COLUME :BMARlESO'f?iTE HX00039489 ;:y^^W:;^-Jv^ *»■ ^ - — ^-^ r' V ^ . -Idk (Enlumhta llntu?rstti| iSttnmtt IGtbrarg Digitized by the Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/essentialsofgyne1901crag SA UND E RS' QU ESTION-COMP ENDS. No. W. ESSENTIALS OF GYNECOLOGY ARRANGED IN THE FORM OF QUESTIONS AND ANSWERS PREPARED ESPECIALLY FOR STUDENTS OF MEDICINE BY EDWIN B* CRAGIN, M.D. Professor of Obstetrics, College of Physicians and Surgeons, New York; Attending Physician to the Sloane Maternity Hospital ; Consulting Gynecologist to the New York Infirmary for Women and Children ; Consulting Obstetric Surgeon, Maternity Hospital ; Fellow of the American Gyneco- logical Society, the New York Obstetrical Society, the New York Academy of Medicine, etc. FIFTH EDITION, THOROUGHLY REVISED BY FRANK S. MATHEWS, M.D. Assistant Surgeon and Pathologist, St. Mary's Free Hospital for Children: Attending Gynecologist, Roosevelt Hospital, Out-Patient Department ; Assistant Pathologist, Woman's Hospital, State of New York WITH 57 ILLUSTRATIONS PHILADELPHIA AND LONDON W. B, SAUNDERS & COMPANY J90J Copyright, 1901, By W. B. SAUNDERS & COMPANY. Registered at Stationers' Hall, London, England. ELECTROTYPED BY PRESS OF WESTCOTT & THOMSON, PHILADA. W. B. SAUNDERS &. COMPANY. ESSENTIALS OF GYNECOLOGY. Since the issue of the first volume of the Saunders Question=Compends, OVER 200,000 COPIES of these unrivalled publications have been sold. This enormous sale is indisputable evidence of the value of these self-helps to students and physicians. PREFACE TO FIFTH EDITION. Advances in Gynecology since the last edition of this work again demand its revision. It is believed that the changes and additions embodied will render the book more than ever acceptable to those for whom it is intended. E. B. C. 9 347532 PREFACE TO FIRST EDITION. No one appreciates more fully than tlie Author the madeqaacy of this little work for a thorough study of Gynaecology. This has not been the aim. He only hopes that as a means of review and as a summary of the results of more extensive reading, the student may find the work of some value. The Author wishes also to state that in its compilation he has freely consulted, and made use of, the standard works of Hart and Barbour, Thomas, Schroeder, The American System of Gynaecology, notes on the lectures of Prof Geo. M. Tuttle at the College of Physicians and Surgeons, New York, and numerous journals. ' E. B. a CONTENTS. PAGE Mods Veneris, 17 Labia Majora, . , 17 Labia Minora, ■ . 18 Clitoris, • 18 Vestibule, 20 Fourchette, 20 Fossa Navicularis, 20 Bulbs of the Vestibule, 20 Vulvo- vaginal Glands, 21 Hymen, 21 Vagina, 21 Vaginal Secretion, 22 Uterus, 23 Mucous Membrane of Uterus, 25 Fallopian Tubes, • ... 31 Ovaries, 32 Parovarium, 35 Urinary Tract, 35 Bladder, .....* 36 Rectum, 38 Pelvic Floor, 40 Perineal Body, 41 Muscles of the Perineum, 42 Ischio-rectal Fossa, 42 Development of Pelvic Organs, 43 Physical Examination of Pelvic Organs, 43 Vaginal Examination, 44 Bimanual Examination, 46 Rectal Examination, 47 Instruments, 48 Specula, 48 The Sims Speculum, ...» 49 Tiie Simon's Speculum, ...,,,. 5]^ 13 14 CONTENTS. PAGE Instruments, the Fergusson Speculum, 51 The Brewer Speculum, 52 Volsella, 54 Uterine Sound, 55 Uterine Prohe, 59 Uterine 'Applicators, 59 Dilators, 59 Tents, 59 Graduated Hard Dilators, 61 Elastic Dilators, 63 Stem Pessaries 63 The Curette, 64 Vulvitis, 65 Acute Simple Catarrhal, 65 Chronic Catarrhal, 66 Gonorrhoeal, 66 Phlegmonous, 68 Croupous, 69 Gangrenous, 69 Follicular, 70 Cyst and Abscess of Yulvo- vaginal Gland, 71 Pudendal Hernia, 72 Pudendal Haematocele, 73 Hemorrhage from Yulva, 74 Skin Diseases of the Vulva, 75 Erj'thema of the Vulva, 75 Eczema of the Vulva, 75 New Growths of the Vulva, 77 Simple PaiDillomata, 77 Pointed Condylomata, 77 Syphilitic Condylomata, 78 Pruritus Vulvae, 78 Hypersesthesia of the Vulva, 80 Vaginismus, 80 Coccygodynia, 81 Irritable Urethral Caruncle, 82 Prolapse of Urethral Mucous Membrane, 83 Malformations of the Vulva, 83 CONTENTS. 15 PAGE Diseases of the Vagina, 84 Bacteria of the Vagina, 84 Simple Catarrhal Vaginitis, 84 Gonorrhoeal Vaginitis, 86 Ulcerative Vaginitis, 86 Croupous Vaginitis, 87 Pelvic Peritoneum, 87 Pelvic Peritonitis, 88 Pelvic CelhiUtis, 91 PeMc Hsematocele and Hematoma, 94 Menstruation, 98 Disorders of Menstruation, 99 Amenorrhoea, 99 Vicarious Menstruation, 100 Menorrhagia and Metrorrhagia, ] 01 Dysmenorrhoea, 102 Obstructive, 102 Congestive, 103 Neuralgic, 104 Ovarian, 104 Membranous, 105 Malformations of the Vagina, 106 Atresia of the Vagina, 107 Stenosis of the Vagina, 108 IMalformations of the Uterus, 108 Displacements of the Uterus, 113 Anteversion, 113 Anteflexion, Ill Retroversion and Retroflexion, 116 Pessaries, 121 Alexander's Operation, 124 Hysterorrhaphy, 126 Prolapsus Uteri, 127 Laceration of Perineum and Relaxation of \'aginal Outlet, . - . 130 Hegar's Operation, 131 Emmet's Operation, » . . . = 133 Saenger-Tait Operation, . . o 131 Cleveland's Operation, 137 Hypertrophy of the Cervix, . = .... 140 16 CONTENTS. PAGE Stenosis of the Cervix, 142 Laceration of the Cervix, 142 Trachelorrhaphy, 145 Endometritis, 147 Acute, 147 Chronic - 148 Metritis, . « . . „ = . . . .. 153 Metritis, Acute Metritis, . 153 Chronic Metritis, 154 Atrophy of the Uterus, 156 Fibroid Tumors of the Uterus, 157 Inversion of the Uterus, 166 Polypi, 171 Carcinoma Uteri, 175 Vaginal Hysterectomy, 177 Sarcoma of the Uterus, = . 178 Decidnoina Maligmim, 179 Salpingitis, 180 Tubercular Salpingitis, 183 AfJections of the Ovaries, 184 Hemorrhage into tlie Ovaries, 184 Ovaritis, 184 Prolapse of the Ovary, 188 Tumors of tlie Ovary, 188 Cysts of the Ovary, 189 Parovarian Cysts, . . ♦ . ] 94 Preparation of Catgut, o c . 198 Ectopic Gestation, 199 Fistula, 202 Recto- vaginal Fistula, o . 00. 204 ESSENTIALS OF GYNJICOLOGY. What is included in the term external genitals ? That portion of the genital tract which is visible when the patient is in the dorsal position, with knees elevated and the labia separated with the fingers, viz. : Mons Veneris, Labia Majora, Labia Minora, Clitoris, Vestibule, Fourchette and Fossa Navicularis. What other terms are in common use for the external genitals ? Pudendum and Vulva. The term vulva is inexact, as it originally applied to the labia, nevertheless it is in common use. What comprise the internal organs of generation ? The Uterus, Fallopian tubes and Ovaries. The Vagina connects the external with the internal generative organs. Budin regards the Hymen as anatomically a folding in of the vaginal walls. Mons Veneris. Describe. The Mons Veneris is a triangular projection, or cushion of adipose tissue, situated over the symphysis pubis. Anatomically, in addition to adipose tissue, it contains fibrous and elastic tissue. After puberty it is covered with hair, which has a tendency to curl, and is usually somewhat darker than the hair of the head. Numerous sebaceous and sweat glands are present. Labia Majora. Describe them. The labia majora are two folds of skin which extend from the mons veneris in front to meet in the fourchette posteriorly ; they 2 17 18 ESSENTIALS OF GYNECOLOGY. are covered externally with coarse hair, and richly supplied with sebaceous and sweat glands ; they also contain adipose, fibrous and elastic tissue. Above, the round ligament can be traced into them on either side ; also the remains of" the canal of Nuck, which sometimes continues pervious and admits of hernia. The inner surface of the labia is smooth, and somewhat resembles mucous membrane, a few fine hairs, however, are visible on close inspection. The labia majora in the virgin lie in contact ; in old women they become atrophied and allow the labia minora to protmde. Tbe arterial supply is the superficial perineal branch of the internal pudic and the superficial external pudic. The veins communicate with the bulbs of the vagina and take the course of the arteries. The lymphatics empty into the inguinal glands. The nerve supplj^^^ is from the superficial perineal branches of the internal pudic, the ilio-inguinal, and the genito-crural. Labia Minora. Describe. The labia minora, or nymphae, are two folds of muco-cutaneous tissue which arise about the middle of the labia majora on their inner surfaces, and extending upward divide into two portions ; the two lower uniting just below the clitoris to form the fr^enum, the two upper just above the chtoris to form the prepuce. The venous supply is rich ; it communicates with the bulbs of the vagina and with the pudic and perineal veins. The arterial supply, nerves and lymphatics are the same as for the labia majora. The sebaceous glands are very abundant. Clitoris. Describe. The chtoris, the analogue of the penis in the male, is situated at the apex of the vestibule ; it consists of a glans, a bodj^^ and two crura. The glans, the only part visible, is a mass of erectile tissue, about the size of a small pea, veiy abundantly supplied with nerves and partially covered by its prepuce. The body also consists of erectile tissue ; it is about an inch long, surrounded by a firm fibrous covering, and shown, on section, to CLITORIS. • 19 consist of two halves, corpora cavernosa, separated by an imperfect septum. The crura are two prolongations of erectile tissue with a dense fibrous sheath ; they arise from the anterior borders and inner sur- faces of the pubic and ischiatic rami, and extend forward to unite in the body just beneath the pubic arch. Give the vascular supply of the clitoris. The arterial sujoply is from the two terminal branches of the in- ternal pudic. The blood is returned by the dorsal vein which empties into the vesical plexus. Describe the lymphatics of the clitoris. The clitoris is surrounded by a plexus of lymphatics which termi- nate in the inguinal glands. Describe the nerve supply of the clitoris. The clitoris receives numerous filaments both from the sympa- thetic system and from the pudic nerve. According to Savage, " small as this organ is compared with the penis, it has in proportion four or five times the nervous supply of the latter." What are the differences between the clitoris and the penis ? The clitoris has neither corpus spongiosum nor urethra, both of which are present in the penis. What are the points of resemblance between the clitoris and the penis ? They are both erectile. They each consist of a glans, a body and two crura. They each have two corpora cavernosa separated by an incomplete septum. The glans in each is partly covered by a prepuce, with its frgenum attached below. What do we find in the female as the analogue of the corpus spongiosum in the male ? The bulbs of the vestibule and the labia minora, which, in the female, lie at the side of the urethra, correspond to the corpus spongiosum in the male. 20 ESSENTIALS OF GYNECOLOGY. What in the male is the analogue of the labia major a in the female? The scrotum. Vestibule. Describe. The vestibule is a triangular area covered with mucous membrane, in the base of which is situated the meatus urinarius ; the apex hes just below the clitoris ; the sides are formed by the inner edges of the labia minora, the base by the upper margin of the vaginal oiifice. Beneath the mucous membrane lies a venous plexus called the pars intermedia. The vestibule differs from the labia and mons veneris in having no sebaceous glands. Fourchette. Describe. The fourchette, or posterior commissure, is a mere fold of skin formed by the junction of the labia majora at the anterior edge of the perineum. Fossa Navicularis. Describe. The fossa navicularis is a boat-shaped cavity which is formed between the lower portion of the hymen and the inner aspect of the fourchette, when the latter is pulled down with the finger, or the labia are separated. When the parts are at rest, no such hollow exists. Bulbs of the Vestibule. Describe them. The bulbs of the vestibule are two oval masses of erectile tissue situated on either side of the ostium vaginae and base of the vesti- bule ; posteriorly, they lie in contact with the anterior layer of the triangular ligament ; they are partially covered in front by the bulbo- cavernosi muscles ; they extend as high as the meatus urinarius, and are connected by the pars intermedia with the cavernous tissue of the clitoris. Their size varies greatly from that of a bean, as given by Hart and Barbour, to a mass an inch and a half long. VAGINA. 21 Vulvo-Vaginal Glands. Describe. The vulvo-vaginal, or Bartholinian glands are small oval bodies about the size of an almond, lying just behind the lower extremities of the bulbs ; thej^ lie between the layers of the triangular ligament, and each gland has a duct about half an inch in length which opens just in front of the hj^men on each side. They secrete a glairy mucus which lubricates the parts. Hymen. Describe. The hymen is a fold of mucous membrane which surrounds the ostium vaginae ; it has a connective tissue framework, and contains blood-vessels and nerves, and has a squamous epithelium covering. From its histology and embryology, it is a fold of the vaginal wall. The hymen may be of several forms ; the most common being the crescentic. Other forms are the annular, making a ring about the ostium ; the cribriform, perforated by numerous small holes ; and the fimbriated, with a fiinged edge. It is sometimes imperforate, a pathological condition. What value has the hymen as a criterion of chastity ? Very slight, as neither is its absence proof that intercourse has taken place, nor is its presence an absolute proof to the contraiy. What are the carunculae myrtiformes ? In women who have borne children there are found papillary elevations surrounding the vaginal orifice. These are the remains of the hymen, and are called carunculae myrtiformes. Vagina. Describe. The vagina is spoken of by Hart and Barbour as " a mucous slit in the pelvic floor;" it is the canal connecting the uterus and the vulva, lying between the bladder and urethra in front and the rectum behind ; its walls, which are anterior and posterior, aro normaDy in contact. 22 ESSENTIALS OF GYNECOLOGY. The anterior wall measures 2-2J inclies in length, the posterior 3-3i inches. The anterior wall is shorter than the posterior, from the fact that the uterus is set into the anterior wall. The vagina is very dilatable, and when distended is conical in shape, being much more roomy above than below. The vaginal walls on section are seen to consist of three layers : 1, mucous ; 2, muscular ; 3, connective tissue. The mucous membrane on both anterior and posterior walls presents at the lower portion of the canal numerous ridges or ragae, extending transversely from a central column ; the anterior being the more distinct. The epithelium covering the mucous membrane is of the squamous variety. The vaginal mucous membrane normally con tains no glands. The muscular coat consists of two layers of unstriped muscle, the outer longitudinal one being well developed, the inner circular one being poorly developed except at the orifice. The outer coat is of connective tissue, and contains the external plexus of veins. The roof, or fornix of the vagina, that portion of the canal sur- rounding the cervix, is, for convenience, divided into four portions : the anterior fornix, the posterior fornix, and the lateral fornices; of these the posterior is the deepest. Describe the vaginal secretion. It is a rather scant, white, opaque, curdy material, made up of exfoliated cells of the vaginal mucous membrane and some exudate from the blood-vessels. It contains mucus only from admixture with the cervical secretion. It has a decided acid reaction due to lactic acid, resulting from the action of the many saprophytic bacteria normally found in the vagina. What is the arterial supply of the vagina ? The arterial supply is from the vaginal arteries, which supply the lateral walls ; branches of the uterine arteries supplying the upper portion, and branches of the pudendal arteries the lower. These anastomose with each other and with the vesical and recta' arteries. Describe the veins of the vagina. The vaginal veins form plexuses which surround the canal liio ^ UTERUS. 