPERATIVE METHODS OF TREATMENT it is much practised. The successful application of massage to pelvic disorders implies an accurate diagnosis. The indications are limited to but a few lesions in the pelvis, and the pathological conditions which preclude its application must be recognized if dangers are to be averted. Physiological Action. — The circulation in the blood and lymph vessels is accelerated. This increases the nutrition of the tissues on the one hand and favors the absorption of exudates on the other. Furthermore, the involuntary muscle fibers of the viscera are made to contract, which in turn favors the circulation in these organs. Indications. — Chronic Non-suppurating Pelvic Inflammations. — When they involve the uterus, its appendages, the pelvic cellular tissue and peritoneum, well-directed massage is a valuable adjunct to the more generally employed methods of treatment. When the uterus and its appendages are displaced and immobilized to a greater or less degree by adhesions the offending bands may be stretched or severed, thus providing for the replacement of the viscera. Inflammatory exudates in and about the organs of the pelvis are made to disappear by stimulating the lymphatic circulation through a systematic and oft- repeated system of massage. Contracted Uterine Ligaments. — Contracted uterine ligaments, result- ing from an inflammatory infiltration, may be stretched and the inflammatory exudate absorbed by intelligent and persistent massage. By so doing the uterus and its appendages may be placed in their normal position and retained either by the wearing of a suitable pessary or by some operative procedure. Atony of the Uterine Supports. — ^Atony of the uterine supports may be corrected when not of long standing, but when the muscular fibers and connective tissue which are incorporated in the uterine supports have lost their power of retraction and contraction the results of massage are not encouraging, and will usually be disappointing. Incarceration of the Pregnant and Non-pregnant Uterus and of Tumor Formations. — These may be corrected by means of massage. An anesthetic is usually required. Contra-indications. — Certain conditions may exist in the pelvis which render pelvic massage both useless and dangerous. It is, there- fore, imperative that such conditions be excluded before resorting to massage. Acute Pelvic Inflammations. — Massage is contraindicated not only be- cause of the pain occasioned by the manipulations, but more so because of the possibility of extending the infection. An infection confined to the uterus may be made to extend to the tubes; when in the tubes it may be stripped from the fimbriated end into the peritoneal cavity; when walled off in the peritoneal cavity by adherent coils of bowel and omentum the pus may be liberated and invade the free peritoneal cavity, and finally a virulent infection may be passed on by way of the blood and lymph streams to remote parts of the body. There is a special danger in massage of an infected puerperal uterus, filled as it PELVIC MASSAGE 217 is with septic thrombi. These thrombi may be dislodged and con- veyed to the lungs, where they cause one of the most fatal of lesions — i. e., pulmonary embolism. The rule should be to avoid all unnecessary ma7iipulations during the acute stage of a pelvic inflammation. Malignancy. — Unquestionably malignant growths are made more active and are disseminated by massage. Inasmuch as no possible good can come from massage in these cases, and much harm may ensue, the practice is condemned. Tuberculosis of the Pelvic Organs. — This offers the same objections to massage as malignancy. Pregnancy. — Pregnancy, both intra-uterine and extra-uterine, is to be classed with the contra-indications to massage. An exception may be made when the pregnant uterus is adherent or incarcerated. In such cases gentle manipulations may succeed in replacing the uterus, and in making the uterus freely movable, without interrupting preg- nancy. When there is a possibility of tubal pregnancy all manipulation must be avoided for fear of rupturing the tube. Fig. 98 Combined vaginal and abdominal massage. Patient lying on couch. All constriction about the waist line removed. Two fingers of the right hand within the vagina. Left hand on the abdomen. Phlebitis and Thrombosis. — Phlebitis and thrombosis of the pelvic and femoral veins contra-indicate massage for fear of dislodging thrombi, an event which may culminate disastrously through the development of pulmonary embolism. Technic. — Before proceeding with massage of the pelvis the rectum and bladder should be emptied, and the clothing so arranged as to eliminate all constriction of the waist, and to avoid any embarrass- 218 NON-OPERATIVE METHODS OF TREATMENT ment to the manipulations of the operator. The patient should lie upon a low-firm couch with the hips brought to the end of the couch, the legs flexed upon the thighs and the feet resting upon a chair placed at the end of the couch. The operator sits at one side of the couch, passes his forearm under the corresponding knee of the patient, and introduces the index and middle fingers into the vagina to the vaginal vault at the point to which the massage is to be directed. No manipulations are performed by the fingers within the vagina; they are introduced for the purpose of supporting and steadying the structures to be massaged. The opposite hand, placed upon the hypogastrium, performs rotary move- ments, very gently at first and increasing in speed and pressure as the Abdominal massage. abdominal muscles relax. There should be short intervals of rest and the whole sitting should not consume more than ten minutes, and shoidd be repeated daily. Massage of the uterus is carried out by bringing the uterus as far forward as possible by the combined efforts of the fingers within the vagina and those of the hand placed upon the abdomen. The move- ments are directed by the hand upon the abdomen to the posterior wall of the uterus, while the fingers within the vagina press upward and forward, and upward and backward against the cervix. The tubes are massaged from their outer extremity to the uterine horn. The manipulations of the ovaries are similar to those of the uterus. In massaging inflammatory exudates the operator begins at the periphery of the mass, passing around the circumference and gradually approaching the centre. PELVIC MASSAGE 219 Stretching and breaking of adhesions binding the uterus and its appendages should be done without force. Undue force in breaking up adhesions, as advised by Schultze, is to be discountenanced because of the danger of hemorrhage, of tearing into an adherent bowel and of the liability of the uterus to adhere again and to resume a faulty; position. The gradual breaking and stretching of adhesions is conducted by the index and middle fingers of the left hand within the vagina, directed to the site of the adhesions. The fingers of the right hand placed upon the abdomen are made to approximate the fingers in the vagina by a series of rotary movements which, when gently performed, will cause the abdominal walls to relax and permit of deep pressure. No great pain must be caused, otherwise the contractions of the abdominal muscles will embarrass the procedure. The manipulations of the abdominal hands are at times reinforced by the fingers within the vagina, the pressure being directed on the adherent organ in such a manner as to put the adhesions on the stretch. Xo rule can be formulated to govern the amount of pressure to be exerted, or to regulate the time to be consumed in breaking up the adhesions. The operator must exercise needed caution. The replacement of a malposed uterus by massage deserves careful consideration because the procedure is in common practice throughout the medical world. Little or no success has resulted from the application of massage in pathological anteflexion. The method consists in pressing backward upon the cervix with the vaginal finger and at the same time, backward, intermittent pressure is made with the fingers of the other hand upon the fundus. In the effort to correct a lateral position (lateroversion, lateroflexion, lateroposition), pressure is directed upon the side of the uterus. When the broad ligament is infiltrated it must be massaged independently of the uterus to favor the absorption of the inflammatory exudate. Retrodisplacements of the uterus are particularly favorable to correction by pelvic manipulations. The index and middle flngers of the left hand make pressure upon the posterior wall of the uterus; the pressure is steady, firm, and in an upward direction. Counter-pressure is made over the hypogastrium with the other hand in the eft'ort to grasp the fundus of the uterus. Gradually the abdominal fingers are brought behind the fundus, when by the combined efl^orts of the fingers over the abdomen and in the vagina, the uterus is drawn to a vertical position. To bring the uterus more nearly to the normal position, that of anteversion and anteflexion, the fingers within the vagina are shifted to the front of the cervix, and backward pressure is made upon the vaginal portion of the cervix, while forward traction is made upon the fundus by the fingers on the abdomen. When the uterus is righted in its position, a Hodge-Smith pessary is inserted to maintain the uterus in its normal position. As an aid to the hands in replacing the uterus, Olshausen recommends 220 NON-OPERATIVE METHODS OF TREATMENT the uterine sound. In the hands of the inexperienced this instrument is dangerous. In the author's judgment it is better to dispense with it altogether in view of the Habihty of puncturing the uterus, even in the hands of the most careful and experienced. When the uterus is displaced backward and is freely movable it may be possible to effect a replacement by placing the patient in the knee-chest position and introducing a Sims speculum into the vagina. The air will balloon out the vagina, the intestines will fall away from the uterus and permit it to fall forward upon the anterior abdominal wall. As an aid to the replacement of the uterus, traction may be made upon the cervix by a vulsellum forceps. When the uterus lies far back and upon the rectum, pressure may be best directed upon the fundus by the index finger inserted high in the rectum. In atony of the uterus resulting in uterine hemorrhage, gentle massage will cause the uterus to contract; in this manner the caliber of the bloodvessels is lessened and the hemorrhage checked. It is said that massage of the posterior wall of the uterus at a point near the internal os will most effectually stimulate the contractions of the uterus. Abdominal Massage.^ — ^Abdominal massage may be beneficial in conjunction with pelvic massage. This applies particularly to those cases in which constipation is a disturbing factor, or when there is a general or localized accumulation of adipose tissue in the abdominal wall, when the muscular development of the abdominal wall is poor and the recti are separated, when there is hyperesthesia of the abdomi- nal wall, and, finally, when there are old inflammatory exudates and adhesions in relation to the abdominal wall. Technic. — The operation should not be performed in less than two hours after eating. The patient lies upon a firm couch with legs flexed upon the thighs and the thighs upon the abdomen, the mouth open. The index, middle, and ring fingers of the left hand are laid upon the abdomen. The same fingers of the right hand make pressure upon them as seen in figure 98, and direct the fingers of the left hand in performing rotary movements as outlined in the spiral lines upon the abdomen in Fig. 99. The pressure is at first light, and after the abdominal walls are relaxed, it is increased sufficiently to affect the underlying visceral structures. PRESSURE THERAPY Indications Technic The so-called "absorption cure" as applied to certain chronic inflam- matory diseases of the pelvis was introduced by W. A. Freund. The absorption of pelvic exudates is facilitated by means of pressure applied directly to the exudate. A bag containing several pounds of shot is placed over the abdomen and a rubber condom, filled with 800 to 1000 grams of shot, is inserted into the vagina and impinges upon the exudate. Freund reports excellent results in the treatment of fixed PRESSURE THERAPY 221 retroverted uteri, salpingitis, acquired and congenital narrowing of the vagina. Other methods have been introduced, based upon the same general principle. Chrobak practised traction massage by applying a weight of one to one and a half kilograms to the cervix, making traction for one-half to ten hours. Saenger advised interrupted traction on the cervix. Pincus used a shot-bag over the abdomen and an air pessary or air- bag in the vagina. This method is based upon the theory that the pressure from without was of prime importance, and the air-bag or pessary within the vagina was merely to support the uterus. Freund, however, laid greater stress upon intravaginal pressure. An important modification of Freund's method was introduced by Joseph Halban. In place of a rubber condom filled with shot, he used a Carl Braun's colpeurynter filled with quicksilver. This modification has a twofold advantage, in that it is easy of application, and a greater and more evenly applied pressure can be obtained with the same bulk in the vagina. A pressure of 1500 grams of quicksilver is possible by this method, a pressure that is altogetlier impossible in Freund's method. Then, too, quicksilver in the colpeurynter moulds itself more perfectly to the exudate than is possible for a bag of shot. Indications. — Pelvic Cellulitis. — This treatment is particularly eft'ective by reason of the location of the lesion. The exudate is found most frequently in the cul-de-sac of Douglas, or in the base of the broad ligament, where direct pressure can be exerted. The whole vault of the vagina may be surrounded by a stone-like mass, suggestive of malignant infiltration; the uterus and adnexa may be lost in the mass, and yet after two or three treatments the size of the mass may be so decreased that the uterus and its appendages can be clearly outlined. The rapidity with which these results are obtained can only be accounted for on the supposition that the bulk of the mass is largely composed of serous exudate which rapidly disappears on pressure, leaving a greatly reduced cellular exudate. It has been frequently observed that the subjective symptoms do not always disappear in proportion to the decrease in size of the exudates. In the treatment of retro-uterine exudates, Halban tried introducing the colpeurynter into the rectum, but found this method impractical because of pain, and of the more direct pressure upon the rectum rather than upon the pelvic exudate. Perimetritic Exudates. — In perimetritic exudates the effect of pressure is not so satisfactory because of the higher location of the exudate. When the adhesions are high on the fundus of the uterus little pressure can be directly exerted. Pelvic massage or the more radical operative procedures are preferred. When the exudate is located low on the pelvic floor the adhesions commonly disappear early and there is relief from pain. When the uterosacral ligaments are involved in a chronic inflammation they become contracted and throw the uterine body for- ward. The patients complain of painful coition, and a similar pain is caused by the drawing forward of the cervix, though the uterus itself and its appendages are not sensitive to pressure. A colpeurynter filled 222 NON-OPERATIVE METHODS OF TREATMENT with quicksilver placed behind the cervix will so stretch the uterosacral ligaments as to give most satisfactory results in correcting the con- traction of the ligaments and in ^elie^dng the pain. When the uterine appendages are involved, the results of pressure therapy depend largely upon the position of the diseased appendages. If in a normal position intravaginal pressure cannot be effectively applied, but if the tubes and ovaries lie low in the pelvis, as is often the case, direct pressure may be applied with telling effect. It is impossible, in all cases, to foresee the presence of a virulent infection which may lie latent in the adnexa. Great caution must therefore be exercised in applying such energetic treatment for fear of exciting an acute exacerbation of a chronic inflammation. This is particularly true' of gonorrheal infection. It is well known that the size of the adnexal tumors is not proportionate to the pain caused, and so it is with the treatment, the inflammatory exudate may be greatly reduced in size with little or no relief from pain; on the other hand, the exudate may be but little reduced in size and the pain wholly disappear. Fixed Retroverted and Retroflexed Uteri. — It is in the replacement of fixed retroverted and retroflexed uteri that pressure therapy gives the most brilliant results. In Schauta's clinic it is now" rarely found necessary to anesthetize a patient in order to replace a fixed retro- placed uterus. The colpeurynter placed behind the cervix crowds the uterine body forward, favors the stretching and absorption of adhesive bands, and at the same time the posterior vaginal wall is put upon the stretch and tends to draw the uterus forward. Incarcerated Pregnant Uterus. — The Halban method has been lately advised in the treatment of incarcerated pregnant uteri. Halban reports success in a single trial, and says it is not advisable to make more than two or three efforts at replacement by this method. He has given 30 to 40 treatments in a single case and observed no progress after the first two or three treatments. Incarcerated pelvic tumors may be treated by the same method if located low in the pelvis. Pressure therapy is not recommended as a substitute for massage in all cases. There are cases in which massage is preferable, as for example in adhesions attached to the fundus of the uterus, or involving normally placed appendages; but in the majority of instances the Halban pro- cedure is more convenient of application and the results are more quickly gained, requiring days where pelvic massage may require weeks, and even months. Technic. — In applying this method the patient is placed either upon her back or side; on her back if the exudate lies behind the uterus; on the corresponding side if the exudate lies to the side of the uterus. The colpeurynter is rolled like a cigar, smeared with vaseline, and introduced into the vagina by a dressing forceps. It is placed in direct contact with the exudate. The foot of the bed is raised and additional elevation gained by pillows placed under the hips. The bladder and rectum must be empty, otherwise some discomfort will be caused when the bag is filled. The colpeurynter is now filled with quicksilver, poured through X-RAY THERAPY 223 a funnel. At first it is well to use not more than 500 grams, and later to increase the amount to 1000 grams. Were the patient lying on a level plane the pressure would be largely applied to the rectum, while with the hips elevated the pressure is in great part applied to the vagina and uterus. Halban uses one to three pounds of shot for counter-pressure over the abdomen; when the patient lies on the side the bag of shot is retained in place by adhesive straps. This pressure is continued for not less than an hour, and may be prolonged throughout the entire day. When pain is caused by the pressure of the quicksilver a part or all of it must be removed without delay. The danger of continuing the treatment lies not alone in the discomfort, but in the liability of exciting an acute exacerbation of a subacute or chronic inflammation, and in the dissemination of an unrecognized virulent infection. ' In the diagnosis of pelvic exudates it is not always possible to exclude the presence of a virulent infection, hence it is well to proceed with caution by first using not more than 500 grams, and this for but a short time, to be repeated the following day with a larger amount and for a longer period. If pain is caused the treatment is discontinued, and for a few days, rest, hot douches, and like conservative methods are substituted, to be then followed b}^ a repeated trial of the pressure therapy. If pain is again caused the treatment should be abandoned for other conservative methods. ELECTRICITY Little need be said of electricity as a therapeutic agency in the treatment of diseases of women. It has been extolled as a panacea for almost all afflictions of women. One by one these diseases have been removed from its category until now little place is given to the consideration of the subject in text-books or periodicals, and few gynecologists find any place for electricity in the treatment of diseases of women. Electricity in gynecology has had its day and now finds no place in rational gynecological therapy. No consideration will therefore be given to the subject in this text. X-RAY THERAPY There is a limited scope for the application of the .r-rays in the treat- ment of gynecological diseases. The lesions which are amenable to this form of treatment are either rare, are seldom recognized early enough to insure success, or else are inaccessible to the influence of the rays. There are, however, selected cases in which the .r-rays are of special value. Indications. — Cancer. — Cancer of Uterus. — Cancer of the uterus in its earliest stages never calls for .r-ray treatment, but demands a radical 224 XOX-OPERATIVE METHODS OF TREATMENT surgical procedure. Only inoperable cancers of the cervix and recurrent cancerous growths after hysterectomy call for a consideration of such tentative measures. The treatment is in no sense curative; at most it can only clear up the superficial lesions and thereby stay the dis- charges. Little or nothing is accomplished in relieving pain because of the impossibility of reaching the infiltrated areas in the deep-lying structures. Insofar as the .r-rays check the wasting discharges they promote nutrition, and if they serve no other purpose than to encourage the patient, they are not without value. In one instance a recurrence of a cancer of the cervix occurred one year after hysterectomy. The author removed a growth the size of a hazel-nut from the vault of the vagina and in five days it had returned to double the original size. The growth was again excised and cauter- ization applied as deeply as seemed safe. During the following year the .T-rays were applied; at first three times a week and later at longer intervals. There has been no sign of recurrence in the ten years following the last operation. The author is of the opinion that the .r-rays should be applied to the vault of the vagina after convalescence from hysterectomies done for cancer of the cervix. AMien properly applied they can do no harm and may do good. Cancer of the Vagina and Vulva. — Cancers of the vagina and vulva are more accessible to the application of the .r-rays, and are slower in their spread than cancers of the uterus. The results from the applica- tion of the .T-rays are therefore better than in cancer of the cervix. The treatment is usually only palliative, but in some instances it is curative. It is not to be understood that the .r-rays in any instance should replace surgery when the lesion is operable, but should be applied as a supplementary procedure after a surgical operation and the healing of the wound. In inoperable cancer of the vulva and vagina much may be done with the rays to promote comfort and to prolong' life. When a cure appears to have been effected it is advisable to continue the applications of the rays at intervals of weeks or months for a period of several years, if not for the entire life of the individual. Sarcoma. — The same rules should apply to sarcoma as to carcinoma, though the results are less certain. Tuberculosis. — In tuberculosis of accessible regions of the genitalia the .r-rays have produced most gratifying results. The response to the treatment is usually prompt and a complete cure may be expected in a few weeks, even in cases which have advanced to ulceration. Failure to obtain good results is largely accounted for by faulty technic in the application of the rays, and in not recognizing the presence of the lesion in the upper genital tract, beyond the reach of the rays. Pruritus Vulvae. — A number of successful cases have been recorded in which the rays have been applied to the itching area. AMien other means have failed the .r-rays should be given a trial. Eczema. — In the chronic indurative stage, eczema usually responds very promptly to the influence of the r-rays. Other modes of treatment SWABS 225 may be combined with their application. The itching will usually cease after a few treatments. Lichen Planus. — This is rarely seen on the vulva. The .r-rays deserve a trial in such cases, but the results are uncertain. Osteomalacia. — Osteomalacia has been successfully treated by the a;-rays. The results are obtained by producing atrophy of the ovaries. It must be borne in mind that in the application of the .r-rays sterilization and the artificial menopause may be brought about through atrophic changes in the ovaries. This fact has led to the application of the rays in cases in which it is desired temporarily to check or permanently to do away with the menstrual flow by directing the rays to the ovaries. Menorrhagia. — ^Menorrhagia due to chronic metritis, subinvolution, uterine fibroids, and muscular insufficiency of the uterus has been controlled by repeated applications of the rays. The effect is to destroy the functionating capacity of the ovary and in time to cause atrophy of the ovaries. Uterine Fibroids. — Experiments on animals have demonstrated that marked changes are produced in the ovaries by the action of the x-rays. There is degeneration of the follicular epithelium, death of many of the ova, sclerosis of the bloodvessels, and finally disappearance of all follicles. The follicles are replaced by hyaline tissue. Similar observations have been made on the human ovary. Small hemorrhages have also been noted in the ovarian cortex. In myomata, nuclear degeneration and cellular destruction have been observed, together with minute hemorrhages. Jaugeas believes that the a'-rays should be applied to cases in which there are multiple small fibroids scattered in the uterine wall. They may also be used when the tumor is large and does not give rise to symptoms demanding immediate relief. Old slow-growing tumors are not much influenced by the .r-rays. Jaugeas applies the rays alternately over either ovary and the uterus. Special caution must be exercised when the abdomen is heavy with fat for fear of producing necrosis. Gauss is of the opinion that hemorrhages can be controlled in every instance by repeated applications of the .r-rays; these should be made at frequent intervals and over a period of not less than two months. When the ovaries lie behind large tumors no results will be obtained by the action of the rays. Whenever degenerative changes are suspected in the tumor no time should be lost in applying the rays ; such cases are preeminently surgical. SWABS Indications Technic There is only a limited field of usefulness for the uterine swab. Too much needless and even harmful use has been made of the swab in office practice. 15 226 NON-OPERATIVE METHODS OF TREATMENT Indications. — The swab has a legitimate field of usefulness in: Removal of Mucus from the Cervical Canal. — Before making topical applications to the cervix and to the endometrium, the mucous secre- tions which cling tenaciously to the cervical mucous membrane should be removed by means of an applicator of absorbent cotton. Sterility is sometimes due to a plug of mucus in the cervix, and pregnancy has been known to follow upon the removal of such a plug. Before making applications to erosions of the cervix the surface should be cleansed by swabbing with sterile absorbent cotton on a dressing forceps. Application of Escharotics and Antiseptics to the Cervix and Endome- trium. — Much harm has been done by the application of too strong escharotics and antiseptics to these surfaces. It may be further charged that too often these applications are made when there is no indication for their use. There are but two indications for such applications, i. e., hemorrhage in which styptics are occasionally applied and chronic infection. Fig. 100 Topical application to the cervix by means >of a swab. Technic. — The patient is placed in the lithotomy or Sims' position and the cervix exposed by a bivalve speculum in the former position and by a Sims' retractor in the latter position. When it is necessary to dilate the cervix this may be done under anesthesia or by means of laminaria or tupelo tents. For convenience the author is in the habit of using small wooden applicators on which a film of absorbent cotton is tightly wrapped. These are sterilized and kept in a sterile receptacle. A dry swab is first inserted to remove the mucus, and this is followed by one or two medicated swabs. For infec- SERUM AND ORGANOTHERAPY 227 tion of the cervix the author usually employs pure formalin or a 5 per cent, solution of zinc chloride. Without an anesthetic it is needless to attempt to swab the endometrium. Fig. 101 Swabbing the cervix. The cervix is exposed by a retractor held by an assistant. The cervix is grasped by a tenaculum and swabbed with a sterile probe wrapped with sterile absorbent cotton. SERUM AND ORGANOTHERAPY Much interest has been manifested during recent years in the serum treatment of gynecological diseases, but as yet no definite results have been obtained. Antitoxin of Diphtheria.— The one exception to the above statement is in respect to the antitoxin of diphtheria. In diphtheritic vulvo- vaginitis a prompt reaction will usually follow the administration of antitoxin. The rarity of true diphtheritic infection of the genital tract, and particularly in the non-puerperal state, provides little justification for the consideration of this most valuable serum in this text. _ Ovarian Extract.— Ovarian extract has been recommended in cases of premature menopause, whether from unknown causes or from the removal of the ovaries. It is said to replace the lost internal secretion of the ovary, which has a controlling influence upon the general 228 NON-OPERATIVE METHODS OF TREATMENT metabolism, and nervous equilibrium of the individual. The author's experience with the remedy in a large number of cases has never satisfied him that it is of any special value. Corpus Luteum Extract. — Corpus luteum extract is the desiccated powder of the ovaries of pigs put up in capsules holding 5 grains in each. It has proved of great value in the author's hands in controlling the nervous manifestations incident to the artificial menopause. He believes it should always be given shortly' after an operation in which the ovaries have been removed and continued for a period of at least three months. The dose is 5 grains three times daily. Not only does the corpus luteum extract lessen and often forestall the nervous dis- turbances of the superinduced menopause, but the author has observed cases in which sexual desire had been lost for one or more years after the removal of the ovaries and was restored by the administration of corpus luteum extract. IMore than this, it happens in a small percentage of cases in which the ovaries have been removed that the menstrual cycle will proceed as long as corpus luteum extract is given. It is sometimes possible to reestablish the menses by the administration of corpus luteum even after a period of amenorrhea of twelve to eighteen months following the removal of both ovaries. The author has had good results in about three-fourths of the cases of the artificially induced menopause, but he has had little success with the corpus luteum extract in the management of the natural menopause. Thyroid Extract. — Thyroid extract has been advocated for the treat- ment of fibroid tumors of the uterus on the assumption of the reciprocal trophic relationship existing between the thyroid gland and the uterus, as demonstrated by the occasional occurrence of uterine atrophy after thyroidectomy, of menstrual disorders in goitre, in cretins, and in myxedema, and by the occasional atrophy of the thyroid gland follow- ing hysterectomy. Few clinical observations have been made to sup- port this hypothesis, and consequently no conclusions are yet possible. Pituitrin as a Styptic in Gynecology. — ]\Iuch has been written recently concerning the use of the extract of the hypophysis (pituitrin) as an oxytocic and hemostatic in obstetric practice, but there has been little said of its application in gynecology. Bab extols its use as a hemostat in uterine hemorrhages due to metritis and inflammations of the adnexse. He obtained good results in 94 per cent, of his, cases. In some of these instances, ergot, hydrastis, and stypticin had failed. A subcutaneous injection of 2 to 3 c.c. was given. Gonorrheal Vaccine. — See chapter on Gonorrhea in Women. , Tuberculin. — See chapter on Tuberculosis in Women. Vaccine Treatment of Pelvic Infections. — There is little encouragement in the vaccine treatment of either acute or chronic pelvic infections. Polak obtained encouraging results in the treatment of 225 cases, both puerperal and non-puerperal. His best results were obtained when the infection was localized in the absence of a bacteriemia. He employs the mixed vaccine obtained from reliable laboratories. The initial dose given was 25,000,000 to 100,000,000 organisms. CHAPTER XII HYGIENE AND DRESS Htgienb of the School-girl Physical Training in Schools Public Playgrounds and Baths Indoor Exercise Dress Hygiene of the School-girl. — It is encouraging to note that the public school, which was primarily established for the development of the mind of the child, is enlarging its scope and is today giving serious consideration to the development of the body. As a result the children of the poor find conditions in the school more favorable to their physical development than in their homes. Up to the time of puberty there should be no distinction made between the work and play of the girl and the boy. It is at this time of life that the child should acquire jSxed hygienic habits and in this the home and the school should cooperate. The hours of play and of rest, the food and the clothing, are matters of such vital importance as to engage the combined efforts of parents and teachers. The child who comes to school without sufficient clothing and without breakfast, and who has neglected the morning bath, as well as the care of the hair, the teeth and nails, is more in need of instruction and assistance in the care and development of the body than of the mind. Means for giving the needed service should be at the command of the teacher. The modern school-girl is dressed in an ideal way. The dress combines lightness with warmth, there is an absence of constriction at the waist line, the clothing is evenly distributed and hangs from the shoulders, and the shoes are heavy and comfortable. It would be well if such a dress were not discarded in later years. The importance of medical inspection of the pupils cannot be over- estimated. Many children are physically disqualified for receiving school instruction, and it is at this time that many defects can be remedied which if left uncorrected and unrecognized would lead to permanent disability. Children who are underfed, who have adenoids, defective vision, and scoliosis are placed at an immense disadvantage in their education. It is estimated that 90 per cent, of children who are backward in their lessons are physically defective. More than half the children who enter the public schools are in need of medical attention, and it may be affirmed that these ailments, if allowed to exist, will engender in girls many of the pelvic disorders which become manifest with the establishment of puberty. The underfed child cannot assimi- late knowledge. " Good nutrition, therefore, is essential to good educa- tion." It would be well if the public schools in this country would 230 HYGIENE AND DRESS follow the example of some of the European schools in providing break- fast and luncheon for the underfed child. Thomas Madden Moore is quoted as saying: "If the State, for reasons of public policy, determines that all children shall be com- pulsorily educated from their earliest years, it should certainly afford the means by which this may be least injuriously and most effectively carried out, by providing sufficient food as well as education for every pauper child compelled to attend school." It must not be inferred that malnutrition is the heritage of the poor alone; the child of the well-to-do may suffer from the lack of plain, nourishing food and an oversupply of sweets and pastries. The school desk is an important factor for consideration. A faulty attitude assumed by the child at the desk leads to many physical defects which may have an important bearing in later life. Physical Training in Schools. — The effect of physical training in schools is apparent to all who have had opportunity for observation. This effect is not only manifested in the physical development of the child, but in the mental development as well. Regular systematic gymnastics should be a part of the curriculum of every public and private school, and should be demanded of the children of the rich as well as of the poor. Such exercises not only benefit the child of normal development, but will correct many of the physical defects due to faulty posture and carriage. The gymnasium is of special value to the girls because of the greater difficulty experienced in having them take the needed outdoor exercises. There should be no distinction made between the exercises required of the girls and that of the boys before the age of puberty. Up to this time there is no essential difference in their physique, and the demands for their development are identical. The girls should be encouraged to spend several hours a day in the open air in their sports. Pubhc Play-grounds and Baths. — No greater boon has been conferred on the children in large cities than in the establishment of public parks, play-grounds, and baths. Children of the crowded tenement districts who live in poorly lighted rooms are afforded the opportunity for fresh air, sunlight, and healthful exercise. More than this there is a watchful control exercised over these children which safeguards them from injury and develops manly and womanly qualities in them. It would be well if public laundries were also established in crowded tenement districts. All these conveniences are not mere luxuries, they are absolute necessities, if the right sort of wage-earners, wives, and mothers is to be developed. The public purse can well aft'ord to make adequate provision for them. Indoor Exercise. — Whatever adds to the general physical develop- ment of women adds to the sexual development, and should be encouraged. Both indoor and outdoor exercises are more appreciated today than at any time in the history of the American race, and to this fact may be ascribed much that has contributed to the well-being INDOOR EXERCISE 231 of women. Golf, tennis, riding, and other forms of exercise, when judiciously practised, produce a healthy, vigorous type of women, and in this general improvement the sexual organs share. Indoor exercises are of value as adjuncts to the treatment of diseases of women. The capacity of the lungs and the development of the muscles of the thorax and abdomen have much to do with the equilib- rium of the circulation in the pelvic organs. Hence it follows that whatever exercise will develop the capacity of the lungs and the strength of the abdominal and thoracic muscles wdll tend to prevent displacement of the uterus and congestion of the pelvis. Fig. 102 Fig. 103 Fig. 104 Deep breathing. The shoulders and chest elevated. Contractions of the abdomen. Bending backward of body. Women of advanced years are especially in need of such exercise. Inasmuch as they are less inclined to physical activity their muscles become relaxed and atrophied, fat accumulates in the abdominal wall and omentum, and there is a tendency to the development of a pen- dulous abdomen. Such a condition predisposes to uterine displace- 232 HYGIENE AND DRESS Fig. 105 ments and pelvic congestion with all their attending evils. It must not be assumed that the accumulated fat is the offending factor, nor must efforts be directed solely to reduction in weight, but rather to strengthening the retaining power of the abdominal wall by increasing the muscular tone through well- directed exercises. If indoor exercise is to afford the best results certain conditions must be maintained ; the clothing must be free of constriction — pajamas are preferred; the room must be supplied with an abundance of fresh air, yet free of drafts; the bowels, bladder, and stomach must not be loaded, and finally the exercise should be taken in the morning before breakfast and in the evening before retiring. JMoreover, it is essential that the exercises should be taken at regular intervals and not be subject to the whims and moods of the individual. They should not be carried to the point of fatigue, and after the exercise in the morning, while the cir- culation is yet accelerated, a cold bath or shower should be taken, followed by vigorous rubbing of m Fig. 106 Bending forward of body. First step. Bending forward of body. Second step. the body with a coarse towel. After the evening exercise a full hot bath should be taken and the body dried with a soft towel and the patient should then retire to bed. There are certain movements which are especially directed toward the object desired. Those in general practice are the following: IXDOOR EXERCISE 233 Exercise 1. — Deep Breathing. — The erect posture is assumed with the hands resting upon the hips, the arms akimbo. The chest is slowly expanded to the full capacity of the lungs. The air is held for a few seconds, with the abdominal muscles tightly contracted, then slowly and completely expelled. This exercise should be repeated six times in a minute. Exercise 2. — Abdominal Contractions. — The erect posture is assumed with the hands resting upon the hips, the arms akimbo, the abdominal muscles alternatelv contracted and relaxed. Fig. 107 Fig. 108 ^*^'® vS^ Bending of body sidewise. T-sristing of bodJ^ Exercise 3. — Trunk Bending Forward. — The erect posture is assumed, the arms are stretched vertically above the head, the palms facing forward, and the thumbs interlocked. The chest is slowly expanded to the full capacity of the lungs, the abdominal muscles are contracted tightly, and then the trunk is bent upon the hips without bending the knees^ m the effort to touch the tips of the fingers or the palms of the hands to the floor. A deliberate return is then made to the erect 234 HYGIENE AXD DRESS posture, and wliile the arms are being slowly lowered to the side the air is exhaled. There should be an interval of ten seconds before the exercise is repeated. Exercise 4. — Trunk Bending Backward. — The erect posture is as- sumed, the hands resting upon the hips and the arms akimbo. Under full expansion of the chest and firm contraction of the abdomi- nal muscles, the body is slowly bent backward, then gradually straightened again and the air exhaled. Fig. 1C9 Raising of bodv. First step. Fig. 110 Raising of bodj'. Second step. Exercise 5. — Trunk Bending Sideicise. — The erect posture is assumed with the hands resting upon the hips, the arms akimbo. The chest and Imigs are fully expanded and the abdominal muscles contracted. The trunk is then slowly bent to the right and to the left several times in succession. Exercise 6. — Trunk Twisting. — The erect posture is assumed, the hands resting upon the hips, the feet close together, the legs and thighs rigid. The chest and lungs are fully expanded, the abdominal rnuscles tightly contracted. The body and head are then repeatedly- rotated from left to right and from right to left. Exercise 7. — Trunk Raising. — The body lies straightened upon the floor, the hands resting upon the hips, the feet together, a full breath INDOOR EXERCISE 235 is taken and then the body is slowly raised to the sitting posture. The orio-inal posture is then slowly resumed as the air is exhaled. There should be a rest of a few seconds before repeating the exercise. Fig. Ill Raising one leg. Fig. 112 Raising both legs. Exercise 8.-Le„ Rm.sing.-The same posture is assumed as in Exer- cise r Then with the luigs fully expanded and the knees st.ftened, 23() HYGIENE AND DRESS Fig. 113 Dip movement. First step. Fia. 114 Dip movement. Second position. Fig. 115 Squatting position. DRESS 237 the legs are slowly elevated to a right angle with the trunk; as they are lowered the air is exhaled. This exercise is repeated at intervals of a few seconds. If difficulty is experienced in elevating both legs together they may be elevated alternately. Exercise 9. — The Dip Movement. — Lying prone upon the face and abdomen with the palms and toes upon the floor, the back, neck, and legs stiffened, a full breath is taken. The whole form is elevated upon the arms and toes, then lowered as the air is exhaled. Exercise 10. — Squatting. — With deep inspiration in the erect posture, the hands resting on the hips, the patient squats so that the buttocks are close to the heels. She then straightens up and exhales. This movement is repeated at intervals of ten seconds. Dress. — Faulty habits of dress are responsible for many of the ailments of women. The chief faults are combined in the insufficient protection from dampness and cold and in undue constriction and traction about the waist. As a result of insufficient protection the surface of the body becomes chilled, and the internal organs, particularly those of the pelvis, become congested, their functions deranged and their texture altered. The pernicious habit of wearing thin-soled shoes and sleeveless, low-necked gowns contributes largely to the disorders of the pelvic organs. Three essentials to dress are emphasized by Dudley, whose views are in accord with the classical paper of Dickinson.^ These conditions are: 1. Even distribution for uniform protection against cold and wet. 2. Freedom from waist constriction. 3. Freedom from traction. 1. Even Distribution. — In this respect the modern dress displays an utter disregard of hygienic principles. No adequate protection is afforded the head; the neck, shoulders, and arms are either bare or insufficiently clad; layer upon layer of cloth bind the waist; skirts hang about the lower extremities, but provide little warmth and do immeas- urable harm by traction and constriction of the waist; the legs are poorly protected by stockings; and tight shoes with thin soles hamper the free action of the feet and expose them to cold and dampness. High heels tilt the body forward, thus putting undue strain upon the muscles of the back and contributing to backaches and fatigue in the effort to maintain the equilibrium of the body. More than this, the normal curves of the spine and the obliquity of the pelvis are altered. 2. Waist Constriction. — By constricting the waist with corsets and bands the muscles of the abdomen and back are seriously embarrassed, the abdominal viscera are displaced and their functions impeded; the inability to perform abdominal respiration impedes the action of the lungs and heart. Passive congestion of the abdominal and pelvic organs may result from waist constriction, and, as a consequence, the menstrual functions become deranged, discomfort is complained of in the pelvis and the capacity for childbearing is limited if not wholly lost. 1 Trans. Amer. Gyn. Soc, 1893. 238 HYGIENE AND DRESS Fig. 116 Furthermore, the stomach is compressed and its functions impaired. The peristaltic moA^ements of the bowel are embarrassed, leading to constipation and intestinal indigestion. The transverse colon and kidneys are crowded downward. In short, there is not a single viscus in the chest, abdomen, or pelvis which may not be affected directly or indirectly by the constriction of the waist. While it is apparent that the corset is capable of much harm, it must in all fairness be admitted that a corset may be so made and adjusted that it will do no harm and be a benefit in certain particulars. This statement should be qualified, however, for in women who are compelled to assume the stooping posture day after day in their work, any sort of a corset will compress the abdomen. It is estimated that a woman who draws in her sta^s three or four inches places herself under a direct pressure of from twenty to thirty pounds' weight, and that this pressure is increased by the food and liquids taken into the stomach, by the loading of the bowel, and by the weight of the skirts (Playfair). During pregnancy, constriction of the waist is particularly apt to produce dis- placements of the uterus, and may be the cause of abortions and malpositions of the fetus. At this juncture it may be well to refer to the abdominal supporters worn in the childbed period. Such a binder, when tightly applied, operates in an injurious way by increasing the intra-abdominal pressure, and thus contributes to the congestion of the uterus. Unques- tionably, not a small percentage of displaced uteri are accounted for in this way. Fig. 117 Fig. 118 Forward bending. Corset steels forcing the pelvic organs downward. (Steele-Adams.) Undershirt ratvertf ba7id Vhite Drawers band tinise . Corset Corsei-cover Flannel-skirt ba^id flTiite-skirt band Dress-skirt hand Dress-waist lined 17 LAYERS Layers of material about waist in old style of dress. (Dickinson.) IJnion Undergarments Eqiiesfrirnne tighU Muslin imi^t and i^kirt Dress Layers of material about waist in new style of dress. (Dickinson.) A flabby uterus, slightly supported by the relaxed ligaments and pelvic floor, affords little resistance to the intra-abdominal pressure, but the author would not be understood as condemning the wearing DRESS 239 of all abdominal supports after labor. When the abdominal walls are greatly relaxed, a properly adjusted binder will provide the needed support to the viscera and add to the comfort of the mother. 3. Waist Traction. — Corsets and waist-bands prevent the free exer- cise of the abdominal and dorsal muscles. This leads to an under- development of these muscles. They are unable to withstand the weight of the skirts without fatigue. In this fact lies one explanation for the habitual backache of women. Moreover, the underdevelopment of the muscles of the abdomen weakens the expelling powers of labor. Hence it follows that all unnecessary traction at the waist must be eliminated. Body forms that are factors in questions of corset postures and pressures. A thin build shows a long trunk seriously affected by constriction during adolescence. A square build and broad trunk may be squeezed to develop fat pad deformities, but rarely into displacements or serious defects. (Dickinson.) To meet the conditions necessary to provide even distribution for uniform protection against cold and wet, together with freedom from waist constriction and traction, Dudley recommends a hygienic dress composed of the following garments: 1. Union undergarment. 2. Equestrienne tights (in winter). 3. Muslin or silk waist and skirt. 4. Dress in one piece, or so made that its principal weight may be distributed over the shoulders, bust, and hips. These garments may be modified in many ways to suit the fancy without violating the essential principles — that of even distribution and freedom from waist constriction and traction. Corsets. — In a series of observations made by Dickinson upon the construction and physical effects of the corset, he finds that the average Fig. 120 'Kii'n i^e.t moved T\K"i^00d cox^ct" of shouUdfi forivdrd chin foiwaii atid foweud fiampered organs pusficd doivniv'd pcfcic contenb exposed to pressure fromaMe l» \ 'yionV'^U^scotset, vicious pc5turc ^yie$$vic Fig. 122 Fig. 123 $f\c\itdix$ far forward of ftipj fine uprigfit. ei ' uearfy: prfjsuro (bseii upward 3. 'uarfiin^ faiify free oiijans nctpre^ill downward pcFvic com teiib feci? ^om fine ofprepure *^^dmn'maf ccwct: ^od po5tuu,fowpie55Utt^ Figs. 121. 122, 123. — The three types of corset, hourglass, straight, abdominal." Vicious pressures compared with tolerable pressures; harmful forms vs. neutral; bad posture or good; pelvic inclination inviting displacement as against tilt which saves from pressures. Picturesquely unfavorable instances of the first and second class are here selected tocontrast with a good or corrective example of the third. (Dickinson.) PLATE XIII Govcr 1 Clw |f faper Ifacinj: m5mm ffasfic rroa^erv cfi '^eel hr Simple Method of Recording Outlines. di'wjn? LaJ? 'r T:r.Ti:mT'''{ The paper is dipped to wall or knee aetaon is shown by the snug sheet Diekinso^.) ^^ ^""^ DRESS 241 corset shows little effect on increase in the vaginal pressure in corseted women whose abdominal walls and pelvic floor are firm, but they cause a marked rise in the intrapelvic pressure from exertion in women whose muscles are flabby and whose interior supports are relaxed. Dickinson is of the opinion that the tight corset does little harm to vigorous women, and great harm to weak women. The woman with a long body, compressed chest, and sagging viscera is harmed by corsets. Dickinson attempts to group the various types as follows: 1. A limited number of women who are not seriously affected by excesses in pressure and constriction. 2. A large number of women who are not seriously affected by moderate degrees of constriction. 3. A large number of women in whom abdominal constrictions gradually induce considerable alterations which may result in per- manent disability. 4. A small proportion of women who are seriously affected by slight departures from the normal. To estimate the amount of pressure exerted by the corset, note the gap between the steels on loosening the corsets; this gap should not be greater than two inches. The hand passed within the corset will locate the respective points of pressure and will roughly indicate the degree of pressure. Effect of Corsets iqjon Posture. — We have observed the effect of faulty posture upon backstrain and have referred to this factor as a frequent cause of backache. Corsets may correct or exaggerate a faulty posture, hence relieve or increase backache. Dickinson finds that the normal posture calls for a line from the back of the buttocks to the back of the shoulders that inclines forward about one inch, i. e., the shoulders are about one inch in front of the buttocks. Office Test of Posture. — Dickinson stands the patient on a mark on the floor, sidewise to a paper on the wall, when the shoulder-blade and buttocks are indicated on the paper. The difference in these two points with and without the corset will demonstrate the effect of the corset on posture. Essentials of a Well-fitting Corset. — Following are the essential features of a well-fitting corset: 1. Loose at the top. 2. Waist not reduced more than one or two inches. 3. Laced snug at the hips. 4. Straight front with little or no incurve at the waist. 5. Long below and low at top. 6. Separate lace for lower six or eight holes. 7. Support large breasts independently from the shoulders. 8. When the abdomen is large or the abdominal walls relaxed a front lace corset should be adjusted in the recumbent position or the abdomen may be raised by slipping the hand inside the corset before tightening while in the erect position. 16 CHAPTER XIII PREPARATION OF PATIENT FOR OPERATION Examinations for Contra-indica- TIONS Local Treatments Preparatory to Operation Preparation of the Field of Opera- tion Choice of Local or General Anes- thesia Local Anesthesia General Anesthesia Spinal Anesthesia Combined Gynecological Opera- tions Diet The time consumed in the preparation of a patient for a major operation depends upon two factors: (1) The urgency of the indication for the operation; (2) the condition of the patient in reference to the general nutrition, blood, kidneys, and respiratory tract. Examination for Contra-indications. — When there is no contra-indica- tion to an immediate operation from the causes referred to below, twenty- four hours will be sufficient time in which to prepare a patient for operation; but conditions may be such as to necessitate a delay of days, weeks, and possibly months before an operation can be performed without unwarranted risk to life. The author is persuaded that lives are not infrequently lost by failure to look to the details of preparations for operation. The following are the main considerations in the pre- paratory management of operable cases: Blood. — The blood should be examined in all cases before proceeding with an operation, and no major operation of convenience should be undertaken with the hemoglobin lower than 50 per cent, and the number of red cells less than 2,500,000. If the patient is losing blood more or less continuously, as from a uterine fibroid or carcinoma, a preliminary curettage or vaginal pack may be resorted to for the purpose of checking the hemorrhage, while rest, forced feeding, and tonics are administered. By such a process the author has seen the blood restored at the rate of 10 per cent, a week. Heart. — When the heart is irregular and weak in its action, rest in bed, together with small doses of strychnine, should be enjoined until the heart has regained its strength and regularity of action. Rest in bed, a light, nutritious diet, and carefully regulated doses of strychnine and digitalis may in a few days or weeks so restore the action of an incompetent heart as to render it capable of withstanding the strain of a prolonged operation. Irritation of the Air Passages. — When there is acute irritation of the air passages operation should be delayed, if possible, until all signs of irritation have subsided. Failure to observe this precaution may precipitate a bronchopneumonia. LOCAL TREATMENTS PREPARATORY TO OPERATION 243 General Lowered Vitality. — General lowered vitality is a factor which the surgeon would do well to consider carefully before operating. Patients with low resistance, as manifested in poor nutrition, a low blood-count, and low blood-pressure, should be given a course of rest, feeding, and tonics before subjecting them to an operation of convenience. Faulty Secretions. — Faulty secretions may constitute a justifiable contra-indication to operations of convenience. If the urine secreted is below the normal amount, or if it contains morbid elements, such as blood, albumin, and casts, operation should await the correction of this condition, unless it be an emergency that will brook no delay. Local Treatments Preparatory to Operation. — The haste which characterizes modern life is exemplified in surgery. This criticism applies, in large part, to the management of pelvic inflammations in the acute and subacute stages. Too great haste in surgical intervention, under such conditions, may result in unnecessary sacrifice of organs which, by tentative mangement, might have been restored to functional if not organic health. More than this, infections which are localized may be extended, and with disastrous results, if attacked early in their course. In such cases non-interference is the watchword; rest, hot douches, and glycerin — ichthyol tampons are means which conserve the tissues and prepare them for possible operations in which the hazards will be greatly diminished. This is not true of the chronic forms of pelvic inflammation wherever located. Here local preparatory treatment is of no value. As will appear later, many cases which are included in the domain of general surgery can be relieved by local and general treatment, but it takes a clear understanding of the diagnosis and the relative values of conservative and radical measures to permit of a ready decision as to the proper procedure to be adopted. In the days of Emmet, at a time when surgical cleanliness could not be relied upon, operations for lacerated cervix and perineum, dis- placed uteri and abdominal tumors were not undertaken without local preparatory treatment. A clearer understanding of pathology and a greater confidence in immediate surgical preparation have largely done away with such preparatory measures. This does not apply to fistulse which may demand careful and long preparation before operation. When there is nothing in the condition of the patient to contra- indicate an immediate operation, the time for the preliminary prepa- rations need not exceed twenty-four hours. Only when confronted with an emergency should the preliminary preparation of the field of operation be omitted. A double prepara- tion of the field of operation should be the rule several hours before the operation; the second immediately preceding the operation, either before or after anesthesia. The author's preference is to make the 244 PREPARATION OF PATIENT FOR OPERATION second preparation of the field of operation after the anesthesia is well started, unless there is special reason for shortening the time of anesthesia, the patient nervous, or the scrubbing causes too great discomfort. It is expected that the patient will reach the stage of relaxation in the anesthesia by the time the preparatory measures are completed. Diet. — Twenty-four hours or more before operation the diet should be light and nutritious and the bowels thoroughly evacuated. Cartharsis. — The author has never deemed it necessary to deviate from the established rule practised years ago, that of giving 1 or 2 grains of calomel and sodium bicarbonate, followed in six to eight hours with | ounce of Epsom salt; again in six hours with a high colonic flushing, given in the knee-chest position, and finally a low colonic flushing given three hours before the operation. Other cathar- tics may be given, with perhaps equally good results. By thoroughly cleansing the bowel there will be less distress from gas pains subsequent to the operation, and in vaginal operations there is not the likelihood of soiling the field of operation. Stimulation. — As a rule no stimulation should be given before the operation. It is found that the patient suft'ering from depression during the operation, reacts more promptly to stimulation when she has not been stimulated prior to the operation. A good precautionary measure against postoperative vomiting is to encourage the drinking of large quantities of water up to two hours before the anesthetic. Combined Abdominal and Vaginal Preparation. — Whether a vaginal or abdominal operation is proposed, it is wise to take the precaution to prepare both the vagina and abdomen, because of the uncertainty which attends such a large proportion of gynecological operations. Before beginning an operation it is not possible to say with absolute certainty that it will not be necessary to open into the vagina for the purpose of drainage or the removal of the uterus. In like manner a proposed vaginal operation may lead to the opening of the abdomen through the finding of an unsuspected condition in the pelvis or the accidental perforation of the uterus. Preliminary Examination. — When the patient is relaxed under anes- thesia, and before the operation is begun, it should be the invariable rule to make a bimanual examination, for unsuspected conditions may in this way be revealed. Such preliminary examinations prior to operation may alter the decision of the operator and cause him to do a vaginal rather than an abdominal operation, and vice versa; hence the advisability of preparing both the vagina and abdomen in all proposed operations on pelvic lesions. Failure to do so will occasionally lead to great embarrassment to the operator and add unwarranted risks to the patient. Preparation of the Field of Operation. — A great variety of methods is employed in the preparation of the field for operation. All have merit and no one excels over all others. The following is the method which the author employed for many years : PREPARATION OF THE FIELD OF OPERATION 245 Preparation of Abdomen. A, Preliminary (twelve to twenty-four hours before operation). 1. Scrub with green soap and sterile water. 2. Shave the entire abdomen, groin, vulva, and chest to the level of the breasts. 3. Scrub ten minutes with green soap, sterile water, and sterile gauze. 4. Wash with sterile water. 5. Wash with alcohol, 95 per cent. 6. Wash with ether. 7. Apply creolin solution, 1 per cent. 8. Apply dressing of dry sterile gauze and binder. Fig. 124 Painting the abdomen -nith iodine and alcohol, equal parts. B. Immediate preparation before or after anesthesia. 1. Scrub with alcohol. 2. Apply solution of creolin eight parts and glycerin two parts, rubbing well into the skin for three minutes. 3. Remove creolin solution with sterile gauze and wash with alcohol. 4. Cover patient with sterile sheets and towels. Iodine Sterilization. — In the past two years the author has used the iodine preparation on the abdomen, with good result, and has practically discarded the above method because the iodine sterilization is equally trustworthy and is far more convenient. The method consists in: 1. Dry shave. 2. Scrub with alcohol or benzine. 3. Paint field of operation with 3 per cent, tincture of iodine. 4. Wait ten minutes. 246 PREPARATION OF PATIENT FOR OPERATION 5. Paint again with 3 per cent, tincture of iodine. When the patient can be prepared on the previous day the author carries out the usual preparation of scrubbing, shaving, washing with alcohol, and applying a sterile pad and binder. He is not convinced, however, that such precautions add security to the patient. Preparation of Vulva and Vagina. A. Preliminary. 1. Scrub with green soap and sterile water. 2. Shave external genitals and inner aspect of thighs. 3. Wash with sterile water. 4. Cleanse vagina with green soap and sterile water, using only the fingers rather than gauze in scrubbing, for fear of removing the vaginal epithelium. 5. Irrigate vagina with sterile water. 6. Apply 1 per cent, solution of creolin to vagina, scrubbing well with the fingers. 7. Scrub external genitals with creolin solution, 1 per cent. 8. Apply perineal dressings preparatory to operation. Iodine Sterilization. — It will be found perfectly safe to swab the vagina and external genitals with 3 per cent, tincture of iodine. Choice of Local or General Anesthesia. — When all things are made ready for an operation the choice of the anesthetic devolves upon the operator. The greater the experience of the operator the more does the importance of this task appeal to him, for with experience comes an appreciation of the dangers involved in individual cases. The surgeon of experience knows that no anesthetic is without some element of danger, that every case is a law unto itself and demands special con- sideration in the choice of anesthetic. There are cases in which the operation is so slight that neither general nor local anesthesia is required. The slight discomfort in the procedure would not justify the risk, however slight, of a general or local anesthetic. There are other cases in which there is profound depression from sepsis or hemorrhage, or the heart, lungs, or kidneys are in such a condition as to contraindicate the use of any general anesthetic. Such cases compel the operator to resort to local anesthesia or to abandon all anesthetics. All sorts of operations have been performed with endermic injections of cocaine or Schleich's solution without the degree of suffering that would be expected. Vaginal and abdominal operations are performed under local anesthesia, with surprisingly little pain, provided no trac- tion is made upon peritoneal ligaments and mesentery. The author has performed as capital operations, with the aid of local anesthesia alone as with general anesthesia, and the results have been equally satis- factory. In all these cases the condition of the patient presented positive contra-indications to the administration of a general anesthetic and yet would brook no delay. Such, for example, were cases of ruptured tubal pregnancy, with the escape of a large quantity of blood, and, again, of profound sepsis associated with great depression. CHOICE OF LOCAL OR GENERAL ANESTHESIA 247 It is the rule of the author, when operating under local anesthesia in major cases, to have an assistant drop upon an Esmarch inhaler a mixture of alcohol and wintergreen. This the patient believes to be an anesthetic. By this ruse, and with words of assurance from the operator and anesthetizer, she is carried through the operation with much less suffering than would be expected. While a general anesthetic facilitates the operation, and without it the niceties of technic cannot always be accomplished, it must be borne in mind that the purpose of the operation is to restore health and save life, and to this end the first consideration is that of the safety of the patient. Unquestionably general anesthesia is frequently resorted to when a local anesthetic or no anesthetic whatsoever should be given. Fig. 125 Operating room in hospital. Patient in Trendelenburg position preparatory to making an abdominal incision. Local Anesthesia. — ^When the field of operation is superficial and limited to a small area a local anesthetic will usually suffice. When a general anesthetic is contraindicated in major vaginal or abdominal operations the initial incision through the vaginal or abdominal wall may be made painless by a local anesthetic. The further steps of the operation can usually be taken without creating great suffering on the part of the patient. Cold. — The application of cold to the surface in the form of a spray of ethyl chloride benumbs the surface by paralyzing the sensory nerves. The spray is applied for about five minutes or until a crust of ice forms 248 PREPARATION OF PATIENT FOR OPERATION upon the surface at the point of incision. Bengue's ethyl chloride is supplied in vials containing 30 grains. These vials are provided with brass tips containing a capillary opening and screw-top. Anesthesia may be almost as effectively accomplished by applying a bag filled with cracked ice and salt for five or ten minutes. Cocaine. — The hydrochlorate of cocaine may be applied to the surface of the mucous membranes or injected under the skin. An application to the surface of the vaginal mucosa will not anesthetize the tissues; here an injection is required as in skin surfaces. Injections of cocaine into the urethra and rectum are dangerous. Under a 2 per cent, cocaine anesthesia, vulvar and vaginal cysts may be removed, the urethra may be dilated with little pain, and polyps may be removed. In exceptional cases, perineorrhaphy and colporrhaphy may be per- formed; but, as a rule, little can be accomplished in the relief from pain because the anesthetic effect of the cocaine does not persist throughout the operation. Schleich's Solution. — This solution consists of morphine, cocaine, and normal salt solution. It has been found less dangerous and more efficient than cocaine as a local anesthetic. By the hypodermic injection of Schleich's solution the nerve terminals are paralyzed through pressure. The needle is thrust under the skin in a nearly perpendicular direction, and the fluid is forcibly injected until the skin is elevated and blanched. Successive injections are made at the periphery of the swelling, along the line of incision. No time should be lost in the making of the incision after the injections. It is probable that the injection of normal salt solution will be found equally as efficacious. General Anesthesia. — The choice of anesthetic will depend upon the condition of the patient, with particular . reference to the respira- tory tract, heart, kidneys, blood, and the general resistance of the individual. In the United States ether is generally regarded as the safest of the general anesthetics when not contraindicated by irritation of the respiratory tract. Anesthetizer. — There can be no more fatal error than to fail, to appreciate the responsibilities of the anesthetizer. To relegate the administration of the anesthetic to an inexperienced assistant is an unpardonable act. The choice of the anesthetizer is only second- ary to that of the operator, and equal experience and skill should be demanded of both. Equally to be condemned is an anesthetizer who permits himself to be absorbed in the operative procedure and fails to be attentive to his duties. An inexperienced or careless anesthetizer either harasses the operator by failing to keep the patient relaxed or endangers the life of the patient by giving an unwarranted amount of anesthetic. When a competent anesthetizer is employed the decision as to the time and amount of stimulation should rest with him. The anesthetizer should always be provided with a mouth gag, tongue retractor, bits of gauze held by forceps with which to swab the mucus from the throat, and a watch to note the pulse rate. Failure to observe these precautions have not infrequently led to fatal error. CHOICE OF LOCAL OR GENERAL ANESTHESIA 249 Signs of Complete Anesthesia: 1. Complete muscular relaxation. 2. Deep, slow and regular breathing. 3. Contracted pupils. 4. Loss of pupil reflex. Signs of Danger. — When the anesthetic has been pushed too far the first approach of danger is usually observed in the grayish pallor of the face. The pulse becomes feeble and rapid, possibly irregular, and the respirations shallow and slow until both become imperceptible. The blood from the wound becomes dark and may cease to flow. The pupils are dilated and fixed. Resuscitation of the Patient. — Prompt and masterly action is demanded of the anesthetist when signs of danger arise. A feeble pulse, cessation of the respirations, dilated pupil, and pallor point to impending death, and no time should be lost in putting into force all known methods of restoration. The foot of the table should be raised to an angle of 40 to 50 degrees; the operation must be suspended; all open vessels secured with hemostatic forceps; the wound covered with warm sponges; the jaws held forward and upward and the tongue retracted by means of especially constructed forceps which should always be at hand. If necessary to resort to artificial respiration the Sylvester method should be employed. The head is made to fall slightly backward by elevating the thorax with a small pillow. The surgeon standing at the head of the patient grasps both wrists and elevates both arms above the patient's head, drawing them upward and outward so as to describe a circle. By so doing the pectoral muscles expand the chest. The arms are then lowered and are made to compress the chest firmly, thereby forcing the air out of the lungs. These movements are repeated at intervals of three to five seconds until respiratory movements are reestablished. Gas Anesthesia. — In the author's experience he has found the greatest satisfaction in the employment of gas for operations of short duration and as a preliminary to ether anesthesia. He has never attempted the prolonged administration of gas, but as a preliminary measure to ether anesthesia, time and ether are saved and the patient is spared the distressing experiences of struggling under ether during the preliminary stages of excitement. Ether Anesthesia. — Care should be exercised in the selection of a pure brand of sulphuric ether. The only absolute contraindication to the use of ether is laryngeal and bronchial catarrh. Nephritis has been generally regarded as a contraindication, but there is probably no rational basis for this belief. Many of the inhalers on the market are cumbersome, and only serve to burden and confuse the anesthetizer. As an improvised inhaler a cone made of stiff paper and towel still remains in general favor. In the author's judgment the safest pro- cedure is the drop method, in which the ether is dropped from a can or bottle upon an Esmarch inhaler in the same manner as chloroform is administered, but in larger quantities. 250 PREPARATION OF PATIENT FOR OPERATION It is an error to force the ether upon the patient; it should be given slowly and continuously. When the patient gags and vomits the mask should not be removed, but the ether should be continued until the spasmodic efforts of the patient are under control. Ripened judgment is required after general relaxation is obtained and constant vigilance is exacted of the anesthetizer in order that neither too little nor too much ether be given. Chloroform. — While chloroform is the anesthetic of choice in Europe, and indeed in the Southern States, there is a general prejudice against its use in the Northern States. While the patient is put to sleep in less time, with less discomfort and the disagreeable after-effects are minimized as compared with ether, the hazards to life are proportion- ately great. Adulteration of the product increases the risks, and hence the greatest care should be exercised in the selection of the brand. The one absolute contraindication to the use of chloroform is an incompetent heart. Valvular lesions of the heart in the presence of good compensa- tion offer no contraindication. According to Hare, chloroform is more irritating to the kidneys than ether. Whenever it is essential that struggling shall be avoided, chloroform is preferred. In such cases it is well to precede the administration of chloroform by the hypodermic injection of J grain of morphine, given a half-hour in advance. Hare affirms that death from chloroform is more often the result of respiratory than of cardiac paralysis. As a rule the pulse fails earlier than the respiration. The administration of chloroform should never be wholly intrusted to an inexperienced assistant. Unlike ether anesthesia the mask should be removed when the patient vomits or the throat fills with mucus, and should not be replaced until the struggling ceases. Spinal Anesthesia. — For a time much was expected of the injection of cocaine into the subdural space of the cord for anesthesia of the abdomen and lower extremities, but it may be safely affirmed that there is no place for the procedure in view of its many dangers. Combined Gynecological Operations. — The term combined gyneco- logical operations implies the performance of two or more gynecological operations under the same anesthesia. Advantages of Combined Operations. — Two or more lesions com- monly exist in the pelvis and together contribute to the symptom- complex. It is self-evident that failure to correct all of the lesions will result in failure in obtaining complete relief. For example, a displaced uterus should not be restored to its normal position without correcting any existing defect in the pelvic floor and vaginal walls. Furthermore, lesions resident in the appendages and appendix should receive due consideration. Again, when the uterus and its appendages are in- fected it will serve no good purpose merely to curet the uterus; the lesions resident in the upper genital tract should, at the same' time, be disposed of. Pain, hemorrhage, leucorrhea, and sterility are the complaints common to gynecological cases. One or all of these complaints may be due to a single lesion, but not uncommonly there is a combination of lesions, each contributing its share to the symptom-complex, hence DIET 251 the importance of looking beyond a single lesion for the cause of a symptom or group of symptoms. ^Yhen two or more contributing factors are found to account for the complaints, all should be removed under a single anesthetic if the physical resistance of the patient and the time limit of the operation will permit. In the course of an operation minor lesions are often disposed of which in themselves might not justify operative intervention, i. e., cystic ovaries, small superitoneal fibroids, and relaxed uterine supports without displacement of the uterus. When the low vitality of the patient will not permit an extended operation or the combined work required is too great for a single anes- thetic it is advisable to perform the operation in two or more steps, but, as a rule, all work should be completed before the patient leaves the hospital. Diet. — It is important for the surgeon to be well informed in dietetics, but the scope of this work does not permit an extended discussion of the subject. In selecting a suitable diet for a patient the first con- sideration is that of nourishment and the second is that of palatability. To meet the varied requirements of individuals it is essential to have a thorough knowledge of dietetics. Liquid Diet. — It is the author's custom to prescribe nothing but liquid diet for the first twenty-four hours following a major operation. As a rule, milk should be excluded from the diet list until the functions of the digestive tract are well established, and this generally requires several days following the operation. In the first twenty-four to forty- eight hours the diet should consist of broths, gruels, bouillon, albumen water, and beef juice. These may be given at four- to eight-hour intervals, and in small quantities. If milk is given at this early date it is well to add lime water, Vichy, or Seltzer. To add to the digestibility of milk the contents of one of Fairchild's peptonizing tubes may be dissolved in four ounces of water and one pint of milk. This may be given either hot or cold. ]Milk may be albumenized by adding the white of an egg to two ounces of milk, this to be stirred gently with a spoon, care being taken to avoid coagulation of the albumen. Again, the milk may be rendered more digestible by pasteurizing at a temperature of 160° F. for one-half hour. Koumiss is digestible and palatable to many patients. A good substitute for koumiss is buttermilk, served either hot or cold. Egg-nog may be served between meals when forced feeding is desired. Whisky, sherry, or brandy may be added in small quantities. Soft Diet. — In all but exceptional cases a soft diet may be given the second or third day following operation. In addition to the food- stuffs mentioned under liquid diet, there are added such articles as soft- boiled, poached, or scrambled eggs, baked or creamed potatoes, toast (dry, milk, or cream), cereals (oatmeal, cream of wheat, cracked wheat), fruit (stewed prunes, baked apple, oranges), egg custards, corn-starch pudding, and rice pudding. It is well to withhold all meats, vegetables, and fruits not included in this list until the patient is well on the way to recovery. CHAPTER XIV PRINCIPLES OF ASEPSIS IN GYNECOLOGY Sterilization of Field of Opera- ' Preparation of Instruments TioN Sterilized Water Disinfection of Hands and Fore- Preparation of Operating Room ARMS Preparation for Operation in Pri- Preparation of Surgical Utensils vate House Preparation of Gauze and Sutures Operating Bag Until recent years the principles of asepsis in surgery were little known and imperfectly practised. The field of operation, the hands of the assistants and operators, the materials used in the operation — including instruments, suture material, gowns, sponges, dressings, and solutions — were not perfectly sterile. The rendering of all these things free of pathogenic microorganisms constitutes aseptic surgery. The procedure is of such vital importance that a detailed recital of the methods of sterilization might be of interest, but the details are so varied that the author must confine himself to a description of those methods which he himself employs. In many instances they are no better than others elsewhere in vogue, but space will not permit of a consideration of all approved methods. Sterilization of the Field of Operation. — See page 244. Disinfection of the Hands and Forearms. — The surgeon and his assistant should guard against the contamination of their hands with septic material. They should, therefore, not engage in postmortem examinations or in the treatment of acute infectious diseases. When operating on the cadaver or on septic cases the hands and arms should be protected by long rubber gloves. Failure to regard such precautions may be the means of conveying infection to the field of operation. In disinfecting the hands and forearms greater importance should be attached to mechanical than to chemical disinfection. Undue reliance is often placed upon chemical disinfection. No amount of antiseptics can atone for laxity in the use of the scrub brush. A stiff sterile nail brush should be chosen, and should be of sufficient size to permit vigorous usage. The author is in the habit of scrubbing his hands under running water from the tap. The temperature of the water should be as hot as can be borne comfortably by the hands. Green soap is preferred to all others. The arms should be scrubbed to the elbows, and special care should be directed to cleaning the inner surfaces of the fingers and nails. An orange stick and peroxide of hydrogen are best suited for cleaning the finger nails. Ten minutes should be occupied in scrubbing. The arms and hands are then thoroughly rinsed in sterile water and dried with a sterile towel. DISINFECTION OF THE HANDS AND FOREARMS 253 An assistant pours into the palms of the hands about two drams of a sokition composed of eight parts of creolin and two of glycerin. This Fig. 126 Scrubbing of hands. The nurse pours liquid green scap on the hands of the operator. Fig. 127 Method of putting on dry sterile gloves. Gloves and hands are powdered with sterile talcum. The assistant holds the sleeve of the glove well apart while the operator inserts his hands. In this manner the hand does not touch the outside of the glove. 254 PRINCIPLES OF ASEPSIS IN GYNECOLOGY solution is rubbed into the hands and arms for five minutes. The hands and arms are then washed in a 1 per cent, creohn solution, next in sterile w^ater, and finally in alcohol. A long sleeve gown is then put on and the hands covered with sterile rubber gloves. A mouth-piece of several layers of sterile gauze should cover the mouth and nose. One objection to the creolin and glycerin solution is that it smarts the arms. This can be largely overcome by thoroughly drying the hands and forearms before applying the solution. Fig. 128 Operator prepared for operation. Preparation of Surgical Utensils. — Brushes. — Small, flabby nail brushes should never be employed; they should be made of stiff bristles, and when the bristles have lost their stiffness the brushes are to be dis- carded. They should be large enough to afford a good grasp, but not so large as to be unwieldly. Sterilization of the brushes should be by boiling, preferably in water containing soda bicarbonate. Before taking up a sterile brush to scrub the hands, they should be first washed with soap and water, otherwise the brush will become unneces- sarily contaminated. After vigorous scrubbing with the brush the author completes the scrubbing process by using sterile gauze sponges, green soap, and hot sterile water. The sponge has the advantage of not roughening the hands. PREPARATION OF GAUZE AND SUTURES 255 Basins. — Glass or porcelain-lined basins for the hand solution, instruments, sponges, and dressings are preferred, though agate-ware is acceptable. These are best sterilized by putting a number of such clean basins in a pillow-slip and placing them in a steam sterilizer. When the sterilizer is not large enough to accommodate them they may be boiled in a wash-boiler. For hurried sterilization of pans and glass vessels, they may be rinsed with pure carbolic acid, then with alcohol, and finally with sterile water. In a well-equipped hospital a utensil sterilizer is of the greatest convenience and utility. Rubber Drainage Pads. — A Kelly drainage pad is indispensable for carrying away solutions while preparing a patient for operations and in irrigating during operation. The Kelly pad is cleansed by scrubbing with soap and water, followed by a thorough scrubbing with a strong solution of lysol or creolin. A sterile towel is then placed over the pad. Towels, Bandages, Gauze Dressings, Sponges, and Cotton. — These are subjected to fractional sterilization in a steam sterilizer, first for one hour, then for half an hour on two successive days. If not used for three or more daj's after sterilizing it is well to sterilize them again for half an hour on the day of the operation. All towels, sponges, and dressings should be wrapped in small packages and counted and labelled before being placed in the sterilizer. Preparation of Gauze and Sutures. — Iodoform Gauze. — Sterile gauze is cut in desired lengths and widths. These strips are then saturated in the following solution: Warm Castile soapsuds, 6 ounces; powdered iodoform, 1| ounces. After thoroughly mixing the solution in a sterile basin the gauze strips are saturated by rubbing the solution into the gauze. The strips are then wrapped in small packages, labelled, and placed in a sterilizer and sterilized on three successive days. In preparing the gauze the surgical nurse should wear sterile gloves and gown . Silk and Linen. — Surgical silk and linen are best sterilized by steam. The silk is rolled upon glass bobbins, several of which are placed in an ignition tube with a cotton stopper. The filled tube is then placed in a steam sterilizer, along with the towels, sheets, and sponges. After sterilization the cotton stopper is pushed firmly into the tube and placed in a glass jar to await its use. Frequent sterilization weakens silk and linen, so that only a small amount should be placed on each bobbin. The most serviceable sizes are Nos. 2, 3, and 4. Twisted silk is preferred to the braided. The author has found little need for silk and linen in gynecological practice. Practically the only places where they are used is in closing the abdominal incision where the abdominal wall is very heavy or for the repair of a postoperative hernia. In such cases two to four stay sutures of No. 3 twisted silk or heavy liiien may be passed through all layers except the peritoneum. The external sutures of a perineorrhaphy may also be of No. 2 or 3 twisted silk, the advantage over silkworm gut being greater comfort for the patient. Catgut. — For all private work and for a limited amount of hospital work the surgeon is scarcely justified in preparing his own catgut. It 256 PRINCIPLES OF ASEPSIS IN GYNECOLOGY is safer to rely upon the established firms, such as Lea, Van Horn, Walters, and Lukins. When an operator is using a large quantity of catgut he may, for purposes of economy, prepare his own catgut. The methods of pre- paring catgut are too numerous to mention. The author's preference is for the Bartlett catgut, which is prepared as follows: 1 . " The strands are cut into little coils about as large as a silver quarter of a dollar. These coils, in any desired number, are then strung like beads on to a thread, so that the whole quantity can be conveniently handled by simply grasping the thread. 2. "The string of the catgut coils is dried for one hour at a tem- perature of 180° F., and then for a second hour at 220° F., the change of temperature being gradually a(5complished. 3. "The catgut is placed in liquid albolene, where it is allowed to remain until perfectly 'clear,' in the sense that the term is used in the preparation of histological specimens. This is usually accomplished in a few hours, though it has been my custom to allow the catgut to remain in the oil overnight. 4. "The vessel containing the oil is placed upon a sand bath over- night and the temperature raised during one hour to 320° F., which temperature is maintained for a second hour. 5. "By seizing the thread with a sterile forceps the catgut is lifted out of the oil and placed in a mixture of iodine crystals, 1 part, and Columbian spirit (deodorized methyl alcohol), 100 parts. In this fluid it is stored permanently, and is ready for use in twenty-four hours." The advantages of Bartlett catgut are its strength, elasticity, and antiseptic qualities. Silkworm Gut. — The preparation of silkworm gut is like that of silk. For hurried preparation it may be boiled or carbolized. Preparation of Instruments. — Simplicity in construction is an essential quality for surgical instruments. All irregularities upon instruments add to the difficulties in cleansing, and should be dis- pensed with as far as possible. After operating, all instruments should be scrubbed in soap and water, rinsed in sterile hot water, and thoroughly dried. After use in septic cases instruments should be boiled before being dried. No rusty instruments should be used because of the difficulty in sterilizing them. In selecting instruments for operation the operator should bear in mind the possibility of having to meet with the unexpected, and there- fore the supply of instruments must be liberal. As a safeguard it is always well to sterilize all instruments needed in abdominal and vaginal operations irrespective of the probable demands. In order that no instruments be overlooked the operator should select his own instruments and should lay them in the tray in the order of their expected use. For example, he first selects the knives, then the hem- ostats of all sizes, next the tissue forceps, then the retractors, scissors, pedicle needles, needle holders, tenacula, needles, etc., until the list PREPARATION OF OPERATING ROOM 257 is complete. There should always be at least two knives, two scissosr, and two needle-holders, in case one should drop to the floor or in any way become unserviceable. The instruments are boiled in 1 per cent, bicarbonate of soda solution for ten minutes; this solution should completely cover the instruments. In order to preserve the cutting edge, all scissors and knives should be sterilized by dipping first in pure carbolic acid, then in alcohol, and finally in sterile water. The sterilized instruments are placed in glass trays partly filled with sterile water, or may be laid upon a sterile table and covered with a sterile sheet or towels. Sterilized Water. — All water used in operations should be first filtered and then boiled for a half hour. An abundant supply of sterilized water, both hot and cold, should always be at hand. Preparation of Operating Room. — In the construction of an operating room, utility rather than useless ornamentations should be the aim. Ornamentations only add to the expense and to the labor in keeping the room in order. The essential factors in the construction of a modern operating room are good light, good ventilation, sufficient space, and convenience. The best light comes either through the north side or through a sky- light sloping to the north. Over the operating table should be an electric bracket, with a group of four or more lights, and to this bracket is attached a portable light with a reflector. Gas should be provided as a substitute in case the electricity is out of order. The ventilation should be adequate but of the simplest construction. No currents of air should be permitted to come in contact with the patient. Whatever the material used for walls and floor it must be smooth and of hard finish. While marble is durable and ornamental, it cannot be claimed that it is more serviceable than enamelling. The floors may be of tile, mosaic, or cement. All angles should be rounded to facilitate cleaning. The dimensions of the room should be not less than 12 x 14, and the ceiling not less than ten feet high. A well-appointed operating room suite will consist of an operating room, sterilizing room, surgeons' dressing room, with shower bath, appliance room, anesthetic room, and recovery rooms. The equipment of the operating room should be substantial and simple. The stationary basuis for washing the hands should be three or four in number, and should be provided with hot and cold water controlled by a pedal attachment. No sterilizers, water-boilers, receptacles for dressings and the like should be in the operating room. Warming the Operating Table. — As a preventive measure to shock in cold weather the operating table may be warmed by a series of electric lights fitted to a frame under the table. Robb has devised a series of electric lamps held in an upright position by attachments to two hollow, movable metal tubes, which are applied to the under surface of the table. There are two rows of thirty-two candle-power 17 258 PRINCIPLES OF ASEPSIS IN GYNECOLOGY lamps, each of nine lamps. The amount of heat is controlled by a series of switches, making it possible to turn on two lamps at a time until the desired amount of heat is supplied. The apparatus is detachable and can be used wherever there are electric attachments. Fig. 129 Showing lamps with table in Trendelenburg position. (Eobb.) Fig. 130 Showing lamp detached from operating table. (Robb.) Preparation for Operation in a Private House. — While it is possible to prepare and equip an operating room in a good private house so that the principles of aseptic surgery can be carried out, it is always at the expenditure of much time and labor. The surgeon naturally feels that it is his assistants who fail to adapt themselves to the strange and more or less improvised surroundings, but, as a matter of fact, he himself is not so much the master of the situation as when in his own operating room and hospital. Frequently the needed equipment is not at hand, the light may be faulty, the temperature and ventilation of the room not properly regulated; these and many other things cause him annoyance. The PREPARATION FOR OPERATION IN A PRIVATE HOUSE 259 only satisfactory way is for the operator to take with him his own trained assistants. Preparation of the Room for Operation in the Home. — In preparing a room for operation, light, space, and cleanliness are of the first con- sideration. All unnecessary articles are to be removed. The floor and all wood-work in the room should be scrubbed and the walls and ceiling wiped. The mattress should be aired and covered with fresh linen, underneath which should be placed a rubber sheet. Only a wet cloth should be used in cleaning the room on the morning of the opera- tion, and every precaution should be taken to prevent dust from rising in the air. Clean sheets mav be huns: over the walls. Room prepared for abdominal operation in private house. The following articles should be provided for the room: a common kitchen table, four wooden chairs, a dishpan, a foot bathtub, two water buckets, two small tables, one rubber sheet two yards long by one yard wide, a bed-pan, three earthen pitchers, a new wash-boiler, several quart bottles suitable for hot water, one dozen clean towels and two clean sheets, and four wash-basins, preferably of porcelain-lined granite-ware. A trained assistant should be sent the day before the operation to make all needed preparations. When the time is short the attendant should be directed to scrub a new wash-boiler with Sapolio, to rinse it out thoroughly, and then to fill it two-thirds full of water and boil for 260 PRINCIPLES OF ASEPSIS IN GYNECOLOGY an hour. The water should be boiled two hours before the operation, and without removing the lid it should be allowed to cool and await the coming of the operator. It is exasperating to be compelled to wait for water to cool. Upon arriving at the house the surgeon should inspect everything to satisfy himself that all is as it should be. In emergency cases, when there has not been time to take up the carpets the day before the operation, they should not be removed for fear of raising the dust; instead, damp sheets may be placed over the floor. With a portable operating table, brought by the surgeon, it is possible to perform any operation without serious embarrassments. The operator must exercise great vigilance with his assistants who may not be able to accommodate themselves perfectly to strange environments and therebv be led into grave errors in technic. Fig. 132 Portable combination sterilizer for instruments and dressings. The greatest objection that can be offered to operating in houses is the necessity of leaving the after-care of the patient to other and often inexperienced hands. This is most unfortunate, and in the author's judgment a surgeon is justified in declining to accept the responsibility of such a case unless it be an emergency. He should make sure that the case will receive skilled after-treatment or decline to operate, unless, as has been said, the case is an emergency and cannot be taken to a hospital. Operating Bag. — The surgeon should always have his operating bag in readiness. This bag should contain all needed instruments, freshly sterilized sheets, towels, pads, sponges, and dressings. Upon arriving OPERATING BAG 261 at the house all that is needed is the preparation of the patient, a suit- able table, an abundance of sterile water, and three or four sterile pans. These things should be attended to by the nurse in charge before the arrival of the surgeon, so that there need be little delay. Contents of a Complete Operating Bag for Abdominal Operations. — IxSTEriMEXTS AXD ACCESSORIES : Green soap in compressible tube or glass jar. Four nail brushes. Creolin-glycerin solution, 8 to 2 (four ounces). Bichloride of mercury tablets. Alcohol (eight ounces). Razor. Ether (one pound). Ether mask. Hypodermic syringe and strychnine, 1 to 40 tablets. Rubber irrigating bag with glass nozzle. Four rubber sheets, one yard square. Three long sleeve aprons. Safety pins (one dozen). Laparotomy pads (three sizes). Sponges. Iodoform gauze (one large and several small rolls). Dressings of sterile gauze. Muslin abdominal binder. Surgical Ixstruimexts, Sutures, and Ligatures: Two knives. Two pairs of scissors. One long and two short tissue forceps. One Simpson abdominal retractor. Two Simon's specula. One dozen six-inch hemostats. Six large hemostat forceps. Two needle holders. One dozen assorted needles. Two pedicle needle holders. Silkworm gut. Silk, sizes 2, 3, and 4. Catgut, sizes 1, 2, .3, both plain and chromicized. CHAPTER XV ANOMALIES AND MALFORMATIONS OF THE GENITAL ORGANS Anomalies and Malformations of THE Vulva Absence of Vulva Double Vulva Atresia of Vulva Infantile Vulva Hypertrophy of Vulva Congenital Anomalies of Clitoris Congenital Fissures of the Vulva Anatomy and . Malformations of THE Hymen Anomalies and Malformations of THE Vagina Absence Atresia and Stenosis' Double Vagina Blind Pouches Anomalies and Malformations of THE Uterus Uterus Deficiens Uterus Rudimentarius Uterus Foetalis Uterus Unicornis Uterus Septus Uterus Bicornis Uterus Didelphys Uterus Accessorius Anomalies and Malformations of THE Fallopian Tubes Anomalies and Malformations of THE Ovaries Absence of One or Both Ovaries Congenital Smallness of One or both Ovaries Supernumerary Ovaries Congenital Largeness of One or both Ovaries In view of the fact that malformations and maldevelopments of the genital organs commonly present a multiplicity of deformities in the associated organs, it will be easier to understand the subject if it is considered as a whole. To illustrate: Absence of the vagina suggests the probable absence of the uterus and its appendages; a septum of the vagina suggests the possible presence of a divided uterus, and a uterus of the infantile type suggests the almost certain presence of underdeveloped tubes and ovaries. ANOMALIES AND MALFORMATIONS OF THE VULVA Absence of Vulva. — This condition is rare, and is, as a rule, asso- ciated with a congenital absence of the internal organs of generation. Absence of one or more of the component structures of the vulva is not of such rare occurrence, and may be found associated with well-formed internal organs of generation. Double Vulva. — Double vulva is an extremely rare condition. Atresia of Vulva. — Atresia of the vulva may be found associated with a communication between the rectum, bladder, and genital canal. The fetus is rarely viable, but the defect may be found in mature years. The atresia may be complete. In this case the newborn child will be unable to urinate until the septum is divided. As a rule the coales- ANOMALIES AND MALFORMATIONS OF THE VULVA 263 cence is incomplete, there being a small opening through which the urine and menstrual blood escape and through which it is possible for conception to take place, as in one of the author's cases. Treatment. — The treatment consists in passing a grooved director through the opening and slitting the septum vertically. The vulva is then lightly packed with sterile gauze for three to five days. Fig. 133 ^J>arooplioron or Nephric pt.of Wolffian Body. Uterus -■V. Aberrans Paradidymis or Nephric pt. of Wolffian Body. Urethra III. Relationship of the sexual ducts and their rudiments in the two sexes. /, the indifferent primary type; //, the differentiation in the female; ///, the differentiation in the male. (Adami.) Infantile Vulva. — The infantile type of the vulva may be maintained after puberty. The entire vulva, or one or more of the component parts, may fail to mature to the full sexual type. Cretins and dwarfs mostly retain the infantile type. The vulva may mature at the time of puberty, and subsequently undergo atrophic changes involving part or all of the vulva. Such atrophy occurs in wasting diseases in certain nervous disorders, such as epilepsy, and after removal of the ovaries. A physiological atrophy occurs after the menopause. Hypertrophy of the Vulva. — Hypertrophy of the vulva rarely involves all structures composing the vulva. Congenital Anomalies of the Clitoris. — The clitoris may be absent, bifid, small, or large. 264 AXOMALIES AXD MALFORMATIOXS OF GEXITAL ORGAXS Absence. — This is a rare finding. Atrophy. — Less rare than absence is a congenital hypoplasia of the clitoris. Hypertrophy. — The clitoris varies in size within normal limits. It has attained the size of the penis. There is no fomidation for the belief that masturbation causes the clitoris to enlarge. Syphilis is named as a causal factor. Fig. 134 mons veneris MEATUS URiNARIUS Vulva of a -virgiii. The labia have been widely separated. (Testut.) Symytom^. — ^As a rule no symptoms arise, but in some instances the enlarged clitoris may interfere with intercourse and may cause a deflection of the stream in urinating. At times it causes great annoyance by becoming irritated. Treatment. — Xo treatment is indicated when there is moderate enlargement. ^Mien there is great hj-pertrophy the clitoris should be removed by a wedge-shaped incision and the stump closed by two or more interrupted sutures of Xo. 1 chromic catgut. Irritation of the clitoris is relieved by rest, the application of oxide of zinc ointment, or lead water and laudanum lotion. Sitz baths will afford relief. . Adhesions of the Prepuce. — ^The prepuce may become adherent to the clitoris as the result of uncleanliness and inflammation. It is not ANOMALIES AND MALFORMATIONS OF THE VULVA 265 uncommon to find the entire glans of the clitoris covered by an adherent prepuce. Symptoms. — Local irritation leads to sexual abuses and morbid sexual de- sires. Some maintain that a long train of nervous disturbances is engendered. When the sebaceous material accumu- lates under the prepuce, local tender- ness and pain may result. Wherever there is local irritation an examination should be made. Treatment. — Grasp the clitoris be- tween the thumb and index finger, and make backward traction upon the clitoris. If the adhesions do not yield they may be separated by a dissector. It may be necessary to apply a 10 per cent, solution of cocaine before under- taking the procedure. The glans is anointed daily with carbolized vaseline to prevent reformation of adhesions. Congenital Fissures of the Vulva. — Epispadias. — Epispadias is caused by failure of closure on the part of the anterior abdominal wall, together with a dehiscence of the anterior wall of the allantois. The allantois thus Fig. 135 Adherent labia. The vaginal outlet is re- stored by making a vertical incision along the line of adhesion. Fig. 13S Fig. 137 Hypertrophy of the cUtoris. Amputation of hypertrophied clitoris. A wedge-shaped incision is made and interrupted chromic catgut sutures are passed from side to side. (After Ashton.) 266 ANOMALIES AXD MALFORMATIOXS OF GENITAL ORGANS communicates with the outer world. The defect, if possible, should be remedied by a plastic operation, ^yhen this is impossible a urinal must be adjusted and the parts kept as clean as possible. Fig. 138 Fig. 139 Adhesions of the prepuce. The adhesions are severed by a dissecting instrument. (After Ashton.) Redundant prepuce. First step. The prepuce is severed in the median line and the clitoris exposed. Fig. 140 Adherent prepuce. Second step. Either flap of the prepuce is excised with scissors. Hypospadias. — Hypospadias is formed by a persistence of the uro- genital sinus. The urethra and vagina open high up in the vestibular canal. The perineum is well-developed. The urethra may be absent ANOMALIES AND MALFORMATIONS OF THE VULVA 267 and the bladder communicate directly with the vagina. When there is complete control of the urine no treatment is required, but otTierwise an effort should be made to separate and approximate the mucous membrane of the urethra with sutures. Fig. 141 Fig. 142 Adherent prepuce. Fourth step. The Adherent prepuce. Third step. The sutures of sutures of silkworm gut are tied. This pro- silkworm gut are in place. vides free exposure of the clitoris. Fig. 143 CRESCENTiC FRINGED BILABIAL BIPERFORATE CRIBRIFORM Different forms of hymen. (Testut.) Anatomy and Malformations of the Hymen. — Physiological rupture and stretching of the hymen occur from sexual intercourse and childbirth. 268 ANOMALIES AND MALFORMATIONS OF GENITAL ORGANS It is possible for the hymen to be merely stretched in admitting the penis or in the passage of the child. The lacerations occurring from the first coition are usually radial, and do not extend to the base of the hymen. It is possible for the Fig. 144 Fig. 145 Hymen after coitus. (Testut.) Hymen after parturition. (Testut.) Fig. 144. — C, clitoris; PL, nymphae; U, meatus urinarius; OF, vaginal orifice; H, hymen; D, rents in hymen. Fig. 145. — U, meatus urinarius; P, nymphse; CM, carunculae mjTtiformes; Z, portion of hymen detached and floating; D, a tear through the fourchette. Fig. 146 Imperforate hymen with hematocolpos. hymen to be partly torn from its base without tearing its free margin. As a rule, there is a circular opening. After childbirth the hymen iscompletel}^ severed in many places, leaving isolated tags (carunculse myrtiformes). These lacera- tions often extend into the vagina and perineum. The question of the existence or absence of a hymen is of medicolegal importance. It is self-evident that the hymen is not a trustworthy guide in judging virginity. The hymen may be present and intact after sexual intercourse and even after childbirth, while, on the other hand, it may be totally wanting or but partially developed in virgins. It is possible for a lacerated hymen to heal so perfectly that no evidence of a previous laceration is visible. ^lalformations of the hymen are con- genital or acquired. These malformations are a double hymen, one beside the other, in cases of double vaginae and a hymen ANOMALIES AND MALFORMATIONS OF THE HYMEN 269 imperforatus in connection with other malformations of the Miillerian tract. Atresia caused by an imperforate hymen may be congenital or acquired. As pointed out by Gellhorn, where the remainder of the genital tract is well-formed the atresia is undoubtedly acquired. Neugebauer has collected from the literature the reports of about 1000 cases of atresia of the hymen. In about one-half of this number the lesion was acquired, and in about one-third of the cases the history gave no suggestion of the cause, whether congenital or acquired. Acute infectious diseases and gonorrhea are responsible for the greater number of acquired atresias. Fig. 147 Fig. 148 Hymen with single minute opening. Hymen with two minute openings. When the hymen presents an obstacle to intercourse it should be dissected away with scissors and the raw edges closed with a running catgut suture. Cysts of the Hymen. — Little is known of cysts of the hymen. Wenkel made the first report in 1883. Palm describes a cyst of the hymen measuring 8 cm. in diameter. The average diameter is about 1 cm. Many do not exceed 1 mm. in diameter. They are usually congenital, 270 ANOMALIES AM) MALFORMATIONS OF GENITAL ORGANS Fig. 149 though the^' max not be observed until late years. One or more cysts are located near the free margin of the hymen. The presence ot a variety of epithelium lining the cyst cavity suggests a variety ot sources. As a rule, the epithelium is squamous and stratified, but is occasionally cylindrical . and in a few instances endothelium is found. The origm of the c^•sts of the h^•men is in many cases the epithelial projections; these projections become constricted off, and form the epithelial wall of a space which fills with serum. A few cases apparently arise from Gartner's duct, from dilated lymph spaces, and from retention of the secretions of sebaceous glands. In a valued original communication on the " Anatomy, 1 athology, and Development of the Hymen," G. Gellhorn^ presents numerous lesions of the hvmen not generally recognized. Inflammations of the hymen are primary or secondary to vuh'itis and vaginitis. The inflamed hymen is markedly reddened and bleeds easily. The same changes aft'ect the remains of the hymen (carunculse myrtif ormes) . Tumors of the hymen are rare. Gell- horn finds seventeen cases of hymeneal cysts in the literature, two cases of polypi, and one of angioma. Sanger reported a case of primary sarcoma of the hymen. As yet no case of primary carcinoma of the hymen has been reported. ANOMALIES AND MALFORMATIONS OF THE VAGINA Inasmuch as the vagina is partly developed from the ducts of INIiiller, developmental failures, analogous to those found in the uterus and tubes, are to be found in the vagina. There may be a complete absence or a partial development of the vagina; the ducts of ^Nliiller may fail to coalesce, giving rise to a double vagina; the ducts of Miiller may coalesce but fail to be absorbed, leaving a partial or complete septum, dividing the vagina in the median line. Absence of the Vagina. — Absence of the vagina may result either from failure of the ducts of ]Muller to develop or from complete Xormal \ulva with congenital absence of vagina and uterus. atresia. As a rule the entire Miillerian tract fails to develop, hence 1 Amer. Jour, of Obstet., August, 1904. PLATE XIV Fig. 2 Fig. I. — Atresia at the vulva first causes distention of the vagina, producing hematocolpos. (Sutton and Giles.) Fig. 2. — Atresia at the vulva. Hematotrachelos has followed hematocolpos. (Sutton and Giles.) Fig. 3 Fig. 4 Fig. 3. — Atresia of the vulva has caused hematocolpos, then hematotrachelos, and then hematometra. (Sutton and Giles.) Fig. 4. — Atresia at the vulva. In addition to the conditions in Fig. 3, there is added hematosalpinx. (Sutton and Giles.) Fig. 1 PLATE XV Fig. 2 Fig. 3 Fig. I. ^Atresia in the vagina midway between the vulva and the os externum, causing hematocolpos in the upper half of the vagina. (Sutton and Giles.) Fig. 2. — Same as in Pig. i, except that distention of the whole uterus has followed the partial hematocolpos. (Sutton and Giles.) Fig. 3. — Atresia of the os externum, producing a hematotrachelos. Corpus uteri not yet distended. (Sutton and Giles.) Fig. 4. Fig. S Fig. 4. — Atresia of the os internum, producing hematometra. Fallopian tubes may become distended later. (Sutton and Giles.) Fig. 5. — Atresia of the vulva on one side of a double uterus and vagina, causing a hematocolpos on the affected side. (Sutton and Giles.) ANOMALIES AND MALFORMATIONS OF THE VAGINA 271 the absence of the vagina, uterus, and tubes. The appearance of the external organs of generation may be misleading in determining the sex. Part or all of the vagina may be found wanting, due to a lack of canalization of part or all of the lower segment of the ducts of Miiller. Symptoms. — No symptoms arise until the time of puberty. At this time the attention of the mother is called to the failure of the menses to appear. If the upper genitals fail to develop, the only com- plaint is that of amenorrhea; but if the uterus, tubes, and ovaries develop to the stage of functional activity the menstrual blood will accumulate in the uterus and tubes, and give rise to the presence of a Fig. 150 Incomplete transverse septum of the vagina: a, septum; b, hymen. tumor in the pelvis as outlined in Plates XIV and XV. On examina- tion the vagina will be found to be absent, and there will be discovered a fluctuating tumor above the pelvis and extending down into the pelvis. This tumor is observed to increase in size with each menstrual epoch. Occasionally the absence of the vagina is not observed until after marriage. Treatment. — When the menstrual molimina are not experienced no treatment is advised unless it is desired to make an artificial vagina to provide for sexual intercourse — a procedure that should be under- taken with caution because of its many failures. When, however, 272 ANOMALIES AND MALFORMATIONS OF GENITAL ORGANS the uterus, tubes, and ovaries are developed it becomes imperative to provide an outlet for the menstrual blood. Making an Artificial Vagina. — A sound is placed in the bladder and the indejc finger of the left hand is inserted into the rectum. A transverse incision is then made with the knife immediately in front of the anus. A dissection is then made between the bladder and rectum, with fingers and dissecting scissors, until the cervix is reached. The opening is spread widely by the fingers or forceps and the contained blood is washed away with an antiseptic solution. When the blood does not readily escape from the uterus the cervix must be dilated and the uterus irrigated. The utmost caution should be observed to prevent Fig. 151 Fimbriated extremity of tube. /vr/a^ Fallopian tube. '\\'<:*> Broad ligament, upper part Artery vein. Vagina, anterior wall. The uterus and its appendages. Posterior view. The parts have been somewhat displaced from their proper position in the preparation of the specimen; thus the right ovary has been rai.sed above the Fallopian tube and the fimbriated extremities of the tubes have been turned upward and outward. (From a preparation in the Museum of the Royal College of Surgeons of England.) infection. To prevent subsequent contraction and obliteration of the newly formed channel an effort should be made to transfer a flap of skin from the perineum or labia to the walls of the channel. When this fails a glass plug should be introduced and worn, not only until healing has been effected, but for an indefinite time, to prevent sub- sequent contraction. Failure to provide an artificial outlet for the menstrual blood calls for an abdominal supravaginal hj^sterectomy, leaving the ovaries in situ. Atresia and Stenosis of the Vagina. — As a rule, atresia of the vagina is incomplete. It is usually the lower segment that is closed. In extreme cases only a fibrous or fibromuscular band is found between the bladder and rectum. Back of the obstruction the menstrual blood ANOMALIES AND MALFORMATIONS OF THE VAGINA 273 collects in the vagina (hematocolpos) ; in the uterus (hematometra) ; in the tubes (hematosalpinx), and, finally, in the pelvis (hematocele). The obstructing tissue may be stretched and crowded down, appearing at the vulvar outlet as a dark bluish-red membrane. The retained blood does not usually coagulate, but becomes dark in color. Etiology. — Atresia of the vagina may be congenital or acquired. It may be difficult to determine whether the malformation is developed in intra-uterine or in extra-uterine life. In young infants a vaginitis may form adhesions of the vaginal surfaces without giving rise to symptoms. Whether a fetal vaginitis can account for congenital atresia of the vagina has not been demonstrated. The usual cause of stenosis and atresia of the vagina, occurring during the period of sexual maturity, is trauma incident to labor. In the postclimacteric stage an adhesive vaginitis may narrow or obliterate the vagina. Gonorrhea is the usual underlying cause of senile vaginitis. In congenital atresia the obstruction is most often at the junction of the middle and upper thirds of the vagina, which is the lower limit of the JMiillerian ducts. In the acquired form the obstruction is usually similarly situated. The obstruction may be merely a half-moon or annular ring, a partial or complete septum with perforations, or a membrane varying in thickness, even to filling the vagina completely. Two, three, and even four atresic points have been described. Diagnosis. — The diagnosis of stenosis and atresia of the vagina should present few difficulties. When a girl at the time of puberty fails to menstruate, but suffers from pain in the pelvis, which increases in severity at the time of each monthly period, atresia of the vagina or cervix is suspected. If, in addition, a pelvic tumor develops and fluctuates distinctly, the diagnosis is highly probable, but must be confirmed by a vaginal examination. Vicarious menstruation rarely occurs. In an attempt to make a digital examination of the vagina the finger will meet the obstruction. The extent of the closure is best determined by the finger in the rectum. If the obstruction lies high in the vagina and does not bulge downward it is not likely that there is any considerable secretion pent up above the point of obstruction (Fig. 152). Hematometra is not easy to demonstrate, because of difficulty in palpating the elevated uterus through the rectum. The uterus usually lies near the median line, and is rounded, tense, possibly fluctuating, and somewhat increased in size. Treatment. — When the narrowing of the vagina does not present an obstruction to the menstrual flow or interfere with intercourse no treatment is advised. Forcible Stretching tinder Anesthesia.— This will suffice to remove some of the partial obstructions. Excision and Incision of Seyta. — Excision of septa and whipping the raw edges with a continuous catgut suture, or the making of a crucial incision through the septum and packing the vagina with iodoform 18 274 AXOMALIES AXD MALFORMATIOXS OF GEXITAL ORGAXS gauze for three days are the usual methods employed, ^^^len there is accumulated blood above the point of obstruction the operation inust be done with every possible sm-gical precaution to prevent infection. Fig. 152 Vaginal septum. The index finger inserted into the urethra and the thumb into the rectum are approximated, and by so doing the atresic vagina is demonstrated. When blood has accumulated in the vagina or in the vagina and uterus the field of operation is made sterile, an incision is made in the septum and the pent-up blood is allowed to escape. If the uterus is distended the cervix is carefully dUated to permit the escape of the blood. After the blood has escaped, both the vagina and uterus are irrigated with an antiseptic solution, notably bichloride of mercury, 1 to 2000, and this is followed by a copious irrigation with sterile normal salt solution. The vagina is then loosely packed with iodoform gauze. The gauze is removed at the end of twenty-four hours, and afterward the vagina is irrigated with a mild antiseptic solution once or twice daily. The vulva is protected at aU times by a sterile gauze pad held in place by a T-binder. ^ATnen the tubes are distended great caution must be exercised in manipulating the uterus for fear of ANOMALIES AND MALFORMATIONS OF THE VAGINA 275 rupturing the tubes. Rest should be enjoined, and if signs of infection arise an ice-bag should be applied over the lower abdomen. If blood has escaped into the free pelvic cavity it should be given time for absorption, and if this does not occur, or if the blood becomes infected, vaginal drainage should be established through an opening into the cul-de-sac of Douglas. Double Vagina. — Double vagina is the result of failure on the part of the ]Miillerian ducts to fuse perfectly. From this cause a septum divides the vagina in part or throughout. The vaginal canals usually lie side by side, the septum running anteroposteriorly. The canals may be unequal in size. The septum rarely runs transversely, so dividing Fig. 153 Uterus didelphys, with double vagina. the vagina that one lies in front of the other — this can only be accounted for on the supposition that the Miillerian ducts had rotated prior to their fusion. All degrees of development may be observed in the septum, from a slight ridge to a complete partition composed of fibrous tissue, mingled with seme muscle fibers and covered on either side with mucous membrane. The cervix and uterine body are usually divided. If both canals are pervious no symptoms need arise until labor, when there may be an obstruction to the passage of the child. No treatment is advised unless the septum interferes with intercourse or with childbearing. In either event the septum should be excised with scissors and the raw edges stitched with a continuous suture of catgut, after which the vagina is packed loosely with iodoform gauze for one or two days. 276 ANOMALIES AND MALFORMATIONS OF GENITAL ORGANS BUnd Pouches. — Pouches, varying in size to an inch in length, are rarely formed in the lateral walls of the vagina. These pouches may serve as a receptacle of infection, and in this event it may be necessary to open them up freely to provide drainage. ANOMALIES AND MALFORMATIONS OF THE UTERUS The anomalies and malformations of the uterus are classified according to their origin as follows: I. Those Due to Imperfect Development of Mijller's Duct: 1. Uterus deficiens. j^^^ [ 2. Uterus rudimentarius. I i I 3. Uterus fetalis (infantile uterus). 4. Uterus unicornis. II. Those Due to Imperfect Blending of Muller's Ducts: 1. Uterus septus (bilocularis). 2. Uterus bicornis. 3. Uterus didelphys (uterus duplex, uterus separatus). 4. Uterus accessorius. Uterus Deficiens. — It is very unusual to find a complete absence of the uterus in an adult. When found there is usually also an absence of the entire genital tract, or only a rudimentary development of the vulva, vagina, tubes, and ovaries. The round ligaments may be present, though poorly developed. If the ovaries are present the menstrual molimina will be experienced, and vicarious menstruation may occur. There may or may not be sexual desire. It has been found in such malformations as acephalia, but to find no trace of the uterus in viable fetuses or adults is indeed rare. A bilobed uterus has been mistaken in postmortem examinations for the Fallopian tubes, and a hollow rudimentary uterus for the vagina. There may be no evidence of a uterus other than a thickening of the posterior vesical wall, or a smooth band continuous above with the tubes and below with the round ligaments, or the broad ligaments may be thickened in places by uterine tissue. It is manifestly impossible to make a clinical distinction between such rudimentary conditions and complete absence of the uterus. Mistakes have been made in anatomical dissections. The ovaries are often normal. In fact, the general psychical and physical development is usually perfect. Periodic ovulation seldom occurs. A scanty, bloody discharge occasionally comes from the vagina, but has not been demonstrated to be a menstrual flow. Vicarious hem- orrhages from the nose and rectum have been reported. The condition is usually recognized in the eftort to determine the cause of amenorrhea and sterility. The examination is best made per rectum. A sound placed in the bladder can be palpated along its entire course within the bladder by the finger in the rectum. If the uterus were well developed this would be impossible. ANOMALIES AND MALFORMATIONS OF THE UTERUS 277 Fig. 1.54 Uterus didelphys with double vagina. Fig. 155 Uterus bicornis bicollis. Fig. 156 Fig. 157 Uterus unicornis. Uterus septale. 278 ANOMALIES AND MALFORMATIONS OF GENITAL ORGANS Fig. 158 Uterus subseptate bicollis. Fig. 159 Uterus bicornis unicollis. Fig. 160 Uterus subseptate. ANOMALIES AND MALFORMATIONS OF THE UTERUS 279 The differential diagnosis between a complete absence of the uterus and a rudimentary uterus is scarcely possible without making an explor- atory incision. Placing a sound within the bladder and directing an assistant to hold it while proceeding with a recto-abdominal" exami- nation will demonstrate either an entire absence or a rudimentary development of the uterus (Fig. 162). Uterus Eudimentarius. — As the name imphes, the uterus is rudi- mentary in its development. It remains as a fibromuscular body, ill formed and undersized. The walls may be so thin as to suggest the name uterus membranaceus. The cervix, adnexee, ligaments, and vagina are likewise rudimentary or absent. The external genitals may be well-formed, though this is not probable. As already stated, a diagnosis cannot be made from complete absence of the uterus unless by abdominal section. Fig. 161 Uterus incudiformis. Uterus Foetalis (Infantile Uterus). — The uterus and adnexse remain like those of fetal life or early infancy — they are undersized. No sharp distinction can be made in these cases. In general it may be stated that a uterus is infantile when the cervix is larger than the corpus uteri, the walls thin, and the long axis of the uterus less than two inches. A better term would be hypoplasia uteri. Aside from the size, the most striking feature of the fetal or infant uterus is the disproportion between the cervix and the body of the uterus. The cervix is two- thirds the length of the whole organ, the body one-third. In the mature uterus the cervix is one-third the length of the whole organ, the body two-thirds. Again, the arbor vitae in the fetal or infantile uterus extend the entire length of the uterine cavity, while in the adult uterus the mucosa of the body is smooth and the arbor vitse extend only the length of the cervix. Still another feature of the fetal or infantile uterus is the absence of a fundus; the top of the uterus is either flat or depressed, while in the adult uterus it is convex. 280 ANOMALIES AND MALFORMATIONS OF GENITAL ORGANS The vagina is usually shorter and narrower than is normal, but, as a rule, it is well formed. The vulva may be poorly developed and the breasts likewise, but this is not the rule. A general hypoplasia of the whole cardiovascular system is said to be an underlying factor in this developmental failure. Chlorosis, scrofula, and the general wasting diseases are given as general pre- disposing causes. No general cause can account for local hypoplasia when the other structures of the body are well developed. Cretins and dwarfs commonly possess fetal or infantile uteri, but not infre- quently there is perfect general physical development. It is probable that the developmental failure lies primarily in the ovaries. Fig. 162 a, ribbon-shaped rudiment of the uterus; b, b, round ligaments; c, c, Fallopian tubes; d, d, ovaries. (Mann.) The clinical diagnosis is not difficult. Primary amenorrhea should always suggest the probable existence of an infantile uterus. Sterility is invariably present. If the patient has menstruated normally, or if she has ever been pregnant, there is no possibility of an infantile or fetal uterus. A small vagina and vaginal portion of the cervix suggest a small uterus. A recto-abdominal examination under anesthesia is preferred. When the uterine canal will admit a sound the measure- ment of the length of the uterus may be made, and an estimate of the thickness of the wall can be arrived at by a conjoined recto-abdominal examination, the sound remaining in the uterus. Uterus Unicornis. — Only a single horn of the uterus is developed; the opposite horn is either absent or rudimentary^ ANOMALIES AND MALFORMATIONS OF THE UTERUS 281 The explanation of this defect hes either in a partial or complete failure of one Miillerian duct to develop. The single horn tapers off into the tube. At the juncture of the horn and the tube the round Fig. 163 Uterus unicornis: LH, left horn; LT, left tube; Lo, left ovary; RH, right horn; RT, right tube; Ro, right ovary; RLr, right round ligament; LLr, left round ligament. (Mann.) Uterus septus duplex (natural size), completely double uterus, and incompletely double vagma of a girl, aged twenty-two years: a, a, tubes; b, b, fundus of the double uterus; c, c, c, partition of uterus; d, d, cavities of the uterine bodies; e, e, internal orifices; /, /, external walls of the two necks; g, g, external orifices; h, h, vaginal canals; i, partition which divided the upper third of the vagma mto two halves. (Mann.) 282 ANOMALIES AND MALFORMATIONS OF GENITAL ORGANS ligament is given off. There is no fundus. The vagina and cervix are small, and may be divided partially or completely by a septum. The ovaries and tubes may be rudimentary or absent; so, also, the bladder and kidney may be undeveloped, or there may be absence of the kidney on the side opposite the single horn. The cervix is small and the virgin vagina is narrow. The deformity is difficult to distinguish clinically from the infantile uterus. The lateral deflection of the uterus is highly suggestive. Sterility is the rule, though pregnancy in a rudimentary horn is possible. Amenorrhea is common, but the menstrual functions may proceed regularly. When pregnancy exists in a rudimentary horn the condition is not unlike tubal pregnancy in its chnical aspect. The dangers of rupture and of hemorrhage are the same. There is no way of making a distinction between these two conditions save by abdominal section, unless, as is possible in exceptional cases, the gestation sac is demonstrated by abdominal palpation to lie within the attachment of the round ligament. In tubal pregnancy the gestation sac lies external to the attachment of the round ligament. Utenas Septus (Bilocularis). — The uterus is divided by a vertical septum, extending a variable distance from the external os to the fundus. On the exterior there is no evidence of a septum. The uterus is broader and more globular than is the perfectly developed organ. Not infre- quently the vagina is septate. Various explanatory terms have been applied to the several degrees of the septate uterus — i. e., uterus biforis supra simplex, where the septum is only found near the external os; uterus subseptus unicorporens, where the septum is found in only a part of the cervix and body; uterus subseptus unicellis, where the septum is found in the body, not in the cervix; and uterus subseptus uniforis, where the septum completely divides the body and cervix, there being a single external os. Uterus Bicornis. — The two horns of the uterus are united to a limited and variable degree, the union taking place from below upward. The two halves of the uterus are rarely developed equally. All gradations are observed between the uterus unicornis with a rudimentary second horn and the uterus bicornis with both horns fully developed. The tubes and ovaries are usually normal, but the vagina often participates in the duplexity. The degree of separation varies from completely divided bodies with a single cervix to a union of the two horns, leaving but a notch in the fundus. The two horns are not always of equal size, and may not lie on the same plane. A septum may partially or completely divide the cervix and vagina. One or both horns may be imperforate. The external genitals are usually normal (Fig. 166). In addition to this and other anomalies in the development of the genital organs there may be maldevelopments of the urinary tract — e. g., ectopia vesicae — and absence of or congenital atrophy of the kidney. The behavior of a uterus bicornis is similar to that of the uterus septus. Menstrual disorders are common. Amenorrhea may result from atresia of the lower genital tract, or from an imperforate lumen ANOMALIES AND MALFORMATIONS OF THE UTERUS 283 in both horns of the uterus. The menses may flow simultaneously from the two horns or alternately at intervals of from two to four weeks. When one horn or one-half of a septate uterus is pregnant the opposite Fig. 165 Septate uterus. Left side recently contained a full-term fetus. Sketch of postmortem specimen. Fig. 166 Bicornate uterus with bilateral tuboovarian abscesses. The specimen was removed post mortem. The patient refused operation and died of general suppurative peritonitis. Four children had been born, probably from the larger horn. 284 ANOMALIES AND MALFORMATIONS OF GENITAL ORGANS side may continue to menstruate or may become pregnant at any time during the period of gestation in the other side. A decidua may form Fig. 167 Uterus bicornis unicellis: a, vagina laid open; h, single cervix; c, c, uterine horns; /, /, round ligaments; d, d. Fallopian tubes; e, e, ovaries. (Mann.) Fig. 168 • CI r Double uterus (uterus didelphys): a, right cavit)'; b, left cavity; c, right ovary; d, right round ligament; e, left round Ugament; /, left tube; g, left vaginal portion; h, right vaginal portion; i, right vagina; j, left vagina; k, partition between the two vaginae. (Mann.) in the non-gravid side and be discharged at labor. Pregnancy and labor may progress normally, and uterine contractions occur in both horns. This, however, is not the rule. The uterine contractions are ANOMALIES AND MALFORMATIONS OF THE UTERUS 285 seldom regular and strong; malpositions and malpresentations of the child are common; placenta prsevia and premature detachment of the placenta may occur at any time, and rupture of the uterus during labor is alwavs to be feared. Fig. 169 Uterus didelphys, sho-ndng the two cer-\-ices presenting in the vaginal vaults. The presence of a uterus bicornis or uterus septus is often not sus- pected, even after marriage and childbirth. A double vagina or a double cervix will suggest the presence of a septate or bicornate uterus. When pregnancy does not exist the finger or sound will aid in the diagnosis. Under anesthesia the separate horn may be detected by bimanual examination. Invohition is rarely as perfect in the puerperium as in the normal uterus, and displacements and subinvolution are liable to develop with all their remote consequences. Placental tissue is likely to be retained in the uterus and lead to infection and hemorrhage. 286 ANOMALIES AND MALFORMATIONS OF GENITAL ORGANS Uterus Didelphys (Uterus Duplex, Uterus Separatus). — Not only tbe uterine horns but the cervix as well is completely divided. Each half is equipped with a single tube, ovary, and round ligament. The vagina may be single, double, or partially divided. The two halves may be in different planes and of unequal size. One or both sides may be imperforate. All that has been said of the clinical features of a bicornate uterus will apply to a uterus didelphys. Uterus Accessorius. — This is the rarest of anomalies in the develop- ment of the uterus. Hollander and Skene each observed a case in which a small uterus was situated in front of a normal uterus, the two bodies joined at the internal os. The accessory uterus had no adnexse and no round ligaments. The probable explanation of this anomaly is that a diverticulum of Miiller's duct developed into an accessory uterus. In Hollander's case the patient gave birth to seven children. In an abdominal section placental tissue was found in the accessory uterus. In Skene's case there was a leucorrheal discharge from the accessory organ. ANOMALIES AND MALFORMATIONS OF THE FALLOPIAN TUBES 1. Both tubes may be wanting, in which case the uterus is commonly absent. 2. A single tube may be wanting, in which case the corresponding side of the uterus is usually absent. 3. One or both tubes may be rudimentary and associated with a rudimentary uterus. The tubes may remain infantile in type, very greatly convoluted, and have a small lumen. 4. The lumen of the tube may be partially or completely obliterated or may be abnormally large. 5. Rudimentary tubes or fimbriae may spring from the main tube. Leading into the main tube through the accessory tubes and fimbriae are rudimentary canals and ostia. Webster resected the fimbriated end of a tube; some months later the abdominal cavity was again opened and the fimbriae were found to be regenerated. 6. Diverticula of the endosalpinx are sometimes present, and are known to be a cause of tubal pregnancy. ANOMALIES AND MALFORMATIONS OF THE OVARIES Absence of One or both Ovaries. — This may occur as a congenital defect, or the entire ovarian tissue may be completely lost through the development of atrophic changes or new-formations. When both ovaries are absent the uterus and tubes are either altogether wanting or poorly developed. Menstruation and childbearing are impossible. ANOMALIES AND MALFORMATIONS OF THE OVARIES 287 In a case reported by Quain there was vicarious menstruation from the nose. Two of Martin's cases were sexual perverts: one a nympho- maniac, the other a prostitute. Martin collected twenty-two cases of congenital absence of one ovary. In one of his cases the uterus was normal, but the right tube and ovary were absent. In another the uterus and vagina were rudimentary, and the left tube and ovary absent. In nine of the twenty-two cases there was a uterus unicornis. The vagina and vulva are seldom influenced by the absence of a single ovary, and may be well-formed when both ovaries are absent. Torsion of the tube or adhesions surrounding the tube and ovary may shut off the blood-supply and cause complete atrophy of the ovary. The diag- nosis of the absence of one or both ovaries can only be made by inspection after the abdomen is opened. Congenital Smallness of One or both Ovaries. — This condition may be primary or secondary. Martin reports thirty-six cases of rudi- mentary ovaries; none menstruated, and only seven experienced the molimina. Twelve of the thirty-six had a rudimentary vagina, and in every case the uterus was under size. Rudimentary ovaries have been recognized by a conjoined examination, though this is exceptional. Supernumerary Ovaries. — Supernumerary ovaries are accounted for either as an acquired segmentation of the ovary or as a congenital defect. In 500 cases supernumerary ovaries were found eighteen times by von Wenkel. Sanger reported one that measured 1 cm. by 0.04 cm.; as a rule, they are much smaller. Pregnancy following the removal of both ovaries is explained by the presence of a supernumerary ovary. A true supernumerary ovary is rarely found, but an accessory ovary constricted ofP by adhesions is a comparatively frequent lesion. These accessory ovaries may be connected with the ovary by a pedicle or be completely isolated. Small pedunculated bodies, resembling ovarian tissue, are frequently seen near the ovaries; these are detached tubes of the parovarium, small myomata of the ovarian ligament, or stalked corpora fibrosa. The clinical significance of supernumerary ovaries is in the continuation of the menstrual and childbearing functions after the removal of both ovaries. The diagnosis can only be made by direct inspection. Congenital Largeness of One or both Ovaries. — This anomaly is occasionally found associated with precocious development of the sexual organs. Hypertrophy of the ovary is more often an acquired lesion. It is physiological during pregnancy and is commonly associated with uterine fibroids. It must be remembered that the normal ovary varies in size within Mnde limits. CHAPTER XVI MALPOSITIONS OF THE GENITAL ORGANS Malpositions of the Vaginal Walls Normal Position Cystocele Pectocele Vaginal Hernia Malpositions of the Uterus Normal Position Pathological Mobility Pathological Fixation Anteposition Retroposition Lateroposition Elevatio Uteri Torsion Prolapsus Uteri Prolapse of Pregnant Uterus Inversion Anteversion Anteflexion Retro versioflexion Hernia Malpositions of the Fallopian Tubes Normal Position Changes in Position Malpositions of the Ovaries Normal Position and Histology Changes in Position Descensus Ovarii Hernia of Tul^e and Ovary MALPOSITIONS OF THE VAGINAL WALLS Displacements of the uterus are commonly associated with displace- ments of the vaginal walls and the appendages of the uterus; hence the advisability of presenting the subject of malpositions of the genital organs in its entirety. Cystocele. — Synonyms. — Relaxation or prolapse of the anterior wall of the vagina; prolapse of the bladder; vesicovaginal hernia. Etiology. — 1. Relaxation of the anterior and posterior segment of the pelvic floor, due to labor. 2. Lacerations of the anterior and posterior segment of the pelvic floor, due to labor. 3. Prolapse of the uterus. 4. General malnutrition wdth loss of muscular tone. 5. Violent muscular exertion. Cystocele is occasionally observed in women and girls who have not borne children, and may be caused by a lack of muscular tone and by violent muscular exertion. In many instances, childbearing, with the resultant stretching and tearing of the anterior and posterior seg- ments of the pelvic floor, is the underlying cause for the development of cystocele. The lesion is very common, and its clinical importance has been greatly underrated. Anatomy. — The bladder, which is firmly adhered to the anterior wall of the vagina, will inevitably descend w'th the vagina. This gives MALPOSITIONS OF THE VAGINAL WALL 289 rise to a pouch formed by the posterior waH of the bladder above and the anterior wall of the vagina below. In the early development of a cystocele the walls of the bladder and vagina, which constitute the cystocele, undergo hypertrophy, but as the cystocele enlarges, these walls become stretched and blanched. The vaginal walls become dry and glistening. In extreme cases decubitus ulcers develop upon the vaginal surface. The ureters, as they pass into the bladder, may become so displaced as to lead to constriction, with subsequent dilatation; this, however, is rare. Fig. 170 Fig. 171 Longitudinal section of the vagina. Segment showing posterior wall. (Testut.) Segment showing anterior wall. Symptoms. — A small cystocele presents no symptoms. It is only when the relaxation is great that symptoms arise. The symptoms common to cystocele are a sense of fulness at the vulvovaginal orifice, a feeling of heaviness and dragging in the pelvis, and loss of power in urinating. Sense of Fulness at the Vulvovaginal Orifice. — The patient expresses the belief that her "womb comes down" when she stands, and par- ticularly when she exerts herself at stool or in lifting. Here the increase 19 290 MALPOSITIONS OF THE GENITAL ORGANS in the intra-abdominal pressure forces the pelvic structures downward and exaggerates the cystocele. Feeling of Heaviness and Dragging in the Pelvis. — This feeling is contributed to more by the prolapsed uterus than by the cystocele. Relief comes from lying down. Loss of Power in Urinating. — Residual urine accumulates in the vesical pouch, and the dislocated bladder is placed at a disadvantage in emptying itself because of the faulty contractions of the bladder and the inability of the intra-abdominal pressure to exert a direct influence upon the bladder. As a result the patient is compelled to Fig. 172 •%' Vulva of non-parous woman closed. (Jewett.) make undue exertion in urinating, and believes that she has lost the power to void urine. She acquires the habit of making pressure with the index finger upon the cystocele as an aid to voiding. Decomposition of the residual urine leads to irritability of the base of the bladder, and this, in turn, to frequency of urination, with more or less discomfort. Differential Diagnosis.^Cystocele is to be differentiated from cysts and fibroids of the anterior wall of the vagina and from hernia of the anterior vaginal wall. A sound placed in the bladder and the index MALPOSITIONS OF THE VAGINAL WALL 291 finger of the left hand placed in the vagina will serve to differentiate a cystocele from these conditions. Prognosis. — Unless corrected by operative means the tendency is toward exaggeration of the dislocation. Without operation there is no cure. The operative prognosis is at best uncertain. If the patient is young and the muscular development is good, operation will usually effect a complete cure so far as the symptoms are concerned, but there will commonly be found some degree of pouching afterward. When the pelvic supports are poorly developed, and there is much stretching of the parts, it is difficult to obtain a perfect result. In such cases the operator must be satisfied to obtain a degree of improvement. Fig. 173 Vulva of non-parous woman open, hymen intact. (Jewett.) Treatment. — The treatment is prophylactic, palliative, and operative. Prophylactic Treatment. — To prevent the development of a cystocele it is essential that the general nutrition of the patient should be kept at a normal standard. This implies due regard for all hygienic prin- ciples. The diet and exercise must be regulated to suit the individual 292 MALPOSITIONS OF THE GENITAL ORGANS case. The dress should be so arranged that all undue constriction and traction about the waist line is eliminated. The bowels should be regulated so as to avoid straining at stool, and such duties as call for great exertion should be avoided so far as possible. These precautionary measures are of importance following childbirth, in order that the pelvic tissues ma}- resume their normal tone and position. Fig. 174 "f- Vulva of parous woman closed. (Jewett.) The early correction of injuries to the pelvic floor is imperative, inasmuch as the starting-point of a cystocele is usually a lacerated perineum. The speedy and complete involution of the uterus following childbirth is necessary. This implies the prevention of infection, direct- ing the posture of the patient to avoid the development of displace- ments, and, when there is great relaxation of the abdominal walls, the adjustment of a properly fitting abdominal support. Finally, the cor- rection of a displacement of the uterus by the introduction of a suitable pessary or by operation will often avert the development of a cystocele. MALPOSITIONS OF THE VAGINAL WALL 293 Palliative Treatment. — Not every cystoeele should be operated upon, and not every operation is successful, hence the necessity of palliative measures for the relief of distressing symptoms. The following measures are to be employed: Abdonmial Support. — When the abdominal wall is relaxed and pendu- lous a suitable abdominal supporter should be worn to reduce the intra-abdominal pressure. Tight-lacing and clothing that constrict the waist should be avoided. Fig. 175 Vulva of parous woman open. (Jewett.) Vaginal Tampons. — Vaginal tampons of lambs' wool may be worn as a support to the sagging vaginal walls. These should be removed when fouled by the secretions in the vagina. Vaginal Douches. — Astringent vaginal douches of hot water, with alum, zinc, or tannin, may be given night and morning. These will keep the vagina free of irritating secretions, and will also have a puck- ering effect upon the walls of the vagina. Pessaries. — The only effective pessary for the support of a cystoeele is Skene's. The method of introduction is the same as for an Albert- Smith pessary. (See chapter on Pessaries.) 294 MALPOSITIONS OF THE GENITAL ORGANS Operative Treatment. — Anterior Colporrhaphy. — The first step in the development of a prolapsed uterus is, as a rule, the relaxation and sagging of the anterior wall of the vagina. Too frequently this Fig. 176 Topography of bladder and ureters in cystocele as shown by sagittal section: A.h., hypogastric artery; A.i.e., external iUac artery; C.d., Douglas' pouch; C.v.u., vesico-uterine pouch; Cy., cystocele; L.S., infundibulopelvic ligament; Po., portio vaginaUs; R., rectum; T., Fallopian tube; U., ureter; Ua., urethra; Um., ureteral orifice; Ut., uterus; Ve., bladder. (Tandler and Halban.) fact is not appreciated, and hence the prolapsus is allowed to develop. The sagging of the anterior wall of the vagina proceeds from a point near the urethra upward to or near the cervical attachment; rarely does the sagging proceed from above downward. MALPOSITIONS OF THE VAGINAL WALL 295 Technic of Anterior Colporrhaphy. — This operation was introduced by Marion Sims. Fricke, Hegar, Winckel, Martin, Emmet, Kiistner, Fehling, and others have made various modifications in the technic. Fig. 177 Diamond-shaped area outlined. Flap of vaginal mucous membrane dissected from the bladder. Step one. Four two-pronged tenacula are required: one grasps the anterior lip of the cervix and by it traction is made downward; a second grasps the vaginal wall at a point immediately below the external urethral orifice and with it gentle traction is made upward; the other two are placed one on either side of the cystocele, at the midpoint, and with them gentle traction is made outward. In this manner the cystocele is so stretched as to form a diamond-shaped area, which is readily accessible to the operator. 