23 sheaths ; one being external to the muscular layer, the other just beneath the mucous membrane. "These communicate freely with the pudendal, vesical and hemor- rhoidal plexuses below, and with the plexuses of the broad ligament above." These veins contain no valves. Describe the lymphatics of the vagina. The lymphatics of the lower fourth of the vagina, together with those from the external genitals enter the inguinal glands. The lymphatics from the upper three-fourths of the vagina join with those from the cervix and bladder, and enter the iliac glands. According to Poirier, some of them enter a glarwi at the side of the cervix in the base of the broad ligament. Describe the nerve supply of the vagina. The vagina is supplied by branches of the inferior hypogastric plexuses of the sympathetic system. These plexuses lie on either side of the vagina. Give the relations of the vagina. The anterior vaginal wall is connected in its lower half with the urethra, in its upper half with the neck and fundus of the bladder ; the former connection is much more intimate than the latter. The posterior vaginal wall in its lower fourth lies in connection with the perineal body, in its middle two-fourths with the rectum, in its upper fourth with the cul-de-sac of Douglas. The anterior forniK is distant \\ inches from the utero-vesical pouch, and through this fornix can normally be felt the body of the uterus and the angle it makes with the cervix. The posterior fornix is in contact with the cul-de-sac of Douglas. The lateral fornices are in relation with the bases of the broad liga- ments, and through these fornices can normally be felt the vessels of the broad ligament, and occasionally the ovaiy and tube of that side. The vagina makes an angle of 60° with the horizon when the woman is erect. Uterus. Give the gross anatomy. The uterus, the organ of gestation, is a hollow, pear-shaped organ, flattened antero-posteriorly , situated in the pelvis between the bladder 24 ESSENTIALS OF GYNECOLOGY. and rectum. It measures in the virgin about 3 inches in length, 2 inches in breadth, at the level of the Fallopian tubes, and one inch in thickness. The weight of the virgin uterus varies from 1 to IJ oz. It consists of three portions : the cervix, body and ftindus. As viewed externally, the uteiTis, on its anterior surface, is nearly flat, its posterior surface convex ; a little below the centre is a slight constriction called the isthmus. The cervix is that jDortion of the uterus below the isthmus, and which projects in part into the vagina. Fig. 1. Diagram of Uterus, to show divisions of Cervix. (Schroeder.) a, Infra-vaginal portion; ?>, Intermediate portion; c, Supra-vaginal portion; Bl^ Bladder ; P, Peritoneum. The dotted line shows peritoneum. The body is that portion between the isthmus and the line joining the entrance of the Fallopian tubes. The fandus is the portion above this line. Describe the uterine canal. The uterine canal measures normally 2} inches, and holds about 12 drops ; the cervical portion of the canal is spindle-shaped ; the remainder is triangular, with anterior and posterior walls in contact. What are the openings into the uterine cavity ? There are three : the os externum, which communicates with the vagina ; and the orifices of the Fallopian tubes at the upper angles, MUCOUS MEMBRANE OF THE UTERUS. 25 which connect the uterine with the peritoneal cavity. The os internum connects the cavity of the cervix with that of the body. What divisions of the cervix are made ? Schroeder divides the cervix into three portions, as seen from the accompanying figure, (Fig. 1, a, Z>, c). a. The infra-vaginal portion. h. The intermediate portion. c. The supra-vaginal portion. The infra-vaginal portion of the cervix (a) is that below the level of the attachment of the anterior vaginal wall. The supra-vaginal portion (c) is that above the level of the attach- ment of the posterior vaginal wall. The intermediate portion [h) is that between the infra- and supra- vaginal portions. What portions of the cervix project into the vagina ? The infra-vaginal portion of the anterior lip, and the infra-vaginal and intermediate portions of the posterior lip. For practical purposes, it is sufficient to divide the cervix into the supra-vaginal portion, that above the attachment of the vagina; and the infra-vaginal, that within the vagina. What are the three elements in the structure of the uterus ? 1. The mucous membrane. 2. The muscular coat. 3. The peritoneal coat. Mucous Membrane of the Uterus. Describe that of the cervix. The mucous lining of the cervix difi*ers from that of the body of the uterus. In the cervix it is thrown into folds presenting the arbor vitse appearance, there being a central ridge on both anterior and posterior walls, and from these ridges secondary ridges extend- ing obliquely. Tlie anterior and posterior ridges are not directly opposite, but fit past one another. Tlie epithelium is ciliated on the ridges, non- ciliated in the depressions (de Sinety). 26 ESSENTIALS OF GYNECOLOGY. The mucous membrane of the cervix is rather sparingly supplied with rather simple racemose glands whose secretion is mucous. The mucous membrane covering the vaginal portion of the cervix closely resembles that of the vagina, consisting of vascular papilla3 covered by squamous epithelium. Describe the mucous membrane of the body of the uterus. The mucous lining of the body of the uterus is smooth, velvety and of a grayish red color ; it is directly connected with the muscu- lar coat, with no submucous layer. It averages about -.J^ of an inch in thickness, and consists of columnar, ciliated epithelium, on a base of connective tissue between whose fibres numerous lymph spaces are found. The mucous membrane is thickly studded with glands, the utricular glands, which penetrate the whole thickness of the mucous layer. These glands are of the tubular variety, and are fre-' quently bifurcated at their blind extremities. They are lined with prismatic ciliated epithelium, resting on a thin membrana propria. Their direction is not at right angles to the surface, but, according to Turner, more or less oblique. Their secretion is a serous one. To what changes is the normal uterine mucosa subject? 1. That of the child is destitute of glands. These make their appearance a few years before puberty. 2. Preceding each menstrual flow the cells of the stroma become swollen, the superficial capillaries dilated, and finally there is an exu- dation of plasma and diapedesis of red cells under the epithelium... 3. Should pregnancy occur, the stroma cells become much larger and polj'gonal, glands disappear from the surface of the mucosa, and are only seen as distorted and cj^stic ones in the deep layer. Thus altered the mucosa becomes the "decidua." 4. After the menopause the mucosa atrophies and nearly all glands disappear. Describe the muscular structure of the uterus. The muscular structure of the utenis is most marked after im- pregnation ; it can then be separated into three layers : — 1. Tlie external or longitudinal. 2. The middle or oblique. 3. The internal or circular. MUCOUS MEMBRANE OF THE UTERUS. 27 The external layer is most distinct on tlie anterior and posterior surfaces, where it is seen to consist of fibres running up longitudi- nally over the fundus ; it sends fibres into the broad, round, ovarian and utero-sacral ligaments and also into the Fallopian tubes. The middle, or oblique layer has no regular arrangement ; some of the fibres run longitudinally, some transversely and some obliquely ; they surround the blood vessels, and on this account this layer is of great importance ; it constitutes the chief portion of the uterine wall. The internal or circular layer shows fibres arranged in a circular manner, most distinct around the orifices of the Fallopian tubes and at the OS internum. Describe the peritoneal coat of the uterus. The peritoneum covers the anterior surface of the uterus above the level of the internal os ; it extends over the fundus, covers its posterior surface as low as the attachment of the posterior vaginal wall, and extends down the latter for about an inch. Describe the arterial supply of the uterus. The uterus is supplied by the uterine and ovarian arteries, as seen by the accompanying figure. (Fig. 2. ) The uterine artery arises from the anterior division of the internal iliac, runs between the folds of the broad ligament to about the level of the os externum, and then turns upward along the side of the uterus to unite with the descending branch of the ovarian artery ; it gives off numerous lateral branches to the uterus, anastomosing with those of the opposite side ; these are very tortuous and are called the ' ' curling arteries of the uterus. ' ' Sometimes the vaginal artery springs directly from the uterine. Opposite the internal os, the uterine artery gives off a branch which, uniting with its fellow of the opposite side, surrounds the cervix and is called "the circular artery." The ovarian artery arises directly from the aorta, runs between the folds of the broad ligament, at its upper part, to the upper angle of the uterus ; it gives off a few large vessels to the outer extremity of he tube, and then a number of very tortuous vessels which sur- round the ovary. Just before reaching the uterus, it gives off a number of branches 28 ESSENTIALS OF GYNECOLOGY. to the proximal extremity of the tube and one to the round liga- ment. At the angle of the uterus it divides into two branches ; one. sup- FiG. 2. Distribution of ovarian, uterine and vaginal arteries {HyrtT). a, ovarian artery, a' and 6', branches to tube; c', branches to ovary; b, branch to round ligament; c, branch to fundus; rf, branch to join uterine artery ; e, uterine artery ; /, anterior branch of internal iliac ; g, vaginal arteries ; h, azygos artery of vagina. MUrOUS lilEMBRANE OF THE UTERUS. 29 plies the fundus and anastomoses with its fellow of the opposite side ; the other descends along the side of the uterus and anasto- moses with the uterine artery-. The tortuosity and free anastomoses across the median line are noticeable features of the arteries of the uterus. Describe the venous supply of the uterus. The utems is surrounded beneath the peritoneum by a plexus of veins, called the uterine plexus ; this receives the blood from the uterine walls and communicates with the vaginal and vesical plexuses below and the pampiniform above ; it empties into the internal ihac and ovarian veins. Describe the lymphatics of the uterus. The lymphatics from the body of the uteras join with those from the ovary and tube and terminate in the lumbar glands. The lymphatics from the cei-vix pass beneath the base of the broad ligaments to the iliac glands. The lymphatics of the uterine cornu follow the round ligament and terminate in the inguinal glands. Give the nerve supply of the uterusc The chief nerve supply of the uterus is from the inferior hypo- gastric plexus of the sympathetic. The cervix also receives branches from the upper sacral nerves. What is the normal position of the uterus ? This question has been frequently discussed and at great lengtl), It is now sufficient for practical purposes to say that the uterus, when the pelvic organs are normal and when bladder and rectum are empty, lies slightly anteflexed and slightly anteverted ; but the posi- tion is constantly changing with the degree of distention of the blad- der and rectum, especially the former. What are the ligaments of the uterus ? There are two utero-vesical ligaments, two round, two broad and two utero-sacral. Describe the utero-vesical ligaments. They are two folds of peritoneum passing between the bladder and the lower portion of the uterus on each side. 30 ESSENTIALS OF GYNECOLOGY. Describe the round ligaments. They are two mnsculo-fibrous cords, 4-5 inches in length, which extend from the superior angles of the uterus, in the anterior folds of the broad ligaments and below the Fallopian tubes, forward and outward to the inguinal canal ; thence through this canal where they terminate in three points of insertion : the external, middle and internal. The external blends with the outer jjillar of the ring near Gimbernat's ligament. The middle terminates in the upj^er portion of the external ring. The internal unites with the conjoined tendon. Besides muscular and fibrous tissue, these ligaments contain areolar tissue, vessels and nerves. They are of importance surgically as being those shortened in operations for the correction of posterior displacements. Describe the broad ligaments. They are two folds of peritoneum which extend from the sides of the uterus to the wall of the pelvis, ' ' along a line which is situ- ated between the great sacro-sciatic notch and the margin of the obturator foramen as far down as the level of the ischial spine. ' ' The greater part of its superior border, on each side, is occupied by the Fallopian tube ; the part of the superior border not so occupied is called the infundibulo-pelvic ligament. What is the " mesosalpinx " ? It is that portion of the broad ligament lying between the tube, ovary, and ovarian ligament. What two folds are made in the broad ligament in addition to that occupied by the Fallopian tube ? An anterior fold caused by the round ligament and a posterior fold caused by the ovarian ligament. Describe the ovarian ligament. It is a fibro-muscular cord about an inch in length, which connects the ovary with the side of the uterus, just below the entrance of the Fallopian tube. It lies ha, and is surrounded by, the posterior fold of the broad ligament. What are contained between the folds of the broad ligameiu on either side ? The round ligament. Fallopian tube, ovarian ligament, the par( FALLOPIAN TUBES. 31 varium, cellular tissue, uterine and ovarian arteries, the pampiniform plexus and other veins, numerous lymphatics and nerves. When the broad ligament is held tense the ovary appears as if stuck on its posterior surface. Describe the utero-sacral lig^aments. They are folds of peritoneum containing muscular and cellular tis- sue, which extend from the sides of the uterus, at the level of the internal os, backward and outward to the second sacral vertebra. What is the meaning^ of the term "uterine appendages," as usually employed ? The Fallopian tubes and ovaries. Fallopian Tubes. * Describe them. They are two tubes 3-5 inches in length, which extend laterally from the superior angles of the uterus ; they lie within the folds of the broad ligaments, and their direction is first outward, then for- ward, backward and inward toward the ovary. They are divided for consideration into three portions : the isth- mus, the ampulla and the fimbriated extremity. The isthmus is the narrowest portion ; it measures about an inch in length, and extends from the angle of the uterus directly outward, joining the ampulla ; its lumen is only large enough to admit a fine bristle. The ampulla is the curved, dilated portion of the tube ; its lumen admitting an ordinary uterine sound. The fimbriated extremity (infundibulum) is the expanded, funnel- shaped outer end, which is surrounded by fringe-like processes (fim- briae), both primary and secondary, the latter arising from the former, which are 4-5 in number. The longest of the primary fimbriae lies to the inner side, is grooved, and is attached to the ovary ; this is called the fimbria ovarica. The tubes, oil section, are seen to consist of four layers or coats ; tie peritoneal coat ; two muscular coats, the outer being longitudinal, t!ve inner circular ; and a mucous coat. There is no submucous layer. 