296 MALPOSITIONS OF THE GENITAL ORGANS The area of denudation is then outlined, with a sharp knife, begnnung at the upper angle and extending on either side to the outer angles and thence to the lower angle. The incision should not extend deeper than the vaginal mucosa. It will facilitate the process of denudation to make a straight incision joining the upper and lower angles, thereby bisecting the flaps to be denuded. Row of buried plain catgut placed in bladder wall for the purpose of invaginating the bladder. Second step. With scalpel and tissue forceps the mucous membrane is denuded as shown in Fig. 177, and exposes a raw surface as shown m l^ig. 178. The next step is to unite the lateral margins of the denuded area, crowding the bladder backward, thereby disposing of the cystocele. To do this a No. 2 ten-day chromic catgut suture is passed m an over- MALPOSITIONS OF THE VAGINAL WALL 29- and-over lock stitch from the upper to the lower angle, or interrupted sutures are passed as shown in Fig. 180. When an extensive area is denuded, additional buried stitches may be required to approximate the deeper structures. This is done by making a running stitch in one or more layers with No. 2 plain catgut, and over this the vaginal mucosa is approximated with ten -day chromic catgut. Care must be taken to avoid injury to the bladder and ureters and to leave no dead spaces. Fig. 179 Fig. 180 Running suture of chronic catgut approximating the free margins of the vaginal wall. Third step. Operation complete. Fourth step. Noble's Operation. — Charles P. Noble^ has devised an admirable operation for the correction of cystocele. After curetting the uterus and amputating the cervix when necessary, traction is made downward upon the cervix by means of a vulsellum forceps. Counter-traction is made upward upon the anterior wall of the vagina by means of a bullet forceps inserted immediately below the external orifice of the urethra. In this manner the anterior wall of the vagina is put upon the stretch. A narrow strip of vaginal wall is excised between these two forceps. Artery forceps are made to grasp the sides of the vaginal opening, and outward traction is made upon them while the bladder is stripped from the cervix upward to the peritoneal reflexion and laterally from the vaginal walls to an extent that will permit of the ascent of the prolapsed bladder into the peritoneal cavity. The redundant vaginal tissue is next excised, taking care that too much tissue is not removed, 1 Jour. Amer. Med. Assoc, December 14, 1907. 298 MALPOSITIONS OF THE GENITAL ORGANS The area excised is usually oval, with the base toward the cervix. Two rows of continuous sutures are now placed. At the upper extremity the sutures embrace the deeper layers of the vagina and base of the bladder, and below this point the deeper layers of the vagina are sutured to the anterior wall of the cervix. This line of sutures is followed bv Fio. 181 ■^ — Absc. Retroflexion of uterus, with partial prolapse of uterus and elongation of cervix, uterus. (Tandler and Halban.) . Abscess in wall of a second continuous suture, which approximates the free margins of the vaginal wall. When there is much tension on the continuous- sutures it is advisable to pass two or more interrupted sutures of chromicized catgut through vaginal walls and cervix. Amputation of the Cervix. — When the cervix is elongated or badly lacerated it should be amputated as the next step, following anterior colporrhaphy. For the technic of the operation see page 294. MALPOSITIONS OF THE VAGIXAL WALL 299 After Treatment. — See Perineorrhaphy. Rectocele.— Synonyms.— Prolapse of the posterior wall of the vagina; rectovaginal hernia. Etiology.— 1. Relaxation of the vaginal walls and pelvic floor following labor. 2. Lacerations of the vaginal walls and pelvic floor following labor. 3. Prolapsus uteri. 4. General malnutrition, with loss of muscular tone. 5. Violent muscular exertion. Fig. 182 Anterior wall of the rectum bulges into the vagina (rectocele). M., rectum; S., vagina; BL, bladder; E.V.U., vesico-uterine pouch; E.r.u., cul-de-sac of Douglas; S.r.v., rectovaginal septum; A.u., uterine artery; Ur., ureter. Anatomy.— The pelvic floor is an essential factor in the support of the pelvic organs, and when overstretched or torn, there is a tendency on the part of the uterus, bladder, rectum, and vaginal walls to pro- lapse. It is in this manner that the majority of rectoceles arise, 'While it is possible for the posterior waH of the vagina to prolapse without 300 MALPOSITIOXS OF THE GEXITAL ORGAXS carrying with it the anterior wall of the rectum, it may be said that it is exceptional, the rule being that the anterior wall of the rectum is carried forward with the posterior wall of the vagina. In the early development of a rectocele the vaginal wall is thickened and tlirown into folds, but with increase in size of the rectocele the vaginal wall looses its folds and becomes thin and glistening. These changes are particularly marked in women of advanced age. TMien the pouching walls have protruded from the vulva the mucosa becomes leathery and ulcers may develop; the rectal mucosa may become inflamed and ulcerated, and hemorrhoids, fissures, and fistula may arise Fig. 183 E.T-U. Almost complete prolapse of the anterior vaginal walls and posterior vaginal wall Elongation of the cer\-ix. Partial prolapse of the uterus. Anteflexio-versio-uteri. Cystocele. Hernia of the cul-de-sac. R, rectum; E.r.u., cul-de-sac; A, hernia. (Tandler and Halban.) Symptoms. — Xo symptoms arise from a small rectocele. developed the following symptoms are complained of: 1. Feeling of fulness at the vulvovaginal orifice. 2. Feeling of heaviness and dragging in the pelvis. 3. Loss of power in defecation. When well- MALPOSITIONS OF THE VAGINAL WALL 301 Feeliiig of Fulness at the Vulvovaginal Orifice. — The patient will usually say that her "womb comes down" when she stands or when at stool; the feeling of fulness at the vulvovaginal orifice is due to the bulging rectocele and accompanying cystocele. Feeling of Heaviness and Dragging in the Pelvis. — The feeling of heaviness and dragging in the pelvis is due to the prolapse of the pelvic organs associated with the rectocele. Fig. 184 Rectocele. The index finger in the rectum finds its way into the rectal pouch which protrudes into the vagina. Loss of Power in Defecation. — Under normal conditioEs in the act of defecation the perineum is elevated, the vaginal canal is closed, the contraction of the levator ani assists the sphincter in dilating, and the deep pelvic fascia further supports the leetum. It will be seen that the anterior wall of the rectum, under normal condi- tions, is well supported, but with the pelvic floor stretched or torn these supports are weakened, and, as a result, an undue strain is placed upon the anterior wall of the rectum and posterior wall of the vagina; this gives rise to a rectocele, and once started it tends to increase in size. Constipation is thereby engendered, and there is a feeling on the part of the patient that she is unable to thoroughly evacuate the rectum. Diagnosis. — With the patient in the lithotomy position and the vulva exposed she is asked to strain. The rectocele will then appear at the vulvar outlet as a globular mass, which is readily reduced by pressure with the finger. The index finger inserted into the rectum will identify beyond question the rectocele. 302 MALPOSITIONS OF THE GENITAL ORGANS Treatment. — The only way to correcting a rectocele is by means of a a plastic operation. Without operation the tendency is to increase in size. Prophylaxis. — See Prophylaxis under Vesicocele, page 291. Palliative Treatment. — When operative interference is impossible and the symptoms are distressing, some degree of relief may be obtained by the following procedures: Lessening of the Intra-abdominal Pressure. — This can be accomplished by removing all traction and constriction of the waist through faulty clothing, by relieving constipation to obviate straining at stool, and finally by adjusting a suitable abdominal support when the abdomen is pendulous. Vaginal Douches. — Vaginal douches of hot sterile water and alum, zinc, or tannin will tend to shrink the tissues. Tampo7is. — Tampons of lambs' wool will serve as a temporary support. Pessaries. — Pessaries are not always successful. A large cystocele and rectocele, with a gaping vulvar outlet, will not permit of the wear- ing of any sort of pessary unless it be a cup and stem pessary attached to an abdominal band. Less pronounced relaxation of the pelvic floor and vaginal walls may permit the wearing of a ring pessary. Operative Treatment. — See Perineorrhaph}'. Vaginal Hernia. — Etiology. — Vaginal hernias are thought by some to be due to a congenital maldevelopment of the pelvic peritoneujn and pelvic organs. So far as the author's knowledge goes the lesion is acquired through labor, in which the pelvic floor is stretched and torn. As compared with rectocele and cystocele, vaginal hernia is a rare condition. The more common of the two is posterior vaginal hernia. Anatomy. — One or more loops of small bowel find their way either in front or behind the broad ligaments; the former to produce an anterior vaginal hernia, the latter a posterior vaginal hernia. An anterior vaginal hernia starts in the vesico-uterine pouch of peritoneum; this peritoneal fold is forced downward between the bladder and vagina, and may enter the labium majus in its posterior third. A posterior vaginal hernia starts in the cul-de-sac and descends between the rectum and vagina, separates the muscular fibers of the levator ani, and finally appears in the perineal body or in the posterior segment of the labium majus. Symptoms. — The clinical manifestations of vaginal hernia Ao not differ from those found in a cystocele or rectocele, there being a sense of fulness in the vagina, vulva, or perineum and a feeling of weight and dragging in the pelvis. There should be no disturbance of urination or defecation. MALPOSITIONS OF THE VAGINAL WALL 303 Diagnosis. — Care must be taken not to mistake a vaginal hernia for a cystocele, rectocele, tumor of the vagina, Bartholinean cyst, or inguinal hernia that has descended into the labium majus. Fig. ISo Partial prolapse of the uterus. Moderate elongation of the cervix. Hernia of the cul-de-sac of Douglas. Beginning cystocele. A vaginal hernia is distinguished from these lesions by its soft con- sistency, by becoming tense on coughing, by being reduced on pressure, and by causing a gurgling sound on reduction. Finally, by inserting a finger within the rectum and another within the vagina the presence of an intervening body between the vaginal wall and .rectal wall is disclosed. A sound placed in the bladder and the index finger in the vagina will reveal a similar condition in the presence of an anterior vaginal hernia. 304 MALPOSITIONS OF THE GEXITAL ORGANS All Bartholinean cysts and vaginal tumors are readily distinguished from vaginal hernias by not disappearing on pressure and by their sharply circumscribed character. An inguinal hernia when reduced will follow the course of the inguinal canal and is in this way distinguished from a vaginal hernia. Treatment. — 1. Evacuate the bladder and rectum. 2. Place the patient in the knee-elbow position. 3. Reduce the hernia by gentle manipulations. 4. Prevent recurrence by introducing a hard-rubber ring pessary. 5. Radical cure: The only satisfactory manner of dealing with this condition is by operation. Pessaries will, at best, afford only temporary relief. Fig. 186 Rectovaginal hernia. Pouch of peritoneum is caught with a forceps and twisted into a rope. First step. (After Ashton.) Posterior Vagixal Herxla. — Posterior vaginal hernia is operated in the following steps: 1. Abdominal incision and correction of any existing uterine dis- placement. 2. After separating any existing adhesions the cul-de-sac is seized with forceps and twisted upon itself to form a tight cord. The cord is then transfixed at its base by a ligature of linen, which is tied and the cord severed above the ligature. This obliterates the hernial sac. If the sac cannot be pulled out of its advanced position the space should be obliterated to the normal level of the cul-de-sac by in- terrupted catgut sutures. MALPOSITIONS OF THE UTERUS 305 3. Plastic operations are performed upon the anterior and posterior vaginal walls and perineum when indicated. Anterior Vaginal Hernia.— The operative steps do not differ essentially from those taken in posterior vaginal hernia. Fig. 187 '•}f??^^'i- Retrovaginal hernia. A rope of peritoneum is ligated at its base with linen and severed above the ligature. Second step. (After Ashton.) MALPOSITIONS OF THE UTERUS Normal Position. — Under perfectly physiological conditions the uterus may occupy widely varying positions. In order that these physiological changes in position may occur, the uterine ligaments, pelvic peritoneum, and cellular tissue must possess their normal degree of elasticity (Fig. 192). The normal position of the uterus varies with the attitude of the individual. It is crowded backward by a full bladder, forward by a loaded rectum, and forward and downward by increase in the intra- abdominal pressure from coughing, straining at stool, etc. By reference to Figs. 194 and 195, it will be seen that the normal position of the uterus of a virgin in the erect posture, with the bladder and rectum empty, is one of anteversion, slight anteflexion, anteposi- tion, and slight lateral position. The body of the uterus lies about 1 cm. 20 306 MALPOSITIONS OF THE GENITAL ORGANS behind the upper border of the symphysis pubis, the cervix points to the second sacral vertebra, and Hes about 2 cm. in front of the sacro- FiG. 188 Fig. 189 Fig. 190 Fig. 191 Figs. 188 to 191.— Uterus at varying periods of life. Fig. 188, uterus of newborn child; Fig. 189, uterus at puberty; Fig. 190, nuUiparous uterus fuUy developed; Fig. 191, multipafous uterus. (Modified from Chrobak and Rosthorn.) coccygeal articulation. In the virgin there is less anteflexion than in a multipara. The explanation lies in the fact that the small resisting vagina presses the slender cervix backward (Figs. 193 and 194). TUBAL VESSELS PLATE XVI Fig. 1 ANASTOMOSIS OF UTERINE AND OVARIAN ARTERIES HELICINE BRANCHES '\ FALLOPIAN TUBE ^^/^ UTERINE VEINS VAGINAL VENOU UTERINE ARTERY \ ill SUPERIOR VAGINAL ARTERIES OS UTERI VAGINA CUT OPEN BEHIND Bloodvessels of the Uterus and Its Appendages. (Testut.) Fig. 2 UTEHO-OVARIAN ^ LIGAMENT UTERO-OVARIAN VESSELS UTERINE VESSELS ao y^ DORSAL FOLD OF BROAD LIGAMENT OS UTERI VAGINA The Uterus and Adnexa Viewed from in Front. (Testut.) MALPOSITIONS OF THE UTERUS Fig. 192 307 Internal iliac artery. External iliac arterj'. Vesicovaginal artery. The uterosacralligaments or folds of Douglas. (Testut.) Fig. 193 6 Is 9 11 Coronal section of the uterus of a nulliparous Coronal section of the uterus of a multiparous woman. woman. 1, fundus; 2, lateral walls of the body; 3, cervix; 4, isthmus; 5, cavity of the body; o , internal wall of the body; 6, cornu; 6', opening of the Fallopian tube; 7, arbor vitse; 8, os internum; 9, os externum; 10, 10 , lateral fornices; 11, posterior vaginal wall. (Testut.) 308 MALPOSITIOXS OF THE GEXITAL ORGAXS Pathological changes in the position of the uterus and its neighboring organs are more or less permanent. There is no tendency toward a spontaneous return to the normal position. Fig. 195 Normal position of the uterus. The uterus lies anteposed, anteverted, and slightly anteflexed when the bladder and rectum are empty and the patient in the upright position. Pathological Mobility. — The uterus becomes abnormally movable when the normal supports are weakened or have given way. A relax- ation of the uterine ligaments, of the pelvic floor and of the abdominal muscles will lead to abnormal mobihty of the uterus. Under such conditions the uterus gravitates according to the position of the patient. In the upright posture, with the bladder empty, it may fall forward and downward. In the dorsal posture with the rectum empty, the uterus falls backward into the hollow of the sacrum. This condition, when uncomplicated, cannot be regarded seriously from a clinical point of view. Pathological Fixation. — An abnormally movable uterus may lodge in a position where it becomes fixed and immovable. It is thereby evident that the factors causing increased mobility of the organ may lead to a more or less permanent fixation. Fixation of a misplaced uterus will be considered in subsequent chapters. We will here discuss only fixation of the normally placed uterus. By this is meant a uterus PLATE XV Bloodvessels of the Abdomen and Pelvis. (Leipniann.) 1. Aorta. 2. Ovarian artery. 3. Inferior mesenteric artery. 4. Common iliac artery. 5. External iliac artery. 6. Internal iliac artery. 7. Inferior gluteal artery. 8. Common pudendal artery. 9. Obturator artery. 10. Uterine artery. 1 1 . Superior vesical artery. 12. Inferior epigastric artery. A. Pudendal plexus. B. Vesicovaginal plexus. C. Inferior uterine vein. D. Superior uterine vein. E. Obturator vein. F. Internal iliac vein. G. iSIedian iliac vein (hemorrhoidal plexus). H. Hypogastric vein. /. External iliac vein. K. Common iliac vein. L. Vena cava. M. Ovarian vein. iV. Renal vein. A. Bulbus vestibuli. B. Corpus clitoris. C. Crus clitoris. MALPOSITIONS OF THE UTERUS 309 in normal position, but lacking the degree of elasticity and mobility that is found in health. Parametritis atrophicans (Freund), or parametritis posterior (Schultze), is a condition frequently overlooked. The uterosacral ligaments are firmly contracted and tender. By thickening and con- traction of the uterosacral ligaments the cervix is drawn backward and the whole uterus restricted in its movements. A chronic metritis will diminish the normal flexibility of the uterus, as may also carcinoma and fibroids. Chronic cervical catarrh may stiffen the cervix. Fig. 196 Anteposition. The loaded rectum crowds the uterus forward into anteposition when the bladder is empty. The cul-de-sac of Douglas is almost obliterated. When the rectum is empty the uterus will fall back into the normal position. Anteposition. — Anteposition is an exaggerated normal position; the uterus lies immediately behind the abdominal wall and symphysis pubis. Among the causes of anteposition of the uterus are swellings behind crowding the uterus forward, or adhesions attached to the anterior surface of the uterus pulling it forward, such as are made by ventrofixation. The latter condition is very unusual. The most common causes are tubal and ovarian swellings lying in the cul-de-sac of Douglas, retro-uterine hematocele, tumors of the uterus bulging from the posterior surface of the uterus, and newgrowths of the 310 MALPOSITIONS OF THE GENITAL ORGANS rectum. Anteposition is often combined with elevation, anteversion, and anteflexion. The diagnosis is seldom difficult. On bimanual examination the uterus is found lying close to the anterior abdominal wall. When caused by retro-uterine swellings, which cannot be outlined apart from the uterus, the sound will be required to locate the position of the organ. A retro-uterine tumor, crowding the uterus, forward, is recognized by its irregular outline and its consistency. Here, again, the uterine sound will be of service in locating the uterus. In ever}^ doubtful case an anesthetic should be administered. The one symptom, com- monly present, is frequent urination. (See Plate XVIII and Fig. 196.) Anteposition of the uterus is but an exaggerated normal position, and is not to be regarded seriously. The determining factors and associated lesions, as above named, alone demand serious consideration. Retroposition. — In retroposition the uterus lies back of the normal position without change in the direction of its long axis. The causes of retroposition are swellings in front of the uterus or adhesions behind it. Among swellings in front of the uterus are uterine fibroids, tumors of the bladder and anterior abdominal wall, persistent distention of the bladder, and, occasionally, enlarged tubes and ovaries. Adhesions behind the uterus causing retroposition are largely confined to the peritoneal cavity, and involve, more or less of the posterior surface of the uterus. These adhesions most frequently result from extension of an inflammation from the tubes which, when inflamed, commonly lie behind the uterus. In abnormal mobility of the uterus, due to a relaxation of the normal supports, the uterus falls into retroposition when the patient lies upon her back. It is important to recognize the cause of the displacement, inasmuch as retroposition per se is of little clinical significance. When no tumor mass or adhesions are found in the pelvis and the retroposed uterus displays an abnormal mobility, the displacement is regarded as due to relaxation of the uterine supports. It is not always possible to diagnosticate the presence of adhesions, even when the examination is made under anesthesia. Experienced operators will testify to the frequency with which perimetritic adhesions are unexpectedly found after opening the abdominal cavity. This fact alone would seem to render the Alexander operation of shortening the round ligaments through the inguinal canal an uncertain procedure. Perimetritic adhesions are confined to surfaces normally covered with peritoneum. They are found with the greatest frequency about inflamed tubes and ovaries, and are therefore most commonly located beside or behind the uterus. The uterus is rarely absolutely fixed. The degree of mobility depends upon the location of the adhesions, their extent, length, and firmness. Adhesions binding the uterus to movable structures, such as bowel and omentum, usually permit more or less mobility on the part of the uterus. The diagnosis of a perimetritic exudate — that is, of an exudate lying within the peritoneal cavity and binding together the peritoneal surface of the uterus with the peritoneal PLATE XVIII Fig. 1 Anteposition of the uterus. A retrouterine hsematoeele fills the eul-de-sae of Douglas and the space between the uterus and sacrum. The uterus is crowded forward. Fig. 2 Retrouterine Haematorna Crowding the Cul-de-sac of Douglas Up and the Uterus Upward and For^A^ard. MALPOSITIONS OF THE UTERUS 311 surfaces of adjacent structures, from an exudate involving the pelvic cellular tissue — is made first of all by the location. A parametritic Fig. 197 Left laterodisplacement of the uterus. The left broad ligament is thickened and contracted and drawn the uterus to the left. Fig. 198 Left lateroversion of the uterus. The uterus is crowded to the left side of the pelvis, the long axis of the uterus inclines to the left. The cause of the displacement is a broad Ugament cyst of the right side adherent to the wall of the pelvis. exudate lies low in the pelvis in close proximity to the vaginal wall, while a perimetritic exudate lies on a higher plane and is more difficult to palpate through the vagina. Furthermore, in parametritis the 312 MALPOSITIONS OF THE GENITAL ORGANS adhesive bands are firmer and larger than in perimetritis. The uterine sound may be of service in locating the position of the uterus apart from inflammatory exudates and new formations. Lateroposition. — Lateroposition of the uterus is generally combined with retroposition, less often with anteposition and descensus. A limited lateral displacement of the uterus may be regarded as normal, and is explained by a shortening of the broad ligament on the side to which the uterus leans. This congenital unilateral shortening of the broad ligament and also of the uterosacral ligament accounts for the lateral displacement of the uterus, not infrequently found in virgins. Fro. 199 Retroposition of the uterus. The uterus is drawn backward into retroposition by peritoneal bands ai adhesions extending from the supravaginal portion of the cervix to the sacrum. The usual causes of lateral displacements of the uterus are inflam- matory exudates and new-formations; more rarely cicatricial contrac- tions of the vaginal wall following lacerations and sloughs. Exudates at the sides of the uterus, when large, will crowd the organ to the opposite side of the pelvis. Later, as the exudate organizes and contracts, the uterus is drawn to the side occupied by the exudate (Fig. 199). If the exudate exerts its influence along the entire side of the uterus, the uterus, as a whole, will be first pushed to the opposite side and later drawn to the same side. If the exudate involves the lower segment of the broad ligament, leaving the body of the uterus free and movable, MALPOSITIONS OF THE UTERUS 313 the cervix will be drawn toward the side in which the exudate has collected and the body of the uterus is tilted to the opposite side — a lateroversion or lateroflexion. Likewise, in case of tumor formations lying beside the uterus, if the force is distributed along the side of the uterus there will be a simple lateroposition; if pressure is exerted upon the fundus alone, there will be a lateroversion or flexion in which the body will be crowded to the opposite side, the cervix pointing to the side occupied by the tumor (Fig. 198). Fig. 2C0 Elevatio uteri following a ventrosuspension of the uterus. Adhesions unite the fundus of the uterus to the abdominal wall and retain the uterus" in an elevated position. Slight lateral displacements of the uterus are commonly overlooked. When found they should always lead to a careful bimanual examination, and, if necessary, these examinations should be under anesthesia, in view of determining the cause of the lateral position. Reference to Figs. 197 and 198 will suggest, in a general way, the mechanism of the displacement. The displacement is due to traction on the one side or to crowding on the other. Elevatio Uteri. — In elevatio uteri the uterus is raised above the normal plane and approaches the anterior abdominal wall. In uncom- plicated elevatio uteri the long axis of the uterus is straightened. It is unusual to find an uncomplicated elevation of the uterus, such a condition being, as a rule, associated with lateral, anterior, or posterior displacements. The position is physiological in pregnancy. The 314 MALPOSITIONS OF THE GENITAL ORGANS extent to which the uterus may be drawn upward is astonishing; a perfectly normal uterus may be raised to the level of the umbilicus. Causes of elevation of the uterus may be classified under two general heads, namely, swellings below the uterus crowding it upward, or tumors and adhesions making upward traction upon the uterus. Swellings beneath the uterus and crowding the uterus upward are tumors of the cervix, vaginia, and rectum, hematocele, and hematocolpos. Adhesions binding the fundus to the abdominal wall may develop during pregnancy and the puerperium, leaving the uterus in elevation after the puerperium. Plate XVIIL, Fig. 2, represents the uterus suspended from the abdominal wall in an elevated position. A Cesarean section had been performed, and adhesions developed subsequently between the scar in the abdominal wall and that of the uterus. Torsion of the uterus caused by twisting of the pedicle of an ovarian cyst. A subperitoneal fibroid attached to the fundus and growing into the abdominal cavity may elevate the uterus. Either the pedicle must elongate or the uterus will be drawn upward, since the tumor, when it can no longer be accommodated in the pelvis, rises into the MALPOSITIONS OF THE UTERUS 315 the abdominal cavity. Tumors of ovary with short pedicles may operate similarly. The vagina will be found greatly elongated and the cervix may not be within reach of the examining finger. Torsion. — In torsion of the uterus the organ is twisted upon its long axis. This displacement rarely exists singly, but is generally associated with anteposition, lateral position, or elevation. Within perfectly normal limits the uterus is slightly turned upon its long axis, through shortening of the broad ligament which runs outward and slightly backward. Causes of torsion may be traction on the one hand or pressure on the other. Adhesions running from the side of the uterus backward or forward may turn the uterus upon its long axis, as will also pressure made upon the side of the uterus by tumor formations. Fig. 201 represents a pedunculated ovarian tumor lying in the abdominal cavity. The tumor has been turned upon its long axis, and with it the uterus has become twisted. It is even possible for the uterus to be severed by the twisting. The blood supply to the uterus may be shut off completely and cause gangrene, or partially and result in atrophy. Menstrual and intermenstrual secretions may be pent up in the uterus above the point of torsion. As a rule, the displacement is not discovered until an exploratory incision is made to remove the cause. Prolapsus Uteri. — As suggested by Berry Hart, prolapsus uteri should be considered under the head of displacement of the pelvic floor. The displacement should be regarded as a hernia of the uterus, adnexa, bladder, rectum, and vagina. While the author is in accord with this view, the subject will be considered with other displacements of the uterus. Webster, in his text-book on Diseases of Women, holds that prolapsus of the uterus, vagina, urethra, and bladder is the result of failure on the part of the fascial and other tissues supporting these organs between the bony walls of the pelvis to resist intra-abdominal pressure and gravity. If the power of resistance is weakened, or the intra-abdominal pressure and weight of the uterus are increased, or if both factors cooperate, prolapsus will occur. Webster takes exception to the view of Hart, who regards the perineum as a fixed segment for the support of the uterus, and of Thomas, who holds that the perineum is a supporting wedge. By anatomical dissections Webster has demon- strated that the pelvic fascia, and not the perineum and levator ani muscle, are the real support. The various fascial tissues which meet in the perineum and give support to the pelvic viscera are: (1) The anterior and posterior triangular ligaments. (2) The visceral layer of the rectovaginal fascia. (3) The anal fascia. (4) The deep superficial fascia. Webster holds that the perineal muscles are of little value as a support compared to the pelvic fascia. In the absence of actual rupture of the fascia, it is possible for stretching alone to so weaken the support that prolapsus will occur. 316 MALPOSITIONS OF THE GENITAL ORGANS Prolapsus uteri is a term implying not only a descent of the uterus, but also involvement of the bladder, rectum, vagina, and adnexae. Descent of the uterus may be checked at any point between the normal position and extreme prolapse. Nomenclature. — With Webster, the author will speak of (1) descensus uteri, when the uterus and vaginal walls do not descend beyond the vulvar outlet, and (2) prolapsus uteri, when the uterus and vagina protrude beyond the vulvar outlet. Etiology. — The most frequent displacement of the uterus is descent or prolapse. In the Tiibingen clinic, prolapsus of the uterus constitutes 12 per cent, of all tjie pelvic lesions, ranking first in point of frequency in their case records. The greatest number occur between the ages of thirty and sixty years. That they do not occur with greater frequency before the age of thirty is accounted for. by the fact that prolapsus uteri is almost always the result of childbearing. While the forces of labor weaken the pelvic floor and the uterine ligaments, it is usually not until the long-continued influences of intra-abdominal pressure and of gravity have operated upon the poorly supported uterus that the prolapsus develops. Hence it follows that one or more years usually succeed childbirth before the uterus decends to any considerable degree. This is the rule to which there are few exceptions. The causes of prolapsus uteri may be outlined as follows : Loss of swpioort from below. Relaxation of the pelvic floor. Laceration of the pelvic floor. Traction from below. Cystocele. Rectocele. Fibroid of the cervix. Pressure from above. Tight-lacing. Visceroptosis. Abdominal ascites and tumors. Straining, as in lifting. Increased weight of uterus. Chronic metritis. Fibroids. Subinvolution. Early pregnancy. Diagnosis. — The erect posture of the patient is the most favorable in recognizing a downward displacement of the uterus (Fig. 31). In the recumbent position the uterus may wholly or in part resupie the normal position. The erect position is awkward and embarrassing, and for these reasons is seldom used. With the patient in the lithotomy position the uterus may be so manipulated as to effectively demonstrate the degree of descensus. Bimanual manipulatiop, and, if necessary, traction upon the cervix with a vulsellum forceps, wn"ll bring the uterus MALPOSITIONS OF THE UTERUS 317 down to its maximum degree. Under normal conditions it is not possible to draw the vaginal portion of the cervix beyond the vulvar outlet. Anatomical Diagnosis. — The diagnosis is almost wholly based upon the anatomical findings. It is at times possible to make a diagnosis from inspection alone. Inspection of the vulva may disclose the uterus and vaginal walls protruding from the vulvar outlet. In nearly all such cases the perineum is lacerated, and there may be a prolapsus of the mucous membranes of the urethra and rectum. FR. Urh. ' y.s - O.E. Prolapse of the uterus in an old woman. Cervix greatly elongated. Cystocele (PR) os externum (0£) protrudes from the vulva. Vesico-uterine fold of peritoneum (Evw) lies relatively high. The cul-de-sac of Douglas (Eru) is very deep. The urethra (Urh) is in its normal position. VS, the anterior vaginal wall; HS, the posterior vaginal wall. M. Sph, sphincter muscle. Displacement of the Vagina. — Inasmuch as the uterus is seldom displaced downward without a primary or secondary involvement of the vagina, descensus and prolapsus of the vagina will be first considered. Descensus Vagince. — Descensus vaginse implies a downward displace- ment of the vagina to a point near the vulvar outlet. Preceding the descent of the vaginal walls, there is usually a relaxation or laceration of the pelvic floor. As a rule, the anterior wall of the vagina is first to descend; then follows the uterus as it is pulled upon by the sagging wall of the vagina, and, finally, the uterus in turn carries with it the posterior wall of the vagina. It is unusual for the anterior and posterior walls of the vagina to descend simultaneously and equally, and the primary descent of the posterior vaginal wall is more unusual. A limited degree of descensus vaginae may exist without displacing the uterus. 318 MALPOSITIONS OF THE GENITAL ORGANS The descent occurs from below upward ; seldom from above downward (Fig. 208). Prolapsus Vaginae. — Prolapsus vaginae implies a protrusion of the vaginal walls beyond the vulvar outlet, and is associated with downward displacement of the uterus. In primary descent and prolapse of the uterus, the vaginal walls are inverted from above downward, there Fig. 203 Complete prolapse of the uterus. Complete eversion of the vaginal walls. Hernia of the recto-uterine space. being no pouching of the vaginal walls as in secondary prolapse of the uterus. The lower segment of the vaginal wall may prolapse, the upper segment invert, and the intervening one remain unchanged. The prolapsed anterior vaginal wall pouches into the vagina, dragging the bladder with it, and forming what is known as a c}'stocele. The bladder is intimately attached to the anterior wall of the vagina, so that it is impossible for the vagina to descend without carrying the MALPOSITIONS OF THE UTERUS 319 bladder with it. The vaginal wall loses its usual elasticity, and becomes glistening, dry, and leathery. Decubitus ulcers may form and show but little tendency to heal. Between the posterior wall of the vagina and the rectum no close attachment exists — a fact which explains why in prolapse of the posterior vaginal wall the rectum does, not always descend with the vagina. Fig. 204 PI. IV. R. Total prolapse of anterior vaginal wall. Partial inversion of posterior vaginal wall. Rectum distended and crowding the uterus forward. Partial prolapse of the uterus with elongation of the cervix. Cystocele. Adh., adhesions. (Tandler and Halban.) Descensus and prolapsus vaginse are recognized by inspection and palpation of the vagina. Holding the labia apart, the vaginal pouch, with its transverse folds, is seen to bulge into the introitus. Inversion of the vagina is recognized by a corresponding shortening of the vaginal wall, together with a probable descent of the uterus. Displacements of the Uteras. — After inspection and palpation of the vulva and vagina, the position of the uterus is to be determined. The vaginal walls may be prolapsed to an extreme degree without altering the position of the uterus, though this is rare. In a prolapse of the vagina one expects to find a secondary descent of the uterus. The descent of the uterus may be either primary or secondary. Primary Descent mid Prolapse. — Primary descent and prolapse of the uterus are the result of relaxed uterine supports, of added weight 320 MALPOSITIONS OF THE GENITAL ORGANS to the uterus, or of increase in the intra-abdominal pressure. As the uterus descends, the anterior and posterior walls of the vagina become inverted from above downward, and near the outlet of the vagina the walls are relaxed. In exaggerated cases the vaginal walls may be completely inverted, thereby permitting the uterus to protrude beyond the vulvar outlet. Fig. 205 ■ ' "' Secondarj' prolapsus uteri, vriih elongation of the cer^-ix. Both vaginal walls are completely inverted. The cer^'ix protrudes from the \'Tjlva. Neither the bladder nor the rectum is found in the protruding structures. Secondary Descent and Prolapse. — Secondary descent and prolapse of the uterus follow upon a primary prolapse of the vaginal walls. As the walls of the vagina descend, traction is made upon the uterus at the point of attachment of the vagina. If the supports of the uterus offer little or no resistance, the walls of the vagina, assisted by gravity and intra-abdominal pressure, will inaugurate a descent of the uterus. If, however, the normal supports of the uterus, assisted by adhesions and newgrowi;hs, retard the descent of the uterus, there will usually follow an elongation of the cervix in its supravaginal portion. Further- more, since the anterior wall of the vagina is first to prolapse, the ante- rior lip of the cervix will be elongated to a greater degree than will the posterior lip. If there is a simultaneous prolapse of both vaginal walls, the two lips of the cervix will be equally elongated. Hence, in MALPOSITIONS OF THE UTERUS 321 secondary prolapse of the uterus there is usually an elongation of the cervix, while in primary prolapse there is no such change. In complete prolapsus uteri with inversion of both walls of the vagina, the cervix, having been previoush' elongated, will retract more or less and may be materially shortened. The direction of the long axis of the uterus varies with the descent. The usual position in descensus uteri, when the uterus lies in the pelvis, is that of retroversion, and this position is exaggerated as the uterus descends. The adnexse are drawn down by the uterus, and in complete pro- lapsus are found in a funnel-like depression formed of peritoneum. Fig. 206 Complete inversion of the uterub. The bladder is so intimately connected with the anterior vaginal wall and cervix that it must necessarily share in the displacement of the uterus. As the anterior wall of the vagina pouches it drags upon the base of the bladder. In this manner a cystocele is formed which, in complete prolapse of the vagina, may include the greater portion of the bladder, causing it to protrude from the vulvar orifice. The exact limitations of a cystocele are determined by the catheter or sound placed in the bladder. When the bladder is distended the cystic mass is felt and seen to protrude into the vagina; its outlines can usually be determined by inspection. 21 322 MALPOSITIONS OF THE GENITAL ORGANS The rectum is more loosely connected with the vaginal wall than the bladder. The loose connective tissue may permit of a complete prolapse of the posterior wall of the vagina without displacing the rectum. More often there is a pouching forward of the rectum into the vaginal pouch (rectocele). By direct palpation through the rectum the location and extent of the rectocele are determined. Primarj' prolapse of the uterus. The uterus lies wholly outside the vulva, completely inverted. The cervix is not elongated. The vaginal walls are The anatomical changes occurring in the prolapsed tissues are largely the result of disturbance in circulation, of exposure to the influences of air, and of friction of the thighs. There is first congestion and edematous infiltration, this being followed by induration (h^^jerplasia) of the tissues. Decubitus ulcers, slow in healing, may form on exposed surfaces. When the lips of the cervix are retracted by the vaginal walls, the exposed mucous membrane of the cervix may be transformed into stratified epithelium. Clinical Diagnosis. — The diagnosis of descensus and prolapsus uteri is seldom difficult. It is unusual to find a prolapsed uterus in a nullipara. Beyea estimates that prolapsus uteri in nulliparae occurs in not more than 1 per cent, of all cases. He reported two cases and found sixty- two others in the literature. MALPOSITIONS OF THE UTERUS 323 When, upon physical examination, the pelvic floor is found relaxed or lacerated, and there is also found a rectocele and vesicocele, it may be that the uterus will be found more or less prolapsed. A positive diagnosis can only be made by locating the fundus of the uterus in a bimanual examination. The patient being under anesthesia, firm traction upon the cervix with the vulsellum forceps will determine the exact extent of the displacement (Fig. 209). The finding of the cervix at a lower level than is normal will not suffice for a diagnosis. Such a finding is frequently due to an elongation of the cervix, either with or without a descent of the uterus. Without having located the fundus Fig. 208 Secondary descent of the uterus. The uterus is retroverted and lies on a plane lower than normal. The cervix does not extend to the vulvar outlet. The anterior vaginal wall is prolapsed and the posterior vaginal wall is partially inverted. it cannot be said that the uterus, as a whole, has descended. By a rectal examination it is often possible to locate the point of juncture of the cervix and uterine body and estimate, with some degree of accuracy, the length of the cervix. Measuring the depth of the uterus by the sound will give exact information. It is more difficult to determine whether it is the supravaginal or the infravaginal portion of the cervix that is elongated. This is ascertained by noting the depth of the vault of the vagina. If decreased in depth, the supravaginal portion of the cervix is elongated; if it remains at the 324 MALPOSITIOXS OF THE GENITAL ORGANS normal level, the infravaginal portion of the cervix is elongated. Both the infravaginal and the supravaginal portions of the cervix may be increased in length, in which event there will be little change in the depth of the vault of the vagina. When the uterus is completely prolapsed it is possible to approximate the hands over and abo^•e the body of the uterus, having merely the vaginal walls and bladder between the fingers. By so doing it is possible to absolutely exclude all other conditions (Fig. 211). Fig. 209 Elongation of the cen-Lx with prolapsus uteri. Traction made upon the cervix by a ^^llsellum forceps pulls the cer\-ix two inches beyond the %-ulvar outlet. The body of the uterus lies within the peh-is, but at a lower level than normal. The depth of the uterine ca^-ity, measured by a sound, is five inches. Can the displacement of the vagina and uterus be corrected? This question will naturally arise before the diagnosis is complete. An attempt to replace the uterus may be made without anesthesia, but when there is much tenderness, or when great difficulty is encoun- tered, an anesthetic should be given. Among the hindrances to the replacement of the uterus may be mentioned pelvic tumors, adhesions, inflammatory exudates, and swelling from edema and induration of the uterus and vagina. MALPOSITIONS OF THE UTERUS 325 While the clinical symptoms cannot be relied upon in the diagnosis of prolapsus uteri, they are fairly constant and deserve consideration. Backache is the most common complaint, but is more often due to diseases of the adnex?e and to inflammatory exudates complicating prolapsus. Feeling of weight, pressure, and traction is to be accounted for by the increased size of the uterus, by pressure upon neighboring structures and by traction upon adhesions and the natural supports of the uterus. Fig. 210 Prolapsus uteri. The external os is lacerated and eroded. On the side of the prolapsed uterus is a decubitus ulcer. (Case of Dr. J. Clarence Webster.) Leucorrhea and menorrhagia are the results of passive congestion of the uterus, which in turn is the result of the displacement. Sterility is due to mechanical hindrances and to complicating lesions in the uterus and adnexse. Pregnancy in a prolapsed uterus will either terminate spontaneously or go on to full term. Abortion is most likely to occur about the fourth month, when the pregnant uterus can no longer be accommodated in the limited space of the pelvis. If, however, the uterus does rise into the abdominal cavity the prolapsus is relieved 326 MALPOSITIONS OF THE GENITAL ORGANS for the period of pregnancy. Involution in the puerperium is hkely to be retarded, and the lochial discharge may remain bloody an unusually long time. Disturbances of the bladder functions are almost constant, and are explained by pressure upon the bladder and the displacement of the bladder and urethra. Retention of the urine is possible even to the point of rupture of the bladder. Cystitis may develop. The rectal functions are generally disturbed, though not to the extent and frequency found with the bladder. Constipation, rectal tenesmus, and hemorrhoids are the result of pressure made upon the rectum by the prolapsed uterus. Fig. 211 Bimanual palpation of the prolapsed uterus. Differential Diagnosis, — Prolapsus uteri is most often confused with an elongated cervix. The vaginal portion of the cervix may be so enormously enlarged as to resemble a prolapsed uterus. The differen- tial diagnosis has been considered in a previous paragraph. Complete prolapsus uteri with atresia of the cervix may be mistaken for an inverted uterus. The finding of the fundus will clear up the diagnosis. A large cyst of the vagina may protrude from the vulva, and on superficial examination be mistaken for a prolapsed uterus. Such MALPOSITIONS OF THE UTERUS 327 cysts do not lie in the median line; they fluctuate, and are covered with thin mucous membrane. A recto-abdominal examination, under anesthesia if necessary, will enable the examiner to locate the body of the uterus in its normal position. A pedunculated, submucous fibroid protruding into the vagina, or a pedunculated fibroid of the cervix, may be mistaken for a prolapsed uterus. The absence of the external os in the advancing body, the finding of the fundus within the pelvis at its normal level, and the passage of a sound into the uterine cavity will clear the diagnosis. Fig. 212 Prolapse of the third degree. Uterus protruding through the vulva. Sounds demonstrate the bladder to be in complete descent with the uterus. (Schaffer.) Treatment. — The treatment of prolapsus uteri necessarily embraces the correction of a relaxed and torn pelvic floor and vaginal walls, amputation of an elongated cervix, and the management of the many complications in the uterus and adnexse that are associated with this form of displacement. Prophylaxis. — As a preventive measure the early repair of injuries to the pelvic floor is of the highest importance. Indeed, if such conditions were not neglected, prolapsus uteri would cease to occupy such a prominent place among the lesions of the pelvis. The early repair of the lacerated perineum would eliminate a large proportion of the 328 MALPOSITIONS OF THE GENITAL ORGANS cases, but by no means all, for we have to reckon with the relaxed out- let and pelvic floor, with the overstretched ligaments of the uterus and the intra-abdominal pressure. Modern obstetrical teaching is sufficiently clear in the emphasis it places upon the immediate repair of the pelvic floor, but the gynecologist is chary in his account of the early repair of the neglected injuries to the pelvic floor. The recent lacerations of the perineum, the relaxed vaginal walls which are beginning to drag upon the cervix, and the undue laxity of the overstretched ligaments which have failed to retract; these shoidd be corrected as early as possible after the completion of the puerperium. The correction of a prolapsed uterus in the early stage presents the least difficulties, and assures the best and most lasting results. In the later stages the operation is more complicated, and the sequential results observed in the uterus and in the neighboring organs may make full restoration to health impossible. It therefore follows that the earlier the operation the better the results. The following precautions should be observed: A. In labor: 1. Do not encourage patients to bear down until nature excites the inclination. 2. Do not apply forceps until the cervix is fully dilated. 3. Avoid, as far as possible, all means of hastening the second stage of labor. 4. Repair all wounds of the cervix and pelvic floor immediately after labor. B. During the puerperium: 1. Keep the patient in bed ten to fourteen days. 2. Prevent overdistention of the bladder and constipation. 3. Examine patients at the end of six weeks and make the necessary repair of existing injuries. Preliminary Treatment. — Before resorting to operation certain steps should be taken in preparation for operation. If the general health of the individual is such as to render an operation hazardous, time should be taken to restore these conditions so far as it is possible. Furthermore, there are local conditions which demand attention before operating. The pelvic congestion, so commonly associated with pro- lapsus, should be relieved, and ulcers on the vaginal walls should be healed. General Treatment and Hygiene. — Careful attention should be directed to rest, exercise, baths, diet, and the care of the bowels. All constric- tion about the waist line should be removed and a straight front corset or abdominal binder worn to give support to the abdominal .organs. Constitutional treatment should be given when indicated. Replacement of the Uterus. — To relieve the pelvic congestion and ulcerations of the vaginal walls and cervix, it is essential to first replace the uterus and to keep it in place by a temporary support. All con- stricting clothing is removed from the waist, the bowels and bladder MALPOSITIONS OF THE UTERUS 329 are emptied^ and the patient put in the knee-elbow position. The uterus is then grasped by the hand and gently forced into the vagina, following the line of least resistance. Unless adhesions exist or the size of the uterus will not permit of its free mobility, the organ readily assumes its normal position. It is rarely necessary to give an anes- thetic. In acute displacements the associated congestion and edema may greatly enlarge the protruding uterus. In this event it may be necessary to elevate the hips and apply hot fomentations to the pro- truding mass for several hours before attempting to effect a replacement. As a rule, the patient herself is able to replace the uterus by lying in the knee-elbow or lithotomy position and forcing the projecting mass back with her fingers (Fig. 213). Fig. 213 Patient assumes the knee-chest position and pushes the prolapsed uterus high into the vagina. Tampons. — To temporarily hold the uterus at its normal level, two or more lambs' wool tampons should be inserted high in the vagina while the patient is in the knee-elbow position. These tampons should be applied daily, and if difficulty is experienced in retaining the tam- pons in the vagina, a T-binder should be worn over a vulvar pad of gauze. Vaginal Douches. — In order to protect the vaginal surfaces from irritating discharges, a mild antiseptic vaginal douche should be given once or twice daily. For this purpose the author usually prescribes lysol solution, 1 to 1000. When tampons are worn the douche is given before replacing the tampon. Treatment of Ulcers and Erosions. — As a rule, these lesions will heal spontaneously if the uterus is replaced and the vagina kept clean by 330 MALPOSITIONS OF THE GENITAL ORGANS douches. When the healing is slow the ulcers may be stimulated by the application of a 10 per cent, silver nitrate solution, the application being made twice a week. Pessaries.- — After these preliminary measures have been employed, with the result that congestion has been relieved and ulcerations have healed, it is then necessary to provide a more permanent support. It is not always advisable to operate and not all patients will accept such advice. When the patient is old or afflicted with diabetes, disease of the lungs, heart, or kidney, or with any other disease that will render an operation hazardous, the next step will be to adjust a suitable pes- sary. This is by no means an easy problem. The ordinary pessaries, such as the Hodge or Albert-Smith, will be useless. When the pelvic floor is fairly intact it may be possible to adjust a ring pessary, but in the majority of instances nothing will serve the purpose short of a cup and stem pessary attached to an abdominal support (Fig. 214). This pessary should be removed at night and the ring or cup should be cleansed daily; the vagina also should be irrigated daily, to prevent the development of ulcers. Mcintosh uterine support for prolapsus. Colpeuryriter. — When the pessary causes pain and discomfort a colpeurynter (Braun) will provide relief. The same precautions should be taken in the wearing of a colpeurynter as in the wearing of a pessary. If the vaginal walls and cervix become irritated the colpeurynter should be anointed with zinc oxide ointment. Technic of Operation. — To successfully restore a prolapsed uterus, due regard must be paid to all associated lesions, otherwise the results will not be satisfactory. Not only must the uterus be permanently restored to the normal position, and in such manner as to avoid any possible interference with the normal functions of the pelvic organs, but the cervix, vaginal walls, and pelvic floor will usually demand the attention of the surgeon if the uterus is to remain in its corrected position. This requires plastic surgery on the pelvic floor, to be followed during the same anesthetic by the abdominal work. The precaution is taken to make a complete change of gown, gloves, instruments, and surgical appliances in the interim between the vaginal and abdominal operations. MALPOSITIONS OF THE UTERUS 331 The following is the usual order of procedure: 1. Curettage. 2. Anterior colporrhaphy when there is relaxation of the anterior wall of the vagina. 3. Amputation of the cervix when it is elongated or deeply lacerated. 4. Colpoperineorrhaph}'. 5. Shortening of the round ligaments or — 6. Amputation of the body of the uterus, and fixation of the stump to the abdominal wall. It will be observed that the author has not advised fixation of the body of the uterus to the abdominal or vaginal walls, for reasons which will appear later. 1. Curettage. — The endometrium is commonly hypertrophied in pro- lapsus and gives rise to leucorrheal discharges. (See page 126.) 2. Anterior Colporrhaphy. (See page 294.) 3. Amputation of the Cervix. 4. Colpoperineorrhaphy. (See page 763.) 5. Shortening of the Round Ligaments. (See page 368.) 6. Amputation of the Body of the Uterus and Fixation of the Stump to the Abdominal Wall, a procedure credited to Baldy. The removal of the body of the uterus, followed by the fixation of the cervical stump to the abdominal wall, is unquestionably the best procedure when there is great relaxation of the uterine supports and the patient is incapable of childbearing, either for reasons of advanced age or for anatomical conditions, such as uterine fibroids and chronic metritis. Baldy Operation. — After a supravaginal amputation of the uterus, the cervical stump is fixed to the abdominal wall at the lower end of the incision. Two silkworm-gut sutures are used for this purpose. They are made to transfix the cervical stump from side to side and are brought through the peritoneum, muscle, and deep fascia on either side of the abdominal incision. They are then securely tied and the ends of the sutures cut close to the knots, after which the abdominal incision is closed in the usual manner. Before closing the abdomen care must be exercised in coapting all peritoneal surfaces about the cervical stump and broad ligaments. This is done with a continuous catgut suture. Baldy does not now bury the fixation sutures, but passes them com- pletely through the abdominal wall, as in the operation of ventral fixation, and denudes the under surface of the abdominal wall where it comes in contact with the cervical stump, for fear the support may be weakened by the stripping of the peritoneum. The author does not favor vaginal hysterectomy, total abdominal hysterectomy, or vaginal fixation of the uterus. Results in Operations for Prolapsus Uteri. — From a large number of home and foreign clinics the following statistics have been obtained: In 1000 plastic operations upon the cervix, vaginal walls, and perineum there has been no return of the prolapsus after many years in 70 per 332 MALPOSITIONS OF THE ^~ S %M >Oy '<'& ?-■■■. n ''*'^Z^^^ iKLVMREi—r; Incompletely healed erosion of the cervix. Mucous secreting glands are locked in by manj' layers of squamous epithehum. Formerly the surface was covered by a layer of columnar epithehum from which the glands dipped into the connective tissue. The surface epithehum became transformed into stratified squamous epithehum and the glands were buried beneath. PLATE XX 1 Erosions of Cervix. 1. Hyperemia of cervix. 3. Papillary erosion. 2. Simple erosion. 4. Simple erosion with stellate laceration. PLATE XXI 1 Erosions of Cervix. 1. Follicular erosion. 2. Follicular erosion. 3. Alucous polyp of cervix. 4. PapUlary erosion. EROSIONS OF THE CERVIX 419 either locked in beneath the squamous epithehum or open directly upon the surface, now covered with squamous epithelium. Healing of an erosion is effected by metaplasia of the cylindrical epithelium into many layers of squamous epithelium (Fig. 295). Differential Diagnosis of Endocervicitis.— A clinical diagnosis of endocervicitis is commonly made from the mucous or mucopurulent secretion coming from the cervix. It is well to discriminate between a hypersecretion of the cervix due to passive congestion and a secretion which is the expression of an infection. This, however, is not always possible. A mucous secretion seen to leave the cervical canal must Fig. 296 .<1 " ^'' { V - . - • • »<^Hv> f Incomplete healing of an erosion of the cervix. Between two sections of stratified squamous epi- thelium is a limited amount of columnar epithelium which is invaginated in the form of irregular glands. Numerous glands are locked in beneath the squamous epithelium. In this case the surface was originally smooth and covered with stratified squamous epithehum; the squamous epithelium became destroyed and replaced by a single layer of columnar epithehum, from which glands were formed. Subsequently, through a heaUng process, part of the surface epithelium was transformed into stratified squamous epithelium and the glands were covered over, as seen above. necessarily come from the cervix, there being no mucus in the secretion of the uterine body or Fallopian tubes. When pus is mixed with the mucus there can be no doubt as to the infectious origin of the secretion. Erosions of the cervix may closely simulate carcinoma. The macro- scopic appearance may be identical. The differential diagnosis is given in Chapter XXVII. (See Plates XIX, XX, and XXL) Ectropion of the lips of the cervix may closely resemble erosions. If the lips of the cervix are grasped by tenacula and approximated, the reddened surface will roll into the cervical canal and disappear. If an erosion is present there will be no disappearance of the reddened zone. 420 INFLAMMATIONS OF THE UTERUS ULCERS OF THE CERVIX True ulcers of the cervix are of rare occurrence. Formerly erosions were regarded as such. Decubitus Ulcers. — Decubitus ulcers of the cervix are found in prolapse of the uterus and as the result of ill-fitting pessaries. Such ulcers may attain the size of a silver dollar. They are usually super- ficial, with irregular outlines; the margins are not elevated; the base is granular, firm, and covered by a grayish -yellow secretion. The tendency to bleed is not great, as compared with malignant ulcers. Further- more, in contrast with carcinoma, there is a marked tendency to cicatri- zation. Under the microscope the epithelium is seen to be lost. The base is thickly beset with distended capillaries embedded in the meshes of connective tissue and small round cells. This round-cell infiltration extends a variable distance into the underlying connective tissue. A structureless, necrotic material may collect upon the base of the ulcer. Tuberculous Ulcers. — Tuberculous ulcers will be described below. Cancerous Ulcers. — (See Chapter XXVII.) TUBERCULOSIS OF THE CERVIX Tuberculosis of the cervix as a primary lesion is a rare finding. Beyea found sixty-eight cases of primary tuberculosis of the cervix in the literature, and adds a single case. In nine of these cases the lesion was confined to the cervix; in the balance there was an invasion of adjacent structures. The greatest number occurred between the ages of twenty-one and forty years; the extreme ages were seventeen and seventy-nine. Beyea divides the pathological forms into the ulcerative, hyperplastic, and miliary. Tuberculous ulcers of the cervix may follow primary tuberculous infection of the endometrium; or, as is more often the case, a primary infection of the tubes, with subsequent extension downward to the uterus and cervix. The diagnosis must be based upon the finding of giant cells, tubercles, and of tubercle bacilli in and about the ulcers. The margins of a typical tuberculous ulcer are irregular and under- mined; the base of the ulcer is uneven and tends to heal by cicatrization. Miliary tuberculosis of the cervix has seldom been recognized. In general, it may be said that tuberculosis of the cervix closely resembles erosions and cancers. A positive diagnosis can only be made by the aid of the microscope. The clinical history and the finding of tubercu- losis elsewhere in the body, particularly in the upper genital tract, is of importance in the consideration. ENDOMETRITIS Hitchman and Adler propose a radical change in the classification of endometritis. The author is in accord with the statement of Frank, ENDOMETRITIS 421 that these authors have performed a valuable service in claiming that the majorit}^ of changes hitherto classed as chronic glandular or inter- stitial endometritis are physiological and not inflammatory in origin — that they are the changes normally found in the menstrual cycle. But Frank believes that they have gone too far in their conclusions. While the presence of plasma cells does indicate an inflammatory process, their absence does not necessarily exclude the possibility of inflammation. Matthews Duncan once said in a lecture: "Who can tell what anyone means by endometritis? Often its use is the parent or child of ignorance and confusion." There is yet to be proposed an exact and practical classification of endometritis. In the light of present knowledge we are unable to harmonize our clinical, macroscopic, and microscopic forms of endometritis. In making a diagnosis from promi- nent symptoms and evident etiological- factors, we are unable to foretell the naked-eye and microscopic findings. One and all of the pathological forms of endometritis may exist without clinical signs. On the other hand, any of the pathological lesions of the endometrium may give the same clinical manifestations as endometritis. Furthermore, these symptoms may be present in the absence of an evident pathological change in the endometrium. It is evident that a clinical classification cannot be universally applied. While appropriate in the majority of cases, there will be a minority which can only be recognized by direct examination of the endometrium with the naked eye or with the microscope. Indeed, it not infrequently occurs that the absolute diagnosis is reserved for a microscopic examination of scrapings removed by the curet. In view of what has been said we will give both a clinical and an anatomical classification. Clinical Classification of Endometritis. — Endometritis may be acute or chronic. The distinction between these forms is usually not difficult to make. Acute Endometritis. — In acute infections of the endometrium, the constitutional disturbances may be mild or severe. Fever may exist, but is not always proportionate to the extent and intensity of the inflammation. The pulse-rate corresponds to the degree of general intoxication, and is to be regarded as a more reliable indication of systemic infection than is the temperature. The menses are lessened or suppressed. The uterine discharge is at first serous, later seropuru- lent. There is backache, nausea, a sense of weight in the pelvis, rectal and vesical tenesmus, and pain in the hypogastrium. Bimanual exami- nation reveals a uterus tender to pressure, not perceptibly increased in size, and perfectly movable. The external os may be slightly patulous and softer than normal. Inspection through the speculum shows a congestion of the cervix which is particularly evident at the external OS. From the cervical canal flows a seropurulent or mucopurulent secretion; it is seldom clear, serous, or mucous. A sound introduced into the uterus would cause some pain and bleeding, and should not be used. 422 INFLAMMATIONS OF THE UTERUS Chronic Endometritis. — For practical clinical purposes we will adopt a classification of endometritis based upon the prominent clinical sj'mptoms — hemorrhage, leucorrhea, and pain, and will speak of hemorrhagic, catarrhal, and dj^smenorrheic endometritis. Clinical Forms of Chronic Entjometritis. — 1. Hemorrhagic endo- metritis is characterized by an unusual loss of blood during and some- times between the menstrual periods. Inasmuch as the normal limits , of menstruation vary widely, it is difficult to fix the exact limita- tions of the normal and the abnormal flow of blood. The normal limit in time may be fixed at from two to eight days; a flow continuing longer than eight days may be regarded as pathological. The average normal quantity of menstrual blood is six to eight ounces. Intermen- strual bleeding is always pathological and demands careful inquiry into the cause. It is unusual for endometritis to cause intermenstrual bleeding. Physical exertion may excite hemorrhage, but the loss of blood is never considerable. In hemorrhagic endometritis, leucorrhea and pain may be present, but these are symptoms of less prominence than the hemorrhage. 2. Catarrhal endometritis is characterized by an excessive serous or seropurulent discharge from the uterus. The amount of secretion is not proportionate to the extent and degree of inflammatory changes found in the endometrium. If mucus is found in the secretions, the cervix is involved, there being no mucous secretion from the body of the uterus. To differentiate a uterine discharge from the secretions of the vulva and vagina the Schultze method should be adopted. (See page 409.) Not infrequently women complain of a leucorrheal discharge during pregnancy and immediately preceding and following the menstrual flow. Such are within normal limits, and are to be regarded as hyper- secretions of the congested uterus, vagina, and vulva. The most excessive discharge is found in gonorrheal endometritis. Nothing can be ascertained respecting the essential cause of the infection from the macroscopic appearance of the discharge. Cover-slip prepa- rations may contain the gonococcus. 3. Dysmenorrheic endometritis is characterized by painful men- struation. Pain is little to be relied upon in the diagnosis of endo- metritis. The diagnosis is arrived at by excluding all other possible causes of pain. The pain of endometritis is described as being of a cramping, bearing-down character, and associated with a feeling of weight in the pelvis. However, there is nothing characteristic in the pain. It is more often caused by such complicating lesions as salpingitis, ovaritis, and perimetritis. While the above-named sjrmptoms — ^hemorrhage, leucorrhea, and pain — are commonly present in endometritis, and while one of the three symptoms usually dominates and justifies the terms as given above, it is not uncommon for endometritis to give rise to no symptoms. Further- more, carcinoma, sarcoma, submucous polyps, and retained placental tissue may closely simulate endometritis in their clinical manifestations. ENDOMETRITIS 423 In addition to the above clinical forms of endometritis, may be mentioned several varieties which are not only hemorrhagic, catarrhal, or dys- menorrheic, but are deserving of special designation because of some point of interest relating to their etiology, time, and manner of occur- rence. The following forms are ordinarily recognized: 4. Tuberculous endometritis often follows a primary infection of the tubes. When tuberculous salpingitis is recognized, and there develops a catarrhal discharge from the uterus, the extension of the tuberculous process to the endometrium is suspected. Frequently there is amenorrhea. Cover-slip preparations should be taken from the secretions and an exploratory curettage may be made, with the view of finding giant cells, tubercles, and tubercle bacilli in the scrapings. Fig. 297 Uterus from a patient dying on the tenth day from a mixed infection — streptococci and colon bacilli. (Jewett.) 5. Gonorrheal endometritis can be recognized with certainty only by finding the gonococcus in the catarrhal secretion. It is not alwaj's possible to demonstrate the presence of the gonococcus in the secretions ; this is particularly true of the long-standing cases. When a leucorrheal discharge appears shortly after marriage, and when in addition to leucorrhea there is burning on urinating and infection of the urethra and glands of Bartholin, little doubt can be entertained as to the natiu-e of the infection. No other form of endometritis causes such profuse discharge. 424 INFLAMMATIONS OF THE UTERUS 6. Decidual endometritis is a term applied to the inflammation of the endometrium of p^egnanc3^ The lesion can onl}^ be suspected during pregnancy. A positive diagnosis is made by a microscopic examination of the decidua after the expulsion of the fetus. Gonor- rhea is the usual cause. The symptoms are hemorrhage, which varies in amount and may continue throughout pregnancy; leucor- rhea of a purulent character, less often serous, sometimes known as hydrorrhea gravidarum; and pain of a cramping or bearing- down character. The leucorrheal secretion ceases in the latter half of pregnancy when the decidua reflexa and vera unite. Decidual endometritis may arise prior to pregnancy, and is one of the potent causes of abortion. Fig. 298 Uterus from patient dj-ing on tenth day from a pure streptococcic infection. (Jewett.) 7. Puerperal endometritis occms in the puerperium as the result of instrumental or digital infection. It is not infrequently of gonorrheal origin. 8. Postabortive endometritis follows abortions, usually as the result of instrumental or digital infection. 9. Exfoliative endometritis (membranous dysmenorrhea) is recognized clinically by the periodic expulsion of a membrane from the uterus, ENDOMETRITIS 425 either as a cast of the uterus or in the form of shreds. Expulsion of the membrane is commonly accompanied by severe pain. For differen- tiation of this variety from other discharged membranes see page 142. 10. Senile endometritis, as the name implies, occurs in advanced years, and in its clinical manifestations (hemorrhage, leucorrhea, and pain) may closely simulate carcinoma. There is no satisfactory explanation of the etiology of senile endometritis. ^Yhile the above forms are commonly recognized without difficulty, there is a minority of cases in which endometritis is only distinguished by anatomical (gross and microscopic) observations. It is evident that an additional classification, based upon anatomical findings, will serve when the clinical signs fail. Fig- 299 1 ,-l'A^«« "^ en/'' f I, 'v ~ c r-^ t 3 .'->- * ' f > 1 "^ ^ s »*^ 1*7' >> ^^', ■v \ - N> / 1 -\ ■^- - ^ — --»'> =, ■* r ^ / ' f¥ y '~ ^ i^n I '^'Kr. fi- '-'■ \ ^ ^tl" '/* _*^^'/ I \ " "; ' ' ' ~- ^i ^ ^* \ ^^x^-r _pi" ^/ 1 ^ ^.^^"J. s ~ ^-^ ^<. r^lit-thli" Hj-pertrophic glandular endometritis. The endometrium is thickened, soft, and folded. In the cervix are several distended glands, forming a cystic protrusion. Anatomical Classification of Endometritis. — According to Hitschman and Alder, chronic endometritis exists only in the interstitial type, as expressed by the infiltration of the interglandular tissue by round cells, and that the plasma cells in this infiltrate alone are characteristic. They believe that the hypertrophic and hyperplastic glandular types are nothing but normal premenstrual findings. The author believes that their findings are justified to a degree, but prefers to hold to the anatomical classification of Ruge and Veit, which is here presented. 426 INFLAMMATIONS OF THE UTERUS Macroscopic Forms of Endometritis. — ^Macroscopic forms of endo- metritis are diagnosticated after the uterus is removed and opened. Such- findings may be wholly unsuspected in the absence of all clinical symptoms of endometritis. The following forms are recognized by the unaided eye: 1. Hyyertroyhic endometritis, in which the endometrium is thickened and soft. 2. Fungous endometritis, in which the endometrium is throw^n into folds and fungosities. ,.x^' I r'"'"'- f" Fig. 300 Normal endometriura of a young woman. The surface is covered with a single layer of low columnar epithelium. The glands are tubular, wa^'y, lined with columnar epithelium similar to that of the surface, and extend to the musculature. They run almost at right angles to the surface of the endo- metrium. The connective tissue is embryonal in type, and contains but few small bloodvessels, difficult to demonstrate. 3. Villous endometritis, in w^hich the surface of the endometrium is covered with shaggy villosities. 4. Polyphoid endometritis, in which one or more mucous polyps project from the endometrium. 5. Ulcerative endometritis, in which true ulcers are formed in the endometrium. These ulcers show either a virulent form of infection or malignant degeneration. 6. Pseudodiphtheritic endometritis, following labor and abortion. On the surface of the endometrium is a necrotic layer formed of fibrin, degenerated epithelium, leucocytes, blood, and microorganisms. ENDOMETRITIS 427 Microscopic Forms of Endometritis. — The use of the microscope in the diagnosis of endometritis, already alluded to, affords the only- means of making a positive diagnosis of these cases, for without its aid and relying upon clinical signs and symptoms, not only may the diagnosis and prognosis be faulty, but the uterus may be sacrificed in the treatment of what appeared to be a malignant growth. Further- more, life may be sacrificed from failure to remove a malignant growth in which the characteristic symptoms were absent or suggestive of endometritis. In order that no serious oversight be made, it is important that ■ a systematic microscopic examination be made of all uterine scrapings. Two general forms of endometritis are recognized by the microscope — the glandular and the interstitial. The two forms are commonly associated. 1. Glandular endometritis is characterized by an increase in size or number, or both, of the glandular elements. The surface of the endo- metrium is thrown into irregular elevations, forming folds, fungosities, villi, or polyps. By the increase in size and number of the secreting epithelial cells, the glands become enlarged and irregular in their course. The inter- glandular spaces are decreased proportionately to the increase in the glandular elements. The glands, which in normal conditions rarely penetrate into the musculature, will, when hypertrophied, penetrate this region to a limited degree. The distortion of the glands may be extreme. In longitudinal sections the glands may appear to twist like a corkscrew. The inversion and eversion of the glandular epithelium may give a serrated appearance to the gland. The glands are not only increased in size (hypertrophic glandular endometritis), but may be increased in number (hyperplastic glandular endometritis). The increase in the number of the glands is a result of the budding from preformed glands or of invaginations of the surface epithelium. If we fail to satisfactorily classify the established forms of endometritis, how much more difficult is it to draw the line sharply between inflammatory growths of the endometrium and true tumor formations. Are we to recognize a benign adenoma of the uterus ? Are the mucous polyps to be classified as newgrowths or as polypoid forms of endo- metritis? In short, is it possible to define the so-called hyperplastic glandular endometritis from benign adenoma of the endometrium? Referring to general pathology, we are unable to distinguish hyper- plastic glandular growths of inflammatory origin from benign adenomata. In reviewing the opinions of a number of authors, it becomes evident that to separate the two would be impossible, and to admit of a connecting link between the two lesions is admissible. Rindfleisch, Chiari, Weichselbaum, and Orth favor the view of simple inflammatory hyperplasia to the exclusion of benign adenoma of mucous surfaces. Thoma, Eppinger, and Ponfick recognize adenoma, while others, as Van Heukelom and Birch-Hirschfeld, believe in the existence of a connecting link between these lesions. All believe in 428 INFLAMMATIONS OF THE UTERUS the inflammatory origin of mucous polyps. Polyps of inflammatory origin are found in the stomach by Klebs. Birch-Hirschfeld, Petrow, and Landel describe diffuse and circumscribed growths of the gastro- intestinal tract due to catarrhal inflammation. By a careful analysis of their reports, it is evident that inflammatory hyperplasia of mucous surfaces merges insensibly into tumor growths, both benign and malig- nant. In a large percentage of their cases, carcinoma was associated in the same organ. In the urinary tract, Stoerck, Cahen, Rehn, and Kaufmann recognize papillomata of inflammatory origin. Fig. 301 .