32 ESSENTIALS OF GYNECOLOGY. The mucous membrane is thrown into longitudinal folds ; the epi- thelium is columnar and cihated. Give the arterial supply of the Fallopian tubes. The Fallopian tubes are supplied by the ovarian arteries, which send branches directly to the outer and inner portions of the tube and supply the middle third through branches from the plexus about the ovaiy. "Describe the veins, lymphatics and nerve supply of the Fal- lopian tubes. The veins of the tubes enter the pampiniform plexus on either side. The lymphatics join with those from the upper jDart of the uterus and from the ovary, and terminate in the lumbar glands. The nerve sujDply is from the inferior hypogastric plexuses. What is the direction of the current due to motion of the cilise of the epithelium in the uterus and tubes ? The cilise have such a motion as to propel fluids outward, i. e.. m the tube toward the uterus, and in the uterus toward the vagina. Ovaries. Give their gross anatomy. The ovaries are two " flattened ovoid " bodies lying in the plane of the brim of the pelvis, on either side of the uterus, and appear as elevations on the posterior surface of the broad ligament. They are situated below the outer extremities of the tubes. They present for consideration two borders, an anterior and pos- terior ; two surfaces, a superior and an inferior ; and two extremi- ties, an outer and an inner. The anterior border is nearly straight ; the posterior is convex. The anterior border is called the hUum, and serves for the en- trance of blood vessels and nerves. The superior surface is nearly flat ; the inferior is convex. The outer extremity is broad and convex ; the inner is narrow and tapers into the ovarian hgament. OVARIES. 33 An ovary averages about 1 j inclies in length, f of an inch in breadth and ^ an inch in thickness ; it weighs about 87 grains. Give the minute anatomy of the ovary. The ovary, on section, is seen to consist of a medullary and cor- tical portion ; the former being more vascular and of a softer con- sistency than the latter. The microscope shows connective tissue, numerous Graafian follicles scattered through the cortex, blood ves- sels, lymphatics, nerves and unstriped muscular fibres. At the base or attachment of the ovary to the broad ligament can be seen a white line which marks the transition from the flat cells of peritoneum to the cuboidal ones, the ' ' germinal epithelium ' ' covering the surface of the ovary. The origin of both sorts of cells is the same. Both are derived from the mesothelial cells of the mesoblast, and later become differently modified to fit them to fulfil their very dissimilar functions. The layer of "germinal epithelium " rests on a thin, dense mus- culo-fibrous layer, called the tunica albuginea. The Grraafian follicles are small vesicular bodies, more numerous and smaller in the superficial zone of the cortex than in the deeper, with the exception of a few which have matured and approached the surface of the ovary. Foulis estimates that at birth each human ovary contains not. less than 30,000 Graafian follicles (Play fair). Give the structure of a Graafian follicle. On examining a Graafian follicle from without inward, we find the following structures (Fig. 3) : — The theca folliculi, which is divisible into an outer fibrous layer, the tunica fibrosa, and an inner vascular and cellular layer, the tunica propria ; within this is the memhrana granulosa^ a layer of columnar epithelium which encloses the liquor follicuU ; at one side there is a cellular eminence called the discus proligerus, which encloses the ovum. The outer covering of the ovum is the vitelline membrane^ or zona pellucida, surrounding the vitellus or yolk. At one point of the latter is seen the germinal vesicle., and within this the germinal spot. A Graafian follicle measures from t^o to 2V inch in diameter ; a germinal spot, not over 30V0 iiich. 3 34 ESSENTIALS OF GYNECOLOGY. Give the arterial and venous supply of the ovaries. The ovaries are supphed by the ovarian arteries, which arise directly from the aorta. The veins of the ovary emerge at the hilum and enter the collec- tion of veins called the " bulb of the ovary." This communicates with the veins from the Fallopian tube and upper portion of the Diagrammatic Section of Graafian Follicle. 1. Ovum. 2. Membraua granulosa. 3. External membrane of Graafian follicle. 4. Its vessels. 5. Ovarian stroma. 6. Cavity of Graafian follicle. 7. External covering of ovary. utenis, forming a collection called the pampiniform or ovarian plexus ; from this springs the ovarian vein, which, on the right side, terminates in the inferior vena cava, on the left side, in the left renal vein. The left ovarian vein has no valve at its termination. Some apply the term pampiniform plexus to all the veins in the broad ligament. Give the lymphatics and nerve supply of the ovary. The lymphatics join with those from the tube and upper portion of the uterus and terminate in the lumbar glands. The neiTe sup- ply is fi'om the inferior hypogastric plexus. What is the position of the long axis of the ovary ? This question has been much discussed. The long axis of the ovary may be regarded as lying a little obliquely to the transverse i URINARY TRACT. 35 axis of the pelvis, and with a direction slightly backward. His describes the long axis as vertical, but this does not coincide with the results of autopsies where the pelvic contents have been normal r ^ .^ ., Parovarium. Describe it. ^ The parovarium, which is the remains of the Wolffian body con- sists of a series of tubes situated between the folds of the broad ligament, on either side of the uterus, and lying between the am- pulla ot the tube and the hilum of the ovary. One of the tubes is horizontal and runs toward the uterus ; the others are nearly vertical, converging toward the hilum ; they' vary greatly in number, in fact, from 6 to 30. The outer 6-10 have a well-marked lumen and are lined with cihated epithelium ; those internal to these are merely fine fibrous cords. The horizontal tube running toward the uterus is called the duct of Gartner. It is rarely continued down along the side of the uterus or even to the vagina. The parovarium is of pathological importance, as occasionally the seat of cysts. What in the male corresponds to the parovarium in the female ? The epididymis. Urinary Tract. Describe the urethra. The female urethra is a musculo-membranous canal about If mches in length, imbedded in the anterior vaginal wall, and extend- mg from the vestibule to the neck of the bladder ; it runs upward and backward, " parallel with the plane of the pelvic brim." It consists of three coats ; the outer two being muscular, the inner, mucous membrane. Of the muscular coats, the outer is circular, the inner longitudi- nal. The mucous membrane in the lower portion of the canal is covered with squamous epithelium, while higher up the epithelium is transitional, like that of the bladder. The meatus urinarius, the outer extremity of the urethra, is situ- ated in the median line at the base of the vestibule. 36 ESSENTIALS OF GYNECOLOGY. Describe Skene's tubules. Just within the meatus, on each side, are the openings of Skene's tubules, which he describes as lying near the floor of the urethra, just beneath the mucous membrane, and extending parallel to the canal about three -fourths of an inch. Theu function is unknown. Bladder. Describe it. Tlie bladder is a hollow musculo-membranous organ, situated in the pelvis ' ' between the symphysis pubis in front and the vagina and uterus behind. ' ' The bladder presents for consideration a body, a base or fundus, and a neck. The body is all that portion above the lines joining the ureteric oj^enings and the centre of the symphysis pubis. All below these lines is the base or fundus. The portion of the fundus between the urethral and ureteric orifices is the trigone. The constricted portion continuous vnth the urethra is the neck. The wall of the bladder consists of three coats : a peritoneal, a muscular and a mucous. The peritoneal coat is found only on the summit of the bladder and on the upper part of the joosterior surface. The muscular coat consists of two layers : an outer longitudinal and an inner circular ; the latter being most marked around the urethral orifice. The mucous membrane consists of several layers of transitional epithehum resting on a membrana propria ; the superficial cells are squamous. It contains no glands. The mucous membrane is thi'own into numerous folds, except at the trigone, where it is more closely connected with the underlying tissue. The mucous membrane is supported by a submucous layer of fibrous and elastic tissue, containing blood vessels, lymphatics and nerves. What is the arterial supply of the bladder and urethra ? The bladder receives its arterial supply from the superior, middle and inferior vesical, and from branches of the uterine and vaginal arteries. They are all derived from the anterior division of the internal iliac. The urethra is supplied by branches from the vaginal arteries. BLADDER. 37 What is the venous supply of the bladder and urethra ? ' ' The veins form a complicated plexus round the neck, sides and base of the bladder. ' ' (Gray. ) This is called the vesical plexus ; it lies external to the muscular coat and terminates in the internal iliac vein. The urethra is surrounded by a venous plexus which communi- cates with the vaginal plexus. Give the lymphatic and nerve supply of the bladder and urethra. The lymphatics of the bladder and urethra empty into the ihac glands. Their nerve supply is derived from the inferior hypogas- tric plexuses of the sympathetic system, and from the 3d and 4th sacral nerves of the cerebrospinal system. What are the principal venous plexuses of the pelvis 1 The vaginal plexuses. The vesical plexus. The hemorrhoidal plexus. The uterine plexus. The pampiniform, or ovarian plexus. The bulb of the ovary. Describe the course of the ureters in the pelvis. The ureters cross the external iliacs just beyond the bifurcation of the common iliacs ; they then pass downward and forward along the lateral walls of the pelvis, enter the broad ligaments, and run forward and inward. At the level of the internal os they are crossed in front by the uterine arteries (see Fig. 4), and are there situated about half an inch from the uterus. They pass alongside of the vagina a little wa}^ converge still more, enter the vesico-vaginal septum, and pierce the bladder a little above the middle of the anterior vaginal wall ; they are here separated two inches from each other and one- half to three-fourths of an inch from the cervix. 38 ESSENTIALS OF GYNECOLOGY. Rectum. Describe. The rectum is the lower extremity of the large intestine, about 8 inches in length, extending from near the left sacro-iliac synchron- drosis to terminate in the anus between the coccyx and perineum. Fig. 4. Drawing from a dissection made to show relations of ureters, uterine arteries, bladder, etc. {J. Greig Smith.) ur., ureter; ui.Ar., uterine artery; ou, os uteri exposed by an incision, x, made through the top of the vagina ; bl., bladder, the walls of which are cut down to the insertion of the ureters into its base, Vag., vagina. It presents three curves : — 1. Downward, backward and inward to the 3d sacral vertebra. 2. Forward to the apex, of the perineum. 3. Backward to the anus. The rectum is invested by peritoneum at its upper part. \ RECTUM. 39 It consists of a mucous and a submucous layer and two muscular layers — a longitudinal and a circular, the former being external. The mucous membrane is covered with columnar epithelium and contains numerous follicles of Lieberkiihn. At its lower j^ortion the mucous membrane is thrown into perpen- dicular folds called columns of Morgagni ; the depressions between them being called the sinuses of Morgagni. There are three oblique folds of importance, including not only the mucous and submucous layers, but part of the muscular coat. One projects from the anterior wall IJ inches from the anus. Another is on the right side near the sacral promontory, and a third is situated midway between the two, on the left side. The external orifice is guarded by the sphincter ani muscle which surrounds the canal, and is inserted into the coccyx behind and the perineum in front. Give the vascular and nerve supply of the rectum. The arterial supply of the rectum is from the superior, middle and inferior hemorrhoidal arteries. The veins form a plexus beneath the mucous membrane which communicates with another surround- ing the exterior of the canal ; from this spring veins corresponding to and accompanying the arteries. The superior hemorrhoidal vein empties into the inferior mesen- teric of the portal system. The middle and inferior hemorrhoidal empty into the internal iliac of the general venous system. The lymphatics terminate in the sacral glands. The nerves are derived from the hypogastric and sacral plexuses. Give the relations of the rectum. At its upper portion the rectum is surrounded by peritoneum and lies in direct relation anteriorly with the cul-de-sac of Douglas. At about 3 inches from the anus the peritoneum leaves the rectum, which then lies loosely attached to the posterior wall of the vagina for IJ inches. The remainder is separated from the vagina by the perineal body. Posteriorly, the rectum is connected at its upper part by the meso- 40 ESSENTIALS OF GYNiECOLOGY. rectum to the sacrum ; at its lower part by fibrous tissue to tbe sacrum and coccyx. On eacb side it receives the insertion of the levatores ani and is surrounded below by the sphincter ani. Pelvic Floor. Describe the segments of the pelvic floor. According to Dr. Hart, the j^elvic floor consists of two segments : the j)ubic and sacral ; the pubic consisting of the bladder, urethra, bladder peritoneum and the anterior vaginal wall ; the sacral com- prising the rectum, perineal body and posterior vaginal wall. According to the same authority, also, the pubic segment is made up of loose tissue, loosely attached to the pubes, and is drawn up duiing labor ; the sacral segment is made up of dense tissue, closely attached to sacrum and coccyx, and is driven down during labor. Describe the muscles and fascia of the pelvic floor, as dis- sected from above. On examining the pelvic floor from abo'.e, we find the pelvic fascia attached laterally to the brim of the pelvis, to the spine of the ischium behind, to the lower j^ortion of the symphysis pubis in front, and to a tendinous band — ' ' white line " — joining the two latter points. Behind the spine of the ischium the pelvic fascia is con- tinuous with a thin layer covering the pyriformis muscle. At the "white line" the pelvic fascia divides into the recto-vesical fascia, which covers the upper surface of the levator ani muscles, and the obturator fascia, covering the obturator muscles. The recto-vesical fascia arising from the "white line " extends downward and inward, and unites in the median line with its fellow of the opposite side. This forms a fascial diaphragm which is i^erforated by the rectum and vagina, to each of which it is firmly attached and famishes a sheath from that point downward. The bladder and rectum also receive ligaments from this fascia. On removing this fascial diaphragm, we meet with a muscular diaphragm formed by the levator ani and coccygeus muscle of each side meeting in the median line. PERINEAL BODY. 41 The coccygei arise from the ischial spines, and are attached to the sides of the lower segment of the sacrum and to the sides and ante- rior surface of the coccyx. The levatores ani arise from the posterior aspect of the pubes, from the spine of the ischium and from the ' ' white line ' ' of the pelvic fascia connecting these points. They extend downward and inward and are attached to the vagina, the rectum, to each other and to the tip of the coccyx. This muscular diaphragm surrounds both vagina and rectum. The under surface of this muscular diaphragm is covered by a thin layer of fascia which is attached on each side to the obturator fascia. On removing the muscular diaphragm with its upper and lower fascia, there remains, filling the pelvic outlet, the perineal body, the muscles of the perineum and the ischio-rectal fossa. Perineal Body. Describe. The perineal body is a mass of muscular, fibrous and adipose tissue, somewhat pyramidal in shape, lying between the lower ends of the vagina and rectum ; it measures H inches in height, li inches in breadth and f inch antero-posteriorly. Its base is covered by skin which is sometimes wrongly spoken of as "the perineum," which should always refer to the perineal body. The muscles which are attached to the perineal body are the bulbo-cavernosi, transversi perinei, sphincter and levatores ani. Give the vascular and nerve supply of the perineal body. The arterial supply of the perineal body is from the internal pudics. The veins terminate in the pudic veins. The lymphatics end in the inguinal glands. The nerve supply is from the pudic nerve. What are the functions of the perineal body ? 1. To prevent vaginal rectocele. 2. To help form a compact pelvic floor. 3. To serve as a fixed point for muscular attachment. 42 ESSENTIALS OF GYNAECOLOGY. Muscles of the Perineum, Name and describe them. On each side of the vaginal orifice we find three muscles : bulbo- cavernosus, ischio-cavernosus or erector clitoridis, and the trans- versus perinei. The bulbo-cavemosus arises from the perineal body on each side of the vagina, with its fellow encircles the vaginal bulbs and vesti- bule, and di\ddes into three slips ; one going to the jDOSterior surface of the bulb, another to the under surface of the corpus cavemosum of the clitoris, and the third to the mucous membrane of the vestibule. The bulbo-cavernosi compress the bulbs of the vagina. The transversus perinei arises from the ramus of the ischium and is lost in the perineal body. The ischio-cavernosus or erector clitoridis, arises from the front of the tuberosity of the ischium and is inserted into the cms chtoridis. These muscles are supphed by the internal pudic artery and by branches of the pudic nerve. The veins enter the pudic veins. The lymphatics terminate in the inguinal glands. Ischio-reetal Fossa, Give its gross anatomy. It is a pyramidal-shaped area, largely filled with fat, situated on either side of the rectum ; the sides are formed by the obturator intemus without and the levator ani within ; the base by the trans- versus perinei and the lower edge of the gluteus maximus. Describe the fascia covering the pelvic floor below. From without inward we find the superficial fascia in two layers, the external being continuous with the general superficial fascia of the body. The deep layer is attached to the border of the pubic arch in fi'ont and laterally ; posteriorly, it passes around the trans- versus perinei muscles and is attached to the base of the anterior layer of the triangular ligament. Beneath the perineal muscles we find the triangular ligament, con- sisting of two layers of fascia, the anterior and posterior, filling in the pubic arch. PHYSICAL EXAMINATION OF THE FEMALE PELVIC ORGANS. 43 Development of the Pelvic Organs. Describe briefly. In the latter part of the first month there appear in the foetus, on either side of the primitive vertebrae, the Wolffian bodies, which play the part of temporary kidneys. They soon wither, and by the end of the 3d month have largely disappeared, but their remains per- sist, in the female, in the parovarium and Graertner's duct. At the inner side of the Wolffian bodies there appears an invagination of •ihe germ epithelium ; this develops into the duct of Mueller, one for each Wolffian body. These coalesce below to form the uterus and vagina. The ovary first appears as a white ridge on the inner side of the Wolffian body ; this ridge being formed of connective tissue covered with germ epithelium ; from the former is developed the stroma of the ovary, and from the latter are formed the Graafian follicles and ova. Until the latter part of the second month of foetal life the urinary, genital and intestinal canals open into a common vault — the cloaca. At about the 6th-7th week this common opening is divided into the anal opening posteriorly and the uro-genital anteriorly. This sepa- ration is completed by the formation of the perineal body at about the tenth week. The uro-genital canal is later divided into the urethra anteriorly and the vagina posteriorly. Physical Examination of the Female Pelvic Organs. What are the methods of examination? I. Non-instrumental. II. Instrumental. I. Non-instrumental. a. Inspection of external genitals. h. External abdominal examination. c. Vaginal examination. d. Bimanual examination, with its modifications. e. Rectal examination. 44 ESSENTIALS OF GYNECOLOGY. What should you notice on inspection of the external gen- itals ? 1 . Notice whether or not the vulva is the seat of venereal sores warts, abscesses, pediculi, etc. 2. Separate labia and notice condition of hymen and perineum, whether intact or lacerated ; the shape of hymen if intact. If peri- neum lacerated, notice whether through the sphincter ani or not ; notice, also, condition of urethra. 3. Tell patient to strain, and with labia still separated, notice whether anterior or posterior vaginal walls prolapse or not, thus forming cystocele or rectocele. 4. During this inspection it is well to pass the thumb and fore- finger along each labium majus to ascertain whether the vulvo- vaginal glands or their ducts are enlarged or not. What are the principal elements in a complete external ab- dominal examination ? 1. Position and Preparation of patient. — Patient should be on back with knees drawn up ; the abdomen should be uncovered as low down as the pubes ; the latter not being exposed ; bladder and rectum should be empty. 2. Inspection. — Observe the form and color; notice whether irregularities in form are present or not. 3. Palpation. — Use both hands ; they should be warm ; use the palms and palmar surface of fingers rather than their tips ; employ very little force. If a tumor is present, notice whether it is sohd or fluctuating, whether fixed or mobile ; if possible, determine whether or not it is attached to one of the pelvic organs. Notice whether it pulsates or is the seat of intermittent contrac- tions. Palpate inguinal regions for enlarged glands or hemiae. 4. Percussion. — Patient should be first percussed in usual manner, while lying on back and then when turned on either side. Vaginal Examination. Describe the method of performing it. Have the patient on back ; knees drawn up ; if a married woman, employ two fingers, if unmarried, use one. VAGINAL EXAMINATION. 45 Have the examining finger or fingers well lubricated and folded into the palm until you approach the vulva ; then let them sweep over the perineum and fourchette between the labia till they enter the vagina, orifice. Do not pass from above downward over the clitoris. After entering the vagina pass the finger or fingers back- ward toward the hollow of the sacrum. What are the contraindications to a vaginal examination? A vaginal examination should not be made in an unmarried woman unless there are strong reasons for suspecting trouble with the pelvic organs, and then only in the presence of a relative or female friend. It should not be made during a normal menstruation. What is the value of a vaginal examination per se ? The value of a vaginal examination by itself is comparatively small ; and it is rarely employed save as a part of a bimanual examination. One can, however, determine the following points by a vaginal examination, and they should be carefully noted : — The condition of peiineum and vaginal orifice. Presence or absence of Painful Spots ; Spasm ; Enlargement of vulvo-vaginal glands ; etc. Condition of vaginal walls : — Heat ; Moisture ; Presence or absence of E-ugae ; New growths ; Fistulas ; etc. Projections of vaginal walls from Faeces in rectum ; Inflammatory deposits ; Tumors in the peritoneal pouches. Condition of cervix : — Position ; Density ; Shape ; Mobility ; Size ; Lacerated or not 46 ESSENTIALS OF GYNECOLOGY. Condition of os : — Size ; Shape ; Projections through it. Bimanual Examination. What is the method of performing it ? The position of the patient and the method of introducing fingers are the same as for the vaginal examination just described. As regards which hand shall be used internally, the right is usually employed first ; but to make a complete bimanual, it is best to employ internally the right hand for the right side of the pelvis, and the left hand for the left ; in this way the pahuar surfaces of the internal and external fingers are approximated, and any depart- ure from the normal, on either side, is better mapped out than when the right hand alone is used for the internal examination. Describe the use of the external hand in the bimanual. The ulnar sui-face of the external hand should be used rather than the palm ; it should be api^lied to the abdomen some distance above the pubes and steadily depressed toward the opposing fingers within the vagina, while the patient relaxes her abdominal muscles and breathes quietly, with mouth open. Describe the use of the internal examining fingers in the bimanual. While the ring and little fingers are strongly flexed into the pahn and the thumb lies on the jDubes or between the thighs, place the middle examining finger on the cervix and the index in the anterior fornix and raise the utems toward the external hand. The first step for the student in acquiring skill in the bimanual is to feel, through the abdominal wall, a body which transmits motion from the external hand to the finger on the cei-vix. This, in a normal case, is the fundus of the utenis ; future examinations will enable one to map out more and more the shape of the fundus. What is a good order to follow in making a bimanual exam- ination ? 1. Determine the position of the utems by attempting to approxi- RECTAL EXAMINATION. 47 mate external and internal fingers ; the internal being placed first on ceiTix, then in anterior fornix and then in posterior ; the external hand exerting counter pressure. 2. Determine condition of tubes, ovaries and parametria ; using right hand internally for right side of the pelvis and left for left. Should you normally feel a hard body in any of the four for- nices of the vagina ? If so, which one, and what is it ? Yes, in the anterior fornix ; the body of the utems. Should you normally feel a hard body in the posterior or either of the lateral fornices ? No. What mass might you feel in the anterior fornix ? 1. A fibroid on anterior wall of the uterus. 2. Inflammatory or blood efiusions, rarely. What mass might you feel in either of the lateral fornicea ? Inflammatoiy deposit from celluhtis or peritonitis. Blood efiusion. Enlarged tube or ovary. Body of uteiTis late? o-flexed. Lateral fibroid. What mass might you feel in posterior fornix ? Displaced ftmdus. Faeces in rectum. Fibroid on wall of uterus. Peritouitic or cellulitic deposit. Hsematocele. Displaced ovary. Tumor. Rectal Examination. What are the methods 1 1. Simple rectal. 2. Abdomino -rectal. 3. Simon's method. What are the preliminaries to any rectal examination 1 Have bowels empty. Tell patient what you are to do. 48 ESSENTIALS OF GYNECOLOGY. Have soap under finger-nail. Lubricate finger. How would you perform the simple rectal examination ? Having observed the preceding preliminaries, pass the finger for- ward, noting the presence or absence of hemon-hoids, fissures, polypi, stricture, etc. , till the cervix is felt, then pass along posterior wall of the uterus. How would you perform the abdomino-rectal examination ? Passing the right index finger into the rectum as just described, use the left hand externally, placed on the abdomen as in the ordi- nary bimanual. What is Simon's method ? This consists in passing the whole hand, shaped like a cone, gradually through the anus into the rectum. What is the value of the different methods of rectal exami- nation ? Both the simple rectal and abdomino-rectal are of especial value in vh'gins, where the ordinary bimanual is painful or objected to. By means of a volsella forceps you may draw down the cervix, and then, with finger in the rectum, palpate the posteiior surface of uterus, tubes and ovaries. The above methods of rectal examination are of value in any case where j^ou wish to reach higher than is possible with the ordinai-y bimanual. Advantage is sometimes gained by making the rectal examination with patient in Sims' position. Simon's method is dangerous and seldom justifiable. INSTRUMENTS. Specula. What are the three classes of specula in most common use ? 1. The Spatular. 2. The Cylindrical. 3. The Bivalve. INSTRUMENTS — SPECULA. 49 Give one of the best examples of the spatular variety; describe it. The Sims speculum (see Fig. 5) is the best example of this class ; it consists of two blades united by a handle at right angles to them, the blades being convex on the sides facing each other, concave on the opposite. Many modifications are made by which the length of blade, angle at which it joins the shaft, and weight of the instrument are al- One blade of the speculum is usually shorter and smaller Sims' Speculum whole tered. Sims made than the other. What are the advantages of Sims' speculum ? It does not distort cervix. It gives a good view of all but the posterior vaginal wall, and is the best suited for operations on cervix and anterior vaginal wall. What are the disadvantag^es of Sims' speculum ? It requires an assistant with some training to hold it. - It requires, in most cases, the use of a vaginal depressor, thus employing one hand. What is the proper position of the patient for the use of Sims' speculum ? A patient in the so-called " Sims position " should lie on her left side, with left buttock on the left corner of the table, as you tkae it ; the head being at the right corner of the head of the table, the left arm behind the patient ; the right arm should lie over the right edge of the table, the right shoulder being kept as near the table as possible. The knees should be drawn up, the right a little above tbe left. How would you introduce a Sims speculum ? Having placed the patient in the correct Sims position, select the blade you are to use ; warm and lubricate the convex side of it ; 4 50 ESSENTIALS OF GYNECOLOGY, Fig. 6. take the speculum in tlie riglit hand with the index finger lying in the conca^-ity of the blade, and introduce finger and blade together. The breadth of the blade should be in hoe with the labia until it has entered the vaginal orifice ; it should then be rotated till the convexity lies in apposition with the posterior vaginal wall, which it should hug closely till the posterior fornix is reached and the index finger detects the cei-vix in front of it ; the speculum is then given to an assistant to hold. Some introduce the finger first and pass the blade along it. Fig. 7 Simon's Speculum. How would yon hold a Sims speculum ? There are two methods in conmion use : — (a) One is to grasp the outside blade with the right hand, the angle between blade and handle fitting over index finger, as seen in Fig. 6 ; the thumb lying in the concavity of the blade over the angle. INSTRUMENTS —SPECULA. 