••■'•'^^ -wr.,m'»».««»**'""**^^*"^»«"*»"V jrf»*"»»»"*» ■-0- Qv o' " ■ o- f? - ./ o . o ■Xy'd:^'^ c — ■ ;'V " - •-* "V . c^' " ■-'■'■■', ■ f ■; '' Fig. 304 Fig. 305 Fig. 306 Fig. 307 %-v' \ S^'^5!Sji£,v;y^fV- Fig. 309 /.:C?^^J'S|v' Fig. 30S; •'0 Explanatioa of scheme of gland invagination. Figs. 302 to 308 show longitudinal sections of invagi- nated uterine glands; Fig. 303 to 309 show cross-sections of the same gland. The glands shown in longitudinal section are each crossed by a line showing the plane at which the cross-sections are made. Fig. 302 shows the fundus of a gland invaginated with secondary eversion. Fig. 308 shows intra- glandular papillary invagination of a gland epithelium from the side of the gland. Fig. 304 shows simple invagination of the fundus of a gland. Fig. 306 shows the inner and out^r segments regular and the middle segment invaginated. (Amann, Mikroskopisch-Gynakologischen Diagnostik.) 430 INFLAMMATIONS OF THE UTERUS and when occurrring in old age, or when recurring after repeated curettage, they are to be regarded with suspicion. The buds from parent glands may again and again give off new glands. We speak of an inverted gland when processes of the gland protrude into the lumen; of an everted gland when the processes protrude from the lumen. In the inverted gland cross-sections will give the appearance of a gland within a gland. (See the schematic Fig. 310 m i - j'CsS'*'' '''//'. • ---.1 ^--''''/i'i""rT-' ,/"/';,- !."•*'>'/ Interstitial endometritis. The glands are decreased in size and far separated by mature connective tissue. drawing, page 429.) More or less connective tissue invariably separates the glands — a fact to be remembered in differentiating this condition from malignant adenoma. In rare instances, two or more layers of epithelium are found on the surface of the mucosa or in the glands. Many layers of squamous epithelium have been observed. Such proliferating epithelium is always superficial, never p'assing beyond the basement epithelium, as in malignant glandular growths. Spontaneous healing of glandular endometritis is possible though ENDOMETRITIS 431 not probable. At the time of the menopause the hypertrophied glands may diminish in size along \\-ith contraction of the interstitial connective tissue. -~-.-'i-. .#i : - " ■ " , ■. ^ . ■ ". ■'■••- :<-'--?-''^. 'V. ■: ;':j-; ■ . ■' ■ ■ ^ •y .;, • ■ i- / » ' . *" ft-' , "* ° ■ ' ■ * ■ f- . J- ' J , > ^jj ' . ■•- i, „■ * -y «•. .> ' ',' ' ■' -.- » * ' ** »'. .' "■ ' '•'■' ' ' : '■;'■'- ^c- *- ■ J' \'* , \ ' " ^ ' . '«>**•?'■ . ' ' v\.V* >•!■ • ' 7 ^'?^^^'.'&-:- ■ ',» ' V . ■ .';•*•!'. *^ . '■ " " V, , %"?■ , > ■ ;^ ^' ' '^ ^ c\^-=- " ^» ' '_ <'. - ' -■•■'»"* J" -1 "' ■-' ■ ' " V>* >?•:<*.' "-^^=^■" ,! :*■ ->, ^y ■■'."■ y, - '.J, ' cC^ .-"!•> >» 15. , ;. > • "^ .- V-. ".V ^ ' . 'i.^f »■ t' ■ ■- 'i'a*^<' ■ 1^- •■: . ,. •■ ' ^ 'J'iV' - / ; "^- -H' ■ "'^ . - 'i t'- t, '. • ■ ' ->', , - .- '• ' ':W-r^^^\ -;, ./ ,-'■ . •'V .' '° ' ^' .■* ,' - .:-'-^ '■■'■ ■, ?. ',' '' ' '^' ' ■"• ' si,v ' ■S-"^''' r ' ;■-. .;i-''-A ^'"-^ - *"'■' ■, -^ '' . t? r''^'<'^ - ', f «« ^i^{^":>^-"- •- : / ''. ' * ;-•'. 1 :*.'', ■ ' "" ■ -^ - /• « V "4.^-a!^ , ■>, *'•. - -' ', ■ i" •'"' ' ~ ^ ■ V "^ A •-<• - ' - * \ ^ '•o 'S- ^ '.^ •, \ (.'■_'". ,' ' *- - ,4 i'^o* •"/ • ^-\' :''■ * ■■ ■ ■ ' A r ■ ' '* * - ' ' " Si?^, ..-■•v-^.- \'.^ '•'■' .'''' '■ -^ '-^'-^IV ^^ w ■^ &* - "V * ' •. ^^# ^v"% ' *<■. t,.4.--„* v^vi" ' "'■• ■ :, A- ■ %->^" -'•-.: ,»••>»' '■-"M ;;'3H:&?^;^V:^'i ^' ■■; ■ X'i^\- '" i?Vv?S1:^"?.-?^;^--. ,'' ' 61 •" Tuberculous glandular endometritis. Three giant cells are seen in the section. There is an extensive roiind-cell infiltration and degenerative changes. 2. Interstitial endometritis is characterized by a hyperplasia of the interglandular connective tissue at the expense of the glandular elements. Two stages are recognized — the acute and the clu-onic. 432 INFLAMMATIONS OF THE UTERUS (a) Acute Interstitial Endometritis. — ^x4.cute interstitial endometritis presents a small round-cell infiltration in the stroma, which may be diffuse or circumscribed. The bloodvessels are congested and a serous or serosanguineous exudate permeates the connective-tissue spaces. The glands are crowded apart by the widening of the interglandular spaces. They are irregularly compressed, causing them to be greatly distorted. Healing may be perfect from absorption of the exudate, or the acute stage may gradually merge into the chronic. Acute senile endometritis is described by Dunning, who presents the following summary of the anatomical findings: "The endometrium is thickened, the free surface is devoid of an epithelial covering; there is an increase in the vascularity with a peculiar arrangement of the small bloodvessels; there is a small round-cell infiltration; the glandular elements are diminished; the coats of the arteries of the muscularis' are degenerated." The presence of diseased appendages in both cases reported by Dunning and of a mild form of pelvic peritonitis in one case seems to indicate that the inflammation tends to extend beyond the limits of the uterus. (h) Chronic Interstitial Endometritis. — Newly formed connective tissue separates the glands. The glands are irregularly compressed and may suffer pressure atrophy. In place of the embryonal connective tissue normally found in the endometrium, there is matured fibrous tissue, which first thickens the endometrium and later contracts, result- ing in a diffuse or localized atrophy of the mucosa. The surface of the endometrium becomes irregular. Retention cysts may appear in the endometrium from an obstruction at the outlet of the glands, causing the glands to distend with the secretions. In direct proportion to the distention of the glands, the epithelial cells lining them are compressed and may be quite flattened. The interglandular spaces may be greatly narrowed. When retention cysts are numerous, the term cystic glandular endometritis or cystic interstitial endometritis is applied. When the connective-tissue spaces are filled and distended by a serous or serosanguineous exudate the term exudative interstitial endometritis is applied. Thus there may be a combination of these forms, and one may speak of a hj'pertrophic and hyperplastic cystic, exudative, glandular, and interstitial endometritis — a rather formidable name, but nevertheless suggestive. Combinations of the glandular and interstitial forms of endometritis are the rule. It is unusual for either form to exist alone. Rarely are the glandular and interglandular tissues uniformly involved (diffuse endometritis) . The diagnosis of uterine scrapings in endometritis is preeminently satisfactory and reliable. The loose texture of the endometrium permits easy removal of the mucosa by the sharp curet. It is true that the structures composing the mucosa are more or less distorted in the scrapings, and that the deep layers of the endometrium are seldom found in the removed particles. When it is considered that the upper strata may show glandular ^changes and the lower strata interstitial ABSCESS OF THE UTERUS 433 changes, or the upper strata show an inflammatory reaction and the lower strata maHgnant degeneration, it is evident that the microscopic examination of scrapings is not always reliable. Little can be definitely learned from the naked-eye appearance of the scrapings. Large friable masses, homogeneous in appearance, of a pale gray color, suggest malignancy. In cystic formations the open spaces may be detected by the naked eye. In general it may be said that little that is positive can be learned from a macroscopic examination of particles removed from the uterus by the curet. CHRONIC METRITIS Fig. 312 Endometritis can scarcely exist without more or less involvement of the uterine musculature. In acute affections the muscularis is congested and the connective-tissue spaces are filled with a serous exudate and a round-cell infiltra- tion. Abscesses may develop in the connective-tissue spaces and infected thrombi may form in the blood-spaces. In the chronic stage there is a development of connective tissue between the muscle fibers. As the connective tissue forms and con- tracts the muscle fibers atrophy, and through this process the uterus becomes very firm. The diagnosis is based upon the uniform enlargement of the uterus and upon the change in its con- sistency. In the chronic stage there may be no tenderness on pressure. Chronic metritis may be regarded as a clinical term signifying a uterus that is uniformly enlarged, firm in consistency, and one which has lost its normal flexibility. Chronic metritis is to be diagnosticated from interstitial fibroids (See Chapter XXVI.) Chronic metritic uterus (natural size) re- moved from a patient, aged fifty-two years, who had had nine children, but no miscar- riages. The symptoms were menorrhagia and metrorrhagia since last confinement, nineteen years ago. The last few weeks the hemorrhage had been almost continuous. Note the thick- ness of the endometrium. a, endometrium. (Donald.) ABSCESS OF THE UTERUS Little has been written on abscesses of the uterine wall. Barrows collected forty-one cases from the literature and adds seven of his own. Doubtless many cases escape recognition. Some open spon- 28 434 INFLAMMATIONS OF THE UTERUS taneously into the uterine cavity and are thought to be pus-tubes; others escape into the pelvic cavity or between the layers of the broad ligaments, and again it is highly probable that such abscesses are inadvertently opened by the curet. The majority follows labor and abortion; a few are of gonorrheal origin. The greatest number of these abscesses lie in the anterior wall of the uterus. The treatment is preeminently conservative throughout the acute stage. Rest in bed, ice applied to the abdomen, and sedatives for relief from pain when required, will carry the patient on to the subacute or chronic stage, when drainage should be established. Inasmuch as the abscesses are commonly located in the anterior wall of the uterus the usual procedure is to drain through a suprapubic incision. In exceptional cases vaginal drainage through the cul-de-sac will sufl&ce. TREATMENT OF INFLAMMATIONS OF THE UTERUS In the discussion of the treatment of inflammations of the uterus the subject will be divided into the acute and chronic stages. Acute Metritis. — The most important consideration is the prevention of acute infections of the uterus. Prophylaxis. — Many of the causes of acute metritis are preventable, at least to a large degree. For a discussion of these causes see page 390. Two etiological factors stand foremost in point of frequency and gravity, i. e., puerperal infection following labor and abortion, and gonorrhea. Only an outline will be given of the means employed in preventing these forms of infection. For further discussion see standard works on obstetrics. Prevention of Puerperal Infection. — 1. Avoid all unnecessary hasten- ing of the second stage of labor. 2. Limit to a minimum the extent of puerperal wounds. 3. Repair all lacerated wounds of the perineum at the completion of labor. 4. Limit to a minimum the number of vaginal examinations. 5. Practice scrupulous asepsis before, during, and after labor. 6. Avoid prophylactic douches, unless especially indicated and directed. 7. Regard generative tract after labor as the noli me tangere, save in event of an emergency. 8. Completely remove all secundines from the uterus. Prevention of Gonorrheal Infection. — 1. Educate the profession and laity to a keen appreciation of the serious consequences of the disease. 2. Withhold sanction to marry or to resume sexual relations until, by repeated bacteriological examinations, the gonococci are known to be absent. 3. Avoid instrumental and digital manipulations within the urethra and uterine canal throughout the acute stage. 4. Use clean hands and instruments in all examinations. TREATMENT OF INFLAMMATIONS OF THE UTERUS 435 5. To depend upon medical regulation and supervision of prosti- tution is inadvisable, inadequate, and promotive of a false sense of security from infection. There are many predisposing factors to acute metritis which deserve consideration, such as constipation, tight-lacing, faulty elimination, excessive venery, uterine displacements, and constitutional diseases. These should be eliminated; the remedies are readil}' suggested. Conservative Treatment.— The management of acute metritis must be preeminently conservative. Radical measures have been responsible for much harm. It may be said, without qualification, that there is but one indication for surgical interference in the acute stage of metritis, and that is the presence of placental tissue retained within the uterus. Under all other conditions no operative measures should be entertained. Untimely surgical interference is responsible for the spread of infec- tion. An endocervicitis is spread to the body of the uterus and an endometritis is made to involve the appendages. Every possible precaution should be taken to avoid disturbing the infection. Hence rest is of prime importance. Rest. — Throughout the acute stage of the infection the patient should be confined to her bed. Instrumental and digital examinations should be made only when imperative. Cleanliness.— Cieanlmess should be maintained by means of the vaginal douche. When the discharge has a foul odor, formalin douches, in the proportion of 1 to 2000, will be found effective. Throughout the acute stage the douches should be given under low pressure, with the patient in the recumbent position. The temperature of the douche should be 110°, and the duration about ten to fifteen minutes. Depletion of the Congested Tissues. — Long-continued hot vaginal douches, together with glycerin and ichthyol tampons, will deplete the congested tissues and shorten the acute stage of the inflammation. For a full discussion of the application of vaginal douches see page 196, and of tampons see page 213. No intra-uterine applications are to be made in the acute stage, hence intra-uterine irrigations, injections, swabs, and packs are pro- scribed. The sole exception to this rule is that, subsequent to the removal of retained placental tissue, the uterine cavity should be irrigated with sterile normal salt solution. Relief from Pain. — For relief from pain, cold applications may be placed to the hypogastrium. Here the ice-bag not only relieves pain, but is a valuable aid in reducing the inflammatory reaction. The bowels should be kept freely open by the use of saline laxatives. The diet should be light and nutritious. The fluidextract of ergot in 10-minim doses or ergotol in 5- to 10- minim doses should be given three or four times a day in the puerperal cases, for the purpose of contracting the uterus and limiting the lymph and blood avenues for the conveyance of infection. Stimulation. — Stimulation is required when there is depression from toxic absorption. For this purpose whisky or brandy may be given 436 INFLAMMATIOXS OF THE UTERUS freely; strychnine may be given in doses of ^w to iro grain two to six times a day, and normal salt solution may be given by the bowel or under the skin to the extent of a pint one to four times a day. (See chapter on Hydrotherapy.) The Surgical Treatment of Puerperal Infections. — If we are to intel- ligently apply operative measures in puerperal infections, we must know the nature of the infecting microorganisms, and also the limit to which the infection has extended. ^lore than this, we should be possessed of means of determining the ultimate outcome of a given case, with or without surgical intervention, if we are to intelligently choose between tentative treatment and operative interference. We cannot as yet rely upon our clinical and laboratory guides in determining these factors. According to Sachs the prognosis is dependent upon three factors, i. e., the resistance of the individual, the location of the infection, and the character of the infecting micro- organism. Removal of Retained Placenta. — Placental rests should be removed with the least possible injury to the uterus, and at the earliest possible moment, for the reason that placental remains may harbor sapro- phytes which in time may become virulent. This is best done with the fingers, and if this is impossible the Emmet curet forceps or placental forceps should be used, but the curet should never be used. Retained membranes can be safely left to nature. Curettage. — Curettage of the infected uterus is universally condemned. It is generally conceded that a thorough curettage of the puerperal uterus is a difficult and dangerous task. "The curet is blind," and is capable of much mischief in the hands of the skilled as well as the novice. In the presence of virulent streptococci the danger is great- est because the inevitable wounds created b}' the curet will almost certainly be infected, and then follows an extension of the infection to the uterine musculature, pelvic connective tissue, appendages, peritoneum, and the general circulation of the blood. Hysterectomy. — Inasmuch as there are no certain means of deter- mining the extent of an infection, it is impossible to judge with cer- tainty whether a hysterectomy will fully eradicate the infection. It is not known with certainty what the ultimate outcome of a uterine infection will be. Clinical signs and laboratory guides fail in this regard, and one is therefore at a loss to recognize the indication for hysterectomy in a puerperal infection. The infected uterus should be removed when it has been perforated or torn, when sloughing fibroids are inaccessible to myomectomy, when multiple abscesses of the uterine wall are recognized, and when the infected placenta cannot be removed through the natural channel. In these cases hysterectomy may be permissible, provided the infection has not become general and the strength of the patient will permit. To anticipate a generalized infection by extirpating the uterus when the above conditions do not prevail is not justified by present knowledge and experience. TREATMENT OF INFLAMMATIONS OF THE UTERUS 437 Ligation of the Pelvic Veins in Puerperal Thrombophlebitis. — Fre- quency. — The frequency of puerperal thrombophlebitis is estimated at approximately 30 to 55 per cent, of all fatal cases of puerperal sepsis. The veins primarily involved are the uterine and ovarian or spermatic. For years the aural surgeons were ligating the jugular vein to check the advance of infected thrombi, when W. A. Freund, in 1897, ligated the spermatic veins of two cases of puerperal thrombophlebitis, but without success. Five years later Trendelenburg operated on five cases, with one recovery. Since then Fromme, D. Cuff, Latzke, Whitridge Williams, Lenhartz, Opitz, Osterlow, Vineberg, Miller, Huggins, and others have reported cases. Time of Operation. — ^We are admonished not to operate in the acute stage of the infection. Trendelenburg and Bucura say to operate after the fourth chill. It is questionable if this is a safe rule of practice, inasmuch as many cases are known to recover without operation after a dozen or more chills. Contra-indications. — The operation is not advisable when metastatic abscesses are recognized, when pus has accumulated in the pelvis, and when there are distinct evidences of lymphatic invasion. Pneumonia and endocarditis are placed as contra-indications to the operation, while pleurisy and lung infarcts are not necessarily contra- indications. Technic of Operation. — The thrombosed veins have been approached by three routes: the vaginal, the extraperitoneal, and the intraperito- neal. The first and second procedures have not been generally adopted for the reason that the veins of the pelvis and higher up in the abdomen cannot be under direct inspection. The technic of the intraperitoneal route is briefly as follows: The abdomen is opened in the median line. The uterus and its appendages are inspected. Next the broad ligaments are inspected and palpated, with special reference to the course of the uterine and ovarian veins. If the broad ligaments are found to be thickened along the course of these veins the existence of thrombosis is assumed. The veins are then palpated along their course to a point above the thrombus; here the peritoneum is incised and a ligature is passed about the veins by means of an aneurysm needle. Ligature of the ovarian veins may be made as high as the vena cava on the right side and to the point of union with the renal veins on the left side. When the internal iliac vein is involved, it should be ligated near to its juncture with the external iliac vein. If a median iliac vein exists this should be ligated at its juncture with the external iliac trunk. Lea recommends the ligature of both sides in every case because of the free anastomosis. The more acute the infection the more extensive the ligations. Care must be taken to prevent ligature of the ureters and lumbosacral cord. After such extensive ligations of the veins the pelvic organs and vulva become edematous, but this is soon remedied by the establishment of collateral circulation. When the thrombus has developed into an abscess it is advisable to dissect out the vein with a thermocautery. 438 INFLAMMATIONS OF THE UTERUS My personal belief is that the Trendelenburg operation is a ques- tionable procedure because of the difficulties encountered in the making of an accurate diagnosis and the many dangers attending the operation. Chronic Metritis. — In the chronic stage of metritis the results of treatment are uncertain. This is particularly true of gonorrheal metritis. Much may be accomplished in alleviating symptoms, but it is difficult to restore the diseased tissues to their normal state. There is apparently no disease of the uterus more difficult to cure than chronic metritis, because of the persistence of the infecting microorganisms, notably the gonococcus, and the tissue changes which are the result of infection. There are many cases of ''unsuspected metritis," and by this term is meant the presence of an inflammatory lesion in the uterus without physical or psychic functional disturbances. Menge divides these cases of unsuspected metritis into two classes: (1) Those in which the psychical condition is predominant, and (2) those in which the psychical condition is normal. Neither of these two classes demands local treatment. To instigate local treatments could only serve to centre the attention of the patient upon the genital organs and give rise to grave psychic disturbances. The treatment in such cases is purely hygienic and psychic. Chronic metritis is usually associated with psychic disorders, notably hysteria and neurasthenia. Psychic disorders demand psychic treat- ment; hence it follows that psychotherapy is an essential part of the rational treatment of such cases. General Treatment. — The diet should be nutritious but light. The bowels should be carefully regulated. Systematic daily outdoor exercises are of the highest value. These regulations, together with psychotherapy, should be adopted whether local treatments are or are not employed. For the control of hemorrhage due to endometritis general medication may suffice, but more often the remedies must be supported by local measures. These remedies are ergot, stypticin, hydrastis, styptol, and adrenalin. Rest must be enjoined along with the administration of these drugs. Local Treatment. — Whenever local disturbances arise as the result of chronic metritis, local treatment is indicated. Curettage. — In former years the curet was universally adopted as a means of treatment of chronic metritis. It is certain that its general use has led to much abuse in the hands of the general practitioner and specialist. Olshausen says "that abrasio mucosae is not every man's task." The truth of this statement is verified by repeated observations in which the curet has perforated the uterus, removed the mucosa to an extent that leads to partial or complete atresia of the cervical canal and cavity of the uterus, and again has failed to remove all of the diseased endometrium. The curet should never be used in the presence of a purulent leucorrhea. Indeed, the only indication for the use of TREATMENT OF INFLAMMATIONS OF THE UTERUS 439 the curet in chronic metritis is to control hemorrhage. As indicated abovCj the curet has no place in the treatment of acute metritis. When, therefore, we compare the indiscriminate use of the curet by the profession with the limited restrictions as above recorded we are impressed with the importance of giving serious consideration to the subject. The indications, contra-indications, dangers, and technic of curettage are given in Chapter VII. In event of perforation of the uterus by the cm-et no attempt to repair the injury should be made unless there is infection within the uterine cavity. If infection is present the author is of the opinion that the safest procedure would be to remove the uterus and establish drainage. The patient should rest in bed one week after curettage. Hot vaginal douches, glycerin and ichthyol tampons, careful regulation of the diet, of the bowels, and of exercise should be directed for a variable period thereafter, if good and permanent results are to be obtained. Medicinal Local Treatment. — ^Medicinal applications are made directly to the endometrium and indirectly to the uterus by means of vaginal packs, douches, and suppositories. Douches. — ^Antiseptic douches have no more effect upon an infected uterus than does sterile water of like amount and temperature. The effect is detergent and thermic rather than antiseptic, for the reason that the antiseptic solution does not reach the infected tissues. Astrin- gent douches are likewise deceptive in their action, inasmuch as only superficial tissues can be affected by the astringent properties of the douche. Caustic Applications.— Csiustic applications to the endometrium are applied for the purpose of destroying the diseased endometrium. Some are inert, some injurious, and only one, in the author's judgment, is preeminently satisfactory'. Tincture of iodine is inefficient, and the same may be said of the sesqui chloride of iron; nitrate of silver is liable to cause stenosis; the sulphate of copper produces uterine colic and has not afforded satisfactory results. Formalin in full strength is an excellent antiseptic application. It penetrates deeply, but is not knoTVTi to cause stenosis. Formalin is applied by means of a swab. Intra-uterine injections are not advised for fear of injecting the solution through the Fallopian tubes, and because of the consequent danger of poisoning. Technic of Sicabbing. — In swabbing the uterus it is essential that the cervix be well dilated to allow the application to all parts of the endometrium. The cervix should be exposed, preferably by a hanging speculum overriding the perineum, and a narrow blade retractor for the anterior wall of the vagina. The anterior lip of the cervix is grasped by a single prong tenaculum forceps, by which gentle but firm traction is made upon the cervix. The swab is passed through the dilated cervix, but not without knowledge of the size and position of the uterus previously gained 440 INFLAMMATIONS OF THE UTERUS through a bimanual examination. This precaution is taken to prevent the possible puncture of the uterus. The author generally uses wooden applicators accurately wound with cotton. They are recommended because they can be sterilized, together with the towels, sheets, and gauze, and their cheapness permits of using them but once. A thin film of cotton should be wrapped about the end of the applicator for a distance of at least four inches, in order that the cotton may not be lost in the uterine cavity. The objection to the wooden applicator is that it cannot be bent to conform to the Fig. 313 Intra-uterine injection of zinc chloride. Cervix exposed by a retractor held by an assistant. Cervix grasped by a tenaculum forceps. Zinc chloride injected through a tonsillar syringe equipped with an extended metallic nozzle. curve of the uterine canal. Three applicators are commonly used: one dry for the purpose of removing the mucus within the cervix and two for the application of formalin. A pledget of cotton or strip of gauze should be placed behind the cervix before applying the fqrrnalin, to protect the vaginal wall. To give time for the formation of a slough, for the discharge of the slough, and for the regeneration of the mucosa, these appli- cations should not be repeated at short intervals. Menge advises a second application in five to eight days if improvement in the symp- TREATMENT OF INFLAMMATIONS OF THE UTERUS 441 toms does not follow. As a rule, but a single application is required for postpartum and postabortive infections, but in gonorrheal infection several applications may be required. Only in the chronic stages of inflammation is this treatment indicated. INIenge places the time limit at not less than three months after the initial infection. Zinc chloride solution is an excellent escharotic, and should replace the curet in gonorrheal endometritis. It will as effectively destroy the diseased endometrium as the curet, and does not create wounds by which the infection can spread. The technic of applying zinc chloride to the endometrium is as follows: If the patient is under an anesthetic the cervix is dilated and a 30 per cent, solution of zinc chloride is applied to the endometrium on a swab. A second swab should be used, to make sure that the work is done thoroughly. If no anesthetic is used, the author generally injects into the cavity of the uterus a 5 per cent, solution by means of a small sjTinge with a long curved metallic nozzle. These applications may be repeated from tliree to six times in the course of the following six to ten weeks. Caution must be exercised for fear of creating too deep a destruction of the tissues. Operative Treatment. — Amimtation of the Cermx. — Martin, of Griefs- wald, recommends the amputation of one or both lips of the. cervix in extreme cases of chronic metritis. When preceded by curettage, amputation of the cervix often improves the condition of the uterus. Subtotal Hysterectomy. — In women who have not yet reached the climacterium, an effort should be made to save a part of the body of the uterus so as to preserve the menstrual function. For this purpose the subtotal hysterectomy devised by Bruettner is advised. Following is the technic of the operation: Step 1. — Median abdominal incision or the transverse incision of Pfannenstiel. Step 2. — Careful inspection of the pelvic organs, with special reference to the ovaries. If part or all of the oA^aries can be safely preserved, a cuneiform piece is excised from the fundus, avoiding, if possible, the insertion of the round ligaments. This incision is prolonged on either side into the broad ligaments (Fig. 314). Step 3. — ^The wedge-shape portion of the fundus is grasped by tenaculum forceps and removed with scissors. The uterine arteries are ligated on either side (Fig. 315). Step 4. — The uterine wound is closed by two or three rows of catgut sutures. The broad ligaments are carefully stitched with a continuous catgut suture. This leaves a small uterus, with little or no disturbance of the anatomical relations (Fig. 316). Hysterectomy. — Hysterectomy is indicated in extreme cases of chronic metritis when general and local conservative measures fail to relieve distressing symptoms. When the appendages are removed such a uterus should be removed with them. In tuberculous metritis, not only the uterus but its appendages should be removed by way of the abdomen. 442 INFLAMMATIONS OF THE UTERUS Treatment of Endocervicitis. — The mucosa lining the cervical canal may be infected independently of the body of the uterus. This is notably true of gonorrheal infections. In the treatment of endocervicitis, swabbing with caustics and antiseptics have long been practised and are often of great value. This may be accomplished without anesthesia if the cervical canal is patent to the ordinary swab; if not, an anesthetic may be required to dilate the cervix. Fig. 314 Outlines of cuneiform incision in the fundus. Fig. 315 Wedge-shaped portion removed from the fundus. Fig. 316 Line of suture approximating the surface of the wedge removed from the fundus. The following solutions are applied to the cervical endometrium by means of swabs: nitrate of silver, 25 per cent.; protargol, 5 per cent.; argyrol, 40 per cent.; formalin, full strength; zinc chloride, 5 per cent. In making these applications the cervix is exposed through a bivalve speculum and a pledget of cotton is placed back of the cervix to protect the vaginal walls. A satisfactory method of treatment is to inject PLATE XXII m b ^fM Fig.3. h. oa OU Qjy Figure l', a. Salpingitis Cutarrhalis Hemorrhagica, Cross-section, m. Muscle of the tube. 71. Mucosa of the tube. /. Lumen of the tube. Picrocarmine stain. (Hartnack, Oc. 2; Objec- tive 4.) &. Leucocytes containing blood pigment witli normal red blood-corpuscles from the tubal mucosa. (Harnack, Oc. 2; Objective 7.) Figure 2. Salpingitis Purulenta Acuta Dextra. ou. Uterine opening of tube. oa. Abdominal end of tube. ov. Right ovary. /. Purulofibrinous deposit. Posterior view, natural size. Figure 3. Salpingitis Purulenta Chronica Dextra. ou. Uterine end of tube. oa. Region of abdominal end of tube. ov. Ovary with strongly adherent tube. Posterior view, natural size. 1 August INIartin, Krankheilen der Eileiter. TREATMENT OF INFLAMMATIONS OF THE UTERUS 443 a 5 per cent, solution of zinc chloride into the cervical canal by means of a small syringe, using a long curved nozzle. (See Fig. 603.) Care must be taken not to overdo this treatment for fear of creating stenosis of the cervix. The author does not advise the use of the solution oftener than once in ten days, and not more than three or four times. Vaginal douches of bichloride, 1 to 2000, or formalin, 1 to 2000 to 1 to 4000, should be given twice daily. Fig. 317 Excision of a cervical polj^p. Craig advises the dilatation of the cervical canal followed by curet- tage of the cervical mucosa. This process may have to be repeated several times at intervals of two weeks. Following each curettage the author recommends the application of formalin in full strength. In cases which resist all treatment the cervix should be amputated. (See Amputation of Cervix.) All polyps of the cervix demand removal, and there should always be a microscopic examination of the excised tissues in view of finding a possible malignant growth. 444 INFLAMMATIOXS OF THE UTERUS Treatment of Erosions of the Cervix. — In the management of ero- sions of the ce^^'ix it should be borne in mind that by the removal of the cause, which in the majority of cases is resident in the uterus, the lesion. will ordinarily heal spontaneously. That is to say, if the leucor- rheal discharge ceases, the erosions will usually heal without direct interference. The treatments commonly given in the office for the cure of erosions are often more harmful than beneficial; they are directed to a condi- tion which is of secondary importance as compared with endometritis and other lesions resident in the uterus and adnexse which give rise to the discharges, and thereby to the erosion. Untold harm is done the patient by calling her attention to the existence of the lesion and by magnifying its clinical import. It is ill advised to even hint to these patients that the erosion may develop into a cancer. Simple erosions demand no further treatment than the removal of the cause of the leucorrheal discharges, for with the removal of the discharges, spontaneous healing will follow. Distended follicles (cysts of Xabothii) should be opened with a knife and the cavity swabbed with pure carbolic acid. ^Vhen the erosion resists treatment, as outlined above, the eroded area should be painted with pure carbolic acid once or twice a week, and following this the surface should be painted with tincture of iodine. This will eftectually destroy the surface epithelium and allow the healing of the erosion by squamous epithelium. Several weeks may be required in the process. The applications should not be made oftener than once a week. Papillary and follicular erosions demand more serious consideration, and particularly so if the tissues of the cervix are deeply infected and if deep lacerations exist. When the vaginal portion of the cervix has undergone changes that are permanent, nothing short of excision of the affected tissues will afford relief. Schroeder's wedge-shaped amputation of the cervix is the operation of choice in these cases. It should always be preceded by curettage and the swabbing of the uterus with pure formalin, unless a purulent discharge exists, when the curet should be substituted by the application of formalin or zinc chloride to the infected endometrium. (For the technic of Schroeder's operation see Amputation of Cervix.) It should be remembered that above these erosions is usually found a congested and infected uterus, if not a more extended involvement of structures lying beyond the uterus. It is therefore imperative to carry on a course of depleting treatment for a variable time after the healing of the erosion. (See Chronic Metritis, page 438.) By depleting treatment, reference is made particularly to long- continued hot douches and glycerin and ichthyol tampons. The douches are given twice daily and the tampons three times a week until all evidence of pelvic congestion is relieved. During this course of treat- ment sexual intercourse and all strenuous exercises are interdicted. CHAPTER XX CIRCULATORY DISTURBANCES, INFLAMMATIONS, AND INFECTIOUS GRANULOMATA OF FALLOPIAN TUBES AND OVARIES cleculatory disturbances in the Fallopian Tube Causes Anatomical Diagnosis Clinical Diagnosis Inflammations and Infectious Granulomata of the Fallo- pian Tube General Considerations Classification of Salpingitis Catarrhal Purulent Tuberculous Syphilis of the Fallopian Tube Actinomycosis of the Fallopian Tube Parasites of the Fallopian Tube Treatment of Inflammatory Dis- eases of the Tubes Non-operative Treatment Conservative Operations Radical Surgical Treatment Operative Treatment Circulatory Disturbances in the Ovary Etiology Anatomical Diagnosis Clinical Diagnosis Inflammation of the Ovary (Oopho- ritis, Ovaritis) Acute Ovaritis Chronic Ovaritis Cystic Degeneration of the Ova- ries Abscess of the ovary CIRCULATORY DISTURBANCES IN THE FALLOPIAN TUBES Causes. — Whatever interferes with the general or local circulation in the pelvis may cause congestion of the Fallopian tubes. Thus dis- eases of the heart, lungs, liver, and kidney; abdominal tumors, ascites, chronic constipation, and tight-lacing are among the causes of tubal congestion- Infectious diseases, dyscrasise of the blood, burns, toxemias, and menstrual congestion are additional general causes. A displaced tube, one that is twisted, constricted, or compressed, may cause congestion and possibly hemorrhages into the lumen of the tube. Anatomical Diagnosis. — A congested tube is slightly swollen, dark red in color, and offers unusual resistance to pressure. Hemorrhages may be seen in the mucosa and in the lumen. Necrosis of the tube may result from interference with the blood supply. Martin describes a case of necrosis of the tubes as a result of mitral insufficiency. When the ends of the tubes are closed and blood is extravasated into the lumen in sufficient quantity the tube will be distended into what is known as a hematosalpinx. For further description of hemato- salpinx see page 458. 446 FALLOPIAX TUBES AXD OVARIES The microscope shows the vessels to be deeply engorged with blood extravasated into the tube wall and lumen. Clinical Diagnosis. — A large proportion of cases may not be recog- nized, partly because of the frequency with which the lesion exists in the absence of all clinical manifestations and partly because of asso- ciated lesions. The menstrual periods may be painful, and the functions of the bowel and bladder are performed with more or less discomfort. Tenderness on pressure over the affected tube is the one constant sign. The diagnosis cannot be made with certainty without an exploratory incision. The existence of a possible cause, together wdth the finding of a tube that is somewhat tender to pressure and slightly enlarged, will lead to a probable diagnosis. It is impossible to differen- tiate clinically a congested tube from a catarrhal salpingitis; the former is the forerunner and accompaniment of the latter. Diagnosis. — The diagnosis of hematosalpinx will be referred to on page 450. Treatment. — See page 467. INFLAMMATIONS AND INFECTIOUS GRANULOMATA OF THE FALLOPIAN TUBES General Considerations. — Of all lesions of the Fallopian tubes the inflammatory are most commonly observed. Of the various exciting causes of salpingitis, Noeggerath and Wertheim place the gonococcus at the head of the list of microorganisms. In 302 cases of inflammatory lesions in the tubes there were S3 in which living microorganisms were found, and of this number 56 were gonococci, 11 streptococci, 6 staphy- lococci, 1 pneumococcus, while 122 were sterile. The fact that such a large percentage were sterile adds to the difficulty in determining the essential microbic cause. Xeisser, in 143 cases, found the gonococcus in 80 after a latent period of from two months to eight years. He emphasizes the necessity of repeated examinations and faultless technic. ]Mixed infections are of common occurrence. The path of invasion is usually by way of the uterus, less frequently by the abdominal route from the ovary, bowel, and peritoneum, and rarely by way of the lymph- and blood-streams. The manipulation of an infected uterus, in the process of an exami- nation or operation, is doubtless often responsible for extension of the infection from the uterus to the tubes. - There are no pathognomonic symptoms of salpingitis and none that is invariably present. Associated inflammatory lesions in the genital tract are nearly always found, and hence it is that the s^Tnptoms of the one are so intimately associated with those of the other; therefore it is difficult to obtain a clinical picture of salpingitis. Again, the innervation of the tubes, ovaries, and uterus is so inti- mately connected as to bring these organs into close sympathy one with the other. PLATE XXIII Bulb of the Ovary and its Venous Communications. (Savage. O, ovary; T, Fallopian tube; U , uterus; 1, uterine vein an / ^ -^^'~^ -^^^y .'/ ,... ^^/ " ^ /^V vj' -/'^A'y^ The uterus is amputated at the cervix and is bisected from below upward. The remaining steps of the operation are as in Figs. 333, 334, 335, 336. TREATMENT OF INFLAMMATORY DISEASES OF TUBES 475 The belief that all inflamed tubes call for operative interference is, happily, no longer entertained by gynecologists. They have learned that some of these tubes undergo spontaneoiis healing, and that not a small proportion cease to give serious trouble when managed conservatively. These observations have led the profession to interfere surgically in salpingitis only after conservative measures have been given a fair trial and without avail. Catarrhal Salpingitis. — In the acute stage of catarrhal salpingitis only conservative measures should be practised. The patient should be confined to bed, the diet restricted, ice applied to the abdomen, the bowels regulated, and local depletive measures employed. Long hot vaginal douches, given at intervals of four to eight hours, will do much to allay the inflammatory reaction. When not too painful, glycerin and ichthyol vaginal tampons may be effectively applied. These should be applied daily for six to eight hours. Ordinarily the acute stage will pass in three to five days, and the tubes either return to normal or become chronically inflamed. No surgical intervention should be instituted in the acute stage of catarrhal salpingitis for the reason that a cure by the exercise of conservative measures is always possible, and because of the dangers involved in an abdominal operation upon tubes containing virulent microorganisms. It is further advised to avoid so far as possible all pelvic manipulations in such cases, for fear of exciting the infection to extend from the tubes to the peritoneum. All digital and instrumental manipulations should be restricted to the minimum, and all intra-uterine manipulations should be proscribed unless for the removal of placental tissues and infected tumors. Chronic Catarrhal Salpingitis. — Conservative measures should be instituted in the treatment of chronic catarrhal salpingitis. Hot vaginal douches, glycerin and ichthyol tampons, pelvic massage, and other means may be employed, with benefit; but when given a fair trial, and without affording relief, it is then permissible to resort to surgical measures. The surgery of chronic catarrhal salpingitis holds out the opportunity for the exercise of conservatism. It is not impera- tive in all cases that all of one or both tubes should be removed. It may be that the separation of the matted fimbriae and the expressing of contained secretions is all that is required. Again, a portion of the tube may be resected, leaving a healthy portion to provide for the possibility of childbirth. When both tubes are affected, conservatism should be practised. The removal of one or both tubes is imperative when the uterine end of the tube is so disorganized as to no longer functionate, and when the ovaries have been removed or are incapable of carrying on their function. There is not the need of exercising conservatism in the surgery of the tubes when it is apparent that sterility is inevitable. When it is believed that pathogenic microorganisms exist in the tube, it is not safe to leave a portion. For the technic of the operation see the following pages. 476 FALLOPIAN TUBES AND OVARIES Hydrosalpinx. — A hydrosalpinx may exist without local or general disturbances, and in such cases it cannot be said that surgery should be invoked. There are reasons, however, for intervening surgically which are worthy of consideration. We have learned that hydrosalpinx is sometimes, if not frequently, the result of a congenital closure of the fimbriated end of the tube with subsequent accumulation of the tubal secretions. When bilateral, sterility is the result and relief may be possible by resecting the distended portion. This is only possible when the distention involves the distal portion of the tube and cannot be considered in the presence of other and irreparable causes of sterility. The operative treatment for hydrosalpinx consists in the removal of part or all of the distended tube. When it is possible to leave a portion of healthy tube this should be done, provided other conditions are favorable to childbearing. When the tube is more or less distended, and particularly Avhen there are inflammatory changes in and about the tube, the complete removal of the tube should be made. For the technic of salpingectomy see page 478. Hematosalpinx. — As a general proposition a hematosalpinx should be removed. There is, however, abundant opportunity for exercising conservatism in the saving of healthy portions of the tube. This should not be attempted in the presence of infection within the tube and of irreparable lesions of the ovaries and uterus. Chronic Purulent Salpingitis. — No attempt should be made to eradicate the tube during the acute suppurative stage, and operative intervention in the chronic stages should be deferred until conservative measures have been well tried. Rest, hot vaginal douches, poultices, glycerin and ichthyol tampons may do much to give relief, and may produce a functional cure, and should be given an extended trial before resorting to surgery. If no improvement follows these treatments, operation is indicated. Salpingitis is rarely fatal, hence the opportunity is at hand to give conservative, tentative treatment a fair trial. Efforts to empty the pus through the uterus by curettage and massage are to be condemned as futile and dangerous. Removal of the entire tube is the only alternative when tentative measures have been tried and have failed. Vaginal Drainage for Pyosalpinx. — The following are safe and reliable guides in the management of pyosalpinx: 1. In all recent accumulations of pus within the tubes which call for surgical interference, only vaginal drainage should be considered. 2. In all old accumulations of pus within the tubes which are favorably located for drainage through the vagina, the safest rule to follow is to establish such drainage and await the clearing up of the abscess cavity before proceeding with the removal of the tubes through an abdominal incision. Vaginal drainage of pus located in the tubes is not a simple procedure T RE ATM EXT OF INFLAMMATORY DISEASES OF TUBES 4/7 from a technical point of view, nor is it a safe one in the hands of the inexperienced. Attempts to estabHsh drainage have repeatedly con- veyed the infection to the free peritoneal cavity, and with fatal results. The author views the operation most gravely, and particularly so in cases of acute infection. It has happened in the experience of the operator that vaginal drainage of pus tubes has brought about a complete and lasting func- tional cure when, had the abdominal route been chosen, the tubes and possibly the uterus and ovaries woidd have been sacrificed. Vaginal drainage is feasible when the patient is too depressed to withstand the shock of an abdominal operation. Because of the much lower mortality and the opportunity afforded for the preser\"ation of tissues, vaginal drainage is greatly to be preferred to the more radical abdominal operation in all cases in which the pus can be readily reached per vaginam. Technic of Operation. — The foUowing is the usual method employed by the author: After thorough sterilization of the field of operation the vagina is exposed by a weighted vaginal speculum; the posterior lip of the cervix is grasped by tenaculum forceps and gentle traction is made upward and outward by an assistant. The operator grasps the vaginal wall close to its reflection upon the posterior wall of the cervix with long rat-tooth tissue forceps. A transverse incision is made with long sharp-pointed scissors through the vaginal wall and close to the cervix. This incision is about one inch in length. The finger is inserted through the incision, and by a gentle stripping and boring process the finger finds its way in the direction of the abscess. "When pus is reached, the two index fingers are inserted and the wound stretched to admit of free drainage. When the pus ceases to flow, a careful exploration of the peh'ic ca^'ity should be made to detect and evacuate other accumulations of pus within the pelvic cavity. ^Mien all pus cavities have been evacuated and a free avenue for subsequent drainage provided, the cavity is then loosely packed with washed iodoform gauze. This pack is removed at the end of forty- eight hours and thereafter the cavity is irrigated with sterile >alt solution. It frequently happens that drainage is not always free; in .-uch event the incision should be spread either with forceps or finger. The following precautions should be noted: 1. Before attempting to drain, a bimanual examination should be made to determine the exact size and location of the abscess. 2. The incision should be made close to the cervix, and in burrowing to the abscess the finger should be kept in close proximity to the uterus for fear of injuring the rectum. 3. The greatest caution must be exercised in all manipulations for fear of liberating pus into the free abdominal cavity. 4. In exploring the pelvis with the finger there is danger of perfor- ating a loop of bowel anrl thereby creating a distressing fecal fi-tula. 478 FALLOPIAN TUBES AND OVARIES 5. The cavity should not be swabbed with gauze. No irrigation should be employed for fear of washing infected material into the abdominal cavity. 6. Rubber drainage tubes and tightly packed gauze are dangerous in view of possible pressure necrosis of the bowel wall. 7. When the abscess lies too high to be reached by the finger, an experienced operator may pass closed dressing forceps in advance of the finger. The forceps are passed into the abscess and opened to spread the perforation in the abscess wall. In the hands of the inex- perienced operator this is a dangerous procedure. 8. If the infection is tuberculous, nothing short of a radical abdominal operation will eft'ect a cure, and this should be done after the pus has well drained. Tuberculous Salpingitis. — The author believes that the only safe rule to follow in tuberculous salpingitis is to remove the affected tubes. (For further discussion see page 542.) In the presence of a general peritoneal involvement the effort should be made to remove the primary focus, which in a large percentage of cases is found in the tubes. If a tuberculous lesion of the lungs is found not to be so far advanced as in itself to make recovery impossible, this complication should not deter the surgeon from eradicating the pelvic infection. Having removed the pelvic infection the patient should be placed under favorable hygienic conditions, such as are prescribed for tuberculosis in general. It is well to emphasize the importance of prophylaxis in genital tuberculosis. It is known that the infection can be conveyed by instruments and examining fingers and by the tuberculous husband; the precautionary measures to be observed are self-evident. Technic of Operations on the Tubes. ^ — ^Alien adhesions close the abdominal opening or bind the tube to surrounding structures, and in the absence of structural changes in the tube wall, these adhesions may be carefully severed, leaving the tube intact and in the normal position. Salpingostomy or Amputation of the Tube at the Isthmus or Ampullary Portion. — Two points should be emphasized in this operation: (1) The artificial opening in the tube must closely approximate the ovary, and (2) an ectropion of the tubal mucosa must be produced by stitching the mucosa to the peritoneal covering of the tube. This is done by plain sterile catgut No. 1. This procedure is not without some danger. Cases have been reported in which postoperative hemorrhage has occurred, and infection from the tube has followed, and the newly formed osteum has again closed by adhesions. Salpingectomy or Removal of the Tube. — ^The tube may be removed either by the abdominal or vaginal route. By the Ahdominal Route. — The usual suprapubic, mesial incision is made. Adhesions binding the tube may be broken by the fingers or severed by scissors under the guidance of the eye. With long forceps TREATMENT OF INFLAMMATORY DISEASES OF TUBES 479 the infundibulopelvic ligament may then be grasped and the tube deHvered into the abdominal incision. If firm adhesions bind the tube to the bowel it may be necessary to strip off the peritoneal covering of the tube, together with the bowel, to prevent injury to the bowel wall. A No. 2 plain catgut ligature is made to transfix the infundibulo- pelvic ligament, taking care not to embrace the ovarian vessels if the ovary is to be left intact. Holding the tube with fingers or forceps, the attachments of the tube are severed with scissors from within the ligature placed about the infundibulopelvic ligament, and passing along the attachment of the tube to the broad ligament to the uterine cornua. The tube is then dissected from the horn of the uterus with a knife. All bleeding points are to be secured by forceps. In purulent salpingitis it is best to amputate the tube from the uterus by the actual cautery. The severed broad ligament and open cornua of the uterus are then sutured with catgut. With a running suture of No. 1 plain catgut all bleeding-points are secured and raw surfaces are covered. When the tube is adhered to the floor of the pelvis it is best to proceed with the excision at the horn of the uterus. If the tube is greatly distended with pus and adherent, so that there is great liability of rupturing the tube, it is best to aspirate the contents before attempting to remove it. After completing the operation the abdomen is closed without drainage, unless. pus has been set free in the operation and much raw surface has been created by the severing of adhesions. When found necessary to drain, the proper procedure is to open through the cul- de-sac into the vagina, pass a strip of sterile or antiseptic gauze through this opening into the vagina, and pack the remaining portion of the gauze loosely in the pelvis, then to close the abdominal incision. At the end of forty-eight hours the gauze is removed through the vagina. ' When the drainage is done for a safeguard against infection the patient should be placed for several days in the Fowler position. When, by the removal of the tube, the uterus has lost part of its support the round ligament should be brought over the horn of the uterus and stitched to the posterior surface. This procedure serves the double purpose of maintaining the uterus in its proper position and of covering the raw surface at the cornua. When the ovary is diseased it is to be removed in part or in toto, according to the rules laid down in the following chapter. By the Vaginal Route. — In the past too great enthusiasm has appar- ently been displayed in operating through the vagina upon the uterine appendages. In some cases this may be done satisfactorily, but when extensive adhesions exist the procedure is at best hazardous. The danger of injuring the bowel, of creating uncontrollable hemorrhage, and of leaving a diseased vermiform appendix are sufficient to condemn the operation in such cases. An imperfect recovery is sometimes obtained, due to the extensive raw surfaces left, which lead to the 480 FALLOPIAN TUBES AND OVARIES formation of adhesions. In addition to these arguments in favor of the abdominal route is the greater degree of safety in abdominal opera- tions which are performed under the guidance of the eye. Hysterectomy in connection with the removal of badly infected appendages is much in vogue, and is discussed on page 471. CIRCULATORY DISTURBANCES IN THE OVARY Etiology. — There is a physiological hyperemia of the ovary during menstruation, coition, and pregnancy. The ovaries share in a general pelvic congestion, hence all embarrassments to the general circulation from diseases of the heart, lungs, kidney, and liver, from abdominal tumors, collections of fluid in the abdomen, and constipation will cause passive congestion of the ovaries. In certain hemorrhagic diseases, such as scorbutus and purpura, there are^ hemorrhages into the substance of the ovaries. Hyperemia of the ovary is an accompaniment of all the inflammatory lesions in the pelvis. The more acute the lesion the greater the hyperemia. As remarked in the section on Descensus Ovarii, the ovary is congested. Anatomical Diagnosis. — In hyperemia of the ovary there is a slight increase in size in all diameters and a more livid color. Following long-standing hyperemia there is an increase of the connective tissue. The tunica albuginea is thickened and the follicles, failing to rupture through the thick and resisting tissue, lead to follicular degeneration of the ovary. Fig. 338 Hematoma of the ovary. (Hertzler.) Hematoma of the Ovary. — Hematoma of the ovary is often of obscure origin. It is possible for hemorrhages to occur in the ovary as the result of any of the above-named causes for hyperemia. As an under- CIRCULATORY DISTURBANCES IN THE OVARY 481 lying factor there may be degenerative changes in the bloodvessels of the ovary. Such collections of blood are usually found in the follicles; hemorrhages into the interstitial spaces are less common. Virchow and Olshausen each report a case complicating scorbutus. Torsion of the tube and ovarian ligament may cause hemorrhages into the stroma and follicles of the ovary. Martin reported 109 cases in which blood collections in the ovaries varied in size from that of a bean to a man's fist. Of this number 25 were between the ages of eighteen and fifty-two; 22 were not married; the right ovary was affected 47 times, the left 55 times, and both ovaries 32 times. In all but 8 cases there was more or less peritonitis, and 4 of the 8 had uterine fibroids, 1 chlorosis, 2 endometritis and metritis, and 1 practised masturbation. In 26 of the 109 cases a trau- matic cause could be traced in the history, such as the passing of the uterine sound, the wearing of pessaries, and the replacing of the uterus. Hematoma is an unusual finding in an otherwise perfectly normal ovary. Any of the new formations and inflammatory lesions may accompany hematoma. Fig. 339 Hematoma of the corpus luteum. The ovary is greatly hypertrophied, and at the distal end is a single protruding blood cyst the size of an English walnut, formed from a corpus luteum. Hemorrhages into the substance of the ovary are found in one or more of three places: in the follicles, corpus lufeum, or connective-tissue spaces. 1. Hemorrhages into the follicles may distend them to the size of a man's fist. More than a single follicle may be involved. The stretched walls of the follicles, with their contained blood, have a bluish tint. The contained blood may or may not be coagulated, and is dark red or grayish brown. The inner surface of the follicles is smooth, though occasionally made uneven by coagulated blood adhering to the wall. Fatty degeneration of the epithelium lends a yellowish tint to the 31 482 FALLOPIAX TUBES AXD OVARIES inner surface. The contained blood may be wholly absorbed or con- verted into fibrin, which, by contracting, may obliterate the follicles. Occasionally the follicle bursts, and the blood escapes into the peritoneal cavity. ' The escaped blood has been known to set up a peritonitis, and cases are recorded in which the hemorrhage was fatal. Infection of the blood may give rise to abscess formation in the ovary. 2. Hemorrhages into the corpus lideum are identified by the corru- gated lining membrane of lutein cells or by their granular appearance. Such bodies are single, and are located in the periphery of the ovary. Hematoma of the corpus luteum has been known to attain the size of a child's head. In the hematoma of the corpus luteum the wall is more congested and thicker than in the preceding variety. On the inner surface of the cyst there is a deposit of fibrin, in the meshes of which are disintegrated blood and small round cells. Beneath this are the lutein cells, varying in number, size, and form according to the age and size of the hematoma. External to the lutein cells is the tunica externa, composed of fibrous tissue. 3. Hemorrhage into the connective-tissue spaces is less comrnon. Such hemorrhages are often midtiple, and are seldom of large size. Multiple punctate hemorrhages may be distributed through the stroma and add materially to the size of the ovary. The blood is found in various stages of preservation. In follicular hematoma the epithelium lining the blood cyst may be well preserved, assuming a variety of shapes from cylindrical to flattened. Several layers may be found. In the larger hematomata there may be but a single layer of flat epithelium, and even this may partially or wholly disappear through pressure atrophy. Blood extravasations and con- gested bloodvessels may be seen in the tunica propria. Clinical Diagnosis. — There may be no clinical manifestations. The ovary is usually tender to pressure. Pain in the ovary may radiate to the back and thighs. The pain is at its height during the period of premenstrual congestion, and abates when a free flow is established. It has been said that when pelvic congestion is present and a throbbing pain develops in the ovary, with no elevation of temperature, it is to be inferred that a hematoma has developed in the ovary. A diagnosis can only be made on exploration of the ovary. In a bimanual examination the ovary is invariably found enlarged, though it is seldom larger than a walnut. The consistency is tense and elastic. Although sharply circumscribed the ovary is usually irregular in outline. It is found on a lower level than normal, often lying low beside or behind the uterus. It is difficult and often impossible to difterentiate hyperemia, hema- toma, and inflammation of the ovary. The pain and tenderness may be equally intense, and there may be no distinction in the physical findings. In inflammation the symptoms are usually of longer standing and more pronounced. The history of the onset should be considered. Treatment. — (See Treatment of Ovarian Tumors.) INFLAMMATION OF THE OVARY 483 INFLAMMATION OF THE OVARY (OOPHORITIS, OVARITIS). For practical, clinical purposes inflammations of the ovary will be classified as acute and chronic. Acute Ovaritis. — x\cute inflammation of the ovary is due to direct invasion of the ovary by bacteria or to the influence of their toxic products. Certain inorganic poisons (phosphorus, arsenic) act in a similar manner. All the infectious diseases may be complicated by o^•aritis, including the exanthemata, typhoid fever, cholera, pneumonia, influenza, dysen- tevy, wound infections, gonorrhea, and tuberculosis. The microorganisms found in the ovary under such conditions are staphylococci, streptococci, pneumococci, gonococci, typhoid bacilli, and actinom\'ces. In all the above-named causes of ovaritis the same general anatomical changes follow, there being no essential difference in the anatomy of the various etiological forms. Pfannenstiel considers acute ovaritis under the heads of septic and gonorrheal. Acute Septic Ovaritis. — Acute septic ovaritis is a complication of puerperal sepsis, but a similar lesion may arise from the non- puerperal septic agencies above named. The ovar}' is uniformly enlarged and reddened, and the stroma becomes infiltrated with a serous exudate and small round cells. The follicular epithelium degenerates, the ovum dies and is absorbed, and the liquor folliculi becomes turbid, h'uppuration may follow, leading to the formation of abscesses in the corpus luteum, follicles, and interstitial spaces. Resolution is the rule, and this is possible either by complete absorption of the exudate, leaving the ovary in a normal condition, or by atrophy of the connective tissue, with its subsequent contraction. Acute Gonorrheal Ovaritis. — Acute gonorrheal ovaritis is rarely primary, and is almost invariably secondary to salpingitis. In excep- tional cases the infection is conveyed from the cervix through the lymphatics of the broad ligaments to the hilum of the ovary. Wertheim has succeeded in demonstrating the gonococcus in the ovary. Chronic Ovaritis. — Chronic ovaritis is a clinical term designating a long-standing lesion of the ovary, characterized by hyperplasia of the stroma and secondary atrophy of the parenchyma. Chronic ovaritis may be the terminal stage of an acute infection of the ovary. Any condition causing prolonged congestion of the ovary will result in chronic ovaritis, such, for example, as sexual excesses, menstrual congestion, subinvolution, malpositions of the uterus, habitual constipation, incompetency of the cardiovascular system, pelvic and abdominal tumors, and disorders of the organs of digestion. 484 FALLOPIAN TUBES AND OVARIES Cystic Degeneration of the Ovaries. — It may now be fairly stated that the profession in general has come to regard cystic degeneration of the ovaries in a less serious light than was first presented, but yet accords the lesion its rightful place among the morbid conditions of the ovarv. Fig. 340 -~^x^ ^V/^ — .^ %J Jp' of all the cases of peritonitis which have come to autopsy in the Johns Hopkins Hospital has clearly demon- strated the greater liability to the invasion of bacteria on the part of persons subject to chronic diseases of one or several of the important viscera." The leaving of foreign bodies in the abdominal cavity, such as sponges and instruments, is sometimes responsible for the development of septic peritonitis. Other foreign bodies may produce a generalized or local- ized septic peritonitis, i. e., wandering fibroids, the escaped fetus in a ruptured ectopic pregnancy, the escaped fluid from a ruptured cyst or Fallopian tube, and the accumulation of blood following a pelvic or abdominal operation. Essential Causes. — Referring to the essential causes of septic peri- tonitis, we have to consider the source of the invading microorganisms, their number, and above all their virulence. We have frequently observed pus escape into the free abdominal cavity without producing peritonitis; such pus is sterile, or at most the contained microorganisms are of low virulence. Furthermore, there is wide variation in the absorbing ppwer of the various parts of the peritoneum; the pelvic peritoneum has a relatively low power of absorption, and hence is less susceptible to infection and to the spread of the infection to the upper regions of the abdomen. Of the ordinary bacteria causing peritonitis, by far the most virulent GENERAL PERITONITIS 495 and destructive is the streptococcus pyogenes; the resulting inflam- matory involvement is rarely circumscribed, but spreads rapidly to adjacent and remote parts of the peritoneum. The staphylococcus aureus usually has a lower degree of virulence, and the resulting inflammatory reaction is commonly localized; and when involving all or the greater part of the peritoneum, the prognosis is not so grave as in a streptococcic infection. Other microorganisms which invade the peritoneum and cause a general inflammatory reaction are the gonococcus, colon bacillus, tubercle bacillus, bacillus proteus, bacillus pyocyaneous, bacillus typhosus, and micrococcus lanceolatus. Anatomy. — The inflammatory reaction in the peritoneum is not always proportionate to the degree of general intoxication. Indeed, the most virulent infections may result fatally before there is time for an inflammatory reaction to develop in the peritoneum, beyond that of a moderate congestion and a limited amount of serofibrinous exudate. The greater the virulence, the less the exudate. In such cases a microscopic examination of the peritoneum will generally reveal innumerable streptococci. The pathological findings in acute peritonitis depend upon the nature and intensity of the infection. There may be no more than a loss of luster and a slight deposit of fibrin upon the peritoneum when the infecting microorganisms are of low virulence. In the development of an acute inflammation of the peritoneum there is first a reddening of the bowel, followed by a loss of luster and agglutination of the coils of bowel by a deposit of yellowish-white fibrin flakes. Peritoneal fluid usually accumulates early in the process. This fluid is turbid^ and contains soft pultaceous masses and flakes. Soon the fluid becomes purulent. Later in the process this exudate becomes encapsu- lated between coils of bowel, and is thick and creamy. The fibrinous exudate becomes firmly organized into adhesions. The chronic stage may develop insidiously or may be the terminal stage of an acute inflammation. Chronic peritonitis may be divided into (1) chronic exudative peritonitis, in which there is a serous, sero- fibrinous, or fibrinopurulent exudate, with more or less of a plastic exudate; (2) chronic exudative and adhesive peritonitis, in which there is a preponderance of plastic exudate leading to the formation of adhesions; (3) chronic hyperplastic peritonitis, with the formation of plaques or sheets of hyaline material of a whitish, cartilaginous char- acter, together with a fibrinous exudate. Clinical Manifestations. — It is not easy to recognize a general peri- tonitis in its early stage, at a time when there is the greatest prospect of cure. hi 'postoyerathe seytic peritcmitis the facial expression of the patient is suggestive. She appears anxious and careworn, and as the end approaches, cyanosis develops and the extremities become cold and clammy. Little dependence can be placed upon the temperature. There is usually some elevation of temperature in the beginning, but 496 PERITONITIS later it may be normal or subnormal. The pulse is a reliable guide and a good indication of the progress of the disease. It is increasingly rapid, becoming weaker and more rapid as the disease advances. The patient lies with both legs flexed. Vomiting and hiccough become more and more persistent. The vomitus is not great, and is usually black from the presence of digested blood. Abdominal pain is at first intense, but as the end approaches and the patient becomes profoundly toxic, the pain recedes and the patient may express herself as being quite com- fortable; this is an unfavorable sign. All the secretions are scanty. The skin is dry until near the end, when it is covered with cold sweat, and the tongue is dry and coated. The abdominal distention and muscular rigidity increase, and, as a rule, the bowels fail to move, though diarrhea is an occasional accompaniment. Prognosis. — The outlook is always grave in septic peritonitis, but modern methods of treatment have done much to reduce the mortality. The pulse is a better guide to the prognosis than the temperature. The number of leucocytes in the blood is likewise of prognostic value when correctly interpreted; an increasing leucocytosis in the course of a septic peritonitis indicates increasing tissue resistance on the part of the patient, and hence the value of making repeated blood- counts during the course of the disease. When terminating fatally the course will usually be run in from three to five days, but death may ensue within twenty-four hours, or as late as the fourteenth day. Treatment of General Septic Peritonitis. — In the early years of modern surgery the choice was always in favor of extraperitoneal operations as opposed to intraperitoneal procedures in view of the great liability of infection of the peritoneum; but of late years surgical technic has become so perfected that the paramount question is, How can the best results be obtained irrespective of the chances of infection ? Prophylaxis.— The utmost confidence is imposed in our methods of safeguarding the peritoneum from invasion by septic germs. One of the most important considerations in the prevention of general septic peritonitis is involved in the management of cases of acute pelvic infection. The abdomen should never he opened in the presence of a circumscribed, acute pelvic inflammation, and all recent accumulations of pus in the pelvis should be drained through the vagina. The question as to how soon after an acute attack of pelvic infection it is safe to enter the abdominal cavity for the removal of offending organs is difficult to answer. The acute pain and tenderness, the temperature and rise of pulse-rate, and the leucocytosis must not only have passed away, but some time should intervene in order that the microorganisms may lose their virulence for want of an environment favorable ,to their growth and activity. It is the author's practice to postpone all surgical interference by way of the abdomen for a period of not less than three months, and in the meantime to endeavor to allay the inflammatory reaction by rest, hot vaginal douches, and glycerin and ichthyol tampons. (See Chapters X and XL) GENERAL PERITONITIS 497 If the operator should be misled into the abdominal cavity by the lack of local evidence of an acute pelvic inflammation, and the want of a reliable history, and upon inspection of the pelvic contents through the abdominal incision he is confronted with the presence of an acute inflammatory reaction in the tissues lying outside the uterus, it would be a commendable procedure for him to close the abdominal incision without further interference. This should be done not only to protect the peritoneal cavity from possible contamination, but also to con- serve tissues which might be saved by tentative measures. Not infre- quently the surgeon will find that there will be no occasion for opening the abdomen at a later date because of the relief from all disturbing symptoms and the apparent restoration of the tissues to the normal by the employment of conservative measures. If in an abdominal operation the gloves of the operator or assistants become soiled by infected material or are torn, they should be imme- diately changed, and all soiled sponges, pads, and towels should also be discarded. Careful hemostasis and the covering of all raw surfaces with perito- neum are important factors in the prevention of abdominal infections. Rough handling and unnecessary prolonged exposure of the perito- neum predispose to peritonitis by lowering the resistance of the tissues and by affording greater opportunity for the invasion of microorganisms. No peritoneal surface should be left exposed in an operation for a longer time than is absolutely required for the carrying out of the operation; gauze pads should be used liberally in the covering of all intra-abdominal organs which are not under immediate inspection. Much can be done in the way of preventing the upward spread of a pelvic inflammation by placing the patient in the Fowler position. This should be done during the course of an acute pelvic inflammatory attack both before and after operation, and in all cases of acute or chronic pelvic inflammation operated through the vagina or abdomen. Active Treatment. — Knott^ reported 19 cases of general septic peri- tonitis with 17 recoveries; 4 of this number were gynecological cases. Knott makes a liberal incision in the median line. A long drainage- tube is inserted through the lower end of the abdominal incision and is carried to the floor of the pelvis. Vaginal counter-drainage is made through the cul-de-sac, using a rubber tube. The whole abdominal cavity is washed out with gallons of sterile normal salt solution. The abdominal incision is closed with stitches close to the drainage-tube and quantities of sterile dressings are applied. The patient is then elevated to a sitting posture, being supported from behind by pillows. The head of the bed is elevated twenty-four to thirty inches from the floor. The dressings should be changed frequently. The question of confining the bowels with opiates as opposed to free catharsis is still somewhat under discussion. The author is in accord with the general practice of opening the bowels at the earliest possible 1 Annals of Surgery, July, 1905. 32 498 PERITONITIS moment, and of keeping them open, if possible, thronghout the entire course of the infection. To accompHsh this, I grain of calomel may be given every hour, together with a dram of Epsom salts, followed by enemata consisting of Epsom salts, 2 ounces; glycerin, 2 ounces; sweet oil, 4 ounces. When there is much gas a few drops of turpentine may be added. An effective enema is a pint each of warm molasses and milk; it has a soothing effect, and often accomplishes the expulsion of gas and the unloading of the bowel of fecal matter when other means fail. The author has also found satisfaction in the injection into the bowel of a pint of normal salt solution with 2 ounces of alum. Persistent vomiting may preclude the administration of cathartics by the mouth, and if so, the only resort is rectal injections, preceded by a hypodermic injection of j g- grain of physostigmin. All efforts to move the bowels may fail, and death ensue within five days of the onset of the peritonitis. When the pain cannot be controlled by the application of heat or cold to the abdomen, hypodermic injections of morphine must be resorted to, but these must be used sparingly. No antipyretics, other than cold sponging, should be used because o'f their depressing effects. The strength of the patient should be maintained by nutrient enemata if the stomach will not retain food. When neither the bow^el nor stomach will retain nourishment, the outlook is exceedingly grave. Nourishment by the mouth is withheld until vomiting has ceased. Stimulation may be resorted to by hypodermoclysis of normal salt solution, also by the hypodermic injection of strychnine, gr. g-^Q- to -gV, every tw^o to six hours, and whisky, in 1 to 4 dram doses, given by mouth, bowel, or hypodermically. Operative Treatment. — There is no more difficult problem to solve than the question of when to interfere surgically in the course of septic peritonitis. The most favorable time for surgical intervention is at the very onset of the peritonitis, but the difficulty arises in the making of the diagnosis of peritonitis in its initial stage before it has involved any considerable portion of the peritoneum. So many conditions, such as gas distention, ileus, hemorrhage, and auto-intoxication, having no relation to peritonitis, may closely simulate peritonitis in its early stages, and hence one naturally hesitates to interfere surgically until the clinical evidences are well-marked. Furthermore, the case may be seen at a time when it is believed that any operative procedure will hasten the fatal issue, yet such cases are occasionally saved by free drainage; hence, the surgeon can never be assured as to the proper procedure. The result is that he is impelled to take the chance of operating, though the chance may be ever so small. General septic peritonitis has at times been known to recover without surgical intervention, but the event should never be anticipated. x\ll this confirms the statement that there is no more difficult problem in surgery than that involved in the surgical treatment of septic peri- GENERAL PERITONITIS 499- tonitis, both in its early and late stages. The late achievements in the treatment of septic peritonitis have brought us to the conclusion that in all cases, save those that are in a moribund state, the abdomen should be opened and freely drained; and in all cases when there is good reason to believe that peritonitis is beginning and is advancing, and in which conservative measures have been tried without avail, an exploratory incision should be made. The fact that many of the condi- tions which are confused with peritonitis justify an exploratory incision into the abdomen, gives added justification to surgical intervention in suspected cases. After it has been determined to establish drainage the question arises. Shall the drainage be vaginal or abdominal? It may be said that vaginal drainage offers the least risk, but it is an uncertain procedure because one can never be certain of thorough drainage. Whenever localized accumulations of pus are found in the pelvis they should be drained through the vagina. Having succeeded in establishing free drainage through the vagina, if improvement does not ensue, but, on the contrary, the evidences of general peritonitis progress, the abdomen must be opened for counter-drainage. When no accumulation of pus is found in the pelvis, vaginal drainage alone is not indicated, and can only be considered as a secondary pro- cedure to abdominal drainage. When draining for postoperative peritonitis, the stitches in the lower portion of the wound should be removed and the gloved finger carefully inserted in the direction of the uterus and broad ligaments, in search of pockets of pus. The search is continued to the extent of satisfying one's self that all pockets of pus have been opened and free drainage established through the opening in the abdominal wall. In the search for the accumulated pus it may be necessary to explore the greater part of the abdominal cavity. Caution must be exercised in so doing for fear of contaminating portions of the peritoneum not involved in the infection; hence, the search should only extend to those portions of the peritoneum that are visibly involved. The drainage should be free and lead to the most dependent portions of the infected zone. For this purpose the author uses one or more fenestrated rubber tubes, one-half inch in diameter. Two, three, or possibly four such tubes should be placed, one for each of the pus cavities found, and all are brought through the abdominal incision. If thought advisable, a second and even a third incision may be made through the abdominal wall in order to establish more efficient drainage. When possible, drainage should be established through the vagina by making a transverse incision an inch in length through the posterior fornix. A gauze pack or rubber tube is passed from above through the incision into the vagina. The greatest caution should be exercised in the application of sponges and swabs for fear of removing the protecting lymph and endothelium from the peritoneal surfaces. The same objection is open to irrigation of the abdominal cavity, which presents the additional danger of 500 PERITONITIS spreading the infection throughout the peritoneal surface not as yet involved. For the above reason the author dispenses with both swabs and irrigation, and establishes free drainage only. After the drainage-tubes are in place the wound is dressed with an abundance of sterile gauze and the patient placed in bed in the Fowler position. A rectal tube is inserted high in the bowel, and through this normal salt solution is slowly injected at the rate of 15 drops per njinute, and continued for twenty-four or more hours. Puerperal Peritonitis. — Acute diffuse puerperal peritonitis is generally regarded as fatal unless operated. When the infection has invaded the blood-stream, drainage of the abdomen will be of no avail. If the blood is sterile, no time should be lost in establishing free drainage. Fortunately the blood is late in being invaded in these cases. Treatment. — The treatment of acute diffuse puerperal peritonitis is most discouraging; this is in marked contrast to that of general peri- tonitis following appendicitis. In diffuse puerperal peritonitis there are microorganisms of high virulence and the resistance of the indi- vidual is commonly low"; whereas in peritonitis following appendicitis the micro5rganisms are usually of lower virulence, and the resistance of the individual is usually high. Then, too, there is better oppor- tunity to establish direct drainage of the primary focus of infection in appendicitis. All will agree that early and free drainage of the peritoneal cavity is imperative. Of this there is no question, but the difficulty lies in the making of a diagnosis early enough to insure good results. When the infection has spread directly through the uterine wall to the peri- toneum we encounter germs of high virulence, and drainage of the abdomen will rarely be successful. If, on the other hand, the infection invades the peritoneum by way of the tubes we meet germs (strepto- cocci, staphylococci, gonococci) of lower virulence; hence, the results from drainage are better. In general, the technic of abdominal drainage, of the continuous administration of salt solution by the bowel, and of the enforcement of Fowler's position does not differ from that practised in the manage- ment of peritonitis following appendicitis, and will not be discussed here in detail. It is, however, of great importance to consider the question of removing the primary focus of infection. If an infected uterus has been perforated or lacerated it should be removed, provided the condition of the patient will permit. If it is evident that the patient cannot withstand so formidable an operation, a dam of gauze should be placed about the uterus to protect the general peritoneal cavity. When the infection has spread to the tubes their removal is advised if the condition of the patient will warrant. A ruptured pus-tube should be removed. There is some difference of opinion as to the advisability of flushing the abdominal cavity with salt solution, but the consensus of opinion is strongly opposed to the practice. When there is great distention of the bowel that cannot be GENERAL PERITONITIS 501 relieved by drainage of the peritoneal cavity, and by the usual means employed for the expulsion of gas, multiple punctures of the bowel may be made. Fromme reported 12 cases operated on for acute diffuse puerperal peritonitis; 6 of this number were lymphatic invasions; all died. Only 2 of the 12 cases recovered. These experiences do not condemn the practice of draining the abdominal cavity, but serve to emphasize the necessity of an early diagnosis. We have a suggestion in the practice of Latzki, who makes an explor- atory abdominal incision early in suspected cases of peritonitis. Henkel advises an early exploration through the cul-de-sac and the taking of cultures from the peritoneum. The prognosis depends much upon the nature of the infecting organism. If there is a gonococcus or a mixed colon infection the prognosis is relatively good; if there is a streptococcic infection the prognosis is bad. Bumm drained 45 cases, with recovery in 48 per cent.; Wormser, 177 cases, with recovery in 37 per cent. Latzki operated 47 cases of puerperal peritonitis out of a total of 12-5. Of the 51 cases not subjected to operation only two recovered; of the 47 operated on, 17 (24 per cent.) recovered. He observes that none of the cases with great distention of the bowel recovered. If there is great distention of the bowel, which is not readily controlled by eserine, multiple punctures should be made into the bowel. In the fulminating forms of peritonitis no good can ensue from surgical interference. In the less virulent forms early drainage is imper- ative. This demands an early diagnosis, and suggests the advisability of making exploratory punctures and incisions. Gonorrheal Peritonitis. — Contrary to the views previously entertained, the gonococcus may invade the peritoneum and give rise to an inflam- matory reaction. It is not essential, however, that the gonococcus be resident in the peritoneum, in the presence of an acute or chronic inflammatory lesion of the peritoneum associated with a gonorrheal metritis, salpingitis, and ovaritis. It may be assumed that the peritoneum is involved in the acute stage of a gonorrheal infection when the pelvic pains are sharp and excessive. It is possible that an acute pelvic peritonitis may resolve itself into a normal state, but when the appendages contain pus or when the infection is widespread and persistent, adhesions are almost sure to develop. These adhesions are at first frail, but may develop into strong bands which firmly unite the pelvic viscera to surrounding structures. Accumulations of pus may be found in the meshes of the adhesions, with little danger of contaminating the general peritoneal cavity. Diagnosis. — The severity of the pain and tenderness in the pelvis, the frequent exacerbations, the discomfort occasioned by the movements of the patient, the tendency to bloating at the menstrual periods, are all suggestions of the presence of pelvic peritonitis. 502 PERITOXITIS On bimanual examination the restricted movements of the uterus and its appendages, even to complete fixation, together with the unusual amount of pain occasioned by the manipulations of these organs, are highly suggestive of the presence of adhesions. If with these findings the organs are found displaced, the diagnosis is more nearly confirmed. It may be possible to feel adhesions by a bimanual examination; how- ever, they commonly exist and are not infrequently extensive when it is impossible to feel them, and when the pelvic organs are but little restricted in their movements. It is never possible to diagnosticate the absence of adhesions without inspection or palpation through an incision. General gonorrheal peritonitis is exceptionally rare. Bumm states that he has never seen a case. In his own experience the author has observed only one such case, but in this case his clinical and postmortem diagnosis was not confirmed by a bacteriological examination. Martin, Broese, Veit, Leopold, Penrose, Menge, and Ceppi have all reported cases. The majority of these cases, like that of the author's, were reported from clinical data. Treatment. — The treatment of general gonorrheal peritonitis does not differ from that of other forms of general peritonitis. Tuberculous Peritonitis. — Tuberculous peritonitis is now generally regarded as a surgical disease; this applies particularly to the ascitic variety, and more especially to the cases in which the primary focus can be removed. ^Nluch, however, can be done by medicinal means, and in selected cases only medicinal means need be employed to effect a cure. Cases may be operated, not with the hope of curing the disease, but of removing causes of obstruction to the bowel and of pressure upon nerves and bloodvessels. Tuberculous peritonitis in women is particularly amenable to surgery because of the frequency with which the disease is found to be primary in the Fallopian tubes. According to Osier, 30 to 40 per cent, are primary in the Fallopian tubes. \Yhile it is true that the most favorable cases are those in which the lesion is confined to the peritoneum and the organs resident in the abdomen which are removable, i. e., Fallopian tubes and appendix, it is generally conceded that mild pulmonary and lymphatic tuberculosis do not offer a contra-indication to an abdominal section. Such is the view of Pribram, Yierorett, Schwartz, and Israel. The fibrous and ulcerative forms of peritonitis are not favorable to operation, and when a tuberculous enteritis exists, one should be slow to interfere surgically. Treatment. — Medical. — The medical treatment of tuberculous peri- tonitis is that employed in the management of tuberculosis, of the lungs. Good food and fresh air are absolutely essential. Such' tonics as^cod-liver oil, the hypophosphites, the syrup of the iodide of iron, and arsenic have their place, but do not in the .least supersede fresh air and an abundance of nourishing food. No medicine should be given that will disturb the stomach and interfere with the ingestion of food. PELVIC PERITONITIS 503 . Tuberculin has been extolled, but it is not clear that its value is great as a curative agent. Cures by the administration of tuberculin have been reported by Gray, Rumpf, McCall, Leser, Kummel, and Riegel. von Ruck gives the most encouraging reports, having a record of three cures in four cases. Surgical. — The surgical treatment of tuberculous peritonitis has gen- erally consisted in making a median abdominal incision, in removing all fluid by means of swabs, and irrigating with sterile normal salt solution ; in severing any adhesive bands which may obstruct the bowel, and finally, in removing the primary focus when possible. Unless pus is present drainage is not ordinarily employed. It is seldom that vaginal drainage is established. It is well to remember that too much surgery in these cases is hazard- ous. Abdominal surgery has taught us much about the self-healing of peritoneal tuberculosis. Until these cases were operated the disease was regarded as uniformly fatal. Of late years it has been the expe- rience of surgeons that, in a subsequent abdominal operation, a well- marked case of peritoneal tuberculosis seen in the first section is found partially or completelj^ healed in the second. The profession became overzealous in the surgical treatment of tuberculosis of the peritoneum because of the encouraging reports which came from the many clinics. In later years it was found that many of these cases remained apparently well for one or more years and then developed evidences of recurrence. Because of the great number of such recurrences the tendency of late years is toward conservatism. It is now believed that a cure cannot be pronounced with certainty until the expiration of five years. The combined statistics of 28 foreign and 9 American operators give a total of 1375 cases of peritoneal tuberculosis on which abdominal section was done. Of this number 1011 cures are reported, or a per- centage of 75.5. Inasmuch as no time limit is placed on these cases we are to accept the report as altogether untrustworthy. For further discussion of the subject see page 544. PELVIC PERITONITIS Definition. — Part or all of the pelvic peritoneum is involved in the inflammatory process. We therefore speak of difi^use and localized pelvic peritonitis. When localized various terms are employed to designate the location and extent of the lesion. We speak of peri- metritis when the peritoneal covering of the uterus is affected; of perisalpingitis and peri-ovaritis when the peritoneal coverings of the tube and ovary are involved. Of greater clinical importance is the distinction between general abdominal and pelvic peritonitis and an isolated, well-defined, pelvic peritonitis. A pelvic peritonitis may be primary or secondary- to a general abdominal peritonitis — a fact of considerable importance in its bearing upon the diagnosis and treatment. 504 PERITONITIS The infection is usually conveyed through the uterus and tubes to the peritoneum immediately surrounding these organs. A direct Fig. 345 \ M. Levator ani.' Three divisions of the pelvic cavity, namely, peritoneal, subperitoneal, and subcutaneous. (Fehling.) Fig. 346 Sagittal section of the uterus to show the manner in which the peritoneum is attached. .4, body of the uterus; A', anterior surface; A", posterior surface; B, neck; C, isthmus; 1, cavity of the body; 2, OS internum; 3, os externum; 4, posterior fornix; 5, anterior lip of cervix; 6, anterior vaginal wall, 7, posterior vaginal wall; 8, vesico-uterine septum; 9, wall of the bladder; 10, peritoneum; 11, vesico- uterine pouch; 12, cul-de-sac of Douglas. (Testut.) PELVIC PERITONITIS 505 invasion from the uterus, tubes, rectum, appendix vermiformis, or bladder occurs with less frequency. It is possible for infection to be conveyed along the mucosa of the uterus and tubes to the peritoneum without causing anatomical changes in the uterus and tubes, or such changes may be limited to portions of the mucosa. Likewise, the lymphatic channels may be mere carriers of infection without themselves being involved. We are, therefore, not justified in concluding that infection has not passed by a given route because there are no anatomical evidences of such an event. Etiology. — All that has been said of the etiology of endometritis will apply to pelvic peritonitis, inasmuch as the infection frequently first attacks the endometrium. Pelvic peritonitis has its starting-point less frequently in an infection of the bowel, bladder, vagina, or general peritoneum. Traumatisms of the perineum, cervix, and vagina, incident to parturition and surgical operations, may open the way for infection, which is conveyed by the bloodvessels and lymphatics to the peritoneum. The microorganisms chiefly found in the infected peritoneum are those common to endometritis, salpingitis, and ovaritis — that is, the staphylo- coccus pyogenes albus, aureus, and citreus, streptococcus pyogenes, gonococcus, colon bacillus, tubercle bacillus, Klebs-Loeffler bacillus, pneumococcus, and typhoid bacillus. We w^ill here discuss acute and chronic pelvic peritonitis, peritoneal exudates, and peritoneal adhesions. Acute pelvic peritonitis shows a marked congestion of the bloodvessels or a diffuse blush of the peritoneal surface. Clinically, this stage is recognized by intense pain and tenderness in the pelvis, contraction of the abdominal muscles, tympany, vesical and rectal tenesmus, and painful menstruation. The temperature is elevated, and the pulse is accelerated in proportion to the degree of temperature and general intoxication. Vomiting and hiccoughing are often present in advanced cases, and the patient lies with both legs flexed upon the thighs. All examinations and manipulations should be restricted as far as pos- sible in the acute stage. It must be borne in mind that acute exacerba- tions of chronic peritonitis will give all the clinical evidence of a primary acute attack. Upon opening the abdomen, however, evidences will be found of previous involvement. Bandl says that high fever, great tenderness, and tympany in the pelvic regions are sure signs of pelvic peritonitis. It is only after the acute stage has subsided that a bimanual examination will make sure that the pelvic connective tissue is not diseased and that the peritoneum alone is affected. As a rule, the early symptoms must be relied upon in making the diagnosis, for in the majority of cases no palpable exudations are found. Chronic pelvic peritonitis usually begins as an acute infection, but may be chronic from the beginning. Bandl says: "The lesion can be diagnosticated in girls and sterile women when, during the menstrual period or at any other time, with or without fever, there exist deep- 50G PERITONITIS seated pain in the pelvis and more or less tenderness over the lower portion of the abdomen. If the s^^mptoms are confined to one side, as is usually the case, the process is most probably present in the form of a perisalpingitis and perioophoritis." In the opinion of the author, it is not possible to arrive at any intelligent conclusion from the above data as to the existence of chronic pelvic peritonitis. Too often mistakes are made by rel}'ing on the complaints of nervous and ignorant patients. A physical examination will alone serve to differentiate the many possible causes of such complaints as are found in the inflamma- tory lesions, the displacements, and the new-formations of the uterus and adnexse. The anatomical evidences of chronic pelvic peritonitis are inflammatory exudates and adhesions. Peritoneal exudates follow closely upon the initial acute stage. The exudate is serous, seropurulent, or purulent, and may be found to occupy part or all of the pelvic cavity. The most dependent portion of the peritoneal cavity is the cul-de-sac of Douglas, and into it the peritoneal exudate naturally gravitates. It is possible for such an exudate to cause a bulging of the posterior vaginal fornix, though this is not the rule unless the underlying cellular tissue is involved. In a vaginal examination an exudate in the pouch of Douglas is found to be sharply outlined, rounded below, and flat on the top. When too abundant to be wholly contained within the cul-de-sac, the exudate spreads out upon the posterior surface of the uterus, may extend later- ally, and has been known to fill the entire inlet of the pelvis. The adherent and oftentimes distended intestine gives an indefinite outline to the upper border of the exudate. The consistency of the exudate is variable. Fluctuation may be marked, or the exudate may appear firm, b}' virtue of the surrounding inflammatory infiltration. In exceptional cases the exudate is located at the side or in front of the uterus. It is difficult to palpate through the vagina because of its high location. Without anesthesia there is an indefinite sense of resistance at the seat of the exudate. Under anesthesia the inflam- matory mass may be fairly outlined. When a fluid exudate is encap- sulated by adhesions, "adhesion cysts," it is possible to mistake it for a sactosalpinx or an ovarian cyst. Peritoneal adhesions may follow a serous or purulent exudate, or may develop independent of a fluid exudate. The adhesions may involve any part or all of the pelvic peritoneum. They manifest great variations in development, from a delicate fibrillar structure to dense bands. They are more frequently found about the adnexse and behind the uterus than in front of the uterus, for the reason that the infection commonly travels through the tubes to the peritoneum, and it is unusual for the tubes to lie in front of the uterus. Gonorrhea is the most common cause of adhesions, and next in point of frequency is the infection following labor and abortion. As a result of the adhesions the uterus and adnexse are. more or less fixed, and their position is altered by contraction of the adhesions. With the exception PELVIC PERITONITIS 507 of prolapsus and inversion of the uterus, all varieties of malpositions are caused by adhesions about the uterus and its appendages. CUnical Diagnosis. — The clinical diagnosis rests upon the physical findings. In a conjoined examination the adhesions are recognized as cords and bands, rarely as a diffuse thickening surrounding the viscera of the pelvis and uniting their peritoneal surfaces. Peritoneal adhesions bind the uterus in retroposition. The abnormal fixity of the organs and their displacements are sug- gestive of the presence of adhesions. Not infrequently such fixity and displacements are recognized in an examination without anesthesia, and it is presumed that adhesions exist, though they are not accurately demonstrated without the administration of an anesthetic. When displacements of the uterus and adnexse, which have a restricted range of motion, are associated with tenderness and an indefinite sense of resistance at the side of or behind the uterus, an anesthetic should be administered to determine the possible presence of adhesions and exudates. Differential Diagnosis. — It is at times extremeh' difficult to differ- entiate a pelvic peritonitis from a hyperesthesia yeritonii found in women of nervous temperament. The general nervous state of the individual, the absence of all causes of infection, and finallv a 508 PERITONITIS conjoined examination under anesthesia, will serve to establish the diagnosis. A retroflexed gravid uterus may be confounded with a peritonitic exudate. The fact of pregnancy should be determined by the usual signs. In the first trimester the cessation of menstruation and nausea are occasionally simulated by like complaints due to the inflammatory lesions about the uterus, in the absence of pregnancy. Such exudates are most often found in multiparse in whom the changes in the breast are not usually well-marked during the earh' months of pregnancy. Of greatest importance are the changes in size, form, consistency, and the rate of growth of the uterus. An effort to replace the uterus, with or without anesthesia, will determine the presence or absence of adhesions. In exceptional cases a uterus fixed by adhesions cannot be distin- guished from an incarcerated uterus without an exploratory incision. This is particularly true when adhesions bind the uterus loosely to such movable structures as the bowel, omentum, and bladder. When the uterus is fixed and tender to pressure, adhesions are sus- pected, even though they cannot be felt under anesthesia. A retro-uterine hematocele may organize into peritoneal adhesions in the absence of infection. The history and physical evidences of an ectopic pregnancy, together with the usual signs of a hematoma and the absence of a history of infection, will serve to differentiate this condition from true inflammatory peritonitic adhesions. Tuberculous jjeritonitis, with encysted fluid, according to H. Dure, is differentiated from an ovarian cyst by a family history of tubercu- losis, by signs of the existence of other tuberculous lesions, by a history of frequent abortions or of the death of several children from tuber- culosis; and by general symptoms of tuberculosis, such as loss of weight, strength, and appetite, evening rise of temperature, night sweats, pelvic pains, amenorrhea, leucorrhea, and the previous occur- rence of salpingo-oophoritis. The difterential diagnosis of pelvic inflammatory exudates from sactosalpinx and ovarian cysts is referred to in the chapters on Diseases of the Tubes and Ovaries. Treatment. — The tendency of pelvic peritonitis is to remain localized and not to spread to the peritoneum of the abdominal cavity. It is imperative that the surgeon should aid the forces of nature in limiting the infection, and should refrain from all surgical interference while the acute stage lasts, unless pus is present and can be drained per vaginam without endangering the general peritoneal cavity. Absolute rest should be enforced throughout the acute stage, ice applied to the lower abdomen, and antiseptic douches (formalin, 1 to 2000, lysol or creolin, 0.5 per cent., or bichloride of mercury, 1 to 2000) given at a temperature of 110° and repeated every four to six hours, each douche being twenty to thirty minutes in duration. A light diet and daily evacuations of the bowels are essential. The temperature is combated by cold sponging. AMien the acute stage has passed, the above treatment should be PELVIC PERITONITIS 509 pursued, and in addition, glycerin and ichthyol tampons should be inserted three or more times weekly. A detailed discussion of these treatments will be found in Chapter XI. If an abscess develops in the pelvis during the acute or subacute stages and causes much pain and sepsis, the effort should be made to drain per vaginam. This procedure should be done cautiously for fear of contaminating the general peritoneal cavity. As an argument against too hasty interference in surgery, we note the frequent observation of cases which have come to a functional cure, or have at least been so greatly improved by tentative measures and by the lapse of time, that conservative operations have substituted the more radical measures which were at one time contemplated. In all cases of acute pelvic peritonitis the Fowler position should be maintained. When there is a high degree of septic absorption the patient should drink large quantities of water, and normal salt solution should be introduced per rectum. The continuous administering of salt solution, as advised by Murphy, is preferred. (See page 203.) In the chronic stage of pelvic peritonitis the treatment is both tentative and surgical. There should be a judicious proportioning of the means at our command for the relief of the chronic stage of pelvic peritonitis. Surgery is invoked when tentative measures might suffice, and too often these measures are employed to the exclusion of surgery. A more common error is displayed in the failure to employ such con- servative mean as rest, hot douches, and glycerin and ichthyol tampons, for an extended period after operation. Failure in so doing leads to incomplete cures in many instances. In the treatment of chronic pelvic peritonitis the associated lesions should not be overlooked. The infected uterus, tubes, and ovaries must be attended to first, for they are responsible, in large part, for the manifest disturbances, and without their correction little can be done in the way of affording relief. The conservative measures employed are pelvic massage, pressure therapy, prolonged hot vaginal douches, glycerin and ichthyol tampons, and sitz baths. (For a detailed discussion of these agencies see Chapters X and XL) The surgery of chronic pelvic peritonitis is largely involved in the surgery of chronic metritis and salpingo-oophoritis. When adhesions exist they are to be severed by the fingers or scissors, and all raw sur- faces carefully covered with peritoneum when possible. The acutal cautery is a fair substitute when used to char the raw surfaces. Failure to observe these rules may lead to the reformation of new adhesions, to oozing of blood, and perchance to ileus. CHAPTER XXII PARAMETRITIS (PELVIC CELLULITIS) Acute Parametritis Varicocele of the Broad Liga- Chronic Parametritis ment The loose connective tissue of the pelvis lies immediately beneath the peritoneum. It surrounds the supravaginal portion of the cervix, and extends laterally between the layers of the broad ligament and along the sides of the pelvis. There is but a small amount of connective tissue in front of the uterus, beneath the vesico-uterine fold of peritoneum. Behind the uterus and beneath the uterorectal fold of peritoneum is a considerable amount of loose connective tissue, so intimately associated with the rectum, cervix, and vagina that it frequently becomes the seat of infection. A knowledge of the location, loose texture, and relation of the con- nective tissue to the neighboring structures will serve as a basis for our understanding of pelvic cellulitis. Definition. — By parametritis is meant an inflammation of the cellular tissue of the pelvis. The extent of the lesion varies. While sometimes diffuse, it is usually localized. According to the location of the lesion we recognize paracystitis, when the limited amount of connective tissue about the base of the bladder is involved; paraproctitis, when the inflammation is in the cellular tissue about the rectum ; paravaginitis, when it is about the vagina; posterior parametritis, when in the con- nective tissue lying within the uterosacral folds and beneath the floor of the pouch of Douglas; lateral parametritis, when between the layers of the broad ligament. Classification.^ — Freund classifies parametritis as follows: I. Acute Inflammation of the Pelvic Connective Tissue WITH OR without AbSCESS FORMATION. L Simple phlegmon. 2. Septic phlegmon. ^ II. Chronic Inflammation of the Pelvic Connective Tissue. L Circumscribed atrophic. 2. Diffuse atrophic. The causes of pelvic cellulitis are identical with those of pelvic peritonitis, and these lesions rarely exist singly. Acute Parametritis. — The initial symptoms are usually less violent than in acute pelvic peritonitis. This is particularly true of pain and tenderness. The effect upon the pulse and temperature may be equally severe. ACUTE PARAMETRITIS 511 Bandl says: "If a day or two after an attack of fever and the appearance of the initial symptoms, the uterus is found enlarged transversely in the region in which the broad ligaments leave it, para- metritis certainly exists, and it is hardly necessary to prove it by bimanual examination. If, after fever has lasted for several days, points of resistance are found over Poupart's ligament corresponding to the seat of pain and tenderness ; or if swellings have formed above or extend to the centre of Poupart's ligament, or internally to the anterior superior spine of the ilium, the convex border of which is readily felt or even seen; or if, by firm pressure on the abdominal wall, tumors corresponding to the broad ligament are found, then it is also certain that the process involves the parametrium. If still doubtful, the diagnosis may be confirmed by vaginal examination, which in most cases will reveal the presence of large masses at the sides of the uterus, extending anteriorly or laterally to the pelvic wall, or filling one side of the pelvic cavity, showing clearly that the swellings felt through the abdominal wall are masses of exudate extending below the peritoneum." Fig. 348 Contraction of the left broad ligament, drawing the uterus in a left lateral position. In many cases the exudate cannot be felt through the abdominal wall, because it lies low in the pelvis and is only to be palpated through the vagina. "If, with more or less inflammatory symptoms, masses form in the neighborhood of the cervix, or extend to the deeper portions of the pelvis, being doughy and soft at the beginning, but rapidly becom- ing harder, or if large, w^ell-defined swellings form in the true pelvis, in front of or behind the uterus, the process can be none other than phlegmonous inflammation of the cellular tissue." (Bandl.) 512 PARAMETRITIS Chronic Parametritis. — Chronic parametritis is diagnosticated from the position and consistency of the exudate and from its relation to neighboring structures. The history of the infection, together with the general and local symptoms, can no more than suggest the prob- able nature of the lesion. Position of the Exudate. — The exudate occupies the position of the pelvic connective tissue with greatest frequency in localities in which the connective tissue is most abundant, namely, behind the uterus and between the layers of the broad ligaments. In either case the exudate lies low in the pelvis. Fig. 349 Perityphlitic adhesions. Uterus and appendages are not involved. When involving the connective tissue at the base of the broad liga- ments, the exudate spreads to the sides of the pelvis. Behind the uterus it bulges down into the vagina, forming a rounded, tender swelling in the cul-de-sac. When involving the connective tissue at the sides of the pelvis, it spreads into a flat mass which extends from the sides of the uterus toward the sides of the pelvis. It is possible for the exudate to dissect in front and behind in the subperitoneal connective tissue of the abdominal wall. It is impossible for the exudate to burrow above the umbilicus, because at this level the subperitoneal connective tissue disappears. Furthermore, the dis- section cannot go beyond the median line of the abdominal wall. In this manner an abscess may burrow, there being a greater tendency CHRONIC PARAMETRITIS 513 on the part of purulent collections to gravitate to a lower level than is the case with non-suppurative exudates. The abscess may finally be discharged through the bladder, vagina, rectum, abdomen, or through one of the pelvic foramina. The form of the exudate varies according to its consistency and location, and moulds itself to neighboring structures. Beneath the cul-de-sac of Douglas it is somewhat rounded because of the limited resistance offered by the surrounding soft structures. Between the resisting layers of the broad ligaments the exudate is flattened, and the same is true to a greater degree at the sides of the pelvis. As the exudate is absorbed its form changes, because the absorption proceeds irreffularlv. Fig. 350 Inflammatory exudate in right broad ligament. Mobility of the exudate is scarcely perceptible. If attached by a broad base to an immovable structure, the exudate will be firmly fixed. A small exudate within the broad ligament may show some degree of mobility, but, as a rule, we speak of cellular exudates as fixed and immovable. The consistency is also subject to great variations, depending upon the character of the exudate, whether edematous, fibrinous, or purulent. It may be soft and fluctuating, and again as firm as cartilage. In the early development of the exudate the consistency is elastic and yielding ; later it becomes firm from organization and contraction. If suppura- 33 514 PARAMETRITIS tion ensues there will be a boggy and possibly fluctuating mass. The consistency is best determined by rectal and vaginal palpation. Tenderness to pressure is characteristic of all inflammatory lesions. Large exudates may exist with little tenderness, but tenderness is a reliable guide to the inflammatory character of the mass. The relation of the exudate to neighboring organs is important in difi^erentiating from new formations in the pelvis. The exudate blends intimately with adjacent structures and cannot be outlined apart from them. In intraligamentous exudates the mass lies snugly against the side of the uterus, sometimes surrounding the supravaginal portion of the cervix, but never extending to the fundus. In para- FiG. 351 Appendicular exudate. vaginitis it may be impossible to move the vaginal mucosa from the exudate. In paraproctitis the exudate may bulge into the rectum, narrowing the bowel lumen, and so intimately blend with the wall of the rectum that it moves as one mass. In the absorption of the exudate the periphery is first to disappear. In an intraligamentous exudate the mass may retreat from the side of the pelvis and form an elongated or rounded swelling, firmly adherent to the uterus. Differential Diagnosis. — The distinction between a perimetric and a parametric exudate is at all times difficult. Certain well-defined points of distinction serve to differentiate the two lesions, but they commonly coexist. CHRONIC PARAMETRITIS 515 Parametritis 1. Exudate lies low in the pelvis. 2. Pain may not be great, and is dull and con- tinuous. 3. Exudate commonly at the side of the uterus, never extending to the fundus. 4. Exudate of firm consistency; tendency to suppuration. 5. Uterus partially fixed. 6. Tympanites usually absent. 7. Facial expression may be natural. 8. Nausea and vomiting not common. 9. One leg flexed. Pelvic Peritonitis 1. Lies high in the pelvis. 2. Pain usually more intense, sharp, lancinating and paroxysmal. 3. Exudate commonly behind the uterus, often extending to the fundus. 4. Commonly less firm; no great tendency to suppurate. 5. Uterus may be firmly fixed. 6. Tyinpanites usually present. 7. Facial expression anxious. 8. Nausea and vomiting present. 9. Both legs flexed. Retro-uterine Parametritis 1. Outline rounded below and sharply circum- scribed. 2. Exudate cannot extend to fundus. 3. Uterus may be crowded forward; usually only the cervix is crowded forward. 4. Rectum firmly and closely surrounded by exudate in front and at the side. 5. Mucosa of rectum does not move upon the exudate. 6. Posterior vaginal fornix depressed. Retro-uterine Perimetritis 1. Outline diffuse, not sharply circumscribed. 2. Exudate may extend above fundus. 3. Uterus may be crowded forward by the exudate or drawn backward by adhesions. 4. Rectum crowded backward by exudate. 5. Mucosa moves independently of the mass. 6. Usually not depressed. A yaratyphlitic exudate is not infrequently confounded with an intraligamentous parametritis. It is possible for a paratyphlitic exudate to burrow between the layers of the broad ligament to the side of the uterus. Perityphlitis 1. Initial symptoms: nausea, vomiting, constipa- tion, fever, pain at Mcliurney's point. 2. Tendency of a perityphlitic abscess to rup- ture into the bowel and peritoneal cavity. 3. Tendency to recurrence. 4. Exudate lies high on the right side and spreads from above downward. Parametritis 1. Initial symptoms: fever, constipation, pain low in the pelvis at the .side of the uterus, rarely nausea and vomiting. 2. Little tendency to rupture into the bowel and peritoneal cavity. 3. Tendency to recurrence not so great. 4. Exudate hes lows in the pelvis and spreads from below upward. A ijehic hemato7na may so closely resemble a parametric exudate as to be indistinguishable without an exploratory incision or puncture. Both lesions are confined to the cellular tissue of the pelvis, and in general contour, size, and consistency they may be quite similar. The following tabulated points will usually serve to differentiate the two: Pelvic Hematoma 1. Develops suddenly. 2. History of ectopic pregnancy. 3. Onset marked by normal or subnormal tem- perature and rapid, feeble pulse. 4. Exudate usually beside the uterus and circum- scribed. 5. Exudate at first doughy, later firm, never tender unless infected. 6. Exploratory puncture — blood. Parametritis 1. Develops more gradually. 2. Absent. 3. Onset marked by rise of temperature and increased pulse rate. 4. Exudate beside or behind the uterus and less circumscribed. 5. Exudate firmer and tender. 6. Exploratory puncture- tive. -serum, pus, or nega- Suhserous fibroids may be confounded with a parametric exudate. When the exudate is round and attached by a broad base to the uterus and not especially tender to pressure, the diagnosis is difficult, and may not be cleared up without an exploratory incision. The difficulty in diagnosis is especially great in intraligamentous fibroids. The more movable the mass, the more likely it is to be a fibroid. In a cellular 516 PARAMETRITIS exudate there is a history of infection and the mass grows rapidly. But in fibroids there is no history of infection, and the growth develops slowly. The depth of the uterine cavity is usually increased in uterine fibroids' beyond that found in parametritis. The effects of treatment will aid in the diagnosis; in parametritis the mass should diminish under treatment, while in fibroids little, or no effect will be observed. Malignant disease of the pelvis, involving the parametrium, may arise from a primary focus in any of the pelvic viscera. There is absence of a history of infection, no acute onset being experienced, and there are present the general symptoms of malignancy rather than of infection. The primary seat of malignancy can usually be determined, and the hard, irregular character of the infiltrated area will serve to indicate the condition. Parametritis Pso.'VS Abscess 1. Usually of acute origin. 1. Usually of chronic origin. 2. Absence of spondylitis. 2. Spondylitis present. 3. Exudate tender to pressure. 3. Exudate not tender to pressure. ■1. Fluctuation may be absent; induration about 4. Fluctuation only occasional; no hard exudate abscess always present. about abscess. 5. Thigh flexed, not rotated. 5. Thigh flexed and rotated inward. 6. Temperature may be high. 6. Temperature absent or slight rise, especially in the morning. 7. Exploratory puncture shows absence of tuber- 7. Presence of tuberculous exudate and possibly culous exudate and tubercle bacilli. tubercle bacilli. S. Tuberculin give.s no reaction. S. Tuberctilin usually gives a reaction. Treatment. — The treatment of pelvic cellulitis is in many respects similar to that of pelvic peritonitis. In acute pelvic cellulitis identical conservative measures are practised. The patient is confined to her bed, an ice-bag is placed over the hypo- gastrium, oft-repeated hot vaginal douches are administered, the diet is restricted, and the bowels freely opened. As the acute stage passes away, glycerin and ichthyol tampons are applied daily. If an abscess develops it should be drained per vaginam. (See page 517.) "When the pain is severe opium suppositories or hypodermic injec- tions of morphine must be administered. In chronic pelvic cellulitis the treatment consists in the usual conser- vative measures employed in the management of chronic pelvic inflam- mation in general. Prolonged hot vaginal douches, ichthyol and glycerin tampons, pelvic massage, and pressure therapy are applied in accordance with the rules laid down in Chapters X and XI. When ajielvic abscess exists it should be drained. (See page 517.) Treatment of Pelvic Abscess. — The treatment of abscesses resident in the pelvic peritoneal cavity or in the pelvic connective tissue, exclusive of pyosalpinx and ovarian ab.scess, is drainage per vaginam. This is by no means a minor procedure, in that it must be eftectually done and without injury to neighboring structures or contamination of the general peritoneal cavity. The more acute the infection the greater the danger of its extension, and the higher the location of the abscess, the more difficult the opera- PLATE XXV Method of Packing Douglas' Pouch for Drainage in Cases of Pelvic Abscess. VARICOCELE OF THE BROAD LIGAMENTS 517 tioii and the greater the danger of injuring the surrounding structures, especially the bowel. Two or more separate abscesses may exist, and it is important that an outlet common to all of them should be made. Techiic. — The vulva and vagina are prepared in the usual manner for operation. It is, as a rule, advisable to give a general anesthetic, though the operation may be performed without anesthesia when the patient is greatly depressed. The cervix is exposed by a hanging speculum and two lateral retractors. The posterior lip of the cervix is grasped by a vulsellum forceps and firm traction is made forward and upward. The vaginal wall is grasped by tissue forceps at a point immediately back of the cervix, and with sharp-pointed scissors a transverse incision is made in the posterior fornix of the vagina close to the cervix. This incision extends through the wall of the vagina only, and is about one inch in length. A strip of gauze is then draped over the index finger and by the finger the opening is stretched, the connective tissue is stripped from the cervix, and the finger directed to the seat of the abscess. Having opened into the abscess with the finger the drainage is made more free by stretching the tissues. A careful digital exploration is made in view of the possible finding of other accumulations of pus, and when found they, too, are opened and drained. When the abscess lies high in the pelvis it may be necessary, in order to reach it, to pass long blunt forceps beyond the reach of the finger, and when the abscess has been entered, the forceps is spread to allow the free escape of the contained pus. This is a dangerous procedure, and one that recjuires experience and skill. In exceptional cases the abscess should be opened above Poupart's ligament. After making a free opening through the cul-de-sac into the abscess, the cavity is packed with a long strip of antiseptic gauze. The author advises against irrigating the abscess cavity, immediately after opening, for fear of spreading the infection. The gauze pack should be removed at the end of forty-eight hours and a vaginal douche given. So long as the abscess drains freely, only antiseptic vaginal douches should be given, but if free drainage is interrupted, the incision should be spread with fingers or forceps and the cavity washed out with an antiseptic solution. When it is difficult to obtain continuous free drainage a fenestrated rubber drainage-tube should be inserted and the cavity irrigated daily through the tube. In all acute pelvic abscesses the patient should be kept in the Fowler position. After the abscess has completely drained, the surrounding inflam- matory tissue should be treated with vaginal douches and glycerin and icthyol tampons. Varicocele of the Broad Ligaments. — ^'aricocele of the broad ligaments is rarely met with independent of other pelvic or abdominal lesions. The ovarian \'eins are known to undergo great enlargement in pregnancy, 518 PARAMETRITIS and it might be expected that these veins would occasionally fail to involute in the puerperium. As the result of sexual excitement and menstruation the veins of the broad ligaments become overdistended. These factors may lead to permanent overdistention of the veins. The following conditions are mentioned as etiological factors: 1. General Causes. — Incompetent heart, diseases of the lungs, kidneys, spleen, and liver, which lead to a sluggish pelvic circulation. 2. Local Causes. — Subinvolution of the uterus, pelvic inflammation, abdominal tumors and ascites, extensive lacerations of the cervix into the broad ligaments, uterine displacements, chronic constipation, and tight-lacing; all of which tend to engorge the pelvic veins. Symptoms. — The symptoms are usually marked by those emanating from the associated lesions. There is a sense of weight and fulness in the pelvis which is commonly referred to the iliac, sacral, and perineal regions. This feeling of discomfort is aggravated by long standing and is relieved by lying down. Diagnosis. — The symptoms recorded above will be highly suggestive. The diagnosis is not usually made before the abdomen is opened, and is then often overlooked, because in the Trendelenburg position the veins are collapsed. It is sometimes possible to make the diagnosis by palpating at the sides of the uterus a yielding compressible mass, varying in size to that of a hen's egg. Treatment. — All associated conditions demand consideration. Con- servative measures may afford relief; such are the introduction of a pessary to correct a displaced uterus, the depletion of the pelvis by catharsis, hot vaginal douches, and rest. Operative treatment, in event of failure of the conservative measures, consists in multiple ligatures with linen along the course of the dis- tended veins. The author does not find it either necessary or advisable to dissect out the distended veins. CHAPTER XXIII GONORRHEA IX WOMEN Historical Sketch Prognosis GoNOCoccus OF Neisser i Prophylaxis Etiology j Treatment Diagnosis ! Gonorrhea in Children Historical Sketch. — The prevalence of gonorrhea was not fully appreciated before Noeggerath made known his clinical observations in New York City, in 1877. Two years later Neisser identified the gonococcus as the essential causal factor and made possible the recog- nition of latent cases which hitherto had not been recognized. The statistics of Noeggerath created a furore of criticism and ridicule. He stated that 80 per cent, of married men have had gonorrhea, that 90 per cent, of these have never been healed, and that of five married women, three have gonorrhea. Zweifel and Sanger took issue with Noeggerath and estimated that 18 per cent, of married women have gonorrhea. The author is convinced that the truth lies between the statements of Noeggerath and those of Zweifel and Sanger. Gonococcus of Neisser. — The gonococcus of Neisser is a diplococcus averaging 1.25 mm. in diameter, with an interspace of about 0.8 mm. between the two halves of the organism. Occasionally grouDS of four cocci are seen, and more rarely single cocci exist. The organism grows best at body heat, but its growth is not retarded at freezing temperature or at a corresponding high temperature. It will not grow on gelatin or agar, but on blood serum plus peptone-agar (Wertheim) the organism grows slowly. It grows in a neutral, slightly alkaline, or faintly acid medium. When dry it soon perishes, hence the dried secretions soon lose their virulence. The gonococcus can exist in the tissues throughout the lifetime of the individual, and at any time under favorable influences the infection may light up into what appears to be a new and acute infection, or may transmit a virulent infection without itself becoming manifest. Etiology. — Frequency. — Wolbarst says that 75 to 90 per cent, of all gynecological operations are occasioned by gonorrhea. The number of gonorrheics in New York City is estimated at 225,000 to 800,000. It is estimated by Gerrish that in New York City in 1900, 225,000 men and women died from gonorrhea and sj'philis. Hoff estimated an increase of 50 per cent, of venereal diseases in the United States Army in the period in 1899 to 1905. The section in Hygiene and Sanitary Science of the American ]\Iedical Association reported in 1901 that in the experience of many European 520 GONORRHEA IX WOMEN and American i;ynea)log'ists, 40 per cent, of women suffering from pelvic inflammation have gonorrhea. Wolbarst makes the startHng statement that 70 per cent, of married women who complain of pelvic disorders have acquired gonorrhea innocently from their husbands. Extracougucjal Infections. — It is exceptional for gonorrhea to be conveyed by means other than sexual intercourse. Gonorrhea may be conveyed to the eyes of the newborn. The bathroom is an occasional source of contagion, and cases have been traced to the dispensary and office where the instruments and hands of the examining physician were not properly cleansed. Children attended by infected mothers and maids are sometimes contaminated. Immunity. — Immunity may be acquired, though an individual may be repeatedly infected. General immunity to gonorrheal infection does not exist. Certain tissues, notably gland tissues, appear to be immune. Local immunity in certain tissues, notably the mucosa of the urethra, is said to exist for a brief time; however, this fact is not fully established. A second infection may soon follow the first. The immunity exists only so long as the tissues are under the direct influence of the gonotoxins or of gonococci. The discharge, accompanying a chronic gonorrheal urethritis or endometritis, is proved to be virulent only when the microscope reveals the presence of gonococci or when sexual intercourse results in infection. The amount of the discharge or its constancy does not indicate the degree of virulence. We have demonstrated the presence of the gono- coccus in the absence of a discharge, and we have failed to detect the gonococcus in the presence of a chronic discharge. Individuals have been known to infect others, yet apparently are themselves immune to infection. The explanation lies in the presence of a chronic gonorrheal infection, in the absence of all clinical signs. In the first individual the gonococcus had little virulence, but when transmitted to sterile tissues it assumed an active role. Husband and wife may both be infected, neither manifesting symp- toms of the disease, yet a third individual having intercourse wdth one or the other may acquire a virulent infection. Again, the husband may infect his wife, then have no intercourse wdth her until he is appar- ently cured, when on resuming sexual relations with his wdfe wiiom he had previously infected, he, in turn, is inoculated by her. A gonococcus of low virulence when transferred to a second individual may acquire added virulence. In this manner a husband, w^ho is the carrier of a latent unrecognized infection, may infect his wife and in turn become acutely infected. Period of Inoculation. — It is not possible to establish a definite period of inoculation, but it is said to vary from twelve hours to a ,week or more. Experimental inoculations with pure cultures of the gonococcus have created an inflammatory reaction in twelve to twenty-four hours. Pathology. — In the urethra w^e find, during the acute stage, that the gonococcus advances by way of the intercellular spaces to the deeper structures of the mucosa and into the underlying connective tissue. PATHOLOGY 521 As the acute stage merges into the chronic, there is a less diti'use dis- tribution of the organism and the leucocytes, the gonococci confining themselves to isolated areas in the superficial structures, particularly those areas which present to the unaided eye congested and ulcerated regions. Infection of the glands of the urethra is of frequent occurrence and presents a serious complication because it is in these follicles that the gonococcus may reside for an indefinite time and elude all the ordinary means of treatment. Skene's ducts and para-urethral glands frequently give origin to retention cysts and abscesses. Caruncles grow in the anterior third of the urethra as the result of constant irritation. These sensitive growths are single or multiple, and are composed of a loose vascular infiltrate covered with mucosa. Erosions, red areas, and gray plaques may be seen distributed irregularly over the surface in chronic gonorrheal urethritis. The urethral wall may present a diffuse or circumscribed area of infiltration, which in healing may develop sclerosed bands. It is rare, however, to find a well-developed infiammatory stricture in the female urethra. The author has never observed one. The surfaces of the genital tract which are covered by stratified, squamous epithelium, /. e., vulva, vagina, and vaginal portion of the cervix, evince a peculiar resistance to gonorrheal infection during the period of sexual maturity. In infancy and old age the epithelium has a much lower resistance, and primary gonorrheal vulvovaginitis is not uncommon. In the height of the infectious process the papillae are crowded with small round cells. On the surface of the mucosa is a deposit of pus cells and cellular debris, and in this deposit are found gonococci in varying numbers. These organisms extend into the intercellular spaces of the epithelium, but have not been demonstrated to invade the underlying connective tissue. The vulvar glands, which may be found in great numbers in ad^'ance of the hymen and in the fossa navicularis, may be infected and form shot-like elevations from which pus can be expressed. The term folliculite vulvaire blennorrhagiqiie has been applied to this lesion by Record, Rollete, and ]Martineau. The gonococcus has been found in the expressed pus. Gonorrheal folliculitis of the vulva may result in the formation of fistulse by the opening of these abscesses into the vagina and bowel. Such a condition is rare. The Bartholinean glands, which are frequently involved, are said by Bumm not' to be deeply invaded by the gonococcus. According to Gebhard, all deep-seated infections of the Bartholinean glands are the result of mixed infections of the gonococcus and staphylococcus. In the uterus numerous groups of gonococci were seen to occupy spaces between the superficial epithelial cells and, to a lesser extent, the intercellular connective-tissue spaces. ]Madlener made histological observations in a case ten weeks after the initial infection, which was 522 GONORRHEA IN WOMEN the seventh week of the puerperium. In this case gonococci were distributed throughout the entire uterine musculature. In the Falloinan tubes the gonococcus has been repeatedly recognized in the pus contained within the lumen of the tubes and in the mucous lining. Morax and Raymond found the gonococcus in the superficial layer of the mucosa. Bumm found nests of gonococci in the mesosalpinx, as did also Wertheim. The ovary is rarely attacked by the gonococcus in the absence of a previously infected tube. Under rare conditions the ovary may be attacked by way of the peritoneum, the microorganisms passing through the intact germinal epithelium of the ovary or into the open follicles. Again, it. is possible for the gonococcus to pass through the uterus by way of the lymph vessels of the broad ligaments to the hilum of the ovary. Peritoneum. — Localized pelvic and general abdominal peritonitis, due to gonorrheal infection, has rarely been demonstrated by bac- teriological observations, though clinically it is well known. Cases of general gonorrheal peritonitis are reported by Koehler, Frank, Gushing, Veit, and Menge. Hunner and Harris reported seven cases, and gave an analysis of thirty-nine previously reported cases. Little is known of gonorrheal infection of the pelmc connective tissue. That gonorrheal abscesses do form in connective tissue is demonstrated by Wertheim, Dinkier, and Jadessohn, but the bacteriological observa- tions which have been carried on in cases of pelvic cellulitis of gonorrheal origin have led to great confusion. The bladder is seldom attacked by - the gonococcus. Wertheim, Bierhoff, Barlow, and others have all recognized the lesion. Wertheim has demonstrated the presence of gonococci in the intercellular spaces and in the bloodvessels of the bladder wall. It is at the base of the bladder that the lesion commonly exists, though a generalized gonorrheal cystitis has been recognized by a large number of observers. The urine contains a variable amount of pus and bladder epithelium, sometimes red blood cells, and is alkaline in reaction. In the acute stage gonococci are usually found in the pus cells. Baier found the rectum involved in 30 per cent, of 191 cases of gon- orrhea. Fissures, erosions, and ulcers may accompany a. swelling of the rectal mucosa. The majority of cases are not recognized for want of a bacteriological examination of the mucous secretions of the rectum. In nearly every instance the genito-urinary tract is likewise infected. Diagnosis. — The diagnosis of the presence of a gonorrheal infection is generally an easy task, but it is difficult to determine the extent to which the infection has spread. History. — It is possible to make a practically correct diagnosis from the history alone. A recently married woman may complain of leu- corrhea and burning pain on urinating, and it is learned that her husband w^as at one time infected. In such cases there is little doubt of the existence of gonorrhea, but without a physical examination the diagnosis cannot be established, nor is it known how far the infection DIAGNOSIS 523 has extended. A woman may acquire a gonorrheal infection without her knowledge and in the absence of all local and general signs; hence the uncertainty of relying upon the history. Gonorrheal Urethritis. — The acute attack is ushered in by a tickling and burning sensation before and after urinating. There is a trans- parent serous secretion, in which pus cells, desquamated epithelium, and gonococci are found in variable numbers. By the end of the third day the secretion becomes thick and yellow. There is tenderness along the course of the urethra, and not infrequently in the bladder. Separat- ing the labia with the fingers the meatus appears red and swollen, and from the urethra there may be expressed a drop or more of pus. In three or four weeks the urethra usually appears normal, though a drop of pus can sometimes be expressed by stripping the urethra. In a small Fig. 352 Expressing a drop of pus from the urethra. proportion of cases the lesion passes into a chronic stage, in which the urethra becomes firm from thickening. Through the endoscope part or all of the urethra appears swollen, having little or no secretion. Strictures are seldom formed. Exacerbations, with all the usual manifestations of a recent acute infection, are the rule. These exacer- bations can usually be explained by the presence of gonococci in the crypts near the meatus. From these crypts pus, which contains gonococci, can often be expressed in the absence of an apparent lesion elsewhere in the urethra. The severity of the symptoms of urethritis does not depend so much upon the acuteness of the lesion as upon the location. The farther the infection extends into the urethra, the more intense the suffering. A posterior urethritis gives rise to symp- toms resembling cystitis. The desire for urination is frequent and 524 GONORRHEA IN WOMEN painful, sometimes amounting to tenesmus. Urination is difficult, and sometimes it is impossible to void the urine, thereby necessitating the use of the catheter. The desire for urination may be great, even when there, is but little urine in the bladder. This desire may be experienced only at night or may be worse when the patient is on her feet. Such are the most severe types. In the majority of chronic cases there is no great pain on urinating. Gonorrheal Cystitis. — When a patient complains of a persistent frequency of urination associated with pain in the bladder, two things are required of the physician: (1) A microscopic examination of the urine obtained by means of the catheter, in view of finding pus cells and the gonococcus; (2) a cystoscopic examination, to determine the location and extent of the infection. The gonococcus plays a minor role in the causation of cystitis. The germ is usually far outnumbered by other microorganisms — the colon bacillus, streptococcus, and proteus of Hauser. When the gono- coccus is the initial cause of the infection it usually gives way to the above-mentioned microbes. Young, however, has found a pure culture of the gonococcus in cystitis of five years' standing. While the gonococcus has been found in the pelvis of the kidney and in the cortex of the kidney, the question is still under dispute as to whether the infection of the kidney is due to direct extension from the bladder and ureters or is conveyed by w^ay of the blood current. The weight of evidence is in favor of direct extension. As with the bladder so with the kidney, the gonococcus is usually associated with the colon bacillus and other microorganisms. Gonorrheal vulvitis is often seen in childhood, but is rare in advanced years. It seldom exists in the chronic stage because of the rapidity w4th which healing takes place. As a rule, the vulva is primarily infected in infants, but in adults it is generally secondary to a uterine infection. In acute gonorrheal vulvitis the tissues are deeply congested and the surface is covered with pus or a pseudodiphtheric membrane. Underneath the secretion superficial or deep ulcers may form; they are sensitive and bleed to the touch. The pus accumulates in the fossa navicularis. The hymen is swollen and red. Eczema of the labia and neighboring skin arises from lack of cleanliness. The vulvar glands may be infected and transformed into numerous small abscesses con- taining gonococci. Associated with these changes are sensations of heat and burning about the external genitals, burning on urinating, and embarrassment in Avalking and sitting. These subjective symptoms usually disappear in three to five days, and within two weeks little or no trace of the lesion remains. Healing is slower in childhood and in old age. Gonorrheal bartholinitis may be in evidence as early as the second week of the infection, but, as a rule, these glands are not involved for weeks and months following the initial infection. The mouths of the glands become red and swollen. Here the process may be checked or DIAGNOSIS 525 the glands may enlarge into a round or spindle-shaped body, varying in size from a hazel-nut to a hen's egg. They are tender, and may fluctuate. Both glands are commonly involved, though not to the same degree. Gonorrheal vaginitis is rarely if ever seen in the chronic stage. In the acute stage it is occasionally seen in infancy and old age as a primary lesion, but in the period of sexual maturity it is invariably secondary to a uterine infection. The finding of the gonococcus in the vagina is not evidence of gonorrheal vaginitis. The gonococci may lie in the vaginal secretions without attacking the vaginal tissues. In the acute stage the temperature may be elevated, there is a burning sensation in the vagina, physical exertion causes distress, and to the examining Fig. 353 Palpation of the vulvovaginal gland. finger the vagina is hot and tender. The surface is red and swollen, and in virulent cases erosions and ulcers may develop beneath the purulent secretion which bathes the surface. The disease is usually self-healing within a few weeks. Gonorrheal metritis exists in both the acute and chronic stages. The infection may be confined to the cervix or may invade the uterine body. It is not invariably confined to the mucosa, as was formerly believed, but may invade the musculature throughout its entire extent. In the acide stage the cervix is red, swollen, sensitive to pressure, and may bleed on handling. A mucopurulent secretion extrudes from the cervical canal, and in this secretion the gonococcus is found in large numbers throughout the acute stage. So long as the infection is confined to the cervix there may be an absence of all symptoms. With 526 GONORRHEA IN WOMEN the invasion of the uterine body the temperature usually rises a degree or more, there is pain and tenderness in the hypogastrium and urina- tion is frequent and painful. As a rule, the symptoms rapidly subside, with the exception of a profuse leucorrhea, which commonly persists indefinitely. On bimanual examination the uterus is tender to pressure and is slightly enlarged. Chronic gonorrheal metritis may be so varied and so obscure in its clinical manifestations that the true nature of the infection, and even the existence of an infection, might be overlooked without a systematic bacteriological examination. All the usual symptoms may be wanting. A careful examination of the uterus may reveal no change in its size, mobility, and consistency. There may be no undue sensitiveness and an absence of a visible secretion, yet the gonococci may be found in the transparent, viscid secretion of the cervix. Erosions are often seen on the cervix, and the entire uterus may be enlarged, firm in consistency, and somewhat tender to pressure. Exacerbations of pain, tenderness, and a purulent leucorrhea are suggestive of gonorrheal infection. There is nothing in the macroscopic or microscopic appearances of the tissues of the uterus that will characterize a gonorrheal infection. The tissue changes are identical with those of puerperal infection. On the vaginal portion of the cervix are erosions of the papillary, glandular, and follicular varieties. In the cervix and body of the uterus the macroscopic appearances are those of endometritis of the hypertrophic, polypoid, or fungous types, which under the microscope present the usual picture of glandular or interstitial endometritis. It is only by the detection of the gonococcus in the tissues that the diagnosis can be made with certainty. Gonorrheal salpingitis is always secondary to an infection of the uterus. It is exceptional for the infection to be conveyed to the tubes early in the history of the infection. While the tubes have been invaded within ten to fourteen days of the initial infection in the cervix, the rule is that they are not attacked for months and possibly years. A guarded prognosis, therefore, should always be given in regard to the involvement of the tubes while the infection is confined to the uterus, as it is not known when the infection may extend to the tubes. The Predisposing Causes of Extension to the Tubes are: 1. Untimely intra-uterine manipulations in the infected uterus by means of the sound or curet. 2. Exposure and exertion during the men^strual period. 3. Labor and abortion, causing an extension of a latent infection in the uterus to the tubes. Women who are the carriers of a latent infection in the uterus should not become pregnant. Gonorrheal salpingitis is usually ushered in by a chill, followed by a rise in temperature of 1° to 4° F., together with the development of pain and tenderness in the sides of the pelvis. In event of menstrua- tion, the periods are prolonged and painful, with exaggerated local and general disturbances. PROGNOSIS 527 Without an anesthetic it is impossible to outhne the infected tubes because of the extreme tenderness. In the early stages the tubes are but slightly enlarged and are not readily palpated. As the disease develops the tubes may be palpated as an irregular, elongated structure, extending from the cornua of the uterus to the sides of the pelvis or lying closely adherent to the sides or posterior surface of the uterus. They are tender to pressure, and are, as a rule, more or less fixed by adhesions. It may or may not be possible to detect fluctuation. In the subacute and chronic stages exacerbations of fever, pain and tenderness are occasionally experienced. These are prone to occur at the menstrual periods and to follow undue exertion. Bladder and rectal disturbances are often included in the clinical syndrome, and are due either to infection of these structures or to pressure by the tender and enlarged tubes. Gonorrheal ovaritis is the result of extension of the infection from the tubes to the ovaries, and does not exist independent of salpingitis. The clinical manifestations are identical with salpingitis. All the inflammatory lesions common to the ovary are observed. Adhesions form about the ovary, binding it to the tube and surrounding structures. Newly formed connective tissue may develop in the sub- stance of the ovary and lead to cystic degeneration. These changes in and about the organ are fruitful sources of sterility. In addition to these pathological conditions, abscesses of the ovary are not infre- quently developed. Gonorrheal peritonitis. — -(See page 501.) Gonorrhea of the rectum occurs in about 8 per cent, of all gonorrheal infections of the genital tract. The lesion is commonly overlooked. The contributing causes are coitus per anum, digital and instrumental examinations in the presence of gonorrheal infection of the genital tract, and lack of cleanliness in the presence of leucorrheal discharges of a gonorrheal nature. Caution should be exercised in giving enemata for fear of conveying an infective vaginal discharge to the rectum. When a patient, who is the carrier of a gonorrheal infection, complains of discomfort in the rectum, an effort should be made to discover the gonococcus. Only by this means is the disease recognized. Prognosis. — Inasmuch as one cannot foretell the ultimate outcome of a gonorrheal infection, a guarded prognosis should always be given. The infection may be of low virulence and confined to a limited area. Such an infection may exist without recognition, but it may persist for an indefinite time and be transferred to a second individual, and then give rise to a virulent infection. Again, such a latent infection confined to the lower genito-urinary tract may ultimately spread to the upper genital tract, and with disastrous results. Gonorrhea in Relation to Sterility. — A large proportion of sterile marriages are due to gonorrhea. Bumm estimates that 30 per cent, of women infected with gonorrhea are sterile. IMore than half of the women who have married men known to have had gonorrhea are sterile (Noeggerath) . This statement is probably an exaggeration. Fully 70 per cent, of sterile marriages are chargeable to gonorrhea, either in 528 GONORRHEA IN WOMEN the husband or in the wife, or in both. Sterihty is chargeable to the husband in 70 per cent, of cases according to the statement of Vedeler, in 50 per cent, according to Olshausen, and in 34 per cent, according to Chrobak. These figures refer not only to the percentage of sterility in the male, but to his part in rendering the wife sterile. The so-called "one-child sterility" is accounted for in large measure by the extension of a preexisting gonorrheal infection during the puerperium, for it i:^ a long-established fact that in the puerperium the infection, which was confined to the cervix and urethra, is prone to extend to the corpus and tubes, and will then almost certainly result in sterility. Influence of Gonorrhea on Pregnancy. — Gonorrhea is not necessarily a barrier to conception. In a number of the Continental hospitals it was found that 20 to 25 per cent, of pregnant women were infected. In them the infection was usually confined to the cervix and urethra, though it is well known that the body of the uterus and the appendages may be infected and not preclude the possibility of pregnancy. Influence of Gonorrhea upon the Termination of Pregnancy. — Gonor- rhea is a potent factor in the causation of abortions. Sanger estimates the abortive influence of gonorrhea to be as great as that of syphilis. It is estimated that 20 to 30 per cent, of women who are infected with gonorrhea fail to carry their children to full term. One case in six of puerperal sepsis is caused by gonorrhea. Of this number but few are the result of contamination in labor and the puer- perium. The majority are due to preexisting infections in the genital tract, which are awakened to renewed activity and caused to extend; a gonorrheal cervicitis extends to the body of the uterus and thence to the appendages; a latent infection in the appendages spreads to the peritoneum; thus it happens that an infection which may have been previously unrecognized becomes a serious menace to life and a barrier to conception. Risks to the Offspring. — In the passage of the child through the cervix and vagina of an infected mother, there is great liability to contamination of the conjunctiva. It is estimated that from 10 to 30 per cent, of the cases of blindness in the world are due to gonorrhea. According to Xeisser there are now in Germany 30,000 blind persons whose loss of sight may be thus accounted for. Happily, the frequency of this accident is being materially reduced by antiseptic vaginal douches given prior to the delivery of gonorrheal cases and by the employment of the Crede method of treatment of the eyes of the newborn. Location of the Infection. — The prognosis is largely influenced by the location of the infection, von Winckel presents the following statistics relative to the localization of gonorrhea: Urethra, acute and chronic G2.0 to 85 per cent. Cervix 47.0 to 72 per cent. Uterus 14.0 to .50 per cent. Vagina 2-3.0 to 40 per cent. Bartholin's glands .36 per cent. Vulva 12.0 to 2.5 per cent. Tube 3.6 to 33 per cent. TREATMENT OF ACUTE STAGE ' 529 Bumm made observations in 55 cases and found: 50 (90.0 per cent.) with gonorrheal urethritis. 41 (74.0 per cent.) with gonorrheal cervicitis. 8 (14.0 per cent.) with gonorrheal endometritis. 2 ( 3.6 per cent.) with gonorrheal salpingitis. Prophylaxis. — The prevention of gonorrhea is a problem of vast importance because of the direful results of the infection and the uncertainty of cure. Following are essential features of prophylaxis: 1. The public should be impressed with the prevalence and serious consequences of the disease. 2. The physician should not pronounce a cure or gWe sanction to marriage or to the resumption of the marital relation until repeated microscopic examinations demonstrate the absence of the gonococcus in the secretions. 3. Medical regulation and supervision of prostitution does not protect but rather promotes a false sense of security. 4. So long as a woman is the carrier of gonococci, she should avoid becoming pregnant in the interest of both herself and child. The possible extension of the infection in the mother and the development of ophthalmia in the newborn justify the precaution. Active Treatment. — Before deciding upon a course of treatment it is well to consider the social, economic, and moral influences which affect the individual. When the woman is able to take reasonable care of herself, and when her moral life would favor recovery, con- servative treatment may be looked upon with favor; but when for financial and domestic reasons a long period of treatment and invalidism could not be wisely pursued and when the moral status of the individual will forestall all efforts toward recovery, conservative treatment will fail. Such women should be rid of their troubles in the shortest possible time, and to this end operative procedures are favored. "Thus immoral individuals would be made less a menace to the community, less a burden upon our hospitals, and the wage-earner would be more quickly fitted for pursuing her daily task." Treatment of Acute Stage. — The most essential factor in the manage- ment of gonorrhea in the acute stage is rest. The patient should be confined to bed and all instrumental and digital manipulations inter- dicted for fear of spreading the infection. Cleanliness is second in importance to rest. Antiseptic vaginal douches should be given for the purpose of keeping the vagina free of the leucorrheal discharges. Lysol, creolin, or bichloride douches are preferred. These douches should be given in the recumbent position, they should be at a temperature of 110° to 112° F., and should be given for ten to twenty minutes. The author's preference is for mer- curic chloride (1 to 2000). In addition to the cleansing qualities of the douche the pelvic tissues are depleted, and in this manner the active stage of the infection is shortened. When pain and tenderness are referred to the pelvis an ice-bag should be applied to the lower abdominal region. For relief from pain, aspirin, heroin, morphine, and hyoscyamus 34 530 GONORRHEA IN WOMEN may be resorted to when rest and the application of the ice-bag fail to give relief. The diet should be free from stimulants and spices. Under no circumstances is the uterine cavity or the cervical canal to be invaded in the acute stage with injections or with swabs for fear of extending the infection. Surgery has no place in the treatment of acute gonorrhea, with the possible exception of vaginal drainage in event of an accumulation of pus in the pelvis, an occasion which will rarely arise in the early stage of the infection. In acute infection of the urethra and bladder all injec- tions should be proscribed. Large quantities of water and milk should be drunk for the purpose of cleansing the urinary tract. Urotropin in 0.45 to 0.65 gm. (7 grains to 10 grains) doses, given three or four times a day, is said to have an antiseptic action, and is in general use. Treatment of the Subaxute and Chronic Stages. — Local measures may be instituted in from four to six weeks from the beginning of the infec- tion, depending upon the virulence and extent of the infection. Treatment of Subacute and Chronic Urethritis. — When there is distress from burning pain on urinating, the balsam of copaiba will afford much relief. Jadassohn recommends orgonin in a 1 to 2 per cent, solution, and speaks highly of its effectiveness and of its non-irritating qualities. Pardoe recommends a 2 to 4 per cent, solution of silver nitrate solu- tion as a prophylactic remedy. The application is made in the first twenty-four to forty-eight hours of the infection. In cases of long-stand- ing he irrigates the urethra with permanganate of potassium. Pollard speaks favorably of protargol (5 to 10 per cent, solution) as a prophyl- actic remedy. Bierhoff injects into the bladder 150 c.c. of a 0.25 to 0.5 per cent, protargol solution. The solution is permitted to remain in the bladder until voided. Boldt introduces into the urethra a pledget of absorbent cotton saturated with a 10 per cent, solution of protargol. This application is left for fifteen minutes, when the cotton is removed. Bentler injects a solution of potassium permanganate (1 to 5000) ; this is voided and is followed by an injection into the bladder of a silver nitrate solution (1 to 1000). When the acute stage has passed into the subacute and chronic stages, oleum santale or balsam of copaiba should be administered. The latter may be given in capsules of 15 grains each, three times daily. When there is pain on urination, archovin is said to afford much relief. This remedy produces an acid urine and has a sedative effect upon the mucosa of the urethra; 24 to 48 grains may be given daily in divided doses of 4 to 6 grains each. Gonosan is 80 per cent, sandalwood oil and 20 per cent, kava, soluble in ether, alcohol, or chloroform. Its effect upon the mucosa is to reduce the hyperemia and to anesthetize the sensitive surfaces, thereby relieving pain and diminishing the secretions. That no one remedy has proved eminently satisfactory is evident from the large number of remedies advised, and the hopelessly divergent views of experts as to their proper application. In the chronic stage of gonorrheal urethritis the lesions are localized in one or more areas, TREATMENT OF SUBACUTE AND CHRONIC VULVOVAGINITIS 531 and should be treated with strong astringents and antiseptics, or by the cautery, through an endoscope. For this purpose a 20 per cent, to 50 per cent, silver nitrate solution may be employed, the applications being made with an applicator introduced through an endoscope. Kelly advises the introduction of an endoscope to, but not beyond, the sphincter, and as it is slowly withdrawn the mucosa which folds into view is swabbed with a 5 per cent, silver nitrate solution. To lessen the pain the urethra may be first swabbed with a 10 per cent, solution of the hydrochlorate of cocaine. This may be done through an endoscope in the manner described above. Special attention is to be given the orifices of Skene's glands when infected. Through a large, blunt hypodermic needle a 10 per cent, silver nitrate solution is injected into the lumen of the gland. In obstinate cases the gland should be incised throughout its entire length (one-half inch) by passing a fine probe into the gland and cutting down upon it. The exposed gland is then cauterized with a 10 per cent, solution of silver nitrate. The glands of Bartholin are treated in a similar manner. The efficacy of gonococcic serums in the treatment of gonorrheal urethritis is as yet debatable. Perez-Miro has given intramuscular injections of gonococcic serum, and has observed an initial increase in the secretions, which is later followed by a gradual decrease. Herbst, on the other hand, has had no favorable results from such injections in the acute stage, and doubtful results in subacute and chronic cases. In contradiction to the findings of Herbst, Aronstam obtained positive results in acute cases and negative results in chronic cases. Treatment of Subacute and Chronic Vulvovaginitis. — I"n the treatment of gonorrheal vaginitis the method in general practice consists in inject- ing a 1 to 10 per cent, solution of silver nitrate into the vagina, at intervals of two or three days. In infants this is best done by means of a catheter, and in adults, when ulcers exist, the cautery may be used to advantage, and to prevent cicatrization of the vaginal walls the vagina should be packed with iodoform gauze. While nitrate of silver is unquestionably the most effective agency it may be very distressing. A good substitute, though not so effective, is protargol in a 10 per cent, to 20 per cent, solution. One or more daily vaginal douches of formalin (1 to 4000) or bichloride of mercury (1 to 2000) may be effectively applied. In stubborn cases iodoform powder or aristol may be applied two or three times a week by dusting the powder thickly upon non-absorbent cotton or gauze, and tightly packing the vagina. These packs are removed in twenty-four to thirty-six hours, and are followed by for- malin douches. All infected follicles should be incised and disinfected with pure formalin or burned with a galvanocautery. In the management of acute vulvitis a weak solution of bichloride of mercury (1 to 1000 to 1 to 5000) should be used freely as a douche. Cotton may be saturated with a similar solution and applied several times a. day. The patient should be confined to bed and laxatives administered as required. 532 GONORRHEA IX WOMEN When the BarihoJinean cilanch are infected the most effective cure is found in the eradication of the gLand. If this can be accompHshed without rupturino; the infected gland the wound can be closed with buried layers of catgut. ^Yhen the wound is contaminated by the escape of pus the ca^•ity should be lightly packed with iodoform gauze and allowed to heal by granulations. (For the treatment of vulvovaginitis in infants see page 53(1) Uterus. — Acute Stage. — Whether the infection is due to the gono- coccus alone or to a combination of the gonococcus with the strepto- coccus, staphylococcus, or colon bacillus, non-interference should be enjoined through the acute stage of the infection. All intra-uterine manipulations are proscribed for fear of extending the infection to the tubes and of introducing a secondary infection. An indispensable factor in the treatment of these cases is rest, and to this end such cases are best treated in the hospital or at home under the care of a trained nurse. Antiseptic ^•aginal douches will serve a useful purpose in maintaining cleanliness. The vaginal walls and vulva may become infected from the uterine secretions, and to avoid this, antiseptic ^•aginal douches should be given every four to eight hours. These douches may be of bichloride of mercury ,(1 to 2000) or formahn, 1 dram to j: qua rts of hot sterile water. When all fever has subsided the douches should be given over a period of fifteen to twenty minutes and repeated four times a day. The vagina should be loosely packed with sterile absorbent cotton or gauze tampons soaked in a 7 per cent, ichthyol glycerin solution. These packs should be given e^•e^y da\' or every other day. Six to eight hours is the usual period for the application of the packs. They should be preceded and followed by hot, antiseptic, vaginal douches. No intra-uterine applications should be made until all signs of acute inflammation have passed. This period may be arbitrarily fixed at three weeks. In the acute stage, sitz baths at a temperature of 70° F. may be given for a short period. An ice-bag should be placed over the hypo- gastrium and hot vaginal, bichloride douches should be given at low pressure. Subacute and Chronic Stages. — After the acute stage has passed vaginal douches and glycerin-ichthyol tampons are to be supplemented by topical applications to the infected endometrium. The author's preference is for a 30 to 50 per cent, zinc chloride solution. A general anesthetic is given and the cervix dilated. A 30 to 50 per cent, solution of zinc chloride is swabbed over the infected sur- face. This acts as an escharotic in destroying the superficialh\infected tissues, and has the advantage over the curet in not creating a wound. After an interval of ten days a 5 per cent, solution of zinc chloride should be injected through the cervix into the cavity of the uterus. But two or three drops of the solution should be injected. These treat- ments are repeated at intervals of ten to fourteen days. Not more UTERUS 533 than six to eight injections should be made for fear of too great destruction of tissues. To inject this fluid, the author uses a solid piston tonsillar syringe, with a long curved cannula of a caliber that will permit of easy mtro- duction through the cervical canal without dilatation. Xo anesthetic is required. The curet should never be used in the presence of a purulent leucorrhea, except for the control of hemorrhage. Fig. 354 Injection of the urethra. Labia held apart by the left hand. Throughout the course of the treatment bacteriological examinations of the cervical secretions should be made from time to time. By so doing one can judge of the progress of the case. A cure is pronounced only when repeated bacteriological tests give negative results. When erosions of the cervix exist, these erosions should be painted with a 10 to 20 per cent, solution of silver nitrate or with a 10 to 20 per cent, solution of zinc chloride. These applications may be repeated once or twice a week. When there is a deep-seated infection of the vaginal portion of the cervix the most effective means of treatment is the amputation of the cervix. Hysterectomy is advised when the uterus and its appendages are together involved. It is only when more conservative, tentative 534 GONORRHEA IN WOMEN measures have been given a full trial and have failed to give relief that such heroic measures should be adopted. Fallopian Tubes. — Acute Stage. — During the acute stage the treatment is that of acute pelvic inflammation in general. During this period unnecessary examinations and manipulations are prohibited for fear of stripping the pus contents of the tubes into the pelvic cavity. In addition to rest, measures for the relief of pain and the depletion of the congested tissues, such as vaginal hot douches, glycerin tampons, and ice packs to the lower abdomen, are to be employed. Chronic Stage. — Palliative treatment will forestall operative inter- vention in a large proportion of cases. The application of long-continued hot vaginal douches, of ichthyol and glycerin tampons, the regulation the bowels, and the avoidance of excessive exercise will often serve of to keep the patient in a fairly comfortable condition. When the tubal infection continues to cause serious disturbances, and at intervals of weeks and months is awakened to acute exacerbations, operative measures should be resorted to. The removal of the tubes alone seldom results in complete relief. Nothing short of the complete extirpation of the uterus and infected tubes will promise an ultimate cure in a large proportion of cases. When possible the ovaries or a portion of them should be saved. The choice between a vaginal or an abdominal operation depends upon the extent of the adhesions. Vaginal drainage should be done when the tubes are distended with pus and can be readily reached per vaginam. For further discussion of the operative technic of inflammatory diseases of the tubes and ovaries see respective chapters. Ovaries. — Acute Stage. — The management of acute ovaritis does not differ from that of acute metritis. Chronic Stage. — The utmost conservatism should be exercised in the management of infected ovaries. The author questions, if in a young woman, it is ever necessary to remove all of both ovaries. Even when both ovaries are the seat of abscess formation, it is almost always possible to leave a portion of the abscess wall. All means should be used to conserve the ovaries. When these measures fail to give the desired relief, when the patient persists in her complaints of pain, conservative surgery must be invoked, but not the surgery that demands the sacrifice of both ovaries. Rectum. — ^The infected rectum should be irrigated with normal salt solution. After cleansing it in this manner one of the various silver salts should be injected. For this purpose 20 per cent, protargol or 40 per cent, argyrol solution may be used. In stubborn cases a stronger solution may be used as a swab. Fissures and ulcerations should be treated with the Paquelin cautery. Bladder. — In the acute stage of gonorrheal cystitis internal medication is of value. Urotropin in 7-grain doses should be given four to six times a day, and to this 5 grains of salol may be added. Benzoic acid in 10-grain doses, given three times a day, will act as an antiseptic in the bladder. The following prescription is advised by Bandler: BLADDER 535 I^ — Extract hyoscyam gr. ss . 037 Salol . gr. V 0.325 Urotropin gr. v 0.325 F. tal. capsulse, no. xx. Sig. — One every three hours with water. For relief from pain, sitz baths and hot fomentations are of value, but it may become necessary to resort to hypodermic injections of morphine. A moderate sedative to the bladder is found in a combi- nation of the extracts of opium and hyoscyamus, each 1 grain, given as required. Rectal suppositories of opium and belladonna will afford relief from pain. The local treatment of acute cystitis is of importance. The bladder should first be irrigated with sterile normal salt solution or a 1 per cent, boracic acid solution. A non-irritating silver solution should be injected into the bladder immediately following the irrigation. Pro- targol (1 to 500) may be used for this purpose. If the results are not satisfactory, a solution of silver nitrate (1 to 5000) may be injected in quantities of 2 to 6 ounces and allowed to remain ten or more minutes within the bladder. The strength of the silver solution may be increased to 1 to 500 in stubborn cases. Rest in bed is of the utmost importance. An ice-bag may be applied over the hypogastrium, and short, cold vaginal douches given two to four times daily. Large quantities of milk and water should be drunk. A liquid diet, together with fruits, is advised. All red meats, alcoholic beverages, and condiments should be avoided. A long list of drugs has been recommended for the treatment of acute cystitis, such as oil of sandalwood, copaiba, and sweet spirits of nitre. Some virtue may be ascribed to them, but they are one and all more or less disturbing to the stomach and unreliable. In the chronic stages of cystitis local applications are advised. No drug is so effective or in so general use as the nitrate of silver, injected into the bladder in a solution of 1 to 2000 and retained for twenty to thirty minutes and then voided. The solution may be gradually increased in strength to 1 to 100 when it is well borne. The bladder should be first irrigated with a boracic acid solution before applying the silver nitrate. It is not always possible to get results from any one line of treatment conducted for a considerable time, hence the advisability of resorting to other medicaments when progress is not satisfactory. Topical treatments, made by an applicator inserted into the bladder through an endoscope, will often accomplish the desired results when instillations and irrigations fail. Silver nitrate, in a 10 to 20 per cent, solution, may be thus applied once or twice a week, the application being made direct to the affected area. Finally, if all topical applications fail, the surgeon may put the bladder and urethra at rest and establish free drainage by making vesicovaginal drainage through an artificial fistula. 536 GONORRHEA IN CHILDREN '■ GONORRHEA IN CHILDREN Etiology. — Gonorrhea in children usually arises from contact with soiled linen and sponges. In children's wards the infection may be carried on thermometers and fingers of nurses, who go from one child to another without taking the precaution to thoroughly cleanse their hands and thermometers. Children have been known to become infected when sleeping with an infected mother or nurse. Unjust accusations have been made through ignorance of the fact that gonorrhea in children is not infrequently the result of accidental contamination. That the bath may convey the infection is illustrated by a report from Welt- Kakels, who referred to an instance occurring in Pose, Germany, where 236 school girls acquired vulvovaginitis from a common bath. Kelly says that girls are infected intentionally through a somewhat prevailing superstition among the lower classes that the disease can be eradicated if it is transferred to a healthy person, notably a virgin. Vidvovaginitis.— According to most authorities vulvovaginitis exists in about 1 per cent, of female children, and that the great majority of these cases are gonorrheal. It is the exception that a purulent vaginal discharge in children is due to causes other than gonorrheal. The vulva and vagina of adults are not easily infected because of the presence of multiple layers of. fat epithelium arranged in palisade form. In children these structures are co\'ered with delicate epithelium, which affords little protection against invading gonococci; hence the frequency with which vulvovaginitis is found in children. The gonococci pass between the epithelial cells, and are known to pass beyond the epithelium into the subepithelial tissue. Vulvovaginitis in children, in the acute stage of the infection, does not differ essentially from that found in adult life. The labia are swollen, red, and edematous. The hymen and inner surfaces of the labia are sites of predilection, and the inflammation may extend to the perineum and neighboring skin surfaces. Condylomata may cover the vulvar and peritoneal surfaces and the region about the anus, though this is exceptional. The infected surfaces are usually covered with a greenish or yellowish discharge. The infection may end here, but, as a rule, the vagina is invaded. The recognition of an existing vaginitis is not difficult. After cleansing the vulvar surfaces, pus may be seen to exude through the opening of the hymen, or a very small speculum may be, passed into the vagina, though this latter procedure is open to the serious objection that the disease may thereby be conve^'ed from the vulva to the vagina. Certain so-called congenital anomalies may be ascribed to gonorrhea acquired in titero, i. e., imperforate hj-men, adhesions of the labia and prepuce, diseased and malformed uteri, and Fallopian tubes. The urethra is frequently the seat of gonorrhea, but the author knows of only one reported case in which the infection extended to the bladder, that of Wertheim, who found gonococci in the epithelial interspaces of the TREATMENT 537 bladder, in the wall of the bladder, and within the bloodvessels of the bladder wall. In rare cases the infection may extend from the cervix to the body of the uterus, thence to the tubes, ovaries, and pelvic peritoneum. Goodman reported eight cases of gonorrheal general peritonitis, with two fatalities. The favorable prognosis of gonorrheal peritonitis is worthy of note. The pathological lesions and clinical manifestations do not differ from those found in adult life. Bandler observes that children suffering from pelvic or general gonorrheal peritonitis are commonly assumed to have appendicitis, but the presence of a gonor- rheal vulvovaginitis should lead to a correct diagnosis. Proctitis occasionally accompanies a vulvovaginitis and is recognized by itching and irritation about the anus, a purulent discharge from the rectum, and the detection of gonococci in the discharge. Occasionally ulcers are developed on the rectal mucosa. These ulcers may give rise to a bloody discharge from the rectum and to painful stools. Treatment. — Since the infection is most frequently conveyed by napkins, it follows that all napkins worn by infected children should be burned, and all linen should be soaked in an antiseptic solution, then washed and sterilized. In cleansing the infected parts absorbent cotton should be used in place of sponges. Baths should not be given in tubs shared by other patients and healthy individuals. Strict isola- tion of these cases should be maintained in hospitals, hence they are not to be cared for in wards. This quarantine should embrace the nurse in attendance if further spread of the disease is to be prevented. The quarantine should not be raised as soon as the local signs of inflam- mation subside, but should continue so long as the presence of gonococci can be demonstrated in the secretions. Bandler recommends painting the vulva with a 10 per cent, solution of silver nitrate. Not only the vulva but the surrounding skin surfaces should be treated in like manner. Warm sitz baths should be given once or twice daily. When there is much irritation the surfaces should be anointed with a 2 per cent, protargol ointment. Similar remedies may be employed in the treatment of gonorrheal infection of the rectum. Fissures and ulcers should be cauterized by the Paquelin cautery. It is essential to enjoin rest in bed in all these cases throughout the acute stage. Butler and Long, of Chicago,^ in making a report of their clinical observations with gonorrheal vaccine in the treatment of vulvovaginitis in children, say: "The contention might be raised that gonorrhea is aggravated in female children by local treatment and that the discontinuance of such treatment might be expected to be followed by betterment. The possibility of this should be conceded, but when we are able to trace daily variation in the clinical manifestations with the ebb and flow of the wave of immunity, when we see within twenty-four hours a 1 Jour. Amer. Med. Assoc, March 7, 1908. 538 GONORRHEA IN CHILDREN profuse discharge cease and find negative smears coincident with a marked rise in the opsonic index, the above contention loses much of its weight, and in the cases treated must be excluded from consideration in calculating results. "If from our work any conclusions are permissible, we believe it no exaggeration to state that vaccine therapy has a place in the treatment of gonorrhea in the female, that it appears to be far more efficient, and at the same time scientifically more tenable than local antiseptic treatment," While a vulvovaginitis usually disappears with six to twelve weeks' of careful treatment, exacerbations are often observed. One case is recorded where the disease lasted four vears. CHAPTER XXIV TUBERCULOSIS OF THE GENITAL ORGANS Etiology 1. Primary Infection 2. Secondary Infection Tuberculosis of the Vulva and Vagina Tuberculosis of the Cervix Tuberculosis of the Uterus Tuberculosis op the Ovaries Tuberculosis of the Fallopian Tubes Tuberculous Peritonitis Prognosis Treatment Etiology. — ^While the knowledge of the existence of genital tuber- culosis in women dates to the middle of the eighteenth century, and an accurate and exhaustive contribution on the pathogenesis, diagnosis, and surgical treatment was presented by Hegar as early as 1886, yet it may be stated that the profession in general fails to appreciate the prevalence of the disease. Essential Causes. — ^The essential cause of tuberculosis of the genital organs is the tubercle bacillus of Koch, which is conveyed to the genital organs either directly by hands, instruments, or coitus, or indirectly by way of the bloodvessels and lymphatics from neighboring and distant portions of the body. Predisposing Causes. — As predisposing causes to tuberculosis of the genital organs, Hegar mentions general and local malnutrition, hypo- plasia, and other developmental anomalies of the genital organs, puerperal and gonorrheal infections, syphilis and childbearing. Age. — Genital tuberculosis has been found at ah periods of life. Feise and Schmorl found tubercles in the genitals of a fetus. A number of cases have been reported in ages ranging from birth to eleven years. More than 50 per cent, of all cases occur before thirty years of age and a goodly proportion develop in childhood. Still estimates that 9.5 per cent, of tuberculous girls under twelve years of age have genital tuberculosis. It is exceptional to find tuberculosis developing in the genital organs after forty years of age. Frequency. — About 10 per cent, of ah forms of salpingitis are tuber- culous. In 795 autopsies performed by Berkeley on tuberculous cases 62 showed genital tuberculosis. The proportion of women suffering from pulmonary tuberculosis who have genital tuberculosis is variously estimated at 6 to 12 per cent. In 955 autopsies on women who died of pulmonary tuberculosis, the lesion was found in the genital organs in 14.7 per cent. (Turner). Schlimpert finds about 2 per cent, of genital tuberculosis in his autopsies on women. In every instance there were active or latent foci elsewhere in the body. He demonstrated that the infection was conveyed by way of the blood stream in nearly every instance. 540 TUBERCULOSIS OF THE GEXITAL ORGAXS In all Schlinipert found 73 cases of genital tuberculosis Avith the following organs involved: Uterus, 41 times; cervLx, 3 times; vagina, 7 times; tubes, 51 times; ovaries, 10 times. In about one-half the cases the peritoneum was involved. Genital tuberculosis occurs about five times as frequently in the female as in the male. Amann estimates that 3 per cent, of tuberculous lesions involve the genital organs of the male as compared with 20 per cent, in the female. Primary infection of the genital organs is rare, though it is possible for the vulva, vagina, cervix, uterus, tubes, and ovaries to be the primary seat of infection. Tubercle bacilli may be conveyed direct to these organs by the examining finger, by instruments, and by coitus with a tuberculous male. It is not essential that the male genitals be tuberculous in order that the husband may transmit the disease to the genitals of the wife. Tubercle bacilli have been found in the semen of men whose genitals were free of tuberculosis but whose lungs or intestines were infected. In children the bacilli have been conveyed to the genitals from infected stools and from soiled linen. Without a postmortem examination of all organs, it is not possible to speak with full assurance of a primary lesion in the genital organs. A clinical examination, however searching, may fail to disclose a latent primary focus in the lungs, intestines, bones, mesenteric glands, and elsewhere. Secondary infection of the genital organs is not uncommon when tuberculous foci exist in adjacent or remote regions of the body. From adjacent structures we find tuberculosis extending from the peritoneum to the tubes and ovaries and downward to the uterus, cervix, vagina, and vulva. Again, the infection is conveyed by blood and lymph vessels from the lungs, mesenteric glands, intestines, and bladder to the genital organs. We will here discuss ascending and descending forms of genital tuberculosis. Ascending tuberculosis is observed in a small percentage of cases. The infection in rare instances begins in the lower genital tract and travels upward through the uterus to the tubes, ovaries, and peritoneum. Descending tuberculosis is by far the most common. The lesion may begin in the peritoneum and extend to the ovaries and tubes and downward to the uterus, cervix, vagina, and vulva, though, as a rule, the disease does not extend lower than the uterus. Tuberculosis of the Vulva and Vagina.— Primary tuberculosis of the vulva and \-agina is rare, but possible. The lesion is almost invariably secondary to tuberculosis in the tubes, and back of this there is usually a primary focus in the lungs or some other remote organ. The lesion is easily confounded with lupus, rodent ulcer, esthiomene, cancer, syphilis, and phagedena. (See Chapter XVII.) Beyea reported 69 cases of tuberculosis of the cervix, 19 of this number being limited to the portio vaginalis and 6 to the cervical canal, and in the remaining 44 both portions of the cervLx were involved. TUBERCULOSIS OF THE FALLOPIAN TUBES 541 Tuberculosis of the Cervix. — It is doubtful if tuberculosis ever exists as an isolated lesion in the cervix. It is easily confounded with car- cinoma and syphilis. Tuberculosis is seldom found to coexist in the body of the uterus and cervix. The tubes and cervix may be involved and the uterus remain free of infection. Tuberculosis of the Uterus. — Next to the tubes the uterus is most often involved. In 172 cases of genital tuberculosis reported by Merlette the uterus was invoh'ed 75 times. Palano reports cases ranging in age from nine and a half months to sixty-four years. 83 per cent, of all cases tabulated by Palano dated back to childbirth. Tuberculous metritis is not incompatible with pregnancy, but pregnancy will commonly cause a preexisting tuberculous lesion to become active and to spread to adjacent and remote tissues. The tuberculous lesion is commonly confined to the endometrium, though the musculature is known to be invaded, particularly in childhood. The question is raised as to whether tuberculosis is ever primary in the endometrium. While it is possible, the rule is that the endo- metrium is invaded from the tubes. Doederlein recognized three types of tuberculous endometritis, the miliary, interstitial, and ulcerative. (See page 423.) Tuberculosis of the Ovaries. — In nearly every instance the ovary is infected by the tubercle bacillus secondary to the Fallopian tubes or peritoneum. Wolff finds that 60 per cent, of all cases of tuberculous ovaries are associated with tuberculosis of the tubes or peritoneum. Instances are recorded in which the ovary was the only pelvic organ involved, but in all cases there was a remote primary focus. The ovary is involved in one-third of all cases of genital tuberculosis, and in more than half the cases the lesion is bilateral. It must be borne in mind that miliary tubercles may be scattered throughout the ovary without appearing on the external surface, so that it is possible to over- look the lesion, even with the abdomen open. Without a microscopic and bacteriological examination the lesion may not be recognized. (For the pathology and diagnosis of tuberculous ovaritis see above.) Tuberculosis of the Fallopian Tubes. — While the Fallopian tubes are the most frequent seat of genital tuberculosis the lesion is seldom confined to the tubes, but invades adjacent structures. In a small percentage of cases tuberculous salpingitis is primary, but in nearly every instance tuberculous foci are found elsewhere in the body, and the infection of the tubes is the result of direct extension from surrounding structures or the bacilli are conveyed from the primary focus in remote organs by way of the blood or lymph. Frequency of Tuberculous Salpingitis. — The tubes are involved in about 90 per cent, of all cases of genital tuberculosis, and the infection is confined to the tubes in about one-fourth of this number. In 4470 autopsies performed on women by Schraum, Frerichs, and von Rosthorn, tuberculous salpingitis was found 53 times. In 814 cases of salpingitis (Williams, Martin, von Rosthorn), tuberculosis was found 29 times. In 17,470 autopsies on women performed in the German clinics 542 TUBERCULOSIS OF THE GENITAL ORGANS tuberculosis of the tubes was found in 142 cases, or 1 in 123. About 1 per cent, of all female cadavers have tuberculosis in the tubes. In a total of 884 observations made by Williams, Martin, Menge, and von Rosthorn there was an average of 6.2 per cent, of tuberculosis found in all forms of salpingitis. Age of Appearance. — No age is exempt. It has been found in utero at seven months and at the age of seventy-nine years. The most susceptible period is between twenty and thirty years of age, though the period of ten to twenty and thirty to forty are but little less sus- ceptible. It is rare that the disease occurs after forty years of age. Avenues of Invasion. — The tube is invaded by: 1. Continuity of tissues (peritoneum, uterus, vagina, bowel, and bladder). 2. Bloodvessels and lymph vessels. More often the lungs are the primary seat of infection. Why are the Fallopian tubes more liable to tuberculosis than the other genital organs? Hegar and Sippel offer the explanation that the irregularities in the mucosa of the tubes favor the lodgement of tubercle bacilli. Amann further adds the theory that the convolutions of the tubes and the impoverished blood supply favor the invasion of tubercle bacilli. Gonorrheal infection of the tubes will doubtless lower the resistance of the tissues and render them more susceptible to tuberculosis. Pathology and Diagnosis. — (See page 541.) Treatment of Genital Tuberculosis. — The question of operative interference naturally arises in a discussion of the treatment of genital tuberculosis. In deciding this question, inquiry must be made (1) as to whether genital tuberculosis leads directly to a fatal issue, and (2) as to whether genital tuberculosis leads to invalidism, 7^ genital tuberculosis a direct cause of death f A survey of the literature convinces the author that death is rarely attributed directly to genital tuberculosis. Simmonds, of Hamburg, has never observed a death which he could ascribe to genital tuber- culosis. Schmorl and Schlimpert report 144 autopsies in which genital tuberculosis was found, and in none of these cases was the death directly caused by the pelvic lesion, though in two instances the pelvic lesion was a contributing factor. It follows that there is seldom if ever a vital indication for operative interference in genital tuberculosis. The second question is not so easily disposed of. Does the genital tuberculosis produce symptoms which justify operative interference? We have the authority of Doederlein and Kroenig that ^genital tuberculosis rarely gives rise to a miliary tuberculosis and that ulceration seldom develops between the genital tract and the bladder or rectum. There is much difference of opinion as to the frequency of the develop- ment of general tuberculous peritonitis from a primary focus in the genital organs. There is an evident lack of harmony in the views of TREATMENT OF GENITAL TUBERCULOSIS 543 anatomists and clinicians on this important point. Schickele, of Freiburg, finds but little tendency in this direction. The prevailing impression among clinicians appears to be that there is liability of spreading the infection from the uterine appendages to the peri- toneum. In considering this point it must be borne in mind that genital tuber- culosis is rarely primary; that in the great majority of cases the primary lesion is in the lungs or intestines. It is therefore manifestly difficult to judge the symptom-complex and determine with certainty what should be credited to the lesion in the lung or bowel and what to the genital organs. Symptoms directly due to genital tuberculosis are seldom severe and can usually be relieved by palliative measures. The paroxysmal pains give way to rest and the application of heat. The hemorrhages, which occur in but a small percentage of cases, are in reality the only urgent indication for operative interference. In tuberculous endome- tritis, Hegar advises curettage of the uterus, but Schauta and Pozzi believe curettage to be merely a palliative measure in temporarily checking the bleeding. They argue that curettage is not a harmless procedure because of the danger of spreading the infection, of adding a secondary type of infection, and of awakening a latent infection in the lungs or elsewhere. The conclusion is forced upon us that a radical operation is rarely justified for relief from symptoms caused by genital tuberculosis. This is so because: 1. The symptoms directly referable to genital tuberculosis are rarely severe and will usually yield to palliative measures. 2. Operative measures may cause an awakening of a latent primary focus and result in a local or general dissemination of the infection. 3. There is a relatively high primary mortality in these operations. Doederlein's estimate is 10 per cent. 4. Since genital tuberculosis occurs with greatest frequency in girl- hood and early womanhood, and the tuberculous lesion is seldom con- fined to one portion of the genital tract, operative interference may result in an unwanton sacrifice of organs. 5. There is a marked tendency toward self-limitation and sponta- neous healing in genital tuberculosis. To what extent should the operation be carried f Inasmuch as the tubes are almost always the primary seat of infection, so far as concerns the genital organs, the rule is generally followed to remove only the tubes. Both tubes are involved in about 90 per cent, of cases. The ovaries are only removed when there are evident tuberculous lesions in the ovaries. It is questionable if both ovaries should be removed in young women unless the disease is far advanced. The uterus should be removed when infected if the patient is advanced in years and if there is uncontrollable bleeding. In tuberculosis of the cervix, unaccompanied by an involvement 544 TUBERCULOSIS OF THE GENITAL ORGANS of the upper genital tract, a high amputation of the cervix should be made. In tuberculosis of the vulva and vagina, ulcers may be cauterized or excised and papillary growths may be removed, though here the .r-rays are of special value. Tuberculous Peritonitis. — According to Nothnagel 90 per cent, of tuberculous peritonitis is found in the female. In former years tuber- culous peritonitis was believed to be almost uniformly fatal. In recent literature we find contradictory views expressed. Some would have it that the disease is largely amenable to surgery; others that the indications for operative interference are necessarily restricted to a small percentage of cases. Indications for Treatment. — The purpose of treatment, according to Murphy, is fourfold: 1. To remove the source of supply to the peritoneum. 2. To remo^'e from the peritoneum the products of the infective process. 3. To increase tissue resistance for the purpose of encapsulating the remaining tuberculous foci. 4. To avoid mixed infection. JVhat is ihe cause of death in tuberculous peritonitis f Death may result from: 1. Mechanical ileus due to adhesions. 2. Toxic absorption. 3. Rupture of tuberculous ulcers of the bowel into the free peritoneal cavity. Postmortem observations reveal that the cause of death in 90 per cent, of cases is due to the primary focus in the lungs, meninges, or to general miliary distribution, ^yhen possible the primary focus (tubes, appendix) should be removed; this will increase the percentage of cures and decrease the percentage of recurrences. The fimbriated end of a tuberculous tube usually remains open, and so long as this condition prevails the peritoneum is continually supplied with fresh tuberculous material. Furthermore, the tuberculous lesion in the mucosa of the tubes is slow to heal. For these reasons the infected tubes should be removed when found in the presence of a tuberculous involvement of the peritoneum. Abdominal Section. — The percentage of cures following abdominal section for tuberculous peritonitis is recorded by Koenig as 65 per cent., Margarucci as 85 per cent., Roersch as 70 per cent., and Wunderlich as 20 per cent. The difference in results is largely accounted for by the difference in indications for operative interference. Some would operate only in the exudative type, while others Avould include the adhesive and ulcerative types. Again, there are surgeons who will not open the abdomen in the presence of an active focus in the lung or elsewhere, while others will disregard such complications. Then, too, in the making of statistics some operators include all deaths: those due directly to tuberculous peritonitis and those due to tuber- TUBERCULOUS PERITONITIS 545 culosis of other regions. The only reliable statistics are those based upon a pathological classification. To what extent does tuberculous peritonitis affect the health of the indi- vidual? Doederlein believes that a large percentage are not seriously affected. He says that fully 50 per cent, of the women who enter his clinic with tuberculous peritonitis, and are subsequently operated upon, complain of sterility and have little or no distress in the abdomen. Some com- plain only of backache and others of a large abdomen. Few suffer from severe pain or hemorrhage. Of those who are seriously debilitated, and they constitute the other 50 per cent, of cases, the debility is largely attributable to the primary focus in the lungs or bowel rather than to the peritoneum or pelvic organs. Primary Mortality of Abdominal Section. — The primary mortality of abdominal section for tuberculous peritonitis is relatively high. Ivroenig gives 3 per cent., Lindner 7.5 per cent., and Doederlein 12 per cent. The following rules will govern abdominal section for tuberculous peritonitis : 1. Operate in only the exudative type. The adhesive and ulcerative types are not favorable subjects for operation. 2. Do not operate in the presence of a fever or when there is an active focus of tuberculosis in the body. Borchgrevink recommends medical treatment in tuberculous peri- tonitis. He says that when peritoneal tuberculosis exists without fever the disease will usually run a favorable course and does not require a laparotomy. Medical Treatment. — Medical treatment of tuberculous peritonitis is the same as that employed in the management of tuberculosis of the lungs. Good food and fresh air are essential. Such tonics as cod-liver oil do not in the least supersede fresh air and an abundance of nourish- ing food. No medicine should be given that will disturb the stomach and interfere with the ingestion of food. Tuberculin has been extolled, but it is not clear that its value is great as a curative agent. Cures by the administration of tuberculin have been reported by Gray, Rumph, McCall, Leser, Kummel, and Riegel. Von Ruck gives encouraging reports, having a record of 3 cures in 4 cases; 82.3 per cent, of Borchgrevink's cases were cured by medicinal means. Johnston in a review of the statistics says: "By comparing the statistical results of cases that have been observed for a sufficient time after treatment, one is impressed with the fact that the figures are about the same in those treated surgically as in those treated by medi- cinal means, and one may conclude that the prognosis for recovery is good in one-fourth to one-third of all cases of tuberculosis of the peritoneum." 35 CHAPTER XXV NUTRITIONAL DISTURBANCES OF THE GENITAL ORGANS Retrogressive Tissue Changes Progress^: Tissue Ch.\xges Atrophy of the Vulva (Ivraurosis Elephantiasis Vulvae Vulvse) Condyloma Acuminata Atrophy of the "N'agina Hypertrophy of the Vulva Atrophy of the Uterus H^iDertrophy of the CUtoris Physiological Atrophy H}-pertrophy of the Labia Superinvolution of the Uterus H}-pertrophy of the Cer^^x Atrophy of the Ovary Supravaginal H^-pertrophy Infravaginal H^-pertrophj' Subinvolution of the Uterus HA'pertrophy of the Ovary There are found throughout the genital tract certain nutritional disturbances which cannot be grouped with inflammations or tumor formations, and so for convenience are incorporated in a separate chapter. These nutritional changes may be classified as retrogressive and progressive tissue changes. RETROGRESSIVE TISSUE CHANGES Atrophy of the Vulva (Kraurosis Vulvas). — After the menopause there occurs a physiological atrophy of the vulva in which the labia majora lose their plumpness, the labia minora diminish in size and may wholly disappear, the clitoris is shortened, the mucous membrane becomes dry and pale, and the vulvar orifice is narrowed. Kraurosis vulvae is a term applied to a specific form of atrophy of the vulva, the cause of which is not known. The extent of the atrophy may be greater than that found in old age. The labia majora are flat and flaccid; while the mucosa may be so friable as to be injured by the examining finger. The labia minora and clitoris may wholly disappear. In addition to the dryness of the surface there is extreme sensitiveness. Dyspareunia is a common complaint, and when asso- ciated with itching and a sense of dryness in the vulva, the possibility of kraurosis is to be borne in mind (Fig. 355). Kraurosis occurs chiefly in women of advanced age; in women who have borne children and have become sterile; in the married and in the widow. The lesion sometimes follows removal of the ovaries. That it is due to syphilis and gonorrhea is quite improbable. The lesion is probably of inflammatory origin. The glandular structures RETROGRESSIVE TISSUE CHANGES 547 of the affected area disappear; the papillae are poorly developed and the conum is atrophied. Fig. 355 Kraurosis vulvae. Clitoris and labia minora completely atrophied; the labia majora flattened and wrinkled. (Gerhard.) Fig. 356 Kraurosis vulvae. Marked hornification of the cerium, with round-cell infiltration; papilla are absent. (Gerhard.) PaUiative Treatment.— The pain, pruritus, and burning of kraurosis vulvae demand relief so far as may be given. Local applications afford only temporary relief, if any. Relief may be afforded for some time by the application of a 10 per cent, solution of nitrate of silver or of pure 548 NUTRITIONAL DISTURBANCES OF THE GENITAL ORGANS carbolic acid. Hot fomentations are soothing. The vulva should be kept smeared with a 3 per cent, carbolo-salve; this protects the Fig. 357 Fig. 358 Kraurosis vulvae. Fig. 359 Margins of denuded area approximated. Removal of area involved in kraurosis vulvae. Dotted lines represent area of denudation. surface from the irritating influences of the urine. A gauze pad soaked in a saturated solution of the acetate of lead will afford some relief. Operative Treatment. — When palli- ative measures fail, relief can only be obtained through operative interfer- ence. A forcible stretching of the vulvar outlet will sometimes give relief for a considerable period, but permanent relief can only come from excision of the affected skin surface. Technic of Operation. — An incision is made with the knife 2 cm. outside the involved area. The skin is dis- sected off and the margins approxi- mated with interrupted silkworm-gut sutures. When the greater portion of the vulva is involved the typical operation is carried out as illustrated in Figs. 357, 358, and 359. RETROGRESSIVE TISSUE CHANGES 549 Atrophy of the Vagina. — (See Atresia of the Vagina, Senile Vaginitis, page 409.) Atrophy of the Uterus. — Physiological Atrophy. — Physiological atrophy of the uterus follows the menopause. Similar changes in the uterus follow the removal of the ovaries. Superinvolution of the Uterus. — (Secondary Atrophy, Puerperal Atrophy, Lactation Atrophy.) — In this condition the puerperal uterus has involuted beyond the normal limits and may be reduced to one- half or one-third the normal size. As a rule, the tubes and ovaries share in the atrophic changes. Etiology. — 1. Postpartum and postabortive hemorrhages. 2. Puerperal sepsis. 3. Prolonged lactation. 4. Wasting diseases complicating the puerperium. Secondary atrophy of the uterus and ovaries may be due to con- stitutional disturbances, leading to malnutrition or to indefinite embryological disturbances. Not infrequently these conditions can be traced to the diseases of childhood, notably scarlet fever, measles, mumps, and diphtheria. When the development of the ovaries is checked, there must of necessity follow atrophic changes in the uterus and tubes. This is so because the internal secretion of the ovary is essential to the development of these organs. Chlorosis is believed by many to be associated with a faulty secretion of the ovaries. This theory finds support in the fact that chlorosis occurs exclusively in girls at an age corresponding to their sexual development, between the ages of twelve and twenty. Von Noorden advances the theory that the internal secretion of the ovary stimulates the blood-forming centres, and when this secretion is lacking there is an underdevelopment of blood. In further support of von Xoorden's theory is the common finding of poorly developed genital organs in chlorotic girls. About 75 per cent, of chlorotic girls suffer from a partial or complete loss of their menstrual functions. They usually menstruate early rather than late in life. Obesity may be associated with underdevelopment of the ovaries, tubes, and uterus, and hence with a faulty functionating capacity of these organs. The tendency to lay on fat is probably secondary to the atrophic changes in the ovaries, and suggests the tendency of women to increase in w^eight after the menopause. Associated with the loss of ovarian secretion is the loss of the thyroid secretion, as has been frequently demonstrated. Symptoms. — 1. i^menorrhea. 2. Sterility. 3. Nervous disorders. The patient either fails to resume the menstrual functions or men- struates but little, depending upon the degree of atrophy. Unless the atrophy is checked before the atrophic changes become pronounced 550 XUTRITIOXAL DISTVRBAXCES OF THE GEXITAL ORGAXS the capacity for childbearing will be lost. Such individuals are usually classed as neurotics. They complain of general debility, headaches, lumbosacral pains, and gastro-intestinal disturbances. Diagnosis, — The diagnosis is suggested by the history, ^^^len the patient has been perfectly regular in her menstrual history, has given birth to a child, and one or more of the above causal factors have been interjected, and following childbirth the physiological period of lactation is prolonged beyond the usual period, the presumption is that the uterus has involuted beyond the normal limits. The diagnosis is confirmed by a bimanual examination and by the passage of a sound into the uterus. If the uterine cavity is less than two and a half inches in depth the diagnosis of superinvolution is established. If the cervix is inspected through a speculum and is found smaller than normal, it is assumed that the body of the uterus is correspondingly small, though this is not always the case. Prognosis. — A moderate degree of atrophy may be corrected by increasing the nutrition of the patient, but a well-advanced atrophy cannot be remedied. Treatment. — General Treatment. — Whatever will improve the general nutrhion will tend to develop the uterus. A nutritious diet, exercise in the open air, indoor gymnastics, cold baths, are all of value. Tonics of iron and arsenic, such as Bland's pill and Fowler's solution, may be indicated. Local Treatment. — The pelvic circulation may be stimulated by massage and short, hot douches. The wearing of a stem pessary is also recommended. Atrophy of the Ovary. — The physiological atrophy of the ovary in the climacteric may occur some time before the menstrual periods altogether cease, or may be delayed many years. Atrophy of the ovary usually precedes the menopause by a year or more, but is seldom complete for several years after the menopause. A pathological atrophy of the ovary results from interference with the nutrition of the organ and from direct and continuous pressure upon the ovary by tumor formations and inflammatory exudates. Inflammatory adhesions may contract about the ovary and tube, limit- ing the blood supply and bringing on atrophy. Swellings of the tubes, uterus, and ovaries may cause pressure atrophy. Atrophy of the ovary may follow the infectious and contagious diseases, s\'philis, diabetes, the primary and secondary anemias, myxedema, morbus Basedowii, tabes dorsalis, acromegaly, and poisoning by arsenic and phosphorus. Varicosities of the veins of the mesovarium have been reported by Palmer Dudley as being responsible for atrophy of the ovary. ]\Iartin, in his report of 40 cases, takes the position that the majority of women with atrophied ovaries suffer from pulmonary tuberculosis. The menstrual functions become less active as the atrophy of the ovaries progresses. The indi^'idual often increases in weight. Nervous disturbances are frequently complained of, such as pain and throb- bing in the head, flashes of heat and cold, insomnia, irritability of temper, PROGRESSIVE TISSUE CHANGES 551 and despondency. A positive diagnosis is reserved until direct inspection of the ovaries can be made. Atrophy, together with cystic degeneration, frequently explains the early occurrence of the menopause. Treatment. — The author knows of no treatment that will correct the atrophic changes in the ovaries, but there is in the corpus luteum extract a remedy that will, in a measure, afford a substitute for the diminished fi*^- ^eo ovarian secretions, and in this way will help to control the nervous phenomena incident to the loss of ovarian function. PROGRESSIVE TISSUE CHANGES Elephantiasis Vulvae. — In the early stage of development the growth is not unlike simple hypertrophy, but as it progresses it tends to become more and more pedunculated and may extend to the knees, weighing several pounds. ^^^len the surface is smooth it is known as elephantiasis glabra; when nodular, elephantiasis tuberculosa, and when covered with warty excrescences, ele- phantiasis condylomata. The surface may be more or less ulcerated (Fig. 362). The point of origin may be the labia majora, labia minora, mons veneris, or clitoris. It is unusual for the growth to arise simultaneously from two or more of these surfaces. The greater portion of the growth is of connective tissue, with edematous infiltration of the connective-tissue spaces. There is a scant blood-supply to these growths. The essential cause is the filaria san- guinis hominis. Elephantiasis some- times arises from the base of old ulcers and suppurating buboes. Stenosis or occlusion of the lymph channels is undoubtedly an underlying factor, but the cause of obstruction to the lymph channel is unknown. The patient consults the physician because of the weight of the growth and its interference with walking and coition. Diagnosis. — The diagnosis will involve little difficulty. It is distin- guished from carcinoma by the absence of friability, the slow growth, and, finally, by a microscopic section showing an absence of epithelial Elephantiasis of the \ailva. Pettit.) (Bonnet and 552 NUTRITIONAL DISTURBANCES OF THE GENITAL ORGANS invasion of the connective tissue and the presence of connective-tissue hyperplasia. There are no constitutional effects. Treatment. — The treatment is both medical and surgical. Medical Treatment. — It is only in the acute stage that medical treat- ment will avail anything. At this time the patient should be kept in bed and hot fomentations applied to the affected parts. The application of gauze, saturated in a lead-water and laudanum solution, will help to allay the acute inflammation. When the inflammation has subsided to a degree, mercurial ointment should be applied daily. The iodide of potassium or sodium may be given internally. Throughout the acute and subacute stages, a soft but firm compress of gauze should be applied to the vulva and supported by a T-binder. The a;-rays have been used with good results in the chronic stage. Surgical Treatment. — When the disease has advanced to the chronic stage and has attained considerable proportions surgery may be invoked. The hypertrophied parts should be excised. Condyloma Acuminata. — Of the hypertrophic lesions due to inflam- mation, the most common are the condylomata acuminata, which are almost invariably of gonorrheal origin. Dr. Richard R. Smith reported an advanced case in a child, aged nineteen months (Fig. 361). R. L. Dickinson in discussing "Hypertrophies of the Labia Minora and Their Significance," reported 373 cases, and gave as his conviction that all were due to the habit of masturbating.^ The development of condylomata is particularly rapid during preg- nancy, and is said to be caused by the irritating vaginal discharge. In the early stage of the development these warty outgrowths are pale red or gray. Later the papillary projections become confluent and may assume the proportions of a man's fist. Occasionally the growth is pedunculated. They are found distributed over part or all of the vulva, vagina, and the neighboring skin surface of the mons veneris, groin, buttocks, and perineum. The lesion is essentially an overgrowth of the papillse. The greater part of the growth is due to an increase in the epithelial covering of the papillae. In general appearance such a gro\\i:h is not unlike a cauliflower carcinoma. The distinction is made by the frequent occurrence of the growth during pregnancy by the history of gonorrhea, and by the presence of gonococci in the secretions, together with other evidences of gonorrhea; by the age of the individual, and, finally and conclusively, by the microscopic examination of an excised piece in which there is an absence of epi- thelial invasion of the underlying connective tissue. Treatment. — All venereal warts should be excised with scissors and the base cauterized with the thermocautery. This usually requires an anesthetic. When observed in pregnancy these growths, should be removed prior to labor as a preventive measure to sepsis in the mother and ophthalmia in the newborn. In cases of moderate severity, before resorting to operative procedures, 1 American Gj^necology, September, 1902. PROGRESSIVE TISSUE CHANGES 553 the application of equal parts of calomel and salicylic acid may be tried as a dusting powder, or an ointment of zinc oxide and the subnitrate of bismuth may be applied. During this treatment frequent douches of bichloride of mercury (1 to 4000) are given and the patient kept at rest. Fig. 361 Condyloma acuminata in a child aged nineteen months. (Case of Dr. R. R. Smith.) Hypertrophy of the Vulva. — Precocious Development of the Vulva.— A precocious development of the vulva is occasionally seen in infancy. This condition is usually accompanied by an overdevelopment of the breasts and the early appearance of the catamenia. Hypertrophy of the Clitoris. — A moderate enlargement of the clitoris is not rare, but in exceptional cases the clitoris may assume the pro- portions of the penis. In this event amputation of the hypertrophied clitoris is required. Hypertrophy of the Labia. — The labia are sometimes enormously enlarged. Occasionally they are so large as to be a source of embar- rassment to intercourse. Among the Hottentots the labia minora are known to hang between the thighs for a distance of several inches — the so-called "Hottentot apron." Hypertrophy of the Cervix. — The cervix may be hypertrophied above or below the vaginal attachment. 554 NUTRITIONAL DISTURBANCES OF THE GENITAL ORGANS Supravaginal Hypertrophy. — This condition is usually congenital in origin. As a result the cervix descends and carries with it the vaginal walls to a point where they may present at the vulvar outlet. The process is essentially the same as occurs in descent of the uterus. (See page 319.) Diagnosis. — The diagnosis is made by inspection, palpation, and the introduction of the sound, as discussed under descensus uteri. Fig. 362 Feminine pseudohermaphroditism. Treatment. — ^The treatment is distinctly surgical and necessitates a high circular amputation of the cervix. When the vaginal walls are relaxed, an anterior and posterior colporrhaphy are required. As a final resort in extreme cases, the suggestion of Baldy should be adopted, that of supravaginal amputation of the uterus and anchor- ing of the stump to the abdominal wall. (See page 331.) Infravaginal Hypertrophy. — Here the cervix is h\'pertrophied below the attachment of the vagina. The condition is congenital and is rare. These cases are not common. The elongation of the^ cervical tissues may be so great as to cause the cervix to protrude from the vulva. The diameter of the cervix is not, as a rule, increased. The clinical significance of h^■pertrophy of the vaginal portion of the cervix depends upon the degree of elongation. When of moderate degree no disturbances arise, but when the cervix is greatly elongated. PROGRESSIVE TISSUE CHANGES 000 sterility, interference with intercourse and with locomotion are complained of. In event of pregnancy labor is retarded by the slow dilatation of the cervix. Diagnosis. — The diagnosis is made by sight and touch. Xo difficulty is experienced in recognizing the abnormal length of the cervix. An uncomplicated elongation of the cervix is distinguished from a prolapsed uterus, with or without elongation of the cervix, by noting the position of the fundus in a bimanual examination. Treatment. — (See Amputation of the Cervix.) Fig 363 Hypertrophic e liuu ut the cer\ ix with prolapsus uteri. Subinvolution of the Uterus. — The physiological involution of the uterus following labor and abortion may be arrested at a point short of the norm, leaving the uterus large and heavy. This hypertrophy may be confined to the body or to the cervix, but, as a rule, both are affected. The endometrium commonly shares in the hypertrophy, as do also the ligamentous supports of the uterus. All of these tissues 556 NUTRITIONAL DISTURBANCES OF THE GENITAL ORGANS are congested, and there is a tendency on the part of the heavy uterus to descend and to fall backward. History. — The history dates back to a childbirth or abortion. In man}' instances it is learned that the childbed period was of unusual duration, that there was evidence of a puerperal infection, or that there were unrepaired lacerations. The symptoms above referred to commonly take their origin in these events. Etiology. — 1. Septic infection. 2. Lacerations of the cervix. 3. Uterine displacements. A postabortive or puerperal infection will usually check the process of involution in the uterus. A lacerated cervix, j^er se, probably has little influence in causing subinvolution, but the resulting infection, which so commonly follows lacerations, has an important bearing. Anatomy. — Theilhaber and Meir observed that in childhood the musculature of the uterus is to the fibrous tissue as 2 is to 1, in the muciparous uterus it is as 1 is to 2, while in the postclimacteric period the proportion is again reversed. It is learned from the observations of Pick and Anspach that the elastic tissues of the uterus play an important role in that they support the blood and lymph vessels, reinforce the musculature, and aid materially in the involution of the uterus. During the first four months of pregnancy the elastic tissue increases in amount, then remains about stationary in the later months of pregnancy, and again undergoes increase during the puerperium. The exception to this rule is found in the cervix when the elastic tissue goes on increasing throughout labor and aids in the dilatation of labor. In the subinvoluted uterus there is a disproportionate amount of fibrous tissue and a lack of increase in elastic tissue. All this leads to muscular insufficiency with lack of control over the caliber of the bloodvessels which course through the myometrium. This constitutes the anatomical basis for hemorrhage in subinvolution of the uterus. Symptoms. — 1. Menstrual Disorders. — As a rule, the menstrual flow is excessive. The explanation lies in muscular insufficiency of the uterus. The menstrual periods are prolonged and the amount of blood lost may be two or three times the normal amount. 2. Leucorrhea. — In the absence of a specific infection or other causes of leucorrhea, there is a hypersecretion from the uterus differing only in amount from the normal secretion. 3. Sense of Weight in the Pelvis.— The heavy uterus and relaxed supports lead to a sagging of the uterus and commonly to retroversion. The patient complains of a feeling of heaviness and insecurity in the pelvis. 4. Dysmenorrhea. — The menstrual periods are usually accompanied by heavy cramping pains in the hypogastrium and by backache. PROGRESSIVE TISSUE CHANGES 557 Sterility. — While subinvolution of the uterus does not preclude the possibility of childbearing, it is true that the conditions are not favorable. This is one explanation for the so-called "habit of abortion." The associated lesions, i. e., displacements, lacerated perineum, and cystic degeneration of the ovaries, give rise to symptoms which are not to be credited to subinvolution of the uterus. Diagnosis. — The diagnosis is determined by a consideration of the history, by the complaints of the patient, and by a physical examination. Physical Examination. — Bimanual examination reveals a uniformly enlarged uterus, somewhat soft in consistency, uniform in outline, freely movable, and not sensitive to pressure. Downward and backward displacements are common. Placing a sound in the uterus will demon- strate an increase in size of from one-half inch to an inch. Prognosis. — If taken in the early stages of its development, much can be done to favor involution, but in the chronic stage, when hyper- plastic changes have developed, there is little hope of relieving the condition. Treatment. — It is important to arrest the condition in the early stages of its development. Early Stage. — To prevent permanent enlargement of the uterus the following precautions should be taken : 1. Prevent infection of the uterus by strict observance of all rules known to the obstetric art. 2. Avoid keeping the parturient woman on her back an undue length of time. 3. Repair all lacerations early. 4. Examine every woman at the end of the puerperium. When the uterus has failed to involute no time should be lost in the effort to encourage full involution. The following measures should be adopted: 1. Repair of neglected lacerations. This should be done not later than ten to fourteen days after labor. 2. Correct all recent displacements by a properly fitting pessary. 3. Hot vaginal douches two or three times a day. 4. The administration of small doses of ergot or ergotin over a period of several weeks. 5. Ichthyol and glycerin tampons introduced before going to bed and removed in the morning. These tampons to be preceded and followed by hot vaginal douches. 6. Discontinue all treatments daring the menstrual period. 7. If there is evidence of infection the uterus should under no cir- cumstances be curetted. 8. It is essential to look to the general condition of the individual. The diet should be nutritious and the bowels regulated with saline cathartics. The patient should be restricted in her exercises. 9. The Xauheim baths are of great value in the management of these cases, inasmuch as they tend to equalize the circulation and relieve passive congestion in the pelvis. (See page 195.) 558 NUTRITIONAL DISTURBANCES OF THE GENITAL ORGANS Late Stage. — All that has been recommended for the management of subinvolution in the early stages applies to the late stage, but with less promise of good results. When the condition has become chronic, surgery must be invoked. The following surgical procedures are applicable: 1. Curettage. — It is observed that curettage hastens in^'olution. This should not be done if the uterus is infected. 2. Amputation of the Cervix . — When the cervix is elongated, and particularly when lacerated and eroded, the wedge-shaped amputation of Schroeder should be done. 3. Correction of uterine displacements and lacerations of the cervix and pelvic floor. 4. Subtotal hysterectomy is indicated when the uterus is greatly enlarged and gives rise to pressure symptoms and hemorrhage. (See page 441.) Hypertrophy of the Ovary. — The size of the ovary varies within wide limits, and hence it is not always possible to distinguish between a normal ovary and one that is hypertrophied. Hypertrophy of the ovary frequently complicates uterine fibroids. An hypertrophied ovary measuring four inches in length was removed by Webster, together with a fibrocystic tumor of the uterus which weighed eighty-seven pounds. In true hypertrophy there is an increase in the amount of ovarian tissue. This condition is not to be confounded with hyperplasia of the connective-tissue stroma, the result of passive congestion and inflammation. There are no characteristic clinical signs of hypertrophy of the ovary. Early puberty, unusual sexual vigor, and a late menopause are the usual clinical manifestations. CHAPTER XXVI new-for:matioxs of the vulva and vagixa Netv-formatioxs of the Vulva ^Ialigxaxt Tumoes of the Vulva Benign Tumors of the Vulva Cancer of the A'ulva Fibroma Sarcoma of the A'ulva Lipoma Xett-formatioxs of the A'agixa Enchondroma Cysts Xeuroma Fibromyoma Sebaceous Cysts Carcinoma Dermoid C^^sts Sarcoma Vulvar Cysts S^mcytioma Malignum Cysts of the HjTiien Endothehom NEW-FORMATIONS OF THE VULVA Benign Tumors of the Vulva. — Benign tumors of the vulva are of rare occtirrence. Fibromata arise from the subcutaneous connective tissue of the labia majora and minora, but rarely from the clitoris. They are slow in their growth, and firm, round, and sharply circumscribed. The over- lying skin is not adherent to the tumor. They are known to grow to the size of the patient's head and to hang by a pedicle to the level of the knees. The microscope shows the tumor to be composed of con- nective tissue intermixed with a limited amount of smooth muscle fiber. Cystic degeneration and calcareotis deposits have been described. Lipomata rise from the subctitaneous fat of the mons Veneris and labia minora. They are not so frequently found as are fibromata. They are usually circumscribed, soft in consistency, sometimes apparently fluctuating, and are attached either by a broad base or by a pedicle. The author has found only 22 cases of lipoma of the vulva in the literature. They have been seen from the fifth month of infancy to the fifty-first year. Enchondroma has not yet been fully established. Neuroma has been described as a sensitive papilla or wart, though the description leaves some doubt as to its identity. Peckham described a cyst of the clitoris weighing 60 grams and filled with a chocolate- colored fluid. Sebaceous cysts are fotmd in the labia, at the base of the prepuce, and at the base of the hymen. They appear in the form of small, yellowish, semitransparent elevations filled with sebaceous material. Small, soft- walled cysts, lying at the free margin of the hymen, may be regarded as lymph cysts. 560 NEW-FORMATIONS OF THE VULVA AND VAGINA Dermoid Cyst of the vulva is of rare occurrence. Vulvar Cysts have Httle cHnical significance. An accompanying pruritus may disclose their presence. Cysts of the Hymen. — Little is known of cysts of the h.ymen. Wenkel made the first report of these cysts in 1883. Palm described one measur- ing 8 cm. in diameter. The average diameter is about 1 cm. Many Fig. 364 Pedunculated fibroma of the vulva. do not exceed 1 mm. in diameter. They are usually congenital, though they may not be observed until late years. One or more cysts are located near the free margin of the hymen. These various sources explain the presence of a variety of epithelium lining the cyst cavity. As a rule, the epithelium is squamous and stratified, but is occasionally cylindrical, and in a few instances endothelium is found. NEW-FORMATIONS OF THE VULVA 561 The origin of the cysts of the hymen is in many cases the epithelial projections. These projections become constricted off and form the epithelial wall of a space which fills with serum. A few cases apparently arise from Gartner's duct, from dilated lymph spaces, and from retention of the secretions of sebaceous glands. In a valued original communication on the "Anatomy, Pathology, and Development of the Hymen"^ G. Gelhorn presents numerous lesions of the hymen not generally recognized. Fig. 3C5 Fibromyoma of the posterior u all (jl the Surface ulcerated. Tumors of the hymen are rare. Gelhorn finds 17 cases of hymeneal cysts in the literature, 2 cases of polypi, and 1 of angioma. Sanger reported a case of primary sarcoma of the hymen. As yet no case of primary carcinoma of the hymen has been reported. Treatment.- — All benign 'tumors of the vulva should be excised and the wound closed with silkworm-gut. The sutured wound is covered 36 Amer. Jour. Obstet., August, 1904. 562 NEW-FORMATIONS OF THE VULVA AND VAGINA with a dressing of sterile gauze, held in place by a T-binder. The sutures should be removed on the seventh day. Cancer of the Vulva. — The vulva is strangely exempt from infection and malignant degeneration. In 1147 cancers of the female genitalia Schwarz found 30 to be primary in the vulva. Wenkel tabulated the Fia. 366 Carcinoma of the vulva. A cauliflower growth two inches in diameter was located in the right labium majorum. The tumor was friable and bled freely to the touch. report of 54 cases, in which he found 6 before the age of forty, 16 between forty and fifty, 20 between fifty and sixty, and 20 over sixty years of age. The site of predilection is the outer skin surface of the labia majora; less frequent points of invasion are the frenum, clitoris, Bartholinean NEW-FORMATIONS OF THE VULVA 563 glands, anterior and posterior commissure, and urethral opening. The labia minora are seldom a primary site. The lesion is characterized by superficial infiltration, by ulceration, and by early involvement of the inguinal glands. The growth may be diffuse or circumscribed. The circumscribed growths rarely fail to rise above the level of the surface of the skin. They are commonly round or oval, and the surface smooth, nodular, or papillary. They may grow to the size of a man's fist. At first firm in consistency, sooner or later they disintegrate and form more or less superficial ulcers. The diffuse form may not be evident to the naked eye,_and is recognized by its rigid, firm feel. Superficial ulceration is usually not long in Fig. 367 Early carcinoma of the vulva, confined to the clitoris. (Martin.) appearing. There is nothing uncommon in the appearance of the ulcer; the base is uneven, bleeding freely to the touch, and is covered with a purulent, foul-smelling secretion; the margins of the ulcer are irregular, hard, and elevated. In advanced cases the ulceration may extend to deep crater-like excavations, with markedly infiltrated borders (Fig. 366). Schwarz found the inguinal glands infiltrated with cancer cells eleven times in twenty-three cases. The rate of growth is often slow. The direction to which the growth extends varies. Usually the extension is to the vagina and from the A'agina to the rectum, bladder, and pelvic connective tissue. In not a small percentage of cases the opposite labium is invaded (contact metastasis). 564 NEW-FORMATIONS OF THE VULVA AND VAGINA The microscopic characters of vulvar carcinoma differ somewhat from those of cancer of the vagina and cervix. There is an unusual tendency on the part of the epithelial projections to branch. Cancer pearls- are said to be relatively rare, although in two specimens, one removed by Dr. Reuben Peterson and the other by Dr. J. Clarence Webster, the author found an unusual number of cancer pearls. The extension of the cancer cells along the lymphatics gives the appearance of veins of marble. Ljinphadenoma of the vulva. (Hertzler.) Cancer of the glands of Bartholin is rare. The gland may assume the size of a man's fist, become hard and nodular, with a movable, normal appearing overlying skin. The diagnosis without the aid of the micro- scope is hardly possible. The lesions to be considered in making a diag- nosis are the benign new-formations (lipoma, fibroma), with ulcerated surface, ulcus rodens, tuberculosis, sj'philis, and elephantiasis. In making the diagnosis, one must rely upon the age of the individual, the general effect upon the system, early and superficial ulceration, involvement of the inguinal glands, and above all, upon the microscopic examination of an excised piece of the tumor. The prognosis is relatively good. Schwarz saw ten recoveries in twenty-three cases. Treatment. — Cancer of the \Tilva requires early and radical removal. Not only should the gro-^th be widely excised, but the inguinal glands should also be removed. The loose texture of the structures of the NEW-FORMATIONS OF THE VULVA Fig. 369 565 Early adenocarcinoma of the vulva, limited to the left lesser labium. (Hurdon.) Fig. 370 Extirpation of the vulva. Lines of initial incisions. 566 NEW-FORMATIONS OF THE VULVA AND VAGINA viih'a permits of ready approximation e\-eii after a large area is removed. Fig. 370 presents an outline of the area to be resected in advanced cases. Fig. 371 Carcinoma of the ^n.lh-a. (Hertzler.) Palliative Treatment. — Following the removal of the growth and in all inoperable cases, the .r-rays should be applied at intervals. When the growth is too far advanced to permit of removal, the cancerous tissue should be deeply cauterized and a moist dressing of the following solution applied: I^ — Glycerin giij Water gviij Formalin Vf[xv A vulvar pad is saturated with this solution and held in place by a T-binder. Frequent vulvar douches of formalin (1 to 4000) should be given. NEW-FORMATIONS OF THE VAGINA 567 Prognosis. — Taussig compares the prognosis of cancer of the uterus with cancer of the vulva, and reveals the interesting fact that while it is generally true that superficial cancers give a more favorable prog- nosis than do the deep-seated cancers, the reverse is true of genital cancers in women. He gives the percentage of cures in cancer of the body of the uterus as 80, in cancer of the cervix between 20 and 30, and in cancer of the vulva as 12. He accounts for the high mortality in cancer of the vulva by the advanced age of the patient, (average sixty to sixty-five years), early metastasis to tributary lymph glands, and the proximity of the cancer to the urethra and pubic arch. In cancer of the vulva, as in cancer elsewhere in the body, the secret of successful results lies in early diagnosis and in early operation. Sarcoma of the Vulva. — This is a very rare lesion. Hunter Robb has described a m}'xosarcoma of the clitoris. Melanotic sarcoma of the vulva is an intensely malignant growth. Bailley reported a melano- sarcoma in a woman, aged seventy- two years. Recurrence is almost certain. ^Mueller removed from the labium minor a melanosarcoma as large as a walnut. There was no recurrence until the end of three years. Fisher reports a recovery in a woman, aged fifty-six years, from whom a melanosarcoma the size of a walnut was removed from the labium major. Treatment. — (See Cancer of the Vulva.) NEW-FORMATIONS OF THE VAGINA Cysts of the Vagina. — Cysts of the vagina are not of great rarity. Xeugebauer found .36 cases in 600 observations (Fig. 372). Histogenesis. — The fact that the epithelial lining of the cysts varies in form suggests various origins, ^'^eit believes them to develop from remains of the Wolffian ducts. The ducts of Gartner do not ordinarily continue below the vault of the vagina, but instances are known in which they extended as far as the urethral opening along the lateral and anterior walls of the vagina. In these ducts muscle fibers and cylindrical epithelium are observed, and it is believed by some that cysts located in the sides or in the anterior wall of the vagina, and containing muscle fibers and epithelium, arise from the ducts of Gartner. As further evidence of this origin, may be mentioned their occasional elongated form with their long axis in a line corresponding to the long axis of the vagina. Still more significant is the rosary-like arrangement of two or more cysts along the line of Gartner's duct. Preuschen suggests that the origin of vaginal cysts may be the glands of the vagina. Cysts lying in the posterior wall of the vagina are thus explained. They are regarded as retention cysts. Davidson holds that the glands of the vagina are purely misdevelopments. Those in the upper segment of the vagina are misplaced from the cervix and maintain the character of cervical glands, while those in the lower segment of the vagina are from the vulva. Retention cysts arising 568 NEW-FORMATIONS OF THE VULVA AND VAGINA from these glands are usually multiple, of small size, and lined -with a single layer of columnar epithelium. Cysts may arise from partial adhesion of the folds of vaginal mucous membrane inclosing spaces lined with flat epithelium. Fig. 372 Cyst of the anterior wall of the vagina. A thin-walled, translucent cyst protrudes from the vulva. Such a growth may be mistaken for an inverted uterus or a complete prolapsus uteri. The cyst fluctuates, there are no tubal or ceri-ical openings, and the uterus is found in its normal position by a recto-abdominal examination. -Freund believes that cysts of the vagina arise from the rudimentary ducts of Miiller. Furthermore, it is apparent that the lymph spaces may distend into cysts lined with endothelium. Cysts of the vagina are rarely of large size, ranging from that of a pinhead to a hazel-nut. In exceptional cases they are as large as a child's head. They are slow in growth. The sites of election are the anterior and lateral walls, rarely the posterior wall of the vagina. They lie i m mediately underneath the epithelium and bulge into the vagina. NEW-FORMATIONS OF THE VAGINA 569 The consistency is elastic and the contents clear, watery, or mucoid. Occasionally the contents are milky from the presence of degenerated epithelium; sometimes chocolate colored from admixture with blood. Cheron reports the presence of a stone in a cyst. Cholesterin crystals are occasionally found. As a rule, the cysts are simple, but they may be multilocular. The cyst wall is composed of fibrous tissue, occasion- ally mingled with some muscle fibers. The inner surface is generally lined with a single layer of cylindrical epithelium, but sometimes with several layers of cylindrical or flat epithelium. It is seldom that endo- thelial cells are found. They are not usually of clinical interest, but are known to interfere with sexual intercourse and with childbirth, and have been mistaken for prolapsus uteri and inversion of the uterus. Treatment. — The treatment of cysts of the vagina is surgical, and consists of partial or complete removal of the sac. Partial Removal of the Sac. — Unless the cyst is superficial and small, no attempt should be made to remove the entire sac for fear of injury to the bladder, rectum, ureter, or peritoneum. When the dissection is deep there is great danger from troublesome bleeding. Technic of Operation. — The patient is placed in the lithotomy position and the cyst exposed by specula. Step 1. — The cyst is grasped at its apex by bullet forceps, and a second pair is made to grasp the cyst wall a half inch removed from the other forceps. The sac is then opened with a knife and its contents emptied. Through the opening the examining finger explores the cavity of the cyst and notes its relations to surrounding structures. Step 2. — The incision in the sac wall is extended to the limits of the sac, and each half of the sac wall is excised to the level of the vaginal wall. Step 3. — The margins of the cyst wall are stitched to the cut edges of the vaginal wall with chromic catgut. The cavity of the cyst is then packed with iodoform gauze and a sterile dressing applied and held in place by a T-binder. The gauze is removed at the end of forty-eight hours and the open wound kept clean by frequent antiseptic irrigations until healing is complete. Complete Removal of the Sac.^ — Only small and superficial cysts should be wholly removed. The cyst is removed by incising the vaginal wall over the sac and dissecting the sac en masse from the surrounding structures; then closing the wound with catgut. Fibromyoma of the Vagina. — Richard R. Smith collected 101 cases from the literature. They commonly occur between the ages of twenty and forty years, and have been observed as early as one and a half years and as late as seventy-eight years. The largest one recorded weighed ten pounds. They .are usually round and attached by a broad base or pedicle. The surface is smooth or nodular, and is covered with vaginal mucous membrane. They are seldom of soft consistency. Their origin is in the submucous connective tissue. They are rarely multiple, and are generally located in the anterior wall of the vagina. The usual forms of degeneration common to fibroids are possible. The 570 NEW-FORMATIONS OF THE VULVA AND VAGINA diagnosis is not difficult. A soft fibroid might be mistaken for a cyst, a cystocele, or a rectocele. The bluish, semitransparent color of the cyst is of special significance. Treatment. — The treatment consists in the removal of the tumor. Caution must be exercised for fear of injuring the bladder, rectum, ureter, or peritoneum. The vaginal wall is incised over the tumor; the tumor enucleated with a blunt dissector, all bleeding-points secured by ligatures, the redundant vaginal walls excised, and the wound closed with chromic catgut. Fig. 373 Fig. 374 Enucleation of a vaginal cyst. Vertical incLsion made through the vaginal wall. (Modified from Ashton.) Step 2. Vaginal wall reflected from the cyst by a dissector. (Modified from Ashton.) Carcinoma of the Vagina. — Etiology. — Less than 1 per cent, of all cancers in women are of vaginal origin (Williams, Bristol). Kiistner collected 22 cases of primary cancer of the vagina, and estimates that about 0.02 per cent, of cancers of the genital tract arise primarily in the vagina. As a rule, primary carcinoma of the vagina arises between the ages of fifty and sixty; two cases are reported at twenty years of age. Child- bearing does not influence the development of the growth, and heredity plays a minor role. A number of cases have been recorded in which ill-fitting pessaries have caused ulceration and eventually malignant NEW-FORMATIONS OF THE VAGINA 571 degeneration. Prolapse of the vaginal walls subjects the vagina to mechanical insults, and upon the injured surface a carcinoma may be developed (Fig 377). Anatomical Diagnosis. — In 123 cases 71 were found on the posterior vaginal wall, 13 on the lateral walls, and 16 were annular. The growth may be papillary, nodular, or infiltrating. To the unassisted eye cancer of the vagina usually presents a thickened, ulcerated area. The margins are irregular, hard, and elevated. The base of the ulcer is uneven, bleeds freely on handling, and is covered with a foul-smelling secretion. Fig. 375 Fig. 376 Step 3. Part of cyst wall excised. The cyst extends too deeply into the underlying struc- tures to permit of complete enucleation. Step 4. Sutures placed for closure of the cavity. When the cyst is not wholly removed the cavity should be packed with iodoform gauze and left open to heal by granulation tissue. Surrounding the vagina the tissues show an inflammatory reaction, and secondary nodules "may be seen distributed over the surface. The growth rarely attains the size of a man's fist. Extension into the paravaginal tissue is rapid. Reaching the lymph spaces of the para- vaginal connective tissue, the cancer cells are rapidly carried to the retroperitoneal glands. The inguinal glands are enlarged when the lower segment of the vagina is invaded. As a rule, the uterus is not invaded so early as the vulva, and metastasis to distant organs is late. The microscope shows nothing unusual. The tumor is a flat-cell growth, the cells are arranged in nests, and contain many pearls. 572 NEW-FORMATIONS OF THE VULVA AND VAGINA Clinical Diagnosis.— The lesion may go unrecognized until far advanced. As with cancer of the uterus, all symptoms may be wanting until there is ulceration and sloughing of the growth. Hemorrhage, pain, and a foul-smelling discharge are the cardinal symptoms, but Fig. 377 Primary carcinoma of the vagina. On the posterior wall of the vagina is an irregular infiltrated area, friable and bleeding. they do not differ in any manner from the same group found in cancer of the vulva or uterus. Pain is rarely present until the gro-«i;h has extended into the paravaginal tissue, and the absence of pain is a marked feature in the early stage. NEW-FORMATIONS OF THE VAGINA 573 Stenosis .of the vagina may hide a growth lying above the point of constriction, and render the early diagnosis perplexing. Secondary cancer of the vagina is of frequent occurrence. Cancer of the cervix is especially liable to extend to the vagina, but normal tissue may intervene between the primary growth in the cervix and the secondary gro-v\i:hs in the vagina. Cancer of the bladder and rectum rarely invade the vagina. Metastatic growi:hs from the ovary are seldom observed in the vagina. Wahn, Fisher, and Kalkenbach report implantations of cancer cells upon eroded surfaces in the vagina through the medium of a leucorrheal discharge. The secondary growths take the same histological forms as the primary growth. The average duration of primary cancer of the vagina is said to be sixteen months, but it may last several years. DifEerential Diagnosis. — Decubitus ulcers caused by ill-fitting pessaries may be mistaken for carcinoma, and have been known to be its starting- point. The hard, elevated margins, friable and bleeding when handled, are distinctive of malignancy. When doubt exists, a microscopic examination of an excised piece, or scrapings from the suspected portion, will determine the diagnosis. Syphilitic and tuberculous ulcers of the vagina are recognized by the clinical history, by evidences of lesions elsewhere in the body, and by microscopic examination of excised pieces. Friability and bleeding of the suspected tissue are suggestive of carcinoma. Treatment. — Early and complete removal of the growth is the only effective treatment. Radical Treatment. — When the growth is limited in extent only a part of the vaginal wall need be sacrificed, but when the growth is extensive it may require the extirpation of the entire vagina. Removal of the growth. Step 1. — The tumor is exposed by specula. An incision is made far outside the infiltrated area and around the entire circumference of the growth. The tumor is then pulled forward by bullet forceps and dissected from the underlying tissues. So far as possible a blunt dissector should be used. Step 2. — The wound is then united by sutures of chromic catgut. When the bladder or rectum are invaded the incision must be carried through these structures. The inguinal glands should be removed in all cases. After placing the sutures the vagina is packed with iodoform gauze and a T-binder adjusted. The gauze is removed at the end of forty-eight hours and daily antiseptic vaginal douches are then given. When the base of the bladder has been excised a self-retaining catheter should be worn for ten days. Total Extirpation of the Vagina. — There is little encouragement in performing such an extensive operation as the removal of the entire vagina, because when this is required, the disease has advanced beyond hope of radical removal. Palliative Treatment. — When the disease is inoperable, palliative measures should be resorted to. These consist in thoroughly curetting 574 NEW -FORM AT IONS OF THE VULVA AND VAGINA the cancerous friable tissue, cauterizing the surface, and applying acetone. The treatment is that advised for inoperable cancer of the cervix. (See Cancer of the Uterus.) The a-rays are of value in inoperable cases, and should also be applied in all cases following operation. Sarcoma of the Vagina. — Sarcoma of the vagina is found in all ages, from the first to the eighty-second year. Six so-called congenital cases are reported. Of 40 cases reported by Williams, 36 occurred before fifteen years of age. The growth is usually polypoid, of a yellowish-gray or chocolate color. Rarely is there a diffuse infiltration of the vaginal walls, the surrounding structures being early invaded. Distinct metastasis is late, and does not often occur. There is a tendency to early necrosis of the tumor mass, together with infection of the necrotic mass by pyogenic microorganisms, leading to cystitis, pyonephritis, and peri- tonitis. Late in life sarcoma is usually smooth rather than rough and polypoid as in early life. Histologically, the growth is demonstrated to be a fibrosarcoma, myxosarcoma, round-cell or spindle-cell sarcoma, or, finally, a melano- sarcoma. The diagnosis of sarcoma, apart from carcinoma, cannot be made without the aid of the microscope. Treatment. — (See Cancer of the Vagina, page 573.) Syncytioma Vaginae. — Syncytioma malignum (or, as better named, chorio-epithelioma malignum) occurs with relative frequency as a secondary growth in the vagina. Schmidt lately reported two cases of primary growths in the vagina. In both cases the uterus remained normal. Kiible removed a primary syncj'tial growth from the vagina, and in twenty days it had recurred. All newgrowths of the vagina developing weeks and months after labor should be incised and examined, with special regard for malignant proliferation of the syncytium. To the unaided eye the tumor is usually round and elevated. It is of a bluish color. Ulceration is rare. On cross-section the tumor is exceedingly bloody, and may resemble a blood-clot. (See page 174.) Endothelioma of the Vagina. — Endothelioma of the vagina is an exceptional growth. The first case was reported by Klein. By the naked eye the growth cannot be distinguished from a carcinoma. Microscopically the tumor is found to be composed of cells resembling flat epithelium, arranged in a thick mesh-work of connective tissue. The cells arise from the endothelium of the blood or lymph spaces. In distribution they resemble veins of marble. Treatment. — (See Cancer of the Vagina, page 573.) CHAPTER XXVII FIBRO]^n^O^IA OF THE UTERUS Etiology , Treatment Histogenesis , Opeeatioxs for Uterine Fibroids Anatomical Diagnosis Recurrence Microscopic Diagnosis Adenofibromyoma Uteri Degeneration of Fibroids Clinical Characteristics Clinical Diagnosis Differential Diagnosis Effect on Neighboring Organs Vaginal ^lyomectomy Vaginal Hysterotomy Vaginal Celiotomy Abdominal AU^omectomy Hysteromyomectom}" Vaginal Abdominal Fibroids Complicating Pregnancy, Labor, and Puerperium Etiology. — But little is known of the essential cause of uterine fibroids. Certain factors are known to influence their origin and development, and will be briefly discussed. 1. Heredity. — Heredity has been much referred to as a predisposing cause of uterine fibroids. While there are families in which two or more members are known to have fibroid tumors of the uterus, the influence of heredity is not to be overestimated. Engstrom, in flve hundred and thirty cases of uterine fibroids, found a similar lesion in the mother or sisters thirteen times. It has been stated that myo- matous patients come of large families. In the experience of Roger Williams they averaged 8.1 members each. 2. Age. — The usual time of occurrence is during the period of sexual maturity. Fibroids of the uterus are rarely found before puberty, though it is highly probable that most, if not all, of these growths are of congenital origin. They occur with greatest frequency between the ages of thirty and forty, and are rarely known to arise after the meno- pause. Miller reported 299 cases of uterine fibroids, of which number 120 were observed after forty-five years of age. Of the 1762 cases col- lected by Roger Williams, 26 were under twenty years of age. Gusserow reported 1 case ten years of age. Pick described a fibroid of con- genital origin. Cavaillou reports one weighing 3 kilograms in an infant three years of age. At the other extreme of life is a submucous myoma at ninety-two years of age (Van Rensselaer) and a calcified myoma at eighty-six (Wright). It is evident from the study of statistics that fibro- myomata are prone to arise at a time when the sexual functions are waning. 3. Civil State. — It has been stated that fibroids of the uterus are especially liable to occur in women who have not borne children and are not married. The number of children born to mvomatous women 576 FIBROMYOMA OF THE UTERUS is below the average, while abortions are relatively common among them. The average number of children born of myomatous women is estimated at 2.5, as compared with the usual number of 4.5. Thirty per cent, of myomatous women are sterile as opposed to 10 per cent, of sterility in general. On the other hand, sexual excesses are said to favor the growth of uterine myomata. 4. Race. — The negress is generally regarded as preeminently sus- ceptible to uterine fibroids. This is denied by Kelly and Williams, of Johns Hopkins University, where there is abundant opportunity to make reliable observations. In 357 cases reported by Williams, fibroids were only 2 per cent, more frequent in the colored race. They are said to be unknown among savages. 5. Frequency. — Boyle holds that 20 per cent, of women who reach thirty-five years of age have fibroids of the uterus, while Klobs affirms that 40 per cent, of women who reach fifty years of age have fibroids of varying size and number. The lesion is often overlooked even in postmortem examinations. Of all non-malignant tumors uterine myomata are by far the most common. Roger Williams estimates that 10 per cent, of all tumors in women are uterine fibroids. Influence of Menstruation, Pregnancy, and the Climacterium upon Fibromyomata. — 1. Menstruation. — Menstruation is accompanied by a slight enlargement and softening of uterine fibroids, due to increased vascularization. Near the end of the menstrual flow the tumor reassumes its normal proportions. 2. Pregnancy. — Pregnancy is accompanied by a rapid increase in the size of the tumor. There is a corresponding softening of the growth. Such rapidly growing fibroids are prone to become incarcerated and to seriously interfere with pregnancy. Simultaneous with the involution of the uterus in the puerperium there is sometimes a rapid decrease in the size of the tumor. They are even said to wholly disappear, though this is doubtful. However, they are sometimes reduced in size by the end of "the puerperium. The rule is that they are not markedly reduced in size but on the contrary continue to grow after the climacterium and tend to degenerative changes and extrusion. 3. The Climacterium. — The climacterium is generally credited with having a favorable influence upon the growth of uterine fibroids, but experience points to the reverse. The rule is that they continue to grow and are more liable to degenerative changes at this time of life than at any other. Progressively growing postclimacteric fibromyomata are plentiful in the literature. Herman reported one growing thirteen years after the menopause. Tait removed one twenty years after the climacterium. Van Rensselaer removed a submucous myoma from a woman ninety-two years of age. Histogenesis. — According to Kleinwachter, fibroids originate from round cells found in bloodvessels, which later become obliterated. The round cells are converted into muscle and connective-tissue fibers. Rosger believes their origin to be in the muscle fiber of bloodvessels. Gottschalk is of the opinion that it is not the musculature of the blood- ANATOMICAL DIAGNOSIS D// vessels that forms the matrix of the tumor. He observed amebic movements in certain protoplasmic bodies which he interpreted to be parasites, and beheved them to be the essential cause of fibroids. Vedeler thought he discovered animal parasites in uterine fibroids. Virchow believed them to be a h\'perplasia of the uterine musculature. Judging from the above conflicting opinions, it is evident that nothing is positively known of the histogenesis of uterine fibroids. Fig. 378 Cystic fibromyoma of the uterus weighing thirty-seven pounds. Successful removal. (Dr. J. Clarence Webster.) Anatomical Diagnosis. — Under this head we will consider the size, form, consistency, rate of gro"«i:h, number, and position of the tumor, and also its microscopic structure. In size uterine fibroids vary from almost microscopic dimensions to the tumor reported by Hunter, weighing 140 pounds and that of Severann weighing 195 pounds. Webster recently reported a fibro- cystic tumor of the uterus weighing 87 pounds. Recovery followed 37 578 FIBROMYOMA OF THE UTERUS the operation, which was almost wholly performed under local anes- thesia. So far as I am able to find in the records this is the largest uterine fibroid to be successfully removed. Adhesions nearly always complicate these large tumors. Fig. 379 Multiple uterine fibroids. The uterine canal is distorted by two large interstitial fibroids — a pedun- culated and a senile fibroid occupies the surface of the uterus, and on the opposite (right) side is a small subperitoneal fibroid. (Specimen removed by Dr. J. Clarence Webster.) The form is smooth and rounded, or, as is more often the case, nodular. In consistency fibroids vary from soft and semifluctuating to a stone- like hardness. Fibroids are classified as hard and soft. Hard fibroids consist largely of fibrous tissue, with a relatively smaU amomit of muscle fiber; the blood supply is not great. Soft fibroids are^made up of a relatively large amount of muscle tissue, and are quite vascular. The rate of growth of soft fibroids is more rapid than that of hard fibroids. During pregnancy fibroids grow rapidly. After the meno- pause they usually decrease in size, though the menopause is often delayed three to ten years. They are seen to grow with surprising ANATOMICAL DIAGNOSIS 579 rapidity when undergoing myxomatous degeneration. Scholer estimates that fibroids are seldom distinguishable in less than a year; that in five years they may attain to the size of a man's fist, and 'in thirteen vears to the size of a man's head. However, it is not possible to estimate the age of a tumor by its size. This fact is demonstrated by the many small fibroids which are known to be thirty and forty ^'ears of age— "latent fibroids." Fig. 380 Submucous fibroid of the uterus. The tumor is attached to the posterior wall of the uterus by a broad base. The overlying mucous membrane is atrophied. . , It is exceptional for fibroids to exist singly. As many as 400 separate and distinct tumors have existed in the uterus. We speak of fibroids as single or multiple. 580 FIBROMYOMA OF THE UTERUS According to Martin, the tendency to multiplication increases with the age of the patient. Fig. 381 Ain Bin cm Schematic drawing representing the development of uterine fibroids and their relation to the uterine wall. Al, All, AIII, subperitoneal fibroids. BI, BII, BUI, interstitial fibroids. CI, CII, CIII, submucous fibroids, (Suggested by Fehling.) The position of fibroids in relation to the uterine wall is of the greatest clinical importance. The terms submucous, intramural or interstitial, and subserous or subperitoneal, are used to designate the location of ANATOMICAL DIAGNOSIS 581 the tumor. All fibroids are originally intramural, and as they increase in size they tend to grow in the direction of least resistance. For example, an intramural fibroid lying nearer the endometrium than the perimetrium will eventually become submucous. So long as a fibroid is completely enveloped by the musculature, no matter to what extent, it is intramural; but when the capsule of the fibroid is immediately covered with peritoneum or mucosa it becomes subperitoneal or sub- mucous. When the growth is attached to the inner or outer surface of the uterus, with a broad base, it is known as a sessile growth; when Fig. 382 Submucous fibroid of the uterus. The uterus is evenly distended by a large fibroid. the base of attachment is constricted, it is known as a pedunculated growth. The more pedunculated the tumor the slower the growth, because of the limited blood-supply passing through the pedicle. The pedicle when long may so limit the blood-supply to the tumor that atrophy will result. Twisting of the pedicle may completely interrupt the blood supply, in which case the fibroid will usually become gan- grenous. If the tumor is adherent to neighboring structures, a requisite supply may be conveyed by the adhesions and prevent necrosis. A partial twist of the pedicle may be followed by atrophy or edema of the tumor. 582 FIBROMYOMA OF THE UTERUS Spontaneous amputation of the tumor by lengthening or twisting of the pedicle is one of nature's means of effecting a cure in submucous growths. Fibromyomata of the cervix occur in about 6 per cent, of all uterine fibromyomata. Fig. 383 _ Pedunculated submucous fibroid protruding through the cervix. The fibroid protrudes from the cervix as a firm, rounded tumor with a smooth vascular surface. The tumor is attached by a pedicle to the body of the uterus. It is possible for such a growth to be detached and spontaneously expelled. (Specimen removed by Dr. J. Clarence Webster.) 1. Submucous Fibromyomata. — Submucous fibromyomata bulge into the uterine cavity and are directly covered with mucous membrane. They are either pedunculated or sessile, single or multiple, and are seldom as large as the patient's head. The pedicle may permit them ANATOMICAL DIAGNOSIS 583 to protrude into the ce^^'ical canal or farther on into the vagina. They usually possess a relatively large amount of muscle fiber and blood- vessels, and hence are soft in consistency, and their growth is rapid. When large and soft their form is moulded to that of the uterine cavity. They are rarely spherical, but more often elongated. The cervix may constrict them into an hour-glass shape. As the tumor increases in size the overlying mucosa may be atrophied; likewise, the opposing mucosa of the uterus may suffer pressure atrophy, and adhesions may form between the tumor and uterine mucosa. This explains the absence of hemorrhage in many of the large submucous fibroids. Leyden and Kiistner described a case in which a fibromyoma, having become detached from the uterus, adhered firmly to the cervix. Partial inversion of the uterus may be caused by traction upon the fundus by a pedunculated submucous fibroid attached to the fundus. The effort on the part of the uterus to expel the fibroid causes the inversion. 2. Interstitial Fibromyomata. — Interstitial fibromyomata lie encap- sulated within the uterine wall. These growths are rarely distinguished from the uterine musculature (diffuse fibromyomata). When large the growth bulges upon the mucous or serous surface or upon both surfaces. They are usually multiple, and are seldom as firm in con- sistency as subserous growths. 3. Subserous Fibromyomata. — Subserous fibromyomata bulge upon the serous surface of the uterus. They are single or multiple, commonly firm in consistency, though sometimes soft and apparently fluctuating. When pedunculated they ma}' be freely movable or firmly fixed by adhesions which bind the growi:h to surrounding structures. When located at the side of the uterus the growth may develop between the layers of the broad ligament — intraligamentary or broad ligament fibroids. Fibroids of the Cervix. — Fibroids of the cervix may be submucous, interstitial, or subserous (sub vaginal). Submucous fibroids of the cervix are seldom large. They are usually pedunculated, and as such are known as fibrous polyps. Interstitial fibroids of the cervix distort the cervical canal, and may cause complete obstruction, locking in secretions above, and preventing conception. Subserous fibroids of the cervix are very rare, and seldom of large size. They may grow into the vagina or into the paravaginal connective tissue. About 10 per cent, of uterine fibroids occur in the cervix, the balance arising from the uterine body. Cervical fibroids are poor in muscular elements and hence are firm and slow in growth. They are prone to undergo cystic degeneration and rarely become calcareous. As they increase in size, the cervix becomes elongated and distorted. Amann described a cervical fibroid weighing twenty-five pounds. Such large fibroids elevate the uterus out of the pelvis. On cross-section of a fibromyoma bands of fibrous and muscular tissue are seen to run in various directions and form whorls, concentric 584 FIBROMYOMA OF THE UTERUS rings, and wa\ y lines. The color ^-a^ies from gray to a rosy hue, depend- ing upon the relative amounts of fibrous and muscular tissue and upon the blood-supply. Latent Fibroids. — On cross-section uteri are frequently seen to contain numerous small bodies resembling knots of wood. Such growths are termed " latent fibroids" by Bland Sutton. Their whiteness is in marked contrast to the redness of the musculature. In histological structure they are identical to large fibroids. Undoubtedly a large number of fibroids never develop beyond this stage. Pregnancy exercises a quickening influence upon these latent growths. Fig. 384 Subperitoneal fibroid of the uterus. The uterus is crowded backward by a fibroid'attached to the anterior wall. Recurrence of Uterine Fibroids.— The so-called "recurrent fibroids," referred to by older writers, are undoubtedly accounted for by the recurrence of what was an unrecognized malignant growth, and secondly by the development of fibroids which were overlooked. jNIalignant groT\-ths are known to start from the stump of an amputated fibroid. This may be called traumatic malignancy, and is not peculiar to fibroids. Microscopic Diagnosis. — The microscopic diagnosis is based upon the finding of mature connective tissue and muscle fibers. Without a knowledge of the gross appearance of the tumor it is impossible to ADENOFIBROMYOMA UTERI 585 distinguish a fibroid from the uterine wah. The relative amount of connective tissue and muscle fibers varies widely. A pure fibroid does not exist. There is always present more or less muscular tissue. As age advances the connective tissue increases at the expense of the muscular elements. The muscle fibers are invol- untary^ and contain spindle-formed nuclei. The cell protoplasm is homogeneous and hardly ever granular. On cross-section the nucleus is half-moon shape. Some fibers contain two or more nuclei. Karyo- kinetic figures are seldom seen in the muscle cells of the slow developing growths, but are present in proportion to the rapidity of the growth. The connective tissue usually forms a loose texture, poor in nuclei. In associated tumors and in other fields of the same tumor the con- nective tissue may be more compact and contain round or oval nuclei. Bloodvessels course through the connective tissue. Veins are not as numerous as arteries, particularly in old fibromyomata. A central artery, running an irregular course through the centre of the fibroid, is described by Gottschalk, but has not been generally recognized. Lorey and Hertz have described nerve fibers in fibromvomata. Fig. 3S5 Adenomyoma of the uterus. (Hertzler.) Adenofibromyoma Uteri. — Fibroids containing glands are described by numerous authorities. Schroeder believes the glands originate in ■the endometrium. Carl Ruge, Gottschalk, Kossman, and others maintain that they arise from Gartner's ducts. Recklinghausen contends that the glands arise from the Wolffian body or from the endometrium. These peculiar growths are almost invariably intra- mural. They never possess a capsule, and are known as diffuse or 586 FIBROMYOMA OF THE UTERUS infiltrating fibroids. They are found in the tube, the uterine horn, and occasionally in the posterior wall of the uterus. In 700 cases of uterine fibroids operated in Johns Hopkins Hospital, Cullen reports 19 to be adenofibromata. Gebhard gives the following varieties: 1. A hard form in which the muscle tissue predominates over the glandular elements. 2. A cystic tumor with many large spaces. 3. A soft form in which the glandular elements predominate over the fibrous or muscular. 4. A soft form with widened blood spaces — telangiectatic or angio- matous adenomyoma. In the growths are often seen small ducts communicating with a single large one as the teeth of a comb are joined to its back. These ducts are considered by many to be embryonic inclusions of the ducts of the Wolffian body They may distend into cysts and compress the surrounding connective tissue. The contents of the cyst are clear and serous, occasionally colored by pigment. Recklinghausen speaks of pseudoglomeruli in describing elevations attached to the cyst wall by a broad base. Pick described a submucous adenomyoma which weighed 55 grams. Cullen reported to the Johns Hopkins Society an adenomyoma of the round ligament. Degeneration of Fibroids. — The following table shows the relative frequency of the various degenerations and complications in the tumor and uterus in 2274 cases of fibroid tumors collected by C. P. Noble: Carcinoma of the corpus uteri 42 or 1.8 per cent. Carcinoma of the cervix uteri 16 or 0.7 per cent. Sarcoma 34 or 1.4 per cent. Chorio-epithelioma 2 or 0.1 per cent. Necrosis of the tumor 119 or 4.7 per cent. Myxomatous degeneration 89 or 3.4 per cent. Cystic degeneration 58 or 2.5 per cent. Hyaline degeneration 72 or 3.1 per cent. Hyaline degeneration and calcareous infiltration . 8 or 0.25 per cent. Fatty degeneration 7 or 0.03 per cent. Hemorrhagic degeneration 13 or 0.57 per cent. Calcareous infiltration 39 or 1.7 per cent. Edema of tumor 17 or 0.74 per cent. Twisted pedicle 3 or 0.13 per cent. Dangerous hemorrhage 41 or 1.8 per cent. Intrahgamentous development of tumors ... 80 or 3.5 per cent. Subvesicle development of tumor 2 or 0.01 per cent. .Adenomyoma 12 or 0.06 per cent. Total 664 or 26.49 per cent. The statistics of Noble, Frederick, Martin, and Cullingworth prove that fibroids of the uterus are by no means the innocent tumors that former writers apparently believed. The various forms of degeneration of fibroids are not only of pathological interest, but their recognition is of the greatest clinical importance. DEGENERATION OF FIBROIDS 587 Noble estimates that serious complications arise in fibroids in about one-third of all cases. Of these complications the various forms of degeneration constitute a large proportion. Fig. 386 Fibrous polyp of the cervix. The uterus shows senile atrophy together with three small subperitoneal fibroids. The polyp is of unusual size. Such polypoid growths are prone to arise in a senile uterus. They are frequently the cause of hemorrhage in the post-climacteric period. 1 . Atrophy. — A physiological atrophy of fibroids frequently follows the climacterium. A similar change takes place in the event of an artifi- cially induced menopause by the removal of the ovaries. In pedun- culated tumors the blood-supply is limited, and as a result, atrophy may follow. The wasting diseases exercise a staying influence upon the growth of fibromyomata. Atrophy of these growths has been observed to follow abdominal sections, amputation of the breast, and peritonitis. According to Schroeder, this atrophy consists of a fatty degeneration. It is more probably a simple atrophy, in which the 588 FIBROMYOMA OF THE UTERUS muscle cells diminish in size and in number. In this manner large tumors are said to disappear. 2. Calcareous Degeneration. — Calcareous degeneration may occur in fibroids of all sizes and locations. The calcareous deposits are found in the connective tissue, often leaving the muscle fibers isolated and encrusted . Gebhard gives the following analysis of the deposit. Calc. carb . 49.0 Calc. phosph 29.0 Calc. sulph 13.0 Calc. lithat 0.5 Organic substances 0.4 Petrified fibroids are known as "womb stones." It is possible for such stones to be severed from the uterus and lie free in the peritoneal cavity, or, if submucous, to be either retained in the uterus or expelled. Womb stones were described by Hippocrates. Everett reported one weighing 2.04 kg. A few weighing twenty pounds have been reported. Chondrification and ossification have also been reported. Advanced age predisposes to this condition. Fig. 387 Calcareous myoma of the uterus. (Hertzler.)- 3. Fatty Degeneration. — Fatty degeneration of fibroids is of common occurrence following pregnancy. The tumor is soft, and of a mottled yellow tint. Fat droplets are seen in the muscle fibers. Such a case was exhibited by Dr. Reuben Peterson before the Chicago Gynecological Society. DEGENERATION OF FIBROIDS 589 4. Myxomatous Degeneration. — ^Myxomatous degeneration of fibroids is a circumscribed degeneration of the connective tissue. There is seldom a diffuse involvement of the tumor. Before cutting into the tumor it may appear cystic. On cross-section one or more areas of degeneration are seen. The mj'xomatous material is glairy and trans- lucent, containing opaque particles and a fibrillar or fibrous network. By absorption of the m^'xomatous material cystic spaces are formed. Fig. 388 A pedunculated subperitoneal fibroid lies above the promontory of the sacrum and is too large to fall into the pelvis. It has drawn the uterus and vagina upvrard. 5. Suppuration and Gangrene. — Suppuration and gangrene of fibroids is a grave condition, demanding immediate surgical interference. The usual cause is puerperal infection. Subserous fibroids may be infected through the bowel. Twisting of the pedicle of a fibroid may result in gangrene. 6. Amyloid Degeneration. — Amyloid degeneration of a fibroid is described by Stratz. 7. Telangiectatic Fibroids. — Telangiectatic fibroids are of rare occur- rence. They are formed either from a dilatation of the lymph or blood- spaces. The tumor is soft and may fluctuate and even pulsate. 590 FIBROMYOMA OF THE UTERUS 8. Cystic Degeneration. — Cysts are found in about 4 per cent, of all uterine fibroids. The subperitoneal, and particularly the pedun- culated forms, are especially prone to undergo cystic degeneration. Sixty-three out of seventy cases collected by Heer were subperi- toneal. These cysts are usually multiple. They are prone to become infected, in which case the cyst may be converted into an abscess. The contents may be discharged into the peritoneal cavity, with possible fatal results. All of the largest recorded cases of uterine fibroids contain cysts. In the fibrocystic tumor reported and operated by Webster, which weighed eighty-seven pounds, the fluid contents of the cyst Fig. 389 Honiorrhagic myoma of the uterus. (Hertzler.) weighed sixty pounds. Peritonitis, hydroperitoneum, intestinal obstruc- tion, and adhesions frequently complicate these cystic growths. We recognize true cysts with an epithelial lining and pseudocysts which are void of an epithelial lining and are formed by the degeneration and absorption of tissue. The true cysts arise from epithelial inclusions from the uterine mucosa. Wolffian and ]\Iullerian tracts. An endothelial lining has been demonstrated by several authorities. The explanation for the origin of these endothelial cysts lies in the lymphatic or blood- canals. The contents of myomatous cysts are clear and colorless, bloody, purulent, or resemble thick pea soup. CLINICAL CHARACTERISTICS 591 9. Sarcomatous Degeneration. — Sarcomatous degeneration of fibroids will be discussed in the Chapter on Sarcoma of the Uterus. 10. Cancerous Degeneration. — Cancerous degeneration is an unusual form. The epithelial elements are derived from the overlying mucosa in submucous and interstitial growths or from the glandular elements of an adenofibroma. But two cases are recorded in which the cancer began in the substance of the fibroid. Changes in the Endometrium, Myometrium, Tubes, and Ovaries. — The endometrium commonly undergoes hyperplastic changes under the irritating infliuence of the fibroid. Hence it is that these changes are almost invariably found in submucous, usually in interstitial, and seldom in subperitoneal fibroids. There is hypertrophy and hyperplasia of the elements forming the endometrium. In large fibroids bulging into the uterine cavity there may be pressure atrophy of the mucosa. ^Yhen protruding into- the vagina the endometrium may be transformed into many layers of stratified epithelium, and decubitus ulcers may form upon the surface. The myometrium becomes hypertrophied. This is particularly true of submucous and interstitial growths. The hypertrophy is usually proportionate to the size and number of the tumors. Champneys described a case which caused such atrophy of the uterus as to render the musculature scarcely recognizable. The tubes and ovaries share in the hypertrophy of tissues to a limited extent. It is estimated that the tubes are diseased in 10 per cent, of all cases. The tubes are especially liable to be infected in the presence of infected and sloughing fibroids. Clinical Characteristics. — 1. Shape. — A fibroid grows concentrically, and hence is usually round. The firm, subserous tumors, which from their location are less influenced by the uterus, are round or oval. Sub- mucous fibroids of softer consistency are moulded by the uterus. When forced through the cervix they become elongated and even hour-glass- shaped. Interstitial fibroids, confined within the uterine wall, are round. 2. Mobility. — Only pedunculated submucous and subserous fibroids move independently of the uterus. Broad ligament fibroids are restricted in their movements. Fixation by adhesions and by incar- ceration restricts the movements of the tumor and uterus. 3. Consistency. — The consistency of a fibroid varies from a stone- like hardness to the softness of a pregnant uterus, and may even appear to fluctuate. This variation in consistency is largely to be accounted for by the relative proportions of flbrous and muscular tissue comprising the growth. The more fibrous the tissue, the harder the growth. The forms of degeneration causing a hardening of the growth are atrophy (so-called fibroid degeneration), calcareous, cartilaginous, and osteo- matous degenerations; those causing a softening of the fibroid are fatty, myxomatous, cystic, edematous, purulent, gangrenous, telangiectatic, sarcomatous, and cancerous degenerations. During pregnancy the tumor softens and grows rapidly; after pregnancy it becomes smaller and 592 FIBROMYOMA OF THE UTERUS firmer. During the period of menstrual congestion the growth increases sHghtly in size and is more elastic. 4. Rate of Growth.^ — The softer and more vascular the tumor, the more rapid its growth. It is important to observe the rate of growth in distinguishing a growing fibroid from a pregnant uterus and in determining malignant degeneration. Clinical Diagnosis. — The diagnosis of uterine fibroids rests largely upon the local findings. Symptoms at best are only suggestive of their possible presence. Symptoms — Two general groups of symptoms are to be considered: those due to hemorrhage, and those due to pressure and traction made by the growing tumor. 1. Hemorrhage, in the form of an increase of the menstrual flow, is usually the first event that attracts the attention of the patient. An excessive menstrual flow, beginning late in the childbearing period and associated with dysmenorrhea, suggests the probable presence of uterine fibroids. As time goes on the loss of blood may seriously undermine the patient's health, and has been known to cause death. There may be no intermission, or intervals of variable length may be interrupted by profuse and even alarming hemorrhages. It is seldom that the loss of blood is distinctly and exclusively intermenstrual. The blood comes from the endometrium, rarely from the fibroid. The tumor acts as a foreign body irritating the endometrium. Hence it is that hemorrhage occurs almost invariably in submucous fibroids, to a lesser extent in interstitial, and seldom in subperitoneal fibroids. It is possible for a subperitoneal growth to interfere with the circulation in the uterus and indirectly cause hemorrhage. Mental excitement, physical exertion, and instrumental and digital examinations may excite hemorrhage. The blood is often expefled in clots. This clotting is partly the result of obstruction to the outflow of blood by the tumor and by displacement of the uterus. 2. Pressure and traction, made by the growing tumor upon surrounding structures, are later developments than hemorrhage, and are not usually manifest until the tumor has attained considerable size. Subperitoneal growths are most likely to produce these symptoms. A variety of symptoms arises from direct pressure and traction. Pain is caused by pressure of the growing uterus and tumor upon the various structures in the pelvis. A fibroid tumor incarcerated in the small pelvis may early cause pain, sometimes to an intolerable degree. Intraligamentary fibroids no larger than a man's fist may occasion distressing pain. On the other hand, large, freely movable fibroids, occupying the abdominal cavity, may cause no pain. The pain is commonly located in the lumbar and sacral regions, the shoulders, breasts, and thighs, and occasionally in the cervical and interscapular regions. In submucous growths the pain may be due to intermittent uterine contractions, excited by the growing fibroids. Such pains are usually colicky, and are most severe during the period of menstrual congestion. If, as sometimes happens, the outflow of menstrual blood is obstructed. CLINICAL CHARACTERISTICS 593 there will be a so-called obstructive dysmenorrhea, due to intra-uterine tension and to an effort on the part of the uterus to expel the blood- clots. Pain, in most cases of uterine fibroids, first manifests itself at the menstrual period, when the uterus and tumor are swollen and sensitive from congestion. The "birth of a fibroid" — i. e., the expulsion of a submucous fibroid — is often associated with labor-like pains of astonishing severity. After the flow is well started the pain may be relieved. The more abundant the blood-supply to the tumor, the greater will be the menstrual swelling. Acute pain on external pressure may be experienced in the menstrual period from irritation of the peritoneum. ^Mechanical irritation of the peritoneum caused by the movable tumor may set up a localized peritonitis, and this in tiu-n adds to the pain and discomfort. Pressure of a fibroid upon the abdominal and thoracic viscera gives rise to a variety of symptoms. Pressure upon the bladder causes vesical tenesmus, frequent urination, and catarrh of the bladder. A small, subperitoneal fibroid attached to the anterior surface of the uterus may cause serious disturbance in the bladder. The ureters may be compressed, leading to hydronephrosis, pyonephrosis, and uremia. The urethra is rarely pressed upon by the tumor, though the bladder may be elevated and the urethra stretched and distorted. Pressure upon the rectum may cause constipation, rectal tenesmus, a sense of fulness and pressure in the rectum, and a catarrhal discharge from the bowel. Pressure upon the veins of the pelvis may cause edema and vari- cosities of the lower extremities. When the tumor is sufficiently large to fill the abdominal cavity, pressure upon the bowel and stomach will interfere with digestion, and pressure upon the diaphragm will hinder its excursions, and thereby interfere with the functions of the heart and lungs. Great intra-abdomi- nal pressure caused b}' large fibroids undoubtedly embarrasses the functions of the kidneys. Torsion of the pedicle of a fibroid is possible; furthermore, it is possible for a fibroid to cause torsion of the uterus. In this manner a fibroid may be completely twisted from the uterus. Such an event must necessarily be followed by gangrene of the tumor, unless an adequate blood-supply is con^'eyed by the adhesions. Immediately upon the twisting of the pedicle there is severe abdominal pain, together with a sudden increase in the size of the fibroid, ^'omiting and collapse follow — the clinical picture being not unlike that of a strangulated hernia, or the twisted pedicle of an ovarian cyst. AMien the torsion is partial or slow in its development, the symptoms will be less pronounced. ^Yhen a fibroid becomes infected or gangrenous, the event will be ushered in by a rise in temperature, chills, and pain. The tumor will be tender to pressure and increased in size. When submucous, a stinking discharge will come from the uterus. When a subperitoneal fibroid becomes gangrenous the symptoms are less characteristic. Pain may be absent. Rise of temperature and tender- 38 594 FIBROMYOMA OF THE UTERUS ness on pressure are all but constant symptoms. The usual signs of peritonitis supervene when the infection spreads to the peritoneum. Calcareous degeneration gives rise to no symptoms suggestive of the condition. There is but one sign upon which a positive diagnosis can be based, and that is the expulsion of part or all of the growth in which the calcareous deposits are found. This is not of frequent occurrence because submucous fibroids rarely calcify and under such circumstances are seldom expelled. Objective Signs. — It is evident that a positive diagnosis cannot be made from the above subjective signs. From them we can only conclude that there is a swelling of some sort causing pressure symptoms. A physical examination is indispensable in making a diagnosis. The diagnosis is based upon the recognition of a tumor connected, with the uterus and having fairly definite 'characteristics. The recog- nition of a fibroid of the uterus is ordinarily easy, but may be rendered difficult by various circumstances. In order that a diagnosis of fibroids may be made, the tumor must either be seen or outlined by the examining hands. Many conditions may exist to render such a procedure impos- sible, and at such times the diagnosis must be reserved until an exami- nation is made under anesthesia or an exploratory incision has been made. Small interstitial fibroids can only be suspected from the size and irregular consistency of the uterus. In large, interstitial fibroids there is difficulty in outlining the uterus apart from the tumor. The sound passed into the uterine cavity will locate the uterus, and when combined with a conjoined examination, it should be possible to determine the existence of a fibroid and its position relative to the uterus. In outlining the respective positions of the uterus and tumor it is important to recognize the differences in their form and consistency. A subperitoneal fibroid is ordinarily identified by a conjoined exami- nation. \Mien the tumor is large, abdominal palpation may alone be sufficient. The form, consistency, and relation to the uterus may suffice for a diagnosis. Aluch dependence may be placed upon the firmer consistency of the tumor as compared with the uterus, and particularly is this of importance in difi'erentiating a fibroid from a pregnant uterus. As with interstitial fibroids, great difficulty may be experienced in outlining a large, sessile, subperitoneal fibroid from the uterus. The irregular outline, the firmer consistency, the groove or angle which may mark the connection between tumor and uterus, are points which, together with the use of the soimd, should suffice for a diagnosis in the majority of cases. Greater difficulty is experienced with multiple subperitoneal fibroids. In large fibroids a vascular souffie is often heard and may be mistaken for the souffle of pregnancy. The pulsations of the aorta may be transmitted through the tumor and be mistaken for the fetal heart- beat. Intraligamentary or broad ligament fibroids are recognized by their CLINIC A L CHA RA CTERIS TICS 595 point of attachment along the side of the uterus, by their lessened mobility, by the course of the adnexae which run over the tumor, and by the crowding of the uterus to the opposite side of the pelvis. The growth may spring from the supravaginal portion of the cervix or from the side of the uterine body. Plate IV represents a single, large, subperitoneal fibroid causing a rounded protuberance of the abdomen. Plate V represents an abdomen distended by multiple subperitoneal fibroids, in which the irregularities are plainly visible. Fig. 390 Area of dulness in multiple fibroid of the uterus. Submucous fibroids can only be diagnosticated with certainty when they are seen protruding through the cervix or when palpated through the cervical canal. The hemorrhage and uterine colic will suggest the possible presence of a submucous fibroid, but the diagnosis must be kept in reserve for a physical examination. Within the uterine cavity the finger detects a firm, rounded tumor connected with the uterus by a broad base or pedicle. The fibroid may be felt as a circumscribed tumor bulging upon the mucosa. With the sound or curet similar observations may be made, though with less certainty. Fibroids of the cervix are not difficult to diagnosticate when attached to the vaginal portion. Their attachment to the cervix can be demon- strated by inspection or by the finger and sound. Small interstitial fibroids of the cervix are recognized by the firm, rounded, and sharply circumscribed area of resistance which characterizes their presence. The use of the sound in the diagnosis of uterine fibroids is not to 596 FIBRO MYOMA OF THE UTERUS be underestimated, yet its application should be restricted to the cases in which a conjoined examination fails to clear up the diagnosis. Aside from the danger of infection there is the added risk of perfor- FiG. 392 Fig. 393 Fig. 394 It is sometimes possible to locate a fibroid in relation to the uterus by palpating the uterine appendages and round ligaments. Fig. 391. The fibroid is subperitoneal and sits upon the fundus, hence the appendages and round ligaments are not disturbed in their relative positions. Fig. 392. The fibroid is subperitoneal and -sits upon the posterior wall of the uterus, and extends backward and to the left. The appendages and round ligaments are not disturbed in their relative positions. Fig. 393. The fibroid is interstitial and evenly distends the uterus, hence the appendages and round ligaments are separated on the same plane. Fig. 394. The fibroid is interstitial and lies in the fundus and right cornua. The right tube and round ligament are elevated and dislocated outward. ' ating the uterus at a point thinned by the tumor. Great difficulty may be experienced in the passage of the sound. The tumor may be impinged upon and give the impression that the depth of the uterus is short in contrast to the usual lengthening of the uterine cavity, as found DIFFERENTIAL DIAGNOSIS 597 in the presence of submucous and interstitial fibroids. The shape of the uterine cavity is also to be noted by the sound. It may be encroached upon and greatly distorted, so much so that the uterine sound cannot be passed to the fundus. Palpation of the Adnexae and Round Ligaments. — In favorable cases the tubes and round ligaments can be palpated by a conjoined examina- tion. It is observed that their location and points of attachment are altered by the tumor, and it is sometimes possible to locate the tumor in its relation to the uterus by observing the position of the adnexse and round ligaments. When the uterus is small and a large fibroid rests upon the fundus, the tumor may be mistaken for the uterus. The attachment of the tubes and round ligaments, when determined, will indicate the position of the uterus apart from the tumor. The sound will confirm the findings. A submucous or interstitial growth, evenly distending the uterus, will separate the attachments of the round ligaments and adnexse. An interstitial fibroid of the anterior wall will separate the round ligaments and tubes, and if it be to one side of the median line, the correspond- ing tube and round ligament will be elevated above the other. An interstitial fibroid on the posterior surface of the uterus will tend to approximate the appendages. If the fibroid is on the side of the uterus the corresponding round ligaments and tube may be elevated. Figs. 397 to 400 illustrate these facts. The diagnosis of malignant degeneration of a- fibroid is discussed in the chapter on Sarcoma of the Uterus. Differential Diagnosis. — Fibroids of the uterus commonly appear during the period of sexual maturity when pregnancy, inflammatory lesions, and displacements are liable to arise, and it is for this reason that the differential diagnosis is of such importance. Interstitial Fibroids Chronic Metritis 1. Irregular enlargement of the uterus unless 1. Uniform enlargement. tumors are small. 2. Variable consistency. 2. Uniform, firm consistency. 3. Not tender to pressure. 3. Commonly tender to pressure. 4. Uterus freely movable. 4. Uterus usually restricted in its movements. 5. No history of infection. ' 5. History of infection. 6. Symptoms of uterine catarrh not common. 6. Symptoms of uterine catarrh generally present. When the fibroids are multiple and small it may be impossible to distinguish such a lesion from chronic metritis. The clinical history cannot be relied upon. Uterine Fibroids Uterine Pregnancy 1. Usual signs of pregnancy absent. 1. Present. 2. Tumor of firm consistency, rarely soft. 2. Soft and elastic. 3. Intermittent uterine contractions absent. 3. Present. 4. Irregular and asymmetrical growth. 4. Rate of growth regular and symmetrical. 5. Slow growth. 5. More rapid growth. 6. Cervix firm, not patulous. 6. Cervix soft and patulous. 7. Positive signs of pregnancy absent. 7. One or more present, i. e.: a. Fetal heart tones. b. Placental bruit. c. Active fetal movements. d. Palpation of fetal parts. -- e. Ballottement. 598 FIBROMYOMA OF THE UTERUS Of greatest importance in the differential diagnosis of fibroids from early pregnancy is the uniform, rapid growth of the pregnant uterus, the intermittent uterine contractions and characteristic doughy con- sistency of the uterus. Later, when positive signs of pregnancy are elicited, there should be no mistaking the fact of pregnancy. Fig. 395 Subperitoneal fibroid of the uterus in the third month of pregnancy. On the posterior surface of the body of the uterus and cervix is a hard subperitoneal fibroid, the size of a fetal head. The uterine wall is abnormally thickened. The ovary is cystic and adherent to the tube and uterus. (Specimen was removed by Dr. J. Clarence Webster.) A large, soft, interstitial fibroid may evenly distend the uterus. Its soft consistency, regular outline, and rapid growth may suggest the presence of a pregnant uterus. In addition to the above findings there may be nausea and vomiting, enlargement of the breasts, and soft- ening and discoloration of the vaginal portion of the cervix. With such a condition it may be impossible to differentiate from early pregnancy. Keeping the case under observation for a few weeks, it will be noted Pregnant Myomatous Uterus. Medial Section of Pelvis. (Leipmann.) J. Foot of fetus. 2. Umbilical cord. 3. Fibroid in posterior wall of uterus. 4. Head of fetus. 5. Rectum. 6. Recto-uterine fold. 7. External os. 8. Anus. 9. Vesico-uterine fold. 10. Vagina. 11. Urinary bladder. 12. Urethra. 13. Peritoneum. 14. Os pubis. 15. Fibroid in anterior wall of uterus. 16. Necrotic area in fibroid. DIFFERENTIAL DIAGNOSIS 599 that the growth is slower than in pregnancy, that there are no inter- mittent contractions, and that none of the positive signs of pregnancy develops. Fig. 396 Multiple interstitial fibroids in a full-term pregnant uterus. The placenta is retained in situ. The irregular contractions of the uterus, due to the presence of the fibroid tumors, are shown by the irregular course of the uterine cavity. (The uterus was removed by Dr. J. Clarence Webster immediately follow- ing a Cesarean section.) The diagnosis of fibroids complicated by pregnancy is often a diffi- cult problem. Small, subperitoneal fibroids may be mistaken for part of the fetus. Under the influence of pregnancy a fibroid usually grows rapidly and becomes soft. It is, however, unusual for the growth to become as soft as the pregnant uterus, so by the circumscribed area of firmer resistance, the fibroid is outlined apart from the pregnant uterus. If the examination is made during a uterine contraction, this difference in consistency between the uterus and fibroid is not evident. Repeated and prolonged examinations may be required. No tumor other than a pregnant uterus displays these intermittent contractions. 600 FIBROMYOMA OF THE UTERUS When, through a morbid state of the contained fetus, the uterus remains in a condition of tonic contraction, the discovery of an inter- stitial fibroid may be impossible. When in doubt as to the diagnosis, and the condition of the patient does not demand immediate inter- ference, it is always advisable to await developments and make examinations at frequent intervals. Subserous Uterine Fibroids Hematoma and Hematocele 1. No history of recent pregnancy. 1. Frequently history of previous pregnancy. 2. Slow, continued development. 2. Sudden development. 3. Consistency firm, rarely soft. 3. Consistency at first is fluctuating, later is doughy. 4. Sharply circumscribed tumor. 4. Ill-defined tumor. 5. Exploratory puncture negative. 5. Exploratory puncture — blood obtained. Gangrene with fatal termination has been known to follow an exploratory puncture of a fibroid. It is not always possible to remove blood through an exploratory needle because of the firm clotting. In this event an exploratory incision must be substituted. For the dififerential diagnosis of uterine fibroids from displacements of the uterus, carcinoma, sarcoma, tubal and ovarian swellings, and pelvic exudates, see respective chapters on these subjects. A case in the experience of the author, and another observed by Bayard Holmes, presented a soft subperitoneal fibroid near the horn of a pregnant uterus which was thought to be an ectopic gestation.. In both cases the pregnancy was early; the fibroids were not discovered until the pregnant uterus began to rise out of the pelvis, bringing the softened tumor with it. Fibroids Imperil Life. — Fibroids may exist without the know^ledge of the individual carrying them. Again, they may be the source of much distress, and may be the direct or indirect cause of death. The follow- ing are the incidents which seriously influence a myomatous patient: 1. Hemorrhage. — Hemorrhage is the most common, though not the most serious, event. Little need be added to what has already been said. While the patient's health may be seriously influenced by loss of blood, it must be remembered that this is not alone the result of a loss of large quantities of blood. What may appear to be an insignificant amount, when continued over many months and years, may produce a chronic anemia, not unlike pernicious anemia in its clinical features. Excessive bleeding from a fibroid during and between menstrual periods usually indicates septic infection of the tumor. 2. Complicating Pregnancy. — The gravity of fibroids complicating pregnancy depends in great part upon the size and position of the tumor. Submucous fibroids have the most serious influence and subperitoneal the least. A submucous fibroid predisposes to abortion, interferes with the complete emptying of the uterus, and hence renders the patient liable to infection and hemorrhage. Septic infection and sloughing of these growths may follow. Subperitoneal fibroids may become edematous DIFFERENTIAL DIAGNOSIS 601 or infected and lead to peritonitis. Twisting of the pedicle of a sub- peritoneal fibroid is an occasional accident which leads to severe pain, gangrene of the tumor, and peritonitis. In the Baudelocque, 1895 to 1900, there were 85 cases of uterine fibroids complicated by pregnancy. Meneut reports 67 of these having gone to full term and 13 aborted; in 2 cases abortion was induced, and death occurred in 2 cases. Tait found in the literature 39 cases of polypoid myomata complicat- ing pregnancy. Of this number gangrene of the tumor occurred in 6, spontaneous expulsion of the fetus together with much loss of blood in 3, myomectomy in 7, normal delivery in 10, maternal deaths in 8. 3. Septic Infection. — Septic infection is a most serious complication and demands immediate and radical treatment. The infection may be conveyed to the fibroid by instruments and fingers. More often it arises through an infected puerperal wound of the uterus. Tumors adhering to the bowel may be infected from the bowel. A submucous fibroid, protruding through the cervix into the vagina, may be so constricted as to partly shut off the blood supply and lead to edema and congestion, which may later result in gangrene of the fibroid with all its remote consequences. 4. Torsion of the Pedicle. — A long, slender pedicle of a subperitoneal fibroid may permit of rotation of the fibroid in exactly the same manner as in ovarian cysts. The accident is a rare one. Conditions which favor rotation of the fibroid are a long, slender pedicle, free fluid in the abdomen, sudden increase in the intra-abdominal pressure, preg- nancy, the sudden emptying of the pregnant uterus, and lastly, direct injury. The consequences of such twisting are gangrene of the fibroid, followed by peritonitis unless surgical interference is timely. Calcar- eous fibroids have twisted off and have been found free in the abdominal cavity, but giving rise to no disturbances. 5. Impaction. — Impaction in the small pelvis may occur from all varieties of fibroids, but it is far more common in subperitoneal fibroids. This event is especially liable in pregnancy, at which time the tumor and uterus grow rapidly. Retention of urine may be caused by direct pressure upon the urethra. Frequent urination results from pressure upon the bladder. When long continued the bladder and kidneys may suffer permanent injury. Bland Sutton lays down the rule that "when a woman between thirty-five and forty-five seeks relief because she sufi^ers from retention of urine for a few days preceding each menstrual flow it is almost certain that she has a fibroid in the uterus." Broad ligament fibroids are especially liable to impaction, and the pressure exerted by them upon the ureter, pelvic nerves, and bloodvessels may early become serious. 6. Intestinal Obstruction. — Intestinal obstruction may arise from direct pressure of the growth or from the entanglement of the intestinal loops with the pedicle of a subperitoneal fibroid. 7. Nutritive Changes. — Nutritive changes in the fibroid may imperil life. Fibroids grow almost invariably during the period of gestation, and particularly in the early months. The increase in the size of the 602 FIBROMYOMA OF THE UTERUS tumor may be so rapid and attain such a large size as to seriously embarrass not only the course of pregnancy and labor, but also the functions of the abdominal viscera. During labor, degenerative changes may occur in the fibroid as the direct result of trauma. Such tumors are usually located low in the pelvis. According to Hammarschlag these changes are not necessarily dependent upon trauma, but may arise independent of injury. It must be admitted that fibroid tumors of the uterus, even of large proportions, seldom impede the progress of labor. Statistics from the large clinics of the world justify this assertion. During the lying-in period the usual tendency of fibroids is to undergo involution, even to the point of apparently disappearing. Hammarschlag finds that the sudden cessation of the free blood supply which exists during pregnancy sometimes brings about marked necrotic changes in the tumor which may seriously affect the patient. Edema of the tumor may occur during pregnancy, labor, and in the lying-in period. During pregnancy such an event must be looked upon as a fortunate happening, inasmuch as the softening of the tumor permits of such moulding of the growth by the pressure of the advancing child that delivery will be favored. Hemorrhage from the severing of adhesions may arise during the latter part of pregnancy and in labor. Fatal results have been recorded. This event is especially liable to occur when artificial reposition is attempted. Hemorrhage and peritonitis have been known to result from the twisting of the pedicle of a subperitoneal fibroid. Expulsion of a submucous fibroid during labor and the puerperium is a not infre- quent event, and may be followed by serious infection. 8. Cardiopathy of Uterine Fibroids. — Cardiopathy of uterine fibroids is a condition demanding serious consideration because of the gravity of the condition and its frequent occurrence, ^'a^ious functional and organic lesions of the heart are found to be associated with uterine fibroids in about 40 per cent, of cases, not simply as a coincidence but as an inevitable result in some cases. It is therefore imperative to look to the heart in all cases. McGlinn draws the following conclusions from his study of a large number of autopsies: First. A definite entity of a fibroid heart cannot be sustained. Second. If the fibroid tumors of the uterus were the cause of all heart lesions then every tumor, regardless of its size and situation, should be removed. A contention that the most radical would hardly admit. Third. Uterine myomata, occurring in middle and advanced life, are practically always associated with sclerotic heart lesions.^ These lesions are a part of a general process and bear no relation to the fibroid. Fourth. Large tumors, by increasing the work of the heart, and tumors causing pressure on the pelvic circulation may produce hyper- trophy and secondary dilatation of the heart. DIFFERENTIAL DIAGNOSIS 603 _ Fifth. Anemia from hemorrhages, infections, and certain degenera- tions of the tumor may affect the heart, secondarily causing changes such as fatty degeneration, brown atrophy, and cloudv swelHng Fig. 397 Multiple fibroids of the uterus, with sarcomatous degeneration. Fig. 398 'It ^ ^if>'^. .&i ^' £^t.^ _<^. / ^"^^-^^^ -^K^-^ ^y /^l Spindle-cell sarcoma. Section taken from centre of a large fibroid in Fig. 395. Sixth. The majority of cases of fatty degeneration, brown atroph\-. cloudy swelling, myocarditis, etc., found in connection with fibroid tumors of the uterus, are not caused by the tumor but b^• conditions entirely foreign to the tumor. 604 . FIBROMYOMA OF THE UTERUS 9. Malignant Degeneration. — Malignant degeneration of uterine fibroids occurs in 3 to 4 per cent, of all cases, according to Winter. These changes are almost invariably sarcomatous. Coincident malignant disease of the uterus with fibroids has been frequently observed, but to establish a relationship of cause and effect is not justifiable. The fact that they occasionally occupy the same uterus should lead to the consideration of the possible existence of the two lesions in all cases. Causes of Death from Uterine Fibroids. — Pellanda tabulates the causes of death in 171 cases of uterine fibroids as follows: 1. Cachexia, 9 cases, or 5.2 per cent. 2. Hemorrhage, 11 cases, or 6.4 per cent. 3. Infection, 85 cases, or 49.5 per cent. The majority were dependent on labor and abortion followed by infection. 4. Compression of abdominal and pelvic viscera, 44 cases, or 25.8 per cent. 5. Thrombosis of the pelvic veins followed by pulmonary embolism; also cardiac lesions and sudden syncope, 19 cases, or 11.1 per cent. 6. Torsion of pedunculated subserous fibroid, 3 cases. More patients die from postoperative complications than from the tumor itself. Effect of Fibroid Tumors upon Neighboring Organs. — By compression of neighboring organs, fibroid tumors create circulatory disturbances in these organs and so compress and distort them as to give rise to serious functional disturbances. The bladder, rectum, ureters, and urethra suffer greatest from compression. The bladder may be elevated to the level of the umbilicus. The urethra may be greatly elongated, and com- pression of the urethra may lead to retention of urine within the bladder. Hydro-ureter and hydronephrosis, with possible destruction of the parenchyma of the kidney, may result from compression of the ureters. Intraligamentary fibroids are prone to distort and displace the ureter. Compression of the rectum may give rise to constipation, distention of the bowel above the point of compression, and to hemorrhoids. Complete obstruction probably never occurs. Effect of Fibroid Tumors upon the Blood. — Noble reported a case with 10 per cent, of hemoglobin and another with 15 per cent. The anemia may be so profound, as the result of the hemorrhages, as to produce permanent invalidism, and is known to result fatally. Telanda, in a report of 171 cases of death from fibroids without operation, records a mortality of 6.4 per cent, as the result of hemorrhage. The cardiac weaknesses and kidney insufficiencies, as the result of anemia, will explain a certain number of deaths in operated and non-operated cases. Thrombosis, Embolism, and Phlebitis. — Fibroid tumors of the uterus cause thrombosis, embolism, and phlebitis more often than any other pelvic lesion, the pelvic veins and veins of the legs being most often involved. Embolism of the lungs following thrombosis of these veins is one source of sudden death following operation for removal of a fibroid. TREATMENT OF UTERINE FIBROIDS 605 The contributing factors leading to thrombosis, phlebitis, and embol- ism are anemia, slowing of the circulation, injury to the veins, and infection. Treatment of Uterine Fibroids. — The improved technic of myo- mectomy and of hysterectomy, together with a better understanding of the dangers of fibroids, has resulted in a revolution of the treatment of fibroid tumors of the uterus. Expectant treatment is no longer countenanced by some gynecologists. Russell, Lewis, Bovee, Goffe, Eastman, Richardson, and others plead for early surgical intervention. Charles P. Noble gives a critical analysis of 2274 cases of uterine fibroids. Two-thirds of this number were complicated. Noble estimates a prospective mortality of 30 per cent, in fibroid tumors of the uterus pursuing their natural course as compared with an operative mortality of 2.26 per cent. The high mortality in the expectant plan of treatment is ascribed to degenerations and complications in the tumor and uterus and to complications outside the uterus and tumors. Advantages of Early Operation. — 1. Lessens the hazards to life from malignant degeneration of the tumor and uterus. 2. Minimizes the chances of the development of degenerative changes in the tumor which imperil life, also of thrombosis and embolism. 3. Avoids prolonged ill health. 4. Lessens the operative mortality. 5. Preserves the function of childbearing. Sippel supports the statement of Noble that operation is less dan- gerous than palliation by comparing the results of 47 operated cases in which there were no deaths, with 27 unoperated cases in which there were 6 deaths: 2 from hemorrhage, 3 from pulmonary embolism, and 1 from bronchitis. The menopause does not provide immunity from the evil effects of fibroids; on the contrary, the dangers increase with age. Winter bases his decision as to the indication for operation upon the symptomatology, and does not operate in the absence of symptoms caused by the fibroid or by complicating lesions. He believes that all the degenerations and complications which may prove dangerous will give rise to symptoms. The author is in accord with the views of Winter, believing that the rule should be to operate only when symptoms arise. This implies that all fibroids, however small and wherever located, should be kept under observation, and that they should be operated upon as soon as symptoms arise. Palliative Treatment. — Fibroids, with or without complicating lesions, often give rise to sjTnptoms requiring relief. A radical operation is indicated in all such cases unless serious complications exist which would make operation hazardous or impossible. In this event palliative measures are the only alternative. Relief from Hemorrhage. — A thorough curettage with prolonged rest in bed will most surely control the hemorrhages. Howe^-er depressed 606 FIBROMYOMA OF THE UTERUS the patient may be as the result of anemia, it is usually possible to give the necessary anesthesia for the purpose. The galvanic current was formerly used to control uterine hemor- rhages, but it is now largely discarded. Drugs are of slight value in controlling hemorrhage. Ergotin in 1- or 2-grain doses, given four times a day, will sometimes afford relief. Relief from Pressure. — When a myomatous uterus is displaced back- ward, the pressure symptoms may be relieved by the insertion of tampons behind the cervix or by the wearing of a Hodge-Smith pessary. When the tumor is incarcerated in the small pelvis, and not adherent, it may be elevated by careful manipulations. This may require an anesthetic. No great amount of force should be used in these manipulations for fear of hemorrhages from broken adhesions or pedicle. X-rays. — The .r-rays promise to supplant surgery in many cases of uterine fibroids. By a series of applications of the rays to the ovaries, hemorrhages have been controlled and the tumor in time reduced in size. This action is due to the atrophic changes produced in the ovaries, thereby bringing on an early menopause. To just what extent the a--rays will prove effective in these cases is not yet known, but the method is deserving of extended trial. (See page 225.) Contra-indications to Operation. — While there is no complication pre- cluding surgical interference that does not apply to operations upon uterine fibroids, there are two conditions in particular which, because of their frequency and gravity, deserve special mention, i. e., anemia and incompetent heart action. W^hen these conditions exist to a marked degree, a course of preliminary treatment should precede the operation. For the anemia, rest in bed, forced feeding, massage, and blood tonics are prescribed until the quality of the blood is built up to a degree that will admit of operation. When bleeding continues, a preliminary curettage should be done, and, if necessary, the vagina should be tightly packed with gauze. An incompetent heart demands rest until it may be safely depended upon to withstand the stress of the operation. The patient is confined to bed, the bowels regulated with mild laxatives and enemata, the diet is light and nutritious, and such cardiac stimulants given as will regulate the force and rhythm of the heart action. The blood pressure is a good indication of the heart force, and should be taken at frequent intervals. Uncomplicated fibroids in extreme age would justify non-interference when the same sort of tumor in the uterus of a younger woman would clearly suggest operative interference. Preparatory Treatment. — Because of the frequency with which heart lesions and anemia complicate fibroids of the uterus, the preparation of the patient for operation may require days and possibly weeks. In one instance the author was unable to control the loss of blood from a large submucous fibroid by the usual means of curettage, uterine tamponades, and rest in bed, and was obliged to perform a supra- vaginal hysteromyomectomy in the presence of a blood-count far below the standard of safety. The results were gratifying. Such TREATMENT OF UTERI XE FIBROIDS 607 experiences are exceptional, tliough it has been tlie aiitlior's experience that fibroid cases which have reached a high degree of anemia, as a rule, bear the operation welL On the other hand, there is uncertainty as to the behavior of the heart during and after the operation. Acute dilatation may take place several weeks after operation, and with fatal results. Great caution must be exercised in respect to the heart in all cases of uterine fibroids, and particularly in those which have suft'ered for some time from loss of blood. The absence of heart murmurs and of increase in the area of heart dulness does not fully justify confidence in the integrity of the heart when put to the strain of an operation. The preliminary preparation of the bowels and of the field of operation does not differ from that of other vaginal and abdominal operations. (See Chapters XIII and XIV.) Choice of Operation. — AYhether the tumor shall be removed, leaving the uterus, or the uterus be removed together with the tumor, is a question of great importance. The number and relation of the tumors to the uterine wall, as well as the existence of complicating lesions, such as carcinoma of the uterus, pus-tubes, and extensive pelvic adhesions, may preclude all possibility of choice between hysterectomy and myomectomy. Excluding all cases over forty years of age, and all those in which there was no prob- ability of childbearing because of social conditions, Winter found the following: LS myomectomies for submucous fibroids, 4 conceptions (22 per cent.), 37 pregnancies following myomectomy, 26 (72.97 per cent.) went to term. 46 labors following myomectomy, with 6 abnormal labors, one of which was attributed to the operation. When, however, the statistics of various operators are consulted and it is learned that not more than one woman in ten on whom a myomectomy is performed ever bears a child subsequently, we may conclude that the question of childbearing should not be considered with hysteromyomectomy. However, with the facts clearly stated to the patient, her wishes should be considered in choosing between the two operations when the conditions are favorable to either. Against myomectomy is the possibility of leaving one or more small fibroids which may grow and cause trouble in later years. The majority of fibroids are multiple, and it is not possible to determine with certainty that small intramural fibroids do not exist. The percentage of recur- rences is estimated at 8 per cent. Unquestionably a larger percentage of cases are relie\'ed of their symptoms through hysteromyomectomy than through myomectomy. According to Winter, 73 per cent, are relieved of their symptoms by myomectomy as compared with 97.3 through hysteromyomectomy. We are confronted with the question of the artificial menopause, with its trend of distressing manifestations, such as flashes of heat and cold, sweating, despondency, and numbness. These phenomena, of course, must result from the removal of the uterus and ovaries, together with the tumors. That these symptoms are exaggerated over those of the 608 FIBROMYOMA OF THE UTERUS natural menopause is a question upon which authorities do not fully agree. In my experience I have only observed such cases in which the removed ovaries were almost wholly degenerated, and in such cases the menopausal symptoms are not so pronounced as when the ovaries were normal. However this may be, it is certain that the question of precipitating the menopause should not enter largely into the choice between myomectomy and hysteromyomectomy in view of the greater mortality of the former. In submucous and subperitoneal pedunculated fibroids, in patients yet in the childbearing period, the choice may be made in favor of myomectomy in view of at least preserving the hope for childbearing, even though the chances are small. Finally, the choice of operation must hinge upon the question of the dangers involved This is, after all, the vital question. In the hands of Winter, abdominal myomectomy gave a mortality of 9.8 per cent., while in supravaginal hysteromyomectomy the mor- tality was but 4.8 per cent. Kelly reported 306 myomectomies, with a mortality of 4.5 per cent., and 691 hysteromyomectomies, with a mortality of 3.1 per cent. Rules Governing the Choice of Operation. — The following rules govern- ing the choice of the several operative procedures may be safely adopted : 1. Subserous and submucous pedunculated fibroids should be removed by myomectomy. 2. Necrotic submucous pedunculated fibroids should be removed by vaginal myomectomy. 3. Necrotic submucous pedunculated fibroids should be first removed by myomectomy, and if other fibroids exist in the body of the uterus these should be removed, together with the uterus, at a later date. 4. Fibroids complicated by malignancy of the fibroid or uterus demand panhysterectomy. 5. The choice between supravaginal amputation of the uterus and panhysterectomy may be determined as follows: (a) If the cervix is diseased, perform a panhysterectomy. (b) If malignancy exists in the cervix, corpus, or tumor, panhyster- ectomy should be performed. (c) If drainage is desired, the removal of the cervix will be advisable, though not essential. (d) In all other cases supravaginal amputation will, as a rule, give better immediate and remote results. The rare occurrence of cancer in the stump of the cervix is no argu- ment against supravaginal amputation, in view of the greater safety of the operation. Relative Frequency of Operations. — The following are the statistics compiled by Charles P. Noble from his case records: Abdominal supravaginal hysterectomies . . 235 Abdominal panhysterectomies 14 Abdominal myomectomies 22 Removal of ovaries, etc 15 Vaginal hysterectomies 7 Vaginal myomectomies 44 Total 337 OPERATIONS FOR UTERINE FIBROIDS 609 Kelly favors myomectomy to a greater degree than does Noble. In 997 operations for fibroids, 306 were myomectomies and 691 hy steromy omectomies . A Plea for the Preservation of the Ovaries in Operating for Fibroids of the Uterus. — Should the ovaries be removed together with a myomatous uterus f The consensus of opinion is in favor of conserving the ovaries, or as much of them as is possible. We have the statement of Zweifel that the artificially induced menopause causes more suffering than does the natural one. He therefore endeavors to leave one or both ovaries. Olshausen, Werth, Rosthorn, and, in fact, most of the authorities assume a like position. The author is in full accord with these views because experience has proved that the disturbances incident to the induced climacterium are greatly minimized by allowing one or both ovaries to remain. The ovaries should be dealt with according to their own merits. Every portion of healthy ovarian tissue should be conserved. Bland Sutton has rightly said, "The ovaries are of more importance to a M^oman than the uterus." The author would go one step farther and advise the removal of only what is necessary of the uterus. When the fibroid is located upon the fundus it may be possible to remove the tumor and fundus and still preserve much of the uterus. This the author did recently, and to the satisfaction of the patient, who continues to menstruate. Unfortunately the tumors are seldom so favorably situated. Operations for Uterine Fibroids. — Vaginal Myomectomy. — iVll oper- ators agree that a pedunculated submucous fibroid, uncomplicated by fibroid tumors located elsewhere or by other pelvic lesions demand- ing relief, should be removed per vaginam and without sacrificing the uterus. The scope of vaginal myomectomy has been extended by various operators to the removal of interstitial and subperitoneal fibroids of a size not to exceed that of the head of a fetus at term, but there are serious objections to such a procedure. In the first place the operation may prove difficult. Again, there is the vmcertainty of the possible presence of other fibroids lying within the wall of the uterus, and of the existence of other pelvic lesions which would be recognized in an abdominal operation. The author does not look with favor upon vaginal myomectomy for fibroids other than when pedunculated and submucous. This opinion has no more than a general application, because unquestionably there are cases in which the scope of the operation may be extended to interstitial and subperitoneal fibroids. For this reason the technic of the operation will be presented in its widest scope. hidications for Vaginal Myoviedomy. — 1. Pedunculated submucous fibroids of whatever size. 2. Single sessile submucous fibroids of a size not to exceed 12 cm. in diameter. The operation should be preferred to supravaginal hystero- 39 610 FIBROMYOMA OF THE UTERUS myomectomy only when it is desired that the capacity for childbearing be safeguarded. 3. Single intramural fibroids of small size may be removed through an anterior or posterior colpotomy. 4. Small and moderate-sized subperitoneal fibroids may be removed either by anterior or posterior vaginal celiotomy. The author's prefer- ence is for abdominal myomectomy in such cases. 5. Small and moderate-sized fibroids of the cervix. 6. Infected submucous fibroids. Contra-indications for Vaginal Myomectomy. — The limitations of vaginal myomectomy are largely determined by the size, number, and position of the tumor. In the practice of the author, vaginal myomectomy is only adapted to the removal of infected submucous fibroids, and of cervical fibroids of whatever size, and of uninfected submucous fibroids of small and moderate size. In all other instances he prefers the abdominal route. That there are greater possibilities for the operation is admitted (for indications vide swpra), but in the author's opinion they are ill advised. It may be laid down, as a general rule, that pelvic complications, of whatever nature, so long as they require operative interference, should determine the choice of approach in favor of the abdominal route, or a combination of the vaginal and abdominal routes. Technic of Vaginal Myomectomy. — For pedunculated fibroids pro- truding from the cervix or attached to the vaginal portion of the cervix no anesthetic is required. For all other cases a general anesthetic is desirable. The usual preparation for vaginal operations is made. (See page 246.) Pedunculated Siibmucous Fibroids. — When the cervix is dilated and the tumor presents in the vagina, the growth is grasped by a heavy vulsellum forceps and is twisted from its attachment. If, by traction upon the tumor, the pedicle can be reached with sharp-pointed scissors, it may be severed without fear of serious loss of blood. When there is partial inversion of the fundus, associated with the fibroid, care must be exercised in excising the tumor for fear of injuring the inverted wall of the uterus. If the cervix is not dilated or the tumor is large and wedged in the cavity of the cervix, or the body of the uterus, it will be necessary to perform hysterotomy. This is done by bisecting the cervix laterally or anteroposteriorly. Sessile Submucous Growths. — For the removal of sessile submucous growths, hysterotomy should be performed. The tumor is grasped by heavy vulsellum forceps, the capsule is incised about the base of the tumor, when with firm traction the tumor can, as a rule, be delivered. If the tumor is too large for delivery it may be divided into two or more pieces. All remaining fragments of the capsule are to be trimmed off with scissors, leaving as smooth a surface as possible. The cavity of the uterus should not be curetted or irrigated for fear of puncturing the uterus and washing the fluid into the abdominal cavit\'. After the Vaginal tysteromyomectomv f ^Atter Doederlein and Kroenig.) -^^entoneal cavity opened in front of hemorrhage and t Thereafter dai,, vagi^^doX 7S„T":*,o''o7'"'' '"'^^*'°"- J -I i-u tuuu, are given. 612 FIBROMYOMA OF THE UTERUS Hysterotomy Followed by Vaginal Myomectomy.— ^\hen found impossible to deliver a submucous fibroid through the cervix, the uterus must be incised. The rule is to so incise the cervix as to Fig. 400 Vaginal hysterectomy for an interstitial fibroid of the body of the uterus. Fundus ef the uterus brought forward through the anterior incision. Ligatures placed about the appendages and broad ligaments, passing from above downward. Step 2. best expose the attachment of the tumor. The line of choice is the anterior median, but the posterior median or bilateral incisions are often chosen. OPERATIOXS FOR UTERIXE FIBROIDS 613 The author's preference is for either an anterior or posterior incision, or a combination of the two, for the reason that there is less likeHhood of hemorrhage. More than this, when it is necessary to extend the incision beyond the limits of the vaginal portion of the cervix, the ^'aginal hysterectomy for an interstitial fibroid of the bodj- of the uterus. Final ligature placed about the base of the broad Ugament. Step 3. median incision can be lengthened to any desired extent by extending the incision through the supravaginal portion of the cervix in front or behind, or both. This incision may or may not involve the peritoneal cavity. When firm traction is made upon the cervix, but slight bleeding 614 FIBROMYOMA OF THE UTERUS is occasioned by the incision. After the removal of the tumor the incisions are closed by continuous chromicized catgut sutures. Fig. 402 Vaginal hj-sterectomy for an interstitial fibroid of the body of the uterus. Uterus severed from its attachment to the posterior vaginal wall. Step 4. Vaginal Celiotomy.- — For the removal of intramural and subperitoneal fibroids through the vagina an anterior vaginal celiotomy is performed. OPERATIONS FOR UTERINE FIBROIDS 615 The uterus is drawn down into the vagina by means of a vulsellum forceps and the tumor removed in accordance with the principles laid down above. In all such cases the author's preference is for abdominal myomectomy or hysteromyomectomy. Fig. 403 m-'^ Vaginal hysterectomy for an interstitial fibroid of the body of the uterus. Stumps of ligaments and tubes anchored to the vault of the vagina. Peritoneum stitched to the vaginal walls. Step 5. Noble recommends suturing the vesical fold of peritoneum above the closed wound in the uterus, when the tumor has been removed from the anterior surface, in order to lessen the dangers of hemorrhage and septic peritonitis. If the tumor is removed from the posterior surface of the uterus, a gauze drain is placed in the cul-de-sac for like reasons. The vagina should be lightly tamponed with iodoform gauze. G16 FIBROMYOMA OF THE UTERUS Fig. 404 Fig. 405 ^'aginal hysterectomy for an interstitial fibroid of Splitting of the uterus in vaginal hysterec- the body of the uterus. Closure of the vaginal tomy. Step 2. (After Doederlein and walls with interrupted catgut sutures. Step 6. Kroenig.) OPERATIONS FOR UTERINE FIBROIDS 617 When the uterus is large it will be found easier to split the uterus before attempting to remove it. (See Figs. 405, 406, and 407.) Fig. 407 Splitting of the uterus in vaginal hystereetomj^. Step 3. Abdominal Myomectomy. — Before proceeding with an abdominal myomectomy the uterus should be curetted and irrigated with sterile normal salt solution. This is advised in view of the possible opening into the uterine cavity in the enucleation of the tumor, and of the possibility of substituting a supravaginal hysteromyomectomy for myomectomy. Indicatio7is. — Pedunculated Suhperitoneal Fibroids. — A wedge-shaped incision at the attachment of the pedicle to the uterus and the closure of the wound with No. 2 plain catgut sutures will complete the operation. No raw surfaces are to be left to invite the formation of adhesions. Sessile Subperitoneal and Intramural Fibroids. — Every possible pre- caution must be taken to guard against infection of the wound made in the uterus. Rubber gloves should be w^orn, and after delivering the uterus and tumors through the abdominal incision, a sterile towel should be packed about the edges of the wound to protect the field of operation from the skin surface of the abdomen incision. A straight incision is made over the convexity of the tumor. The extent of the incision is measured by the diameter of the tumor. The muscularis is reflected from the tumor, the tumor is grasped by a vulsellem forceps, and while firm traction is made upon the tumor, 618 FIBROMYOMA OF THE UTERUS the enucleation is proceeded with by means of the handle of a knife, the blunt blades of scissors, or an enucleator especially designed for this purpose. To facilitate the removal of large and deep-seated tumors it may be found advisable to bisect the tumor and enucleate either half separately. Fig. 408 Myomectomy. Removal of an interstitial fibroid from the fundus of the uterus. Fundus grasped by a tenaculum forceps and delivered through the abdominal incision. Step 1. (After Doederlein and Kroenig.) In small and superficial growths there is little loss of blood, but in large and deep-seated growths it is necessary to control the blood supply to the uterus by having an assistant firmly grasp the broad ligaments and supravaginal portion of the cervix with the hand. All spurting vessels should be ligated with fine, plain catgut, taking care to avoid crushing the tissues w^ith forceps or unnecessarily strangulating tissues in the ligature. The cavity occupied by the tumor is obliterated by interrupted sutures of catgut placed in tiers. Care must be taken that no dead spaces are left in which blood may accumulate and that the sutures are not tied too tightly. A smooth serous surface should be left at the line of suture, otherwise adhesions may form. A mattress suture is best adapted for the serous surface. OPERATIONS FOR UTERINE FIBROIDS 619 Incision made over the tumor, including the uterine wall and capsule of the tumor. Tumor by a tenaculum forceps. Step 2. Fig. 410 Obliteration of the cavity in the uterine wall by a continuous suture of plain catgut. Care exercised not to leave dead spaces or to constrict the tissues too tightlj' in Ugating. Step 3. 620 FIBROMYOMA OF THE UTERUS For the average operator a supravaginal hysteromyomectomy wQl yield better results than the remo\'al of multiple tumors from the uterine wall. ^lyomectomy in deep-seated fibroids is not an operation of choice for the average operator. Abdominal myomectomy should never be performed in the presence of a pelvic infection or for the removal of degenerated fibroids. Abdominal Myomectomy for Submucous Fibroids-. — When the cervix is firmly contracted and the tumor is too large to deliver per vaginam, abdominal myomectomy may be considered, in view of possibly preserv- ing the function of childbearing. The abdominal route should not be considered when it is possible to remove the tumor by morcellation. Again, the abdominal route should not be undertaken in the presence of a pelvic infection resident within or without the uterus, nor should a degenerated fibroid be removed through an abdominal incision. Fig. 411 Closure of the uterine musculature and peritoneum with a continuous suture of plain catgut. Step 4. As a preliminary measure the uterus should be curetted and irrigated with sterile normal salt solution. The technic of the operation does not differ from that of abdominal myomectomy in general. A median incision in the anterior wall, extending from the fundus to the cervix, is preferred. Hysteromyomectomy, — 1. Vagixal Hysteromyo^^iectomy. — In the judgment of the author there are few indications for vaginal hystero- myomectomy. To successfully perform the operation without encoun- tering unusual difficulties, the tumor and uterus should be no larger than a fetal head at term, the structures to be removed should be freelv OPERATIONS FOR UTERINE FIBROIDS 621 movable, and the vagina should provide sufficient room to admit of the delivery. In the majority of cases, answering these requirements, myomectomy or abdominal hysteromyomectomy would be preferred. When the abdomi- nal wall is thick and the vagina roomy a vaginal hysteromyomectomy may be preferred to an abdominal operation. Furthermore, in infected and sloughing fibroids demanding the sacrifice of the uterus, vaginal hysteromyomectomy should be the operation of choice. In the presence of a sloughing or impacted fibroid it is advisable to first remove the tumor and await the time when the field of operation is free of infection before proceeding with a vaginal hysterectomy. The technic of vaginal hysteromyomectomy does not differ from that of vaginal hysterectomy in its essential details. (See page 681.) 2. Abdominal Hysteromyomectomy. — The choice between supra- vaginal and total hysterectomy should be made in favor of the former whenever it is possible to leave a healthy cervix. The reasons for so doing are that the operation presents fewer technical difficulties, requires less time, there is less danger of injuring the ureters and less likelihood of creating a cystitis from injury to the bladder. Furthermore, the vault of the vagina is left intact. When drainage is required or the condition of the cervix justifies its removal, and when the tumor is so located as to render a supra- vaginal amputation impossible, total hysterectomy is the operation of choice. I. Suyravaginal Hysteromyomectomy. — Technic. — The following steps are taken in uncomplicated cases: The abdominal incision should be of such length as to permit of easy delivery of the tumor. Care should be taken to prevent cutting the bladder, which may be found much elevated. The hand is passed over the entire circumference of the uterus and tumors to determine the size and position of the tumor or tumors, to locate the point of amputation, and to detect and break up existing adhesions. Delivery of the Tumor and Uterus. — -The tumor is delivered from the abdomen by means of the hands or vulsellum forceps. This may be found difficult and require the aid of an assistant. When incar- cerated in the pelvis, an assistant may place two fingers in the vagina and forcibly push the tumor upward in the axis of the superior strait, thereby reinforcing the efforts of the operator, who is making traction upon the tumor from above. Immediately following the delivery of the tumor large packs of sterile gauze should wall oft' the intestines. For this purpose the author uses one or two five-yard rolls of gauze. Ligation and Severing of the Appendages, Vessels, and Ligaments on Either Side of the Uterus. — For ligatures the author is in the habit of using No. 2 plain sterile catgut passed on an Olshausen pedicle needle. In large fibroids the veins are often found greatly enlarged, hence the necessitv of exercising care in securing all vessels. The 622 FIBROMYOMA OF THE UTERUS ovarian and uterine arteries should be secured by two separate liga- tures, thus affording double security. One linen and one catgut ligature for these vessels will give added security. When the tubes and ovaries are normal there is no good reason for removing them. The preservation of the ovaries will ward off the nervous phenomena of the artificial menopause, which is a matter of grave importance. The first ligature is made to embrace the tube, ovarian ligament, and bloodvessels entering the horn of the uterus. A second ligature is passed immediately to the side of the first. These structures are then severed between the ligatures and the uterine horn. The bleeding from the uterus is controlled by an artery clamp, placed close to the side of the uterus. A ligature is tied about the round ligament at its proximal end and the ligament severed close to the uterus. A single ligature is next passed through the broad ligament close to the uterus, and will, as a rule, incorporate the tissues of the broad ligament to a point near the uterine artery. This portion of the broad ligament is severed close to the uterus and the bleeding from the uterus secured by an artery clamp. The process is repeated on the opposite side. Next the peritoneum is stripped from the uterus, beginning in front at a point, preferably about an inch above the attachment of the- bladder. This incision should only extend the thickness of the peritoneum. With a gauze sponge wrapped about the finger the peritoneum is stripped downward to a point below the proposed line of incision through the cervix. With the bladder pushed downward and forward the ureters are not so liable to injury in ligating and severing the uterine arteries. These arteries are ligated close to the uterus. Two ligatures are passed about them and the incision is made close to the cervix. Any spurting vessel must be secured by a separate ligature. A tenaculum forceps is placed in the cervix at a point below the proposed line of amputation, by which the assistant may later hold the stump of the amputated cervix under control. A wedge-shaped incision is made through the cervix from before backward and downward and from behind forward and downward. The body of the uterus and tumors are then freed and are passed to an assistant. The next step is to disinfect the cervical canal, which may be done with a swab of carbolic acid or pure formalin, or with a Paquelin cautery. The wedge in the cervical stump is then closed with a running suture of No. 2 plain catgut. The stumps of the tubes and ligaments are anchored to the lateral portions of the cervical stump. Linen or silk should be used for this purpose. Finally, the peritoneum is closed over the cervix with a running suture of No. 1 plain catgut and in a manner that will leave a clean floor of peritoneum, free of raw surfaces, to which surrounding structures may not adhere. After carefully removing all blood from the pelvis the abdomen is closed without drainage. OPERATIONS FOR UTERINE FIBROIDS 623 Kelly's Modification of Supravaginal Hysterectomy. — The ligaments and appendages are severed on one side and the peritoneum and bladder are reflected from the anterior surface of the uterus as described above. After ligating the uterine artery, Kelly proceeds to amputate the cervix close to the vault of the vagina. As the amputation proceeds the assistant draws the uterus to the opposite side. As the last fibers of the cervix are severed, the uterine artery of the opposite side presents and is clamped by an assistant about an inch above the cervical stump. By rolling the uterine body still farther to the opposite side the round ligament comes into view; this is clamped at the level of the pelvic brim and severed. (See Fig. 418.) Fig. 412 Supravaginal abdominal hj-steromyomectomy. Posterior aspect. below the appendages. Step 1. Broad ligaments clamped This removes the body of the uterus and tumors and the remaining steps of the operation are the same as described above. This operation is particularly adapted to the removal of a broad ligament fibroid. When it is necessary to remove the appendages of the uterus, the only variation in the above technic consists in the ligation of the 624 FIBROMYOMA OF THE UTERUS infundibulopelvic ligament in place of the structures incorporated in the first ligatures as above described. II. Total Abdominal Hysteromyomedomy. — The first steps of the operation are identical to those of supravaginal amputation. {Vide supra.) These steps are the ligation of the ovarian and uterine vessels, the separation of the appendages and ligaments close to the uterus and down to the supravaginal portion of the cervix and the turning down of the peritoneal cuff and bladder on the anterior surface of the uterus. Fig. 413 Broad ligament cut between clamps and uterus. Ligatures placed about the uterine artery. Ovarian ligament, round ligament, and infundibulopelvic ligament. Step 2. The bladder is stripped entirely from the cervix, exposing the vaginal wall as it is reflected upon the cervix. The uterus is then drawn upward and backward and a transverse slit is made into the anterior vault of the vagina, close to the cervix. This opening is made with sharp- pointed scissors and is about one inch in length. Before making this incision the vaginal wall is carefully identified with the finger and is recognized by palpating the vaginal portion of the cervix through OPERATIONS FOR UTERINE FIBROIDS 625 it. If gauze had been previously packed in the vagina it will be felt through the wall of the vagina before making the incision. The incision is then extended around and is made close to the cervix to avoid injury to the surrounding structures, notably the ureters. This completely frees the uterus from its attachments when it is removed. All bleeding points are temporarily secured with clamps. The peritoneum posterior to the bladder is stitched to the margin of the anterior vaginal flap; the broad ligaments, round ligaments, and tubes are anchored with linen to the outer angles of the vaginal opening and, finally, the vaginal walls and peritoneum are stitched together from before backward, thereby approximating the peritoneum in front with that attached to the posterior flap of vagina. Fig. 414 Peritoneum and bladder reflected from the supravaginal portion of the cervix. Body of the uterus amputated at the internal os. Interrupted sutures placed in cervical stump preparatory to closure of the stump. Step 3. The completed operation leaves a smooth bed of peritoneum at the pelvic floor, with the ligaments so anchored that they prevent prolapse of the walls of the vagina. If the appendages are removed the severed edges of the broad liga- ments are approximated with a running suture of catgut. For all ligatures and sutures the author uses No. 2 plain sterile catgut, with the addition of linen sutures to secure the ovarian and uterine arteries and to anchor the ligaments to the vault of the vagina. 40 626 FIBROMYOMA OF THE UTERUS Conservation of Ovaries after Hysterectomy. — It is the experience of Dickinson that four-fifths of the patients from whom the uterus has Fig. 415 Round ligaments, ovarian ligaments, and tubes anchored to the stump of the cervix and a fold of peritoneum sutured over the stump of the cervix. Step 4 Fig. 416 Completed operation with the appendages removed. The pelvic floor is completely covered with peritoneum. been removed and the ovaries left in situ are free from the disturbances rof the surgical menopause. He finds better results in this regard when OPERATIONS FOR UTERINE FIBROIDS 627 both ovaries are left than when one is removed or both are resected. When the disturbances do occur, their character is less severe and more gradual than after bilateral removal of the ovaries. Sexual vigor is maintained when both ovaries are conserved, but will be lost at an earlier time than in the normal woman. Management of Complications in Hysteromyomectomy. — The compli- cations of fibroids of the uterus are so frequent and varied as to present innumerable and oftentimes serious difficulties. It is not a difficult undertaking to perform an uncomplicated hysteromyomec- tomy, but the presence of complications may require formidable operative procedures that will tax the skill of the most expert operator. The following classification of complications as enumerated by Kelly present a formidable array: 1. Adhesions and Affections of Surrounding Strjictures. — (a) Inflam- matory. — Peritoneal adhesions frequently bind the tumor and the uterus and its appendages to the surrounding structures. These vary in extent and firmness. So far as possible they are to be severed by the fingers; thus the utmost caution must be exercised to prevent injury to adherent structures, notably the bowel, bladder, and impor- tant bloodvessels. When the appendages are inaccessible through overhanging tumor growths and the embedding of the tube and ovary in firm adhesions on the floor of the pelvis, it may be found advisable, as Kelly has pointed out, to at first ligate and sever the ovarian vessels at the outer extremity of the broad ligaments, and to tie and sever the round ligaments at their uterine attachment. This opens up the top of the broad ligament when the uterus can be lifted to the opposite side, thereby giving better access to the appendages. AYhen the adhesions are far more extensive on one side, and particularly when accumulations of pus are to be dealt with, it is best to adopt the Kelly modification, by severing the attachments on the opposite side and removing the uterus, when the infiammatory mass, together with the abscess, may be removed with comparative ease. Whenever pus is suspected great care should be exercised in walling oft' the abdominal cavity with sterile pads before disturbing the adhesions. When pus is encountered it must be aspirated or carefully swabbed out before proceeding with the further steps of the operation. A careful toilet of the peritoneum must be made with sponges, fresh sterile gauze packs should be placed about the field of operation, and the gloves of the operator and assistant changed. In such cases a complete hyster- ectomy is preferred to supravaginal amputation, for the reason that drainage can be more readily established through the vagina. The omentum, containing large bloodvessels, may be adherent to the tumor and require resection before proceeding with the removal of the uterus. Adhesions between bowel and tumor most often in^'olve the sigmoid, less frequently the rectum and cecum, and rarely the small bowel. These can usually be readily separated with the fingers, but when they are closely adherent it is safest to remove the tumor capsule, leaving it attached to the bowel. 628 FIBROMYOMA OF THE UTERUS An appendix adherent to the tumor requires careful manipulation. If the adhesions are light the separation presents no difficulties, but when they are dense it is best to remove the appendix, together with the adhesions. The Kelly modification of removing the uterus and tumors from left to right is applicable in these cases. (b) Tumors and other swellings of the ovary, when large, should be removed before proceeding with the uterus. "V^^len of small size the entire mass should be removed together. (c) Carreer of the cervix and corpus complicating uterine fibroids require panhysterectomy. 2. Complications Due to Changes in the Tumors Themselves. — All sorts of degenerative processes in myomatous tumors (see page 586) are dealt with on the general principle laid down for the classical operations of supravaginal and panhysterectomy. Fig. 417 Fibroid in anterior wall of the uterus, elevating the bladder. 3. Compjlicaiions Due to the Location of the Tumors. — ^Myomatous tumors may be so located as to present a formidable problem to the operator. They may be so located as to crowd the bladder, ureters, sigmoid, and uterus quite out of their normal relations, so that the usual landmarks are obscured. "When the tumor is large and occupies the body of the uterus, making it difficult to recognize and to ligate the broad ligaments which are drawn in a vertical direction close to the brim of the pelvis, it is advised by Kelly to bisect the uterus and remove each half separately. When possible a long forceps or sound should be passed through the uterine canal to serve as a guide. Without this guide there is danger of carrying OPERATIONS FOR UTERINE FIBROIDS 629 the incision into the uterine vessels. Considerable bleeding may be encountered and require the free use of forceps until the uterine vessels can be secured. Again, it may be possible to gain room and thereby facilitate the operation by first enucleating the fibroid, after which the uterus can be removed. Large tumors lodged beneath the vesical peritoneum may expose the bladder to injury in opening the abdomen. To avoid this accident, the peritoneum should be opened at the upper limit of the incision and the incision enlarged downward. Kelly advises to first tie off the left ovarian bloodvessels, then to cut with scissors the peritoneum from round ligament to round ligament, this to be followed by deflection of the peritoneum and bladder when the uterine vessels are exposed and tied. Fig. 418 Supravaginal hysteromyomectomy. Body of uterus amputated from left to right. (After Kelly.) Broad Ligament Fibroids. — The great danger in the removal of broad ligament fibroids lies in the possible injury to the ureters. The displacement of the ureter by broad ligament fibroids of large size may be such as to mislead the most experienced operator. In removing a large, broad ligament fibroid the sigmoid must be carefully freed, so as to expose the ovarian vessels; these are ligated and severed at the periphery of the tumor. The round ligament is ligated and severed near to the uterus, and the two points are connected by an incision made with scissors through the peritoneum over the circumference of the tumor. The peritoneum is then stripped from 630 FIBROMYOMA OF THE UTERUS the tumor, the tumor grasped with a heavy vulsellum forceps and dissected from its bed of celhilar tissue. The uterine vessels are now exposed and Hgated near the uterus, taking care to avoid injury to the uterus. The body of the uterus is then amputated at the internal OS, and from this point the operation proceeds in the usual manner. Combined Submucous and Corporeal Tumors. — When there has been bleeding, making complete extirpation of the uterus hazardous, it is advisable to first remove, per vaginam, the submucous growth and, at a later date, when the patient's strength is restored, to remove the uterus, together with the corporeal tumors. The same method should be adopted w^hen the submucous growth is necrotic. If the strength of the patient will permit, and degenerative changes are absent in the submucous growth, the entire tumor mass and uterus may be removed eji masse through the abdomen. Fibroids Complicating Pregnancy, Labor, and the Puerperium. — Frequency of Fibroids Complicating Pregnancy. — Pinard found 84 cases in 14,000 pregnancies. Klinik Baudelocque had 85 cases in 13,813 pregnancies. It is probable that a larger unrecognized percentage exists. Influence of Pregnancy on Fibroids. — The rule is that fibroids grow rapidly during the period of pregnancy. The rate of growth is pro- portionate to the vascularity of the tumor and to the intimacy of the tumor to the uterus. Hence it follows that interstitial fibroids commonly take on a rapid growth while pedunculated subperitoneal fibroids usually grow slowly, if at all. The increase in size is largely due to edema of the tumor and, to a lesser degree, to true hypertrophy or other forms of degeneration of the tumor substance. Necrotic changes rarely develop in pregnancy, but are common in the puerperium. The form of necrosis is usually suppuration or gangrene. After such an event a submucous fibroid may be expelled from the uterus, and sub- peritoneal fibroids have been known to slough through the bladder, vagina, rectum, and abdominal wall. Influence of Fibroids on Pregnancy. — Pregnancy, labor, and the puerperium may proceed without alteration in the presence of a uterine fibroid, but, on the other hand, serious complications may arise. The influence of a fibroid tumor upon the pregnant uterus is largely deter- mined by the size and position of the growth. 1. Fibroids of the Cervix. — Fibroids of the cervix do not seriously embarrass the development of the pregnant uterus, but may interfere with the engagement of the presenting part and with the delivery of the fetus and placenta. The cervix may fail to dilate in the presence of a fibroid tumor of the cervix. These embarrassments may be relieved by the protrusion of the tumor through the cervix or the spontaneous disengagement of the tumor when it is submucous. Subserous tumors may become pedunculated and rise out of the pelvis, or they may soften from edema and so flatten out as to permit the passage of the child. 2. Fibroids of the Body of the Uterus. — Fibroids of the body of the uterus do not permit of the development and distention of the uterine TREAT ME XT 631 musculature at the seat of the tumor; this leads to a compensatory thickening in the surrounding musculature. As a consequence the uterine contractions are embarrassed, labor is prolonged, and post- partum hemorrhages are liable to occur. Large fibroids distort the uterine cavity and lead to malpositions and malpresentations of the fetus. Malformations of the fetus are the possible result of large sub- mucous and interstitial fibroids. Great difficulty may be experienced in delivering the placenta when it is implanted above a protruding fibroid. In such an event sepsis and postpartum hemorrhages are the possible consecpences. Wenkel estimates that placenta preevia occurs in 3.4 per cent, of all cases of fibroids complicating pregnancy, and adherent placentae are of frequent occurrence. Interference with free drainage of the lochia may result from an obstructing fibroid. Subserous tumors may be incarcerated or adherent in the pelvis in such a manner as to prevent the development of the pregnant uterus. In such an event pregnancy would have to be terminated. Hemorrhage, ileus, ischuria, uremia, hydronephrosis, pyonephrosis, and rupture of the uterus are occasional complications arising out of the presence of a fibroid in the body of the uterus. Fibroids often diminish in size, and in rare instances wholly disappear after the end of the puerperium. This fortunate outcome is not to be anticipated because of its unusual occurrence. Treatment. — Xo definite rules can be formulated for the management of these cases because the uterus, fetus, and tumor present themselves under such varying conditions. 1. No interference is demanded in 70 to SO per cent, of cases. 2. Subperitoneal fibroids, causing pressure sjTnptoms, may some- times be elevated hy bimanual mani-pulations and the pregnancy proceed to term. When this cannot be done an abdominal section is preferred to the induction of abortion. 3. The induction of abortion is not looked upon with favor because of the great liability of hemorrhage and infection and the certainty of leaving a tumor which will subsequent!}' demand operative inter- ference. It is better to accomplish both at the same time. 4. Myomectomy. — Only pedunculated submucous and subperitoneal fibroids justify myomectomy. Even under the most favorable con- ditions there is great liability to miscarriage. Under no circumstances should a fibroid be shelled out of the wall of a pregnant uterus. Myomectomy immediately followed by the induction of abortion is hazardous because of the dangers of rupture of the uterus, hemorrhage, and infection. Cesarean Section. — ^Yhen the child is at or near term and the fibroid tumors are of such size and location as to justify the sacrifice of part or all of the uterus, a classical Cesarean section should be performed and the uterus removed. Care must be taken to a^oid cutting through the tumor in removing the fetus. The Porro operation is preferred to Cesarean section when the uterus is believed to be infected. The location of the tumor will generally determine the choice between supravaginal and total hysterectomy. CHAPTER XXVIII CARCINOMA AND SARCOMA OF THE UTERUS Cakcinoma of the Uterus Treatment of Cancer of Cervix Topographical Classification Complicating Pregnancy Etiology Treatment of Inoperable Cancer Anatomical Diagnosis of Cervix Clinical Diagnosis Treatment of Cancer of Body of Microscopic Diagnosis Uterus Differential Diagnosis Endothelioma Diagnosis of Extension Sarcoma of the Uterus Treatment Etiology Operative Treatment Anatomical Diagnosis Simple Vaginal Hysterectomj' ^licroscopic Diagnosis BjTne IMethod Clinical Diagnosis Schuchardt Operation Prognosis Radical Abdominal Operation Treatment CARCINOMA OF THE UTERUS Topographical Classification. — Carcinoma may arise from any por- tion of the uterine mucosa, both within the uterus and covering the vaginal portion of the cervix. The classification proposed by Ruge and Veit is as follows: 1 . Carcinoma of the vaginal portion of the cervix, including the vaginal surface of the cervix from the external os to the vault of the vagina. 2. Carcinoma of the cervix, including the mucosa of the cervical canal. 3. Carcinoma of the body of the uterus, including the mucosa from the internal os to the horns of the uterus. It will be observed that the location of the newgrowth is not only of pathological interest but has much to do with the manner of diagnosis, the clinical manifestations, prognosis, and treatment. Etiology. — The essential cause of carcinoma is as yet unknown. Certain predisposing causes are well recognized and require consider- ation. Age. — W^e find carcinoma of the uterus commonly appearing about the time of the menopause. Carcinoma of the vaginal portion more often makes its appearance immediately preceding the menopause, and carcinoma of the body usually appears a few months or years later. The earliest recorded case appeared at eight years of age. The author observed a case of carcinoma of the vaginal portion in a woman, aged ninety-three years, forty-eight years after the menopause. The greatest number appear between forty and fifty years of age. ETIOLOGY ' 633 In 3385 cases of cancer of the uterus Gusserow found but two origi- nating before twenty years of age. Heredity. — Heredity, while playing an important role, is of less im- portance as an etiological factor than w'as formerly believed. In 142 cases of uterine carcinoma, Roger Williams found that heredity has some part in their development in 19.7 per cent. Race. — It has been said that the negress is particularly exempt from carcinoma of the uterus. Later observations tend to disprove this view", indicating that she is little less susceptible than the white woman. Uterine carcinoma is believed to be more common in Europe than elsewhere, and is said to be rare in the tropics. Childbearing. — Childbearing appears to have an important relation to the development of carcinoma of the vaginal portion. The author has seen but two carcinomata of the vaginal portion in nulliparae whose cervices had never been dilated. The great rarity of carcinoma of the cervix in nulliparse speaks for the influence of trauma as a factor in the development of cancer. Carcinoma of the body of the uterus is said to be more frequent in nulliparse. There can be no question that the inflammatory lesions of the uterus (endometritis and erosions) are not seldom the starting-points of carcinoma, but that scars in the cervix are such, is justly questioned. Uterine Fibroids. — While fibroids and carcinoma are often asso- ciated in the uterus, it is not probable that the one is in any way dependent upon the other for its existence. So frequently, however, is carcinoma found to develop in a myomatous uterus, that ice are justified in regarding with suspicion of carcinoma a myomatous uterus that begins to bleed after the menopause. Social State. — -Carcinoma of the uterus is found more frequently in the lower orders of society. These classes are more susceptible to and neglectful of infections and traumatisms. On the other hand, the lesion is less frequently seen among the uncivilized classes. Cohnheim's theory of cell inclusion is not supported by observations made upon the carcinomatous uterus. Leopold concludes from a series of experiments that pure cultures of the blastomycetes may be found in fresh carcinoma of the ovary. He injected a pure culture into the testicle of a rat. The animal died, and on the peritoneum were found nodules in which were similar blastomycetic organisms. Leopold infers that this organism may be the cause of carcinoma in man. Frequency. — The frequency of carcinoma of the uterus is variously stated. Welsh found that in 31,482 cases of carcinoma, 29.5 per cent, were of the uterus. In point of frequency the uterus takes second rank to the stomach as a primary seat of carcinoma. There can be no doubt but that carcinoma is on the increase, though it is only fair to admit that the perfected means of diagnosis account in large part for the statistics. Roger Williams estimated that over 10,000 women suffered from uterine carcinoma in England and Wales in 1898. He further estimated 634 CARCIXOMA OF THE UTERUS that of the deaths occurring in women over thirty-five years of age, one in thirty-five is due to carcinoma of the uterus. Anatomical Diagnosis. — 1. Carcinoma of the Vaginal Portion of the Cervix. — Carcinoma of the vaginal portion of the cervix may tend to grow superficially into the vagina, forming a polypoid or cauliflower growth, or it may deeply infiltrate the cervix. (a) Cauliflower Carcinoma. — Cauliflower carcinoma of the vaginal portion of the cervix is seen as a sessile or pedunculated gro^^^th, arising from one or both lips of the cervix. It varies in size up to the complete filling of the vagina. The surface is generally covered with a slimy, gangrenous deposit. The whole mass bleeds readily to the touch and is friable. The surface is uneven, nodular, polypoid, or villous. (h) Infiliraiing Carcinoma of the Vaginal Portion of the Cervix. — Infiltrating carcinoma of the vaginal portion of the cervix appears in the early stage as an irregular thickening and hardening of the cervix. The anterior lip is most often first involved. Cullen distin- guishes three stages according to the degree of infiltration and disintegration of the cervix. While this classification is purely arbi- trary, it will be found convenient for purposes of description : Stage 1. The Stage of Infiltration in the Absence of Disintegration. The surface is hard, friable, and uneven. The color of the surface is glistening, bluish white. Cross-sections of the growth show a gray or yellowish-gray surface, often cutting like cartilage. Fibrous stria- tions are seen to course through the structure, isolating nests of friable homogeneous tissue, the so-called cancer nests. By squeezing the surface these nests may be emptied of their cell contents, leaving smafl, shallow depressions. Such nests are not to be confused with Xabothian follicles filled with inspissated mucus. The two may be found in the same section. Unfortunately, cancer of the vaginal portion is seldom observed at this stage, because of the mild sjTiiptoms which prevail. Not infrequently there is an entire absence of symptoms. While impossible to say without an anatomical dissection, it is prob- able that the growth is still confined to the cervix. Yet it must be borne in mind that not only regional but general dissemination of the carcinoma may occur at this stage. Stage 2. The Stage of Moderate Disintegration. — The carcinomatous tissue has partly disintegrated, leaving a depression with irregular, hard, elevated margins. The base of the ulcer is uneven, and covered with a stinking slough of a grayish-yellow or gangrenous character. Upon handling, the affected tissue bleeds freely and is friable. In this stage the growth is rarely confined to the cervix. Ulceration of a cancerous growth does not usually begin until the disease has run about half its course. In a small proportion of cases the growth never ulcerates. (See Plate XXVIII.) Stage 3. The Stage of Complete Disintegration of the Vaginal Portion of the Cervix. — In the vault of the vagina is a sloughing, stinking, ragged crater. Xo cervix is to be seen or felt. The vaginal walls are invaded and form the margins of the crater. The paravaginal connective tissue, PLATE XXVII ^ .y^ Cauliflower Carcinoma of the Cervix. An irregular papillary gro%A/th oeeupies both, lips of the cervix. It is friable and bleeding. There is no perceptible infiltration of the cervix. PLATE XXVIII Carcinoma of the Cervix, with Partial Disintegration. The growth is soft, friable, and bleeding. The vagina and body of the uterus are invaded. ANATOMICAL DIAGNOSIS 635 broad ligaments, and uterosacral ligaments are infiltrated. The growth is slow to pass beyond the internal os into the cavity of the uterus, but may extend to the fundus. Isolated cancerous nodules may lie in distant portions of the vaginal wall. Contact growths may develop Fig. 419 i ■^ ^^ ^ I > w% ^- ^^1^ ^ -^^ / Early carcinoma of the anterior cer\-ical lip. (Martin.) Same case as Fig. 419, a part of the cancerous area magiii;ii (Martin.) the finger-like projections. upon opposing surfaces. The bladder is involved late in the stage, and the rectum, as a rule, still later. Only in the late stage is the peri- toneum invaded. The iliac glands are the first of the lymphatics to be invaded, but these are usuahy late in being affected, and may entirely 636 CARCINOMA OF THE UTERUS escape. Metastatic growths in distant parts of the body are seldom observed. 2. Carcinoma of the Cervix. — Carcinoma of the cervix takes its origin from the epithehum of the cervical mucosa confined within the bound- aries of the external os below and the internal os above. The usual site of development is immediately above the external os on the anterior lip. Fig. 421 Lymphatics of uterus and upper third of vagina, and iliac and lumbar glands. (Russell.) The carcinomatous growi:h may involve all or a part of the mucosa. It may assume a nodular or cauliflower appearance, or may infiltrate the underlying tissue. The entire cervix may be infiltrated and will eventually disintegrate, leaving a crater-like structure with a thin shell. The lips of the cervix may close in over the growth, hiding it from view. It is seldom, if ever, that the lips are disintegrated, but in the late stages they are infiltrated and glazed. On cross-section the carcinomatous mass is cartilaginous, yellowish-white, and glistening. PLATE XXIX Infiltrating Carcinoma of the CevviiL. The ^«tire cervix is infiltrated and partially disintegrated. In the cavity of the uterus is a fungous growth (fungous endometritis). ANATOMICAL DIAGNOSIS 637 The advancing border is irregular and blends into the normal tissue. The body of the uterus and vagina may be invaded either by direct extension or by metastasis. The cervical canal may be occluded by the newgrowth and be followed by fluid distention of the uterus (pyometra and hematometra) and tubes (hydrosalpinx, hematosalpinx, and pyosalpinx). Fig. 422 15. ^. Advanced cancer of cervix. Perforation into the urinary bladder and peritoneum. Medial section of the peKis. 1, perforation of cancerous uterus into the peritoneal cavity; 2, intestine; 3, peritoneum; 4, carcinoma uteri; .5, perirectal inflammatory infiltration; 6, perirectal inflammatory infiltration; 7, coccyx; 8, rectum; 9, vagina; "10, external meatus of urethra; 11, internal meatus of urethra; 12, per- foration of cancerous uterus into bladder; 13, urinary bladder; 14, os pubis; 15, perforation of cancerous uterus into peritoneal cavity. (Liepmann.) Extension of Carcinoma to Surrounding Structures. — The paravaginal connective tissue is invaded comparatively early. It is unusual to observe a case before the broad ligaments are involved, hence the prognosis is always uncertain. 638 CARCINOMA OF THE UTERUS The peritoneal cavity is invaded late. The tubes, ovaries, bladder, and rectum are seldom attacked. The iliacs are the first of the lymph- atic glands to be invaded. ^Metastasis to distant organs is said to seldom occur. Roger Williams, however, found that 20 per cent, of his cases had disseminated cancerous foci in distant parts of the body. Adenopathy has been known to supervene two years before death, though, as a rule, death follows much more closely upon the involvement of the glands. Winter found the iliac glands involved in 22 per cent, of cases of cancer of the cervix. He found four cases of advanced cancer of the cervix without involvement of these glands. Emil Ries has made extended observations on the involvement of the lymphatic glands in cancer of the cervix. He has shown that the glands of the pelvis are often cancerous when no larger than normal. Again, they are sometimes enlarged from hyperplasia, secondary to an ulcerative process in the growth. Extensive glandular involvement contra-indicates all but palliative treatment. The percentage of glandular in^-ol^'ement in uterine carcinoma is difficult to determine. Peisser estimates that 50 per cent, of uterine cancers are accompanied by glandular involvement, and Williams estimates 72 per cent. These investigations w^ere not verified by the microscope, hence cannot be reliable, for Ries has conclusively shown that there may be no enlargement of the glands in advanced cancerous invasion of the gland structure. Ries further states that the size of the cancer in the cervix is in no regular ratio to the size of the affected gland. He reports a case of his own in which the primary cancer in the vaginal portion was not larger than a thumb nail, but the largest cancerous gland M^as the size of a pigeon's egg. It is of clinical interest to inquire whether the parametrium is always involved prior to the pelvic lymph glands. If so, then failure to detect infiltration of the parametrium would lead us to infer that the pelvic glands are not involved, and hence the Ries-Wertheim operation for dealing with the pelvic glands would not be indicated. Puppel, Cullen, Pryor, Kelly, and others are of this opinion, but Wertheim warns us of the uncertainty of such conclusions. The only positive means of demonstrating the presence or absence of cancer cells in the pelvic lymph glands is aft'orded by serial microscopic sections. Williams points out that in advanced cases of cervical cancer the supraclavicular glands are occasionally enlarged (Trousier's sign) . For a more extended discussion of the subject of the lymph glands in uterine cancer see Gellhorn's article in American Gyjiecology,. yiovemher, 1902. 3. Carcinoma of the Body of the Uterus. — Carcinoma may arise from any part of the mucosa of the uterine body, either as a circumscribed or as a diffuse growth. The surface is never smooth. It begins as a shaggy groT\"th studded with delicate villosities, which may later enlarge and coalesce into polyps or form twig-like processes with numerous offshoots. In late and far-advanced cases the growth presents the appearance of brain tissue. The entire uterine cavity may be filled with the cancerous growth. The musculature of the uterus is very PLATE XXX Carcinoma of Cervix, Advanced Stage. The cervix, is almost completely disintegrated. The vaginal surface is intact. CLINICAL DIAGNOSIS 639 slowly invaded, and it is for this reason that cancer of the body of the uterus is regarded as relatively benign. On cross-section the invading carcinomatous tissue, with its pale, homogeneous and glistening appearance, is in contrast to the mus- culature. The advancing border is irregular. When the serous covering of the uterus is invaded, small grayish-yellow nodules are seen beneath the serosa. The growth is usually late in sloughing. Fig. 423 rj' I Carcinoma of the fundus. A large nodule within the uterine cavity and numerous nodules beneath the peritoneum. (Hertzler.) Extension from the body of the uterus is extremely slow. The internal os is rarely trespassed; the broad ligaments are not infiltrated until late. The peritoneum may be directly invaded, but this is late, if ever. The bladder, rectum, tubes, and ovaries commonly escape invasion. Metastasis to distant parts of the body is late, and may never occur. Kroemer believes that metastasis is more common in carcinoma of the uterine body than of any other part of the uterus. As to the frequency of carcinoma of the body of the uterus, Schatz says that it occurs in 2.5 per cent., while Schauta says that it occurs in 13.8 per cent, of all carcinomata of the uterus. Clinical Diagnosis. — A work of this character could do no greater service than to emphasize the importance of an early diagnosis in 640 CARCIXOMA OF THE UTERUS carcinoma of the uterus and to point out the methods of making such a diagnosis. No departure from the normal menstrual flow should he regarded as trivial in advanced years of life. We are not to be content with the sup- position that it is a phenovienon of the change of life — too many lives hare been sacrificed by such inferences. It is the family physician, not the specialist, who first sees these cases, and it is to him we must look for the early recognition of the danger, if not for a positive diagnosis. The practitioner must be firm in his demand for a local examination. Ignorance, sloth, prejudice, and false modesty are to be discountenanced. When the physician, after a searching examination into the cause of the hemorrhage, fails to satisfy himself, he should appeal to the specialist, whose services at this time are of greater value than in the treatment of the case, for the reason that it takes greater skill to make a diagnosis in these doubtful cases than it does to remove the uterus after the diagnosis is made. Since the early recognition of carcinoma of the uterus rests upon the microscopic examination of scrapings and excised pieces of the suspected portion, it is self-evident that only those especially trained in the work are competent to make such a diagnosis. ^Ye will here discuss acute and chronic cancers. Acute Cancers. — Acute cancers, including those which run their course within a year, are frequently met with. Kiwisch observed a case which ran its entire course in five weeks, and ]\Iartin's case died within nine weeks of its inception. Associated with the gro'^'th in the uterus are febrile symptoms and general dissemination. Chronic Cancers. — Chronic cancers, including those which run their course in three years or more, are rare. Barker's case continued eleven years. Carcinoma of the uterine body is slow in its course as compared with carcinoma of the cervix or vaginal portion. Odebrecht obtained a permanent recovery by operating on a cancer of the body of the uterus five years and four months after it was kno\\Ti to exist. Symp- toms in the early stage, while there is yet time to interfere, are at best only suggestive of the lesion and may be wholly wanting until the disease has reached the inoperable stage. Schauta found that 13 per cent, of the cases which he examined within four weeks of the beginning of symptoms were inoperable. Hemorrhage. — Hemorrhage is usually the first of the s\Tnptoms to appear. It is at first excited by some physical exertion, such as strain- ing at stool, lifting burdens, and sexual intercourse. All departures from the normal menstrual flow, or all losses of blood not in relation to the menstrual period, call for a careful examination. The older the individual the greater the probability of carcinoma. In carcinoma the loss of blood is usually slight at first; more rarely does it begin with a profuse flow. A watery discharge may precede the flow of blood weeks and months, and is highly suggestive of carcinoma. The patient becomes anemic, and her strength fails as a result of the hemorrhage. In the late stage, when there is great enfeeblement, hemorrhage becomes less profuse, and may almost cease. PLATE XXXI ■3aoa^ Cancer of the Vaginal Portion of the Cervix. (Third stage.) The entire cervix is disintegrate