51 The riglit buttock should be raised with the left hand. (b) The other method is to grasp the handle of the speculum with the right hand, having the convexity of the outside blade rest in the hollow between the thumb and index finger. The right buttock being raised as in the other method. What is a Simon's speculum ? A very valuable speculum of the spatular variety is called Simon's (see Fig. 7.) It consists of a common handle into which fit, at right angles to it, blades of diiferent sizes and shapes. It is of especial value with the patient in the dorsal position, for retracting the perineum in curetting the uterus or operating upon the cervix. Fig. 8. FerguBson's Speculum. What is one of the best examples of a cylindrical speculum ? Describe it. The cylindrical speculum of Fergusson (see Fig. 8) is probably the best of its class ; it is a cylinder of glass or hard rubber, with one extremity beveled and the other tnimpet-shaped. The glass ones usually present a mirrored surface from within. The beveled extremity is the one first introduced. What are the merits of the Fergusson speculum ? It is of very limited use ; it may be employed for inspecting the cervix or making applications to it. It is useless for operations on the cervix ; it is only partially self-retaining, and its introduction in nulliparae is painful. How would you introduce a Fergusson speculum ? In this country the Fergusson speculum is usually employed with the patient in the dorsal position. Separate the labia with the fingers of the left hand ; holding the trumpet-shaped extremity with the right hand, introduce the beveled extremity into the Vaginal orifice having the shorter side 52 ESSENTIALS OF GYNECOLOGY. anterior ; depress well the perineum, directing tlie speculum toward the hollow of the sacnim ; by slight vertical, horizontal or rotatory motion of the speculum while looking into it, the cervix is now usually brought into view without difficulty. It is occasionally convenient to draw the cervix more fully into view by means of a tenaculum. Some gynaecologists use the Fergusson speculum with the patient in Sims' position. Fig. 9. A^~-. Brewer's Speculum. What is one of the best examples of a bivalve speculum? Describe it. Tbe Brewer bivalve (see Fig. 9) is probably the best speculum of its class ; it consists of two blades, the outer extremities being trumpet-shaped where they are jointed ; the anterior blade is shorter than the posterior, and has a slot in its outer half, to avoid pressure on the urethra ; this also facilitates the introduction of the sound or probe. The speculum is opened by approximating the handles of the blades and held there by a thumb-screw. There are two sizes of Brewer's speculum, the long and short. How would you introduce a Brewer speculum ? Place patient in dorsal position ; pass speculum into vaginal orifice with the blades lateral, then rotate till they are antero-posterior ; begin to open blades just before they reach the cervix ; when com- pletely open, hold with thumb-screw. INSTRUMENTS — SPECULA. 53 What are the merits of Brewer's speculum ? For inspection of, and applications to, the cervix, it is very valu- able ; it is self-retaining, thus obviating the necessity of an assistant. The long instrument is better than the short, as with it the vaginal walls are not as likely to obstruct the view by falling in be- yond the blades, and at the same time it accomplishes all that the short instrument does. What are the disadvantages of Brewer's speculum? It distorts the cervix, obscures the anterior vaginal wall, and can- not be used for operations on the cervix or vagina. What is the best speculum for examination of the interior of the bladder? The simplest and best speculum for direct inspection of the inte- rior of the bladder is that devised by Dr. Kelly, of Baltimore Fig. 9h Kelly's speculum ready for introduction (a); b, speculum with obturator removed. (Fig. 9J). It is a tubular speculum with obturator, and comes in several sizes. Describe its use. The bladder is emptied ; the patient is placed in an exaggerated 54 ESSENTIALS OP GYNECOLOGY. Fig lithotomy position, with hips elevated 8 to 16 inches above the table. One of the smaller sized specula is introduced, and then a larger, until the desired size is reached. The obturator is then withdrawn, and air enters and distends the bladder. The residual urine is removed b}^ pledgets of cotton held in long thumb- forceps ; light is thrown into the bladder by means of a forehead mirror, and by turning the speculum in different directions nearly the whole of the interior of the bladder may be inspected, and through the spec- ulum the ureters may be catheterized. For a thorough examination anaesthesia is desirable. Sometimes during such an examination the bladder will not distend sufficiently with air. In such cases the object can be accomplished by putting the patient in the knee-chest posi- tion. Volsella. Describe it. The Yolsella, or vulsellum forceps (see Fig. 10) consists of a pair of hooks with scissor handles and joint ; the hooks usually consist of two or more teeth ; the handles fasten with a catch. What are the uses of the Volsella? In all operations on the cervix, trachelor- rhaphy, dilatation, etc. , the volsella, or one of its substitutes, is almost indispensable, to draw down and hold the cervix. For applications to, or operations on, the interior of the body of the uterus, the volsella is also of great value. The use of the volsella to draw down the cervix, in connection with the finger in the rectum, in the combined rectal examination, is of great importance. How would you introduce and apply the Volsella ? If used in operations on the cervix with the patient in the Sims position, it may be introduced either without or with the use of the speculum ; if without the speculum, the first two fingers of the right The Volsella. INSTRUMENTS— UTERINE SOUND. 55 hand are introduced till the anterior lip of the cervix is felt ; the volsella is then |)assed along them and applied to the anterior lip, which is then drawn down. The better wa}^ is usually to employ Sims' speculum and apply the volsella directly to the anterior lip by sight. The volsella is also employed witli the patient in the dorsal position, the instrument being introduced either by touch, or sight aided by a perineal retractor. What could you substitute for a Volsella ? A bullet forceps with a catch makes a very good substitute for a volsella and is getting to be preferred to it, as, having but one pair of teeth, it occupies less space on the cervix. A tenaculum, such as Sims', which is a sharp hook on a long slender shank, is often of great use in holding the cervix and draw- ing it in any direction, and can sometimes be substituted for a vol- sella. Uterine Sound. What are the two sounds in most general use? their descrip- tion and merits ? The Sir J. Y. Simpson's sound and that of A. R. Simpson are the two in most general use. Fig. 11. Sir J. Y. Simpson's Sound. They are both rods of copper, nickel-plated, and so pHable that they can easily be bent with the fingers. The sound of Sir J. Y. Simpson (see Fig. 11) is 12 inches long, with a notched knob 2J inches from the end, and notches at 3J, 4J, etc. , up to 8i inches, ^ The handle is roughened on the side of the concavity of the curve. 56 ESSENTIALS OF GYNECOLOGY. The sound of A. R. Simpson (see Fig. 12) is onlj'^ 9 inches long ; it has a prominent ring at 2 J inches and two rings at 4} inches ; there are also markings at 3J and 5| inches. This sound has an advantage over the preceding in that, being only 9 inches long, the handle, which is broad, can rest firmly on the ball of the little finger even when the tip of the index finger is on the 2| inch ring, thus giving one a complete control of the instrument when the finger is in the vagina with the sound. This is impossible with the sound of A. R. Simpson's Sound. {Hart and Barbour.) Sir J. Y. Simpson, as in similar circumstances the handle is far above the hand, and one can only grasp the shank, which readily rotates. The presence of the double ring is also an advantage in an enlarged uterus. What are the contraindications to the use of the sound ? Patient has skipped a menstraal period. Menstruation present. Acute inflammation present in uterus or neighborhood. Malignant disease of uterus. What are the preliminaries to the use of the sound ? 1. Thoroughly sterilize the sound. 2. Be sure that the patient has not skipped a menstrual period. INSTRUxMENTS — UTERINE SOUND. 57 3. Determine position of uterus by a careful examination. 4. Curve sound to the curve of the uterus. 5. Cleanse the vagina with an antiseptic solution. This is of im- portance to avoid carrying septic material from vagina to uterus by the sound. I^or this reason it is always wiser to introduce the sound with the aid of a speculum, which separates the vaginal walls and enables you to reach the os directly. 6. Position of the patient : — This is largely a matter of choice, but in this country the dorsal position is usually selected, and it has the advantage that in this position the bimanual may be easily combined with the use of the sound. How would you introduce the sound with patient in the dor- sal position ? Having mtroduced a speculum and thoroughly cleansed the vagina, be sure your sound is aseptic and then pass it by sight directly into the os. The introduction is often most easily accom- plished if the uterine body lies forward by starting the sound with its concavity backward, then, when the point is engaged in the cer- vical canal, turning the sound, not by rotating the shank, but by making the handle describe a semicircle from behind, to the left and forward ; the point of the instrument remaining nearly station- ary. By depressing the handle toward the perineum, the sound will then usually pass without trouble. If the point catches in the crypts of the cervix, slight motion will usually disengage it. What variation in this procedure would you make if the fundus lay posteriorly? Having introduced the sound into the cervix as before, with con- cavity backward, continue the introduction without the semicircular motion of the handle= In this position of the fundus the sound is sometimes most easily introduced by a maneuver similar to that in the preceding case but in the opposite direction, viz., starting with the concavity of the sound forward, make the handle describe a semicircle from before backward. 58 ESSENTIALS OF GYNECOLOGY. How would you pass the sound in a marked case of ante- flexion ? If the uterus is anteflexed, the introduction of the sound is facih- tated by curving the sound sharply, and drawing down and steady- ing the cervix with a bullet forceps. How would you introduce the sound with patient in Sims' position ? Here, as in the dorsal position of the patient, the introduction of the sound should be preceded by the introduction of the specu- lum and the cleansing of the vagina and cervix ; the sound rendered aseptic is then passed by sight directly into the os without being allowed to touch the vaginal walls ; in this way the introduction of sepsis into the uterus is avoided. The further introduction of the sound may be continued with the concavity forward, or starting with the concavity backward the semicircular motion of the handle from behind forward may sometimes be employed with advantage. If the uterus lies posterior, the sound can usually be introduced directly with its concavity backward. What are the uses of the uterine sound? (a) To determine — 1. The length of uterine canal. 2. Its permeability. 3. Its direction. 4. Condition of endometrium. 5. Growths in uterus. 6. Relation of uterus to tumors. (h) To replace a displaced uterus. The mobility of the uterus and the relation of cervix and body should be determined by the bimanual, not by the sound. The sound is wisely much less used now than formerly. What are the dangers in the use of the sound ? 1. Pelvic peritonitis or cellulitis, from introduction of sepsis. 2. Abortion. 3. Hemorrhage, especially in malignant disease. 4. Perforation of uterine walls. INSTRUMENTS — TENTS. 59 Uterine Probe. Give its description and uses. The uterine probe is usually a slimmer instrument than the sound, made of silver, hard mbber or whalebone, with end slightly bulbous. Except in cases of stenosis, it is harder to introduce than the sound, and of less general value. It should be introduced by sight, while cervix is steadied with a tenaculum. Uterine Applicator. Give its description and uses. It is usually made of a piece of flexible steel or copper wire flattened at one end and attached to a handle at the other. It is used to apply medication to the uterine mucosa. The applicator is thrust into a small piece of cotton held between the thumb and finger. It is then rotated until the cotton is so firmly twisted about the end that it cannot be easily pulled ofi". It is then dipped into the fluid to be used and inserted in the same manner as the uterine sound. As a general rule it is safer to make such applications only to the cervix. Dilators. What are the methods of dilating the cervical canal ? 1. By tents. 2. By graduated hard dilators. 3. By dilators of the glove-stretcher variety. 4. By elastic dilators — Barnes' bag or Allen's pump. Tents. What do you mean by a tent as employed in gynaecology ? Give the varieties in use. A tent is a cone of some expansile material, which, by absorption of moisture, expands after introduction into the cervix sufficiently, both in extent and force, to dUate the canal. 60 ESSENTIALS OF GYNECOLOGY. There are several varieties of tents in use, named according to their material. 1. Sponge. 2. Sea-tangle (Laminaria digitata). 3. Tupelo (Nyssa aquatilis). 4. Cornstalk. What are the merits of each ? The sponge tent expands easily, but it is the most dangerous of all, from the fact that it absorbs so readily material which easily becomes septic. The sea-tangle tent is less dangerpus than the preceding, and dilates well, but it expands unevenly, and its edges are rough after expansion. The tupelo tent is the best of all. It expands evenly and smoothly, and is the least liable to cause sepsis. The cornstalk is feeble in action and seldom used. What are the indications for the use of tents ? 1. To dilate the cervical canal for purposes of diagnosis or opera- tion. 2 To check hemorrhage. What are the merits of tents for these uses ? The employment of tents has greatly, and very wisely, diminished of late. For diagnostic purposes they are still occasionally employed to dilate the cervical canal, so that the finger can be introduced, but they are dangerous, slow and painful, and we have, in most cases, better means, in dilators of the glove-stretcher variety, for accom- plishing the same result. The use of tents to check hemorrhage was chiefly in abortion ; the dilatation of the canal being sought for at the same time. We now have better means. What are the preliminaries to the use of tents ? All antiseptic precautions should be observed. Patient should have an antiseptic vaginal douche. You should determine accurately the position of the uterus. Tents should be curved to the direction of the canal. INSTRUMENTS— GRADUATED HARD DILATORS. 61 A string should be passed through the tent, for ease in with- drawal. Patient should be in Sims' position. How would you introduce a tent ? 1. Introduce Sims' speculum ; draw down cervix with volsella, then taking the tent in a pair of dressing forceps or on a tent car- rier, pass it into cervical canal by sight ; insert a tampon and give an opium suppository. What should be the future treatment of the case ? Tents should not be left in over 6-12 hours ; sponge tents not over 6 hours. In removing a tent, do not rotate it. Patient must remain in bed for 24 hours, and not leave the house for 3-4 days. Graduated Hard Dilators. Describe them. There are several varieties in common use, among which are Peas- lee's, Kammerer's, Hank's, etc. The first two resemble male sounds, except that the curve is less acute, and at 2J inches there is a bulb. Hank's dilators consist of two sounds on each handle, one at each end. They are often made in sets of six and of hard rubber. Ordinary male sounds, Nos. 15 to 18, French, may often be sub- stftuted for the dilators just mentioned. What are indications for the use of graduated hard dilators ? 1. By themselves to dilate a stenosis of the cervix causing dys- menorrhoea or sterility. Under stenosis here is included that caused by flexions. 2. To maintain a dilatation produced by one of the more power- ful dilators. Describe the mode of employment of these graduated hard dilators. Place the patient in the dorsal position ; thoroughly cleanse the vagina and expose the cervix with a speculum ; draw down and hold cervix with a tenaculum or volsella ; introduce dilator by sight, as 62 ESSENTIALS OF GYNAECOLOGY. you would the uterine sound, beginning with the smallest size and increasing to the largest. Pack the vagina loosely with iodoform gauze or sterilized gauze. In employing" these graduated dilators for stenosis of cervix causing obstructive dysmenorrhoea, how often should they be introduced ? It is usually necessaiy to introduce them once a week during the first Dionth, and once or twice a month for a few months afterward ; exercising each time the same antiseptic precautions. Describe the dilators of the glove-stretcher variety. The two chief styles of these are the Sims and EUinger's ; in the latter of which the blades are caused to move parallel, and on the handle there is a graduated scale. There are numerous modifica- tions of these dilators, among which may be mentioned Wylie's and Goodell's. What are the indications for the employment of these dila- tors? The same indications obtain as for the preceding, and in addition where a more complete dilatation of the cervix is desired. The first and more complete dilatation is often performed with a dilator of this class, and then the dilatation maintained by the graduated hard dilators. What are the preliminaries to the use of the glove-stretcher dilators ? The patient should have an antiseptic douche, and for complete dilatation, anaesthesia. Describe the method of employing these dilators. The patient is usually placed in the dorsal position. Retract the perineum with a Simon's speculum ; thoroughly cleanse the vagina and cervix ; draw down and steady the cervix with a bullet forceps and introduce dilator to the shoulder, separate blades gradually to the desired extent, being careful that the instrument does not slip suddenly and lacerate the cervix. While most of the dilatation is performed in the lateral-diameter of the cervix, it is often well to rotate the dilator and dilate somewhat in other diameters. The ELASTIC DILATORS — STEM PESSARIES. 63 dilatation may also be performed with the patient in Sims' posi- tion and with the aid of Sims' speculum. To what extent should you carry the dilatation? Usually from J to 1 inch. ELASTIC DILATORS. Barnes' Bags, Allen's Pump. Describe them and the method of using^ them. They consist of India-rubber bags, of different sizes, the former being fiddle-shaped, the latter more elongated. They are intro- duced under strict antiseptic precautions, in a collajosed condition, and are then slowly distended with air or water, usually the former ; the Barnes' bags by means of a Davidson's syringe, Allen's by the pump. What are the advantages of these elastic dilators ? Their method more closely resembles the physiological method of dilating the cervix ; the dilatation can be made extensive ; the danger of laceration of the cervix is slight. What are the dangers of mechanical dilatation ? Laceration of the cervix. Endometritis. Salpingitis. Peritonitis. Stem Pessaries. Describe them and their uses. They consist of a hard-rubber or non-corrosive metal rod about If inches long, at one end of which a wide flange projects to keep the pessary from slipping too far into the uterus. There is usually a groove in the rod or else it is hollow to allow the escape of secretion. Their use, which is to maintain a dilatation of the cervix, accom^ plished in one of the above-mentioned waj^s, is attended with con- siderable danger. 04 ESSENTIALS OF GYNECOLOGY. The Curette. Describe it. The curette consists usually of a loop of wire, either blunt or sharp, on a rather long shank, used for scraping irregularities or new growths from the endometrium. Occasionally, it is made like a small cup, with a sharp edge, at- tached to a long shank. Simon's spoon is of this descrij)tion. What are the varieties in common use ? Thomas' wire loop, dull and flexible. Sims' curette. Recamier curette. Simon's spoon. What is the value of the curette ? It is a very valuable instrument, both for diagnosis and treatment. a. For diagnosis, to scrape away some of the contents of the uterus for examination, to determine the cause of hemorrhage. h. For treatment, to scrape away villous growths, which, by their vascularity, easily cause hemorrhage. In malignant disease o:^the utems, the curette is also of value to remove sloughing masses. What are the preliminaries to the use of the curette ? The patient should be anaesthetized, placed in the dorsal position on a Kelly's pad, and knees supported with a" leg-holder. The va- gina should be scrubbed with soap and water ; an antiseptic douche should be given, and all antisevttic precautions should be observed in regard to instruments, hands, etc. The perineum should be retracted with a Simon's or Sims' spec- ulum ; cervix drawn down and steadied with a bullet forceps, then dilated. A gentle curettage can sometimes be performed without anaesthe- sia, but for the thorough operation anesthesia is usually necessary. Describe briefly the method of curettage. After dilatation of the cervix, the curette should be introduced very gently until the fundus of the uterus is reached, then with- drawn with the working edge of the instrument pressed firmly against the wall of the uterus. This process is repeated until the walls of the uterus feel smooth. The cavity of the uterus should VULVITIS, 65 then be irrigated with an aseptic or antiseptic solution. If necessary to check hemorrhage or to maintain dilatation a strip of gauze may then be introduced. As a rule, gauze packing in the uterus hinders ratlier than helps drainage of its cavity. The patient should be confined to bed for several days. What are the danglers of the curette ? Perforation of the uterus ; septic inflammation of the uterus or its adnexa ; peritonitis. Vulvitis. What are the varieties ? 1. Simple catarrhal, acute or chronic 2. Gonorrhceal ; - 3. Phlegmonous ; 4. Croupous; 5. Gangrenous ; h. Occurring in adults : Follicular. a. Occuning in both children and adults : I. Acute Simple Catarrhal Vulvitis What are the causes ? Lack of cleanliness ; Stnimous diathesis ; Discharges from cervix, or vagina ; InjuHes or friction from exercise ; ^ '^ "i'lrlmtion ; j.^,,.. !, ai'd, or oTOf^'^sivp .'oifrt^ : Pt-t'gnancy ; Foreign bodioir ; Parasites ; Acute exanthemata. What are the symptoms ? General malaise ; some local pain and burning ; parts are oedema- tous, congested, covered with a glairy, mucous, excoriating discharge, which may extend to the urethra. What is the treatment ? Rest in bed ; warm sitz-baths ; lead and opium wash frequently apphed to the vulva ; Hnt soaked m it kept between the labia. Bis- 5 66 ESSENTIALS OF GYNECOLOGY. muth, starch, or borax may with advantage be dusted on the vulva in the intervals between the appHcations of the lead and opium wash. If the vulvitis is from ascarides, employ enemata of infusion of quassia, § ij-Oj. Chronic Catarrhal Vulvitis. Describe its occurrence and course. Catan'hal vulvitis in children is most apt to be chronic ; it is seen most frequently in strumous children, often with no histoiy of the acute stage. What are the symptoms ? 1. Discomfort in walking and in micturition ; 2. Pruritus ; 3. Stains on hnen. What is the treatment ? Build up the constitution by tonics and fresh air ; observe cleanli- ness ; if much discomfort, use lead and opium wash, followed later by nitrate of silver (gr. x-^j) apphed to the vulva ; bismuth or borax being dusted on between the lotions. II. GrONORRH(EAL YULVITIS. What is the etiology ? It is produced either directly by intercourse with one who has contracted gonorrhoea, or indirectly by soiled hnen, instruments, etc. ttliat is the diagnostic value of Neisser's gonococcus, found in the discharge ? The gonococcus of Neisser is the sole cause of gonorrhoea, and the disease can only be transmitted through its agency. Give an account of the gonococcus and its inflammations. The gonococcus is a diplococcus pathogenic only for man. It is found in the discharges of gonorrhoea! inflammations and is usually contained in the cell body of pus cells. It is not stained by Gram's method, and grows only on culture- media containing blood-serum. VULVITIS. 67 Its usual inflammations are those of the genital tract, but it may cause conjunctivitis, synovitis, or malignant endocarditis. The gonococous very rarely produces a general peritonitis. It is doubtful whether it is ever the direct cause of cystitis. It is rarely found associated with other bacteria in its lesions. The female genital organs most often the seat of gonorrhoea are the urethra, vulvo-vaginal glands, cervical and corporeal endometrium, and the Fallopian tubes. Upon what points would you base a diagnosis of gonorrhoea in the female? Absence of history of labor, abortion or use of instruments, sud- den onset of symptoms, moderate rise of temperature, as a rule, without chill, yellow purulent discharge, urethritis. Bartholinitis, or redness about the orifice of its duct. Any or all of these signs may be present. The diagnosis becomes positive when the gonococcus can be identified. It is best sought for in the urethral pus. What is the differential diagnosis between gonorrhceal vul- vitis and acute simple catarrhal vulvitis ? In gonorrhoeal vulvitis, the onset is more violent ; more fever, pain, and oedema ; the inflammation extends up the vagina, urethra, and vulvo-vaginal glands ; pus can often be pressed out of the urethra ; gonococci can be found in the discharge ; often warts or buboes are present, and sometimes gonorrhoeal rheumatism. What is the treatment of gonorrhoeal vulvitis ? Keep patient quiet ; give light diet ; keep bowels open ; disinfect t-he parts with bichloride 1-5000, or lysol 1-100 or 200 ; then have the parts irrigated every hour or two with borax water 3j-0j. If discomfort is very great, lead and opium wash may be frequently applied to the vulva, and patient may take warm sitz-baths. The labia should be kept separated with lint or gauze smeared with some simple antiseptic ointment. If the vulvitis tends to become chronic, apply nitrate of silver, gr. x-xx-^j. 68 ESSENTIALS OF GYNECOLOGY. m. Phlegmonous Vulvitis. What is the etiology ? It may arise from the following : — Traumatism ; Irritating discharges ; Acute exanthemata ; Furunculosis. What are its pathology and symptoms ? It is a circumscribed or diffuse suppurative process manifesting itself by the following sj^mptoms : — a. Subjective : Heat and pain, increased by standing orwalkingc b. Objective : Congestion, sweUing, indui'ation ; later, suppura- tion. From what must you differentiate phlegmonous vulvitis ? a. Pudendal hernia ; b. Dislocated ovary ; c. Hydrocele of round ligament ; d. Haematoma of vulva. How would you differentiate phlegmonous vulvitis from pu- dendal hernia ? Phlegmonous Vulvitis vs. Pudendal Hernia, Signs of acute inflammation. None unless strangulated, or injured. Dullness on percussion. Tympanitic on j^ercussion. No impulse on coughing. ImjDulse on coughing. Not reducible. Usually reducible. History of traumatism, etc. History of strain. How would you differentiate phlegmonous vulvitis from a dislocated ovary ? Phlegmonous Yidvitis vs. Dislocated Ovary. Signs of acute inflammation. Usually absent. Gradual development. Sudden development. No especial exacerbation during Larger and more sensitive during menstruation. menstniation. No sense of ovarian compression Peculiar sensation when pressed. when pressed upon. Not the shape of an ovary. Has the shape of an ovaiy. VULVITIS. 69 How would you differentiate phlegmonous vulvitis from hydrocele of the round ligament ? Phlegmonous Vulvitis vs. Hydrocele of Round lAgament. Signs of acute inflammation. No signs of acute inflammation. Opaque. Translucent. Never communicates with ab- Sometimes communicates with dominal cavity. abdominal cavity. How would you differentiate phlegmonous vulvitis from haematoma of vulva ? Phlegmonous Vulvitis vs. Pbrniatom^a of Vulva. Grradual formation. Sudden onset. Less frequent during parturi- More frequent during parturi- tion, tion. Color, red. Color, purplish. First hard, then soft. First soft, then hard. Less often preceded by varicosi- More often preceded by varicosi- ties, ties. What is the treatment of phlegmonous vulvitis? Tonics: Arsenic, quinine, etc. Wet antiseptic dressings, as gauze soaked in cool aluminium acetate solution. When pus has formed, open, drain, and dress antiseptically. lY. Croupous Vulvitis. Give the etiology, symptoms, and treatment. A vulvar inflammation with the formation of a false membrane may be due to diphtheria or other infectious disease, including r>"'^'*'^'^-'"i 'nfection. True diphtheria may appear first on the the membrane resembling that of pharyngeal diphtheria. ' rnt is that of the infectious disease with local use of V. Gangrenous Vulvitis. Give the etiology and treatment. Gangrenous vulvitis is most frequently found complicating preg- nancy, severe types of acute exanthemata, and very violent cases of vulvitis of other varieties. The treatment consists of constitutional tonics and local antiseptics. 70 ESSENTIALS OF GYNECOLOGY. VI. Follicular Vulvitis. Give the pathology. Follicular vulvitis is an inflammation of the mucous and sebaceous glands and hair follicles of the vulva ; all may be simultaneously affected, or one set alone involved. What is the etiology ? It occurs only in adults ; any of the causes of simple acute catarrhal vuhdtis may produce it ; among the most common are the follow- ing :— a. Lack of cleanHness ; h. Discharges from above, especially senile leucorrhoea ; c. Pregnancy ; d. Acute exanthemata. What are the symptoms ? a. Subjective : — Local heat and pain ; Pruritus ; Increased secretion ; Hyperaesthesia ; Vaginismus occasionally present ; Vulvar extremity of urethra is sometimes affected, then ardor urinae results. h. Objective: — The mucous membrane appears very red in spots, resembling the papillae of the tongue. When the sebaceous glands and hair follicles are chiefly affected, they will be found as little round red papiUae, scat- tered over labia and base of prepuce and clitoris, not on vestibule ; later, a drop of pus appears in the apex of these papillae ; they then disappear. How would you treat a case of follicular vulvitis ? Pay strict attention to cleanliness ; duiing the acute stage use mild antiseptic lotions, as borax water (3j-0j) or alum-acetate solu- tion; later, apply nitrate of silver (gr. x-^j). Bismuth or calomel may be used as a dusting powder ; keep labia separated. CYST AND ABSCESS OF VULVO- VAGINAL GLAND. /I Cyst and Abscess of Vulvo- vaginal Gland. Cyst of Vulvo-vaginal Gland. Give the etiology and pathology. A cyst of the Barthohnian or vulvo-vaginal gland is formed by a distention of the duct, or gland itself, caused by any occlusion of the duct, especially from inflammation, either simple catarrhal or gon- orrhoeal. A cyst of the duct is more elongated than of the gland itself ; a cyst of the gland is occasionally multiple. Abscess of the Vulvo-vaginal GtLand. What is the etiology ? The causes of a vulvitis may produce abscess of the vulvo-vaginal gland ; gonorrhoea is the most common cause. What are the symptoms ? Pain ; heat ; swelling and redness, especially near orifice of duct ; it is tender on pressure ; at first hard, later fluctuating. How could you diflferentiate a cyst from an abscess of the vulvo-vaginal gland ? Cyst vs. Abscess. Gives no signs of inflammation. Shows inflammation . Insensitive to pressure. Sensitive to pressure. Duration long. Duration shorter. What is the treatment of a cyst of the vulvo-vaginal gland ? The usual treatment is to excise an elliptical area of mucous mem- brane over the sac on its inner surface ; this exposes the sac ; now cut out a large ellipse from it ; empty the sac, pack it with iodoform gauze, and apply an antiseptic outside dressing. A better plan is usually to dissect out the whole sac, if possible, and bring together the edges of the wound with catgut ; then apply an antiseptic dressing as before. From what may you get considerable hemorrhage in extir- pating the sac ? From the transversus perinei artery, and from the bulbs of the vagina. 72 ESSENTIALS OF GYNECOLOGY. How would you treat an abscess of the vulvo-vaginal gland ? Before the presence of pus is detected, keep the patient quiet in bed ; appl}'' soothing lotions like alum-acetate solution. As soon as pus is detected, proceed as with the cj'st till sac is opened, then with a sharp curette scrape the interior of sac wall ; irrigate with bichloride (1-1000) ; pack with iodoform gauze, and appl^^ an antiseptic outside dressing of iodoform gauze, bichloride gauze, absorbent cotton and a T- bandage. From what must you differentiate vulvo-vaginal cyst or abscess ? From hernia and phlegmonous vulvitis. How would you differentiate vulvo-vaginal cyst or abscess from hernia ? Cyst or Abscess vs. Hernia. No impulse on coughing. Impulse on coughing. Irreducible. Usually reducible. DuU on percussion. Tympanitic on percussion. Abscess shows signs of inflam- None, unless strangulated, or mation. injured. More circumscribed. Less circumscribed. How would you differentiate abscess of vulvo-vaginal gland from phlegmonous vulvitis ? The vulvo-vaginal abscess is more distinctly circumscribed and globular ; the phlegmonous vulvitis is more diffuse. Pudendal Hernia. Describe. The process of peritoneum which follows the round ligament through the inguinal canal to its termination in the labium majus is usually obliterated at birth ; occasionally this obliteration does not occur, and this channel, called the canal of Nuck, furnishes a path for hernia. The hernia may consist of intestine, omentum, ovary oi bladder. The uterus has even been said to follow this canal. What are the causes ? Blows, falls, coughing or violent muscular exertion. PUDENDAL HEMATOCELE. 73 What are the symptoms ? The patient experiences a feeling of discomfort, especially on walking, and finds a swelling, which, if intestine, presents the fol- lowing features : It gives an impulse on coughing ; is tympanitic on percussion; can usually be reduced, and, unless strangulated, or injured, presents no signs of inflammation. If the hernia consists of an ovary, it gives the ovarian sensation on pressure, and its size and tenderness are both increased during menstruation. What is the treatment ? Place patient on her back, with knees elevated ; reduce by gentle taxis, if possible, and apply a suitable truss. If strangulation has occurred, a suro^ical operation is necessary. If the hernia consists of an ovary which has become adherent, protect it from pressure by a hollow pad, or if it occasions great distress, remove it. Pudendal Hsematocele. What are the synonyms ? Haematoma or thrombus of vulva. Define. Pudendal haematocele (better haematomaj consist of an effusion of blood into the tissue of the vulvo-vaginal region, usually into one labium, or into the areolar tissue surrounding the vaginal walls. What is the etiology? Pudendal haematocele is predisposed to by any condition causing, or accompanied by, a dilatation of the vessels of the vulva :— Pregnancy ; Tumors ; Varicocele ; Labor. The exciting causes are blows, falls, muscular efforts, etc. Describe the symptoms and course. The patient experiences pain of a tearing character, which, if the 74 ESSENTIALS OF GYNECOLOGY. effusion is large, may be accompanied by faintness. Sometimes tbe effusion presses on the urethra and causes difficulty in micturition. The swelling is at first soft ; later, hard. If small, it is usually absorbed ; it sometimes remains for a long time ; sometimes suppurates. How would you differentiate pudendal haematocele from hernia ? Pudendal Hcematocele vs. Hernia. History. History. No impulse on coughing. Impulse on coughing. Dull on percussion. Tympanitic. Irreducible. Usually reducible. First soft, then hard. More uniform. How would you treat a case of pudendal haematocele ? While effusion is in progress, apply ice and pressure. If the effusion is large, occurs during labor and obstnicts the passage of the head, incise, turn out the clots and pack with iodoform gauze. If the effusion is small, apply soothing lotions like alum-acetate solution ; if suppuration occurs or if absorption is long delaj'ed, incise, irrigate with an antiseptic solution, and pack with iodoform gauze. Hemorrhage from Vulva. What is the etiology ? The predisposing causes are the same as for pudendal haemato- cele and haematocele itself The existing causes are the following : — Violent muscular efforts ; Blows ; Punctures or lacerations. What is the treatment ? If it is a ruptured haematocele, incise, turn out the clots and pack ; otherwise, catch bleeding points and ligature, or apply pressure, assisted by a tampon in the vagina. ECZEMA OF THE VtJLVA. 75 Skin Diseases Affecting the Vulva. What are the most common? Erythema, eczema, and herpes are most frequentlj^ seen ; eczema may be acute or chronic. Erythema of the Vulva. Give the etiology, symptoms and treatment. Etiology. — Erythema is most apt to occur in fleshy people, espe- cially in hot weather. The exciting causes are : — Lack of cleanliness ; Irritating discharges ; Exercise. Symptoms.- — Tlie parts become red, sensitive, often excoriated and painful, especially in walking. Treatment. — Cleanliness ; Attention to bladder and urine ; Desiccating powders, such as bismuth subnitrate, oxide of zinc, or calomel. Eczema of the Vulva. Give the etiology. Eczema is predisposed to by fanctional disturbance of the gastro- intestinal tract, gout or rheumatism ; it is especially apt to occur in women near the menopause. The most frequent exciting cause is an irritating discharge from the cervix or vagina. What are the symptoms ? The disease may be acute or chronic. In the acute form, the parts become reddened and oedematous ; vesicles appear, break and dis- charge a thick, tenacious fluid, which forms crusts. The subjective symptoms are severe burning and itching. In the chronic form, the parts become thickened and scaly ; the subjective symptoms resemble those of the acute, but are a little less marked. 'J'6 ESSENTIALS OF GYNECOLOGY. What is the treatment ? In the acute form, observe strict cleanliness ; if the burning is vei-y severe, use alkaline sitz-baths and sedative lotions ; later, or at first if burning and itching are not intense, an ointment like the follow- ing is very good: — R. Acidi salicylici, gr, xv, Zinci oxidi, ^ij ss, Pulv. amyli, . .:^ ij ss, Petrolati, ^j. M, Sig. — Apply locally. In the chronic form, use the same treatment during the exacerba- tions as for the acute ; later, an ointment containing oil of cade will be found of value. What are the most common parasites found on the vulva ? The pediculus pubis, or crab louse, is the parasite most often found infecting the vulva. The acarus scabiei, or itch mite, is occasionally, but rarely, found on the vulva as part of a general infection. Give the etiology, symptoms and treatment of infection with pediculi pubis. Etiology. — The pediculus pubis is almost always conveyed directly from person to person, usually in sexual intercourse. Symptoins. — There is burning and itching ; often an eruption resembling eczema. The diagnosis is made by finding the pediculus closely adherent to the roots of the hair. Treatment. — Any one of the following : — Corrosive sublimate, 1-1000 ; Tincture of delphinium ; Carbohc 5 per cent, solution. It is often best to shave the pubes before applying the lotion or ointment. Give the etiology, symptoms and treatment of scabies of the vulva. Etiology. — The acarus scabiei is rarely found on the vulva, but this occasionally occurs as part of a general infection. POINTED CONDYLOMATA. 77 Symptoms. — There is an intense pruritus, worse when the body is warm. The diagnosis is made by finding the burrows on other parts of the body, especially between the fingers. Treatment. — A warm soap and water bath, followed by an oint- ment composed of sulphur alone, or combined with balsam of Peru. New Growths of the Vulva. Mention the principal new growths occurring on the vulva? a, Papillomata — 1. Simple ; 2. Pointed condylomata ; 3. Syphilitic condylomata. h. Cyst of vulvo-vaginal gland. c. Carcinoma. d. Sarcoma. e. Elephantiasis. / Fibromata. g. Lipomata. Ti. Neuromata. ^. Lupus. Simple Papillomata. What is the etiology and treatment ? Etiology. — A simple papilloma, or wart, occurs rarely on the vulva ; it is usually congenital and of little importance. Treatment. — It may be destroyed with nitric acid, or it may be excised under cocaine, and the wound closed with fine sutures. Pointed Condylomata. What is the etiology and appearance ? Pointed condylomata, or gonorrhoeal warts, are caused by the gonorrhoea! poison ; they are always multiple, and occur most fre- quently on the inner surfaces of the labia majora, on the perineum and about the anus ; they are of a grayish color and often pediculated ; 78 ESSENTIALS OF GYNAECOLOGY. their summit is divided into pointed lobules. When on the skin, they are sometimes dry and hard ; on a mucous surface they are soft. In some cases pointed condylomata appear to arise from an irritating discharge, the gonorrhoeal character of which cannot be proved. What is the treatment of pointed condylomata ? The best treatment is to cut them off with scissors or knife and touch the base with nitric acid ; under the use of cocaine this may be made practically painless. Syphilitic Condylomata. What is the etiology, appearance and treatment ? Syphilitic condylomata, or mucous patches, are the result of the syphilitic poison. They are broad and flat, situated most frequently on the inner surface of the labia majora, and usually covered with a grayish, mucus-hke secretion. According to Duhiing, they some- times take on a more warty growth. Treatment. — Cleanhness ; Calomel locally ; Constitutional treatment for syphilis. Pruritus Vulvae. Define. PiTuitus vulvae, a symptom rather than a disease per se, consists of an mitation of the nerves of the vulva, accompanied by intense itching, at first localized, later extending, from the mechanical irrita- tion of scratching. What is the etiology ? The predisposing causes ai'e : — a. Poor health. h. Disorders of the digestive tract. c. Anything producing congestion of the vulva, such as— Pregnancy ; Tumors in neighborhood ; Diseases of uterus or appendages ; Menopause. PRURITUS VULV^. 79 d. Lack of cleanliness. The exciting causes are chiefly the following : — 1 . Irritating discharges from cervix, vagina, urethra or vulva. 2. Diabetic urine. 3. Eruptions. 4. Parasites. 5. Masturbation. 6. Vegetations on vulva. 7. Kraurosis vulvae. This is an atrophic condition of the vulva whose cause is unknown. It begins about the clitoris, and chiefly involves clitoris, vestibule, and labia minora. There is an increase of fibrous tissue in the mucous membrane, with a disappearance of its papillae, giving the parts a smooth white appearance. It causes an intense itching and hyperaesthesia. What are the symptoms ? An intense itching, at first only at intervals after active exercise, over-indulgence at the table, \juig in a warm bed, or sexual inter- course. Later, the itching becomes constant ; the desire to scratch becomes irresistible, causing the patient to avoid society ; it some- times leads to nervous depression and melancholia. What is the treatment ? First ascertain the cause, if possible. Build up the general health. Regulate the diet. ObseiTe strict cleanliness. Destroy parasites if present. If sugar present in the urine, give salicylate of soda. Treat eruptions. If there is an acid discharge from above, tampon vagina. Let patient use frequent warm sitz-baths. Apply any one of the following : — Hot lead and opium wash ; Carbolic solution, 2-3 per cent. ; Bismuth or calomel dusted on vulva ; Nitrate of silver (gr. x-^j) ; Cocaine, 4 per cent, solution. 80 ESSENTIALS OF GYNECOLOGY. Hyperaesthesia of the Vulva. Describe. This consists of an excessive sensibility of the nerves supplying the mucous membrane of some portion of the vulva. What is the etiology ? The menopause seems to predispose to it ; also the hysterical and melancholic state. An irritable urethral caruncle sometimes acts as an exciting cause. A peculiar atrophic condition of the skin of nymphse and vestibule, called krauroses vulvae, is an occasional cause. Often no cause can be assigned. What are the symptoms ? Hyperaesthesia, especially about the vestibule and labia minora ; there is no pruritus, and signs of inflammation are absent except occasional eiythematous spots ; dyspareunia is very marked ; the shghtest friction causes pain. What is the treatment? BuUd up the constitution with tonics, change of air, etc. Interdict sexual intercourse. Administer the bromides iaternally. Externally apply one of the following : — Carbolic lotion, 2-3 per cent ; Nitrate of silver solution (gr. x-xx-^j) ; Lead and opium wash ; Four per cent, solution of cocaine. Vaginismus. Define. Sims defined vaginismus as ' ' an excessive hyperaesthesia of the hymen and vulvar outlet, associated with such involuntary spasmodic contraction of the sphincter vaginae muscle as to prevent coitus. ' ' What is the pathology? There are usually found sensitive papillae about the base of the hymen ; an hypertrophy of the papillae and connective tissue of the hymen ; occasionally the lesion seems to be at a distance, as in the uterus or appendages ; sometimes no lesion is visible. COCCYGODYNIA. 81 What is the etiology ? The predisposing causes are — 1. A narrow vagina. 2. A dense, thick hymen. 3. Malposition of the vulva. The exciting causes are — 1 . Disturbances of the sexual function. 2. Masturbation. 3. Inability of the male to complete the sexual act. What is the treatment ? Palliative. —Forcibly dilate the hymen, under aneesthesia, by insert- ing and separating the thumbs; then insert one of Sims' giass vaginal plugs. Radical— 'EiX.d^Q the hymen and insert one of Sims' plugs. Coccygodynia. Define and give the etiology. Coccygodynia, or coccyodynia, is a "painful affection of the mus- cles, tendons, and neiTes of the coccyx, with or without disease of the bone itself ' ' (Mann ) . It occurs most frequently after childbirth, but is also produced by mechanical causes, such as blows, falls, kicks, etc. Among other causes are disease of the pelvic organs, rheumatism and gout. Hys- teria largely predisposes to it ; in some cases no cause can be assigned. What are the symptoms ? Pain in the coccygeal region, increased by motion bringing into play the muscles attached to the coccyx ; especially rising after sit- ting, defecation, coitus, sometimes even walking. Pressure on the coccyx elicits the characteristic pain. The condition must be differentiated from disease of the rectmij or anus, and from pure hysteria. What is the treatment ? ^ First attend to the general condition, rheumatism, hysteria, etc., if this fails, we have two operations : — 1. Cutting the attachments of the muscles to the coccyx. 2. Extirpation of the coccyx. 6 82 ESSENTIALS OF GYNAECOLOGY. Irritable Urethral Caruncle. Define. An irritable urethral caruncle is a deep red mass, very vasculai and sensitive, situated at the mouth of the urethra, or just withiir the canal ; it consists, according to Hart and Barbour, of dilated capil- laries in connective tissue, the whole being covered with squamous epithelium. What is the etiology ? But little is known of its etiology ; it occui'S at all ages, and in both married and single women. What are the symptoms ? The patient complains of frequent and painful micturition ; later, , this dysuria increases, and pain is caused by walking, pressure or friction of any kind. Intercoui'se causes both pain and hemorrhage. The neiTOUS symptoms are well-marked ; hysteria, melancholia, etc. On examination, one finds a raspberiy-looking mass at the meatus ; it is veiy sensitive and bleeds easUy ; it may be single or multiple. From what must you differentiate an irritable urethral caruncle, and how ? From polypi, venereal warts and prolapse of the urethral mucous membrane. Polypi are usually higher in the urethra, are less vascular and less sensitive. Venereal warts are less vascular, insensitive, and usually accom- panied by others. The history may aid. Prolapse of the urethral mucous membrane may resemble a caruncle in appearance, but it usually surrounds the meatus more, is less vascular and less sensitive, is continuous with the urethral mucous membrane, and can usually be reduced. What is the treatment ? Employ anaesthesia ; cut off the caruncle and touch the base with nitric acid or the actual cautery. You may ligate before cutting. What is the prognosis ? If the growth is single and near the meatus, the prcvgnosis is good ; if multiple and extending up the urethra, they may recur. MALFORMATIONS OF THE VULVA. 83 Prolapse of the Urethral Mucous Membrane. Describe. Prolapse of the urethral mucous membrane may involve the whole circumference of the meatus, or only a portion ; if the latter, it is the lower portion which is usually aifected ; a slight redundancy at the meatus is common ; a prolapse sufficient to form a tumor is rare. At first the exposed mucous membrane is of its normal pink color ; later it assumes an angry red color, often becomes excoriated and sensitive ; urethritis and cystitis may accompany it. What is the etiology ? Frequent child-bearing, dilatation of the urethra and a lax condi- tion of the tissue, from whatever cause, undoubtedly predispose to prolapse of the urethral mucous membrane. The exciting causes are usually vesical and rectal irritation, accompanied by straining. What are the symptoms ? Frequent micturition, which soon becomes painfal, tenesmus, and if vesical tenesmus previously existed, it becomes much aggravated. What is the treatment ? If the prolapse is recent, an attempt at cure may be made by reducing the mucous membrane, keeping the patient quiet in bed, making astringent applications to the urethra and removing the cause of previous vesical or rectal tenesmus, if present. If these procedures fail, remove the prolapsed portion by one of the following methods: — 1. If small, hgate and excise; if more extensive, excise the redundancy and stitch mucous membrane of urethra to the border of the meatus. 2. Emmet's "button-hole" operation. The first method is usually the preferable one. Malformations of the Vulva. What are the principal malformations of the vulva ? 1. Absence of the vulva. 2. Hypospadias, in which the posterior wall of the urethra is defective. 84 ESSENTIALS OF GYNECOLOGY. 3. Epispadias, in which t'ne anterior uretliral wall is defective, usually combined with a defect in the anterior wall of the bladder. 4. The clitoris may be absent, rudimentary, or hypertrophied. 5. The labia minora may be absent, rudimentaiy, or greatly hyper- trophied, as in the ' ' Hottentot apron. ' ' 6. Less often the labia majora may be hypertrophied. 7. No well attested case of true hermaphrodism, i. e., an indi- vidual with both ovary and testicle, has ever been reported. - 8. Pseudo-hermaphrodism, where the external genitals alone resemble those of both sexes, is more common. These individuals are usually mal-developed males. Diseases of the Vagina. Discuss the relation of the normal vagina to bacteria. The vagina normally contains a number of bacterial species which affect an entrance into it soon after birth. None of these bacteria are pathogenic. If pathogenic ones other than the gonococcus are introduced into the vagina they disappear in a few days, or if they remain longer their virulence is diminished. A number of factors contribute to this result, the chief being the acid reaction and an- aerobic condition of the vagina and the bactericidal power of the serum of its secretion. What are the varieties of inflammation of the vagina ? 1. Simple cataiThal vaginitis, or colpitis. 2. Gonorrhoeal. 3. Ulcerative, senile or adhesive. 4. Croupous. Simple Catarrhal Vaginitis. What is the etiology ? The predisposing causes are — a. Greneral bad health. 6. Anything causing local congestion, as — Disease of heart or lungs ; Disease of the pelvic organs ; Pregnancy. SIMPLE CATARRHAL VAGINITIS. 85 The exciting causes are : — a. Irritating discharges from the cervix. h. The use of too hot, too cold or irritating douches. c. Awkward or excessive coitus. d. Foreign bodies, as pessaries, tampons, etc. What are the symptoms ? Simple catarrhal vaginitis may be acute or chronic. The subjective symptoms of the acute are a feeling of heat in the 7agma, pain in the pelvis, and somethnes vesical and rectal irrita- bility. The objective symptoms are a muco-purulent vaginal discharge which may irritate the vulva ; the vagina appears red, perhaps gran- ular or cystic in places. The chronic form resembles the acute except in degree : in it the subjective symptoms, save itching caused by the leucorrhoea, are usually absent. What is the treatment of simple catarrhal vaginitis ? In the early stages, keep the patient quiet ; keep the bowels open, and give light diet ; keep the urine bland by alkahne diluents. If the itching is severe, let the patient take frequent warm alkaline sitz-baths; in addition, irrigation of the vagina with warm water containing either of the following will be found of value : Liquor plumbi subacet. 3j-0j ; borax 5j-0j. After irrigation it is well to dust some desiccating powder, like bismuth, upon the vulva. ^ When the vaginitis becomes subacute or chronic, make applica- tion to the vagina of nitrate of silver gr. x-xxx-^j, or pyroligneous acid. Let the patient use daily vaginal douches of hot water containing borax, .5j-0j ; or sulphate of zinc, 5ss-5j-0j ; or alum, ^j-Oj. The douches should be taken while the patient is in the dorsal position, not sitting. 86 ESSENTIALS OF GYNECOLOGY. Gonorrhoeal Vaginitis. How does gonorrhoeal vaginitis differ from the simple catar- rhal? a. The onset is usually more acute. h. The discharge is more purulent, viscid and offensive than in the simple catarrhal. c. Urethritis is more common. d. Sometimes a history of exposure to infection can he ob- tained. e. Often gonorrhoeal warts or buboes are present. f. The most certain diagnostic point is the presence of gonococcL What are the frequent complications and results of gonor- rhoeal vaginitis ? Vulvitis, urethritis, endometritis, salpingitis, ovaritis and perito- nitis. The dangers of gonorrhoeal vaginitis have been greatly under- estimated. What is the treatment of gonorrhoeal vaginitis ? Keep the patient quiet ; attend to diet ; move the bowels with salines ; keep urine bland. During the acute stage, let the patient have bichloride vaginal douches, 1-10,000, three or four times a day. After the acute stage has passed, thoroughly disinfect the vagina with bichloride, 1-1000, and loosely pack the vagina with sterile gauze to keep the walls separated and the labia apart, thus insuring drainage. Repeat this process every 24 hours until the disease has subsided. If the condition tends to become chronic, apply nitrate of silver, gr. xx-xxx-^j, two or three times a week, letting the patient use daily douches of borax water. The complicating vulvitis requires its own treatment. Ulcerative Vaginitis. Describe. Ulcerative, senile or adhesive vaginitis is present to a greater or less extent in nearly every woman over 60. It may occur earlier in life. PELVIC PERITONEUM. 87 There is a desquamation of tlie squamous epithelium in spots, and where these raw areas he in apposition, adhesion is apt to occur. There is usually a thin leucondioea, which irritates the vulva and causes pmritis. What is the treatment ? The treatment consists in the application to the vagina of such solutions as nitrate of silver, gr. x-xx-5J, or pyroligneous acid, and the use by the patient of astringent vaginal douches, such as sul phate of zinc 5ss-0j, alum 3j-0j, or borax 3j-0j. Croupous Vaginitis. What is the etiology and treatment ? Tt occurs in conjunction with puerperal infection, diphtheria, and severe forms of the infectious diseases. The treatment is the general treatment of the disease and the local use of antiseptics. Pelvic Peritoneum. Describe. The pelvic peritoneum is a continuation of that lining the inner surface of the walls of the abdomen ; it covers, more or less com- pletely, the pelvic organs (the ovary is regarded as not covered by peritoneum), lines the pelvic walls and also the floor of the pelvis. Traced from before backward, in the median line, it leaves the anterior abdominal wall about IJ inches above the sjmiphysis, is reflected over the fundus of the bladder and down its posterior surface to about the level of the internal os ; it then passes over to the uterus, covers its anterior surface above that jjoint, passes over the fundus and down its posterior surface to the vaginal junction, thence down the vaginal wall for about an inch ; it then passes to the rectum, covers the anterior surface of the middle portion, and surrounds the upper portion completely. The pelvic peritoneum is thrown into several folds and forms several pouches. Describe the folds and pouches of the pelvic peritoneum. The principal folds are the broad, utero-vesical and utero-sacral 88 ESSENTIALS OF GYNECOLOGY. ligaments (so-called). The broad ligaments, extending from the sides of the uterus to the sides of the pelvis, in front of the sacro iliac synchondrosis, divide it into two fossas, the anterior and posterior ; these are also subdivided, the anterior by the utero- vesical ligaments, the posterior by the utero-sacral. The pouch between the utero-vesical ligaments is called the utero-vesical pouch ; that between the utero-sacral, the pouch of Douglas, which is the deepest part of the peritoneal cavity. The pouches between the utero-vesical and broad ligaments are called the i3ara-vesical pouches ; those between the utero-sacral and broad ligaments are called bj'' Polk the ' ' retro-ovarian shelves. ' ' Two other pouches are mentioned, which depend on the condition of the bladder : the vesico-abdominal, when the bladder is distended ; and the utero-abdominal, when the bladder is empty and contracted. What are the boundaries of the utero-vesical pouch ? It is bounded in front by the posterior surface of the bladder, behind by the anterior surface of the uterus, and laterally by the utero vesical ligaments. What are the boundaries of the pouch of Douglas ? It is bounded in fi'ont by the posterior sui-face of the uterus and the upper portion of the posterior vaginal wall, behind by the rec- tum, and laterally by the utero-sacral hgaments. What are the boundaries of the retro-ovarian shelves ? They are triangular in shape, bounded in front by the base of the broad hgament, internally by the utero-sacral hgament, and exter- nally by the wall of the pelvis. Pelvic Peritonitis. What is the pathology ? The peritoneum first becomes hyper^emic ; it loses its lustre, and exudation materials are poured out. 1. There may be scarcely any serum exuded ; the inflamed area is coated with fibrin, and adhesions form, binding together the pelvic organs and intestines. PELVIC PERITONITIS. 89 2. The exudation may consist largely of seram, either free in the peritoneal cavity, or encapsulated by adhesions. 3. The exudation in severe, especially septic cases is often puru- lent. Hence the varieties : — a. Adhesive, h. Serous. d. Purulent. What is the etiology ? In a general way, the etiology of pelvic peritonitis may be stated as an extension to the peritoneum of inflammation of the uterus, ovaries or tubes ; in a large majority of the cases, inflammation of the tubes. There is, usually, first an endometritis, then a salpingitis, and then a peritonitis. Individual causes are as follows : — a. Introduction of sepsis during parturition, abortion or opera- tions. h. Gonorrhoea. c. Introduction into the uterus of septic instruments. d. Injection of fluids through uterus and tubes into the peritoneal cavity, e. Catching cold during menstruation. / Tubercular or cancerous disease of the pelvic organs. g. Tumors causing irritation of the peritoneum. h. Pelvic cellulitis and peritonitis are often associated as being produced by the same causes. What are the symptoms ? Pelvic peritonitis may be either acute or chronic. Acute pelvic peritonitis is usually ushered in by a rigor; this, however, is not always present. There are pain and tenderness in the lower part of the abdomen ; patient lies on the back, with the knees elevated ; the pulse is small, wiry and rapid ; the temperature is elevated, 1 01 °-l 03°, sometimes higher ; nausea and vomiting are com- mon ; more or less tympanites is present ; the bowels are constipated ; there is frequently irritability of the bladder; often menorrhagia. Chronic peritonitis may exist and present scarcely any symptoms 90 . ESSENTIALS OF GYNECOLOGY. save a dull pain in tlie pelvis ; usually, there is vesical and rectal irritability, dyspareunia, leucon-lioea, and a disturbance of menstrua- tion, especially menorrhagia. Chronic peritonitis may follow the acute, or may begin as chronic. Pelvic peritonitis is often characterized by exacerbations. What are the physical signs of acute pelvic peritonitis ? The vagina is hot and dry ; pressure in either fornix, or on the abdomen, is intensely painful ; the bimanual is impracticable ; the uteiTis, tubes and ovaries are usually bound fast ; the shghtesl attempt to move them causes intense pain. The fornices may seem k) be covered by a hard, flat roof, formed by a matting together of the pelvic contents, often compared to plaster-of-Paris poured into the pelvis and hardened ; you may feel a tumor close to the uterus, consisting of serum or pus, roofed in by adhesions ; the most com- mon situation of this tumor is in the pouch of Douglas. What are the common results of pelvic peritonitis ? Displacement of uterus, ovaries and tubes, the tubes being often distorted and stenosed by the traction of adhesions ; as a result of these conditions we get disturbances of menstruation, sterility and ectopic gestation. What is the prognosis of pelvic peritonitis ? Simple adhesive peritonitis often ends in complete recovery ; dis- placement of the pelvic organs may remain, however, and give rise to symptoms. The prognosis of purulent peritonitis is grave. What is the treatment of pelvic peritonitis ? In the acute form, keep the patient quiet in bed, give fluid diet, apply cold to the lower portion of the abdomen, either in the form of the ice-bag or cold-water coil. In some cases hot applications are more grateftd to the patient ; if there is great pain, give a little morphine ; after a few days, move the bowels gently, as by calomel gr, j every hour for 3-4 doses, assisted, if necessaiy, by an enema. After the acute stage has passed use hot douches, and in chronic cases, iodine externally and per vaginam, and vaginal tampons of borogb^ceride or ichthyol and glycerine. A wet towel, covered by a dry one for a protective, worn about the pelvis at night, is sometimes PELVIC CELLULITIS. 01 of value in chronic peritonitis. Look after the .t^eneral health by attention to fresh air, administering tonics, and regulating the bowels. Pelvic Cellulitis. What are the principal situations of the cellular tissue in the pelvis ? 1. Between the abdominal wall and peritoneum, behind the pubes 2. In front of and behind the cervix. 3. In the broad ligaments. 4. In the utero-sacral ligaments. What is the etiology of pelvic cellulitis ? The etiology of pelvic cellulitis may almost invariably be summed up in two words — traumatism and sepsis ; the traumatism being, usually, labor, abortion, or operations on the cervix. Pelvic cellulitis was formerly considered very common, but in the light of recent experience, gained by laparotomies, the "masses," "thickenings," etc., are most often found to be salpingitis and peritonitis. In other words, pelvic cellulitis, although it does exist, is com- paratively infrequent. What is the pathology ? There is an exudation of serum, fibrin and white cells ; this may resolve, it may form new connective tissue, cicatricial tissue, or it may, and often does, suppurate. If suppuration occurs, the pus may point above the pubes ; this is especially common in puerperal cases. It frequently ruptures into the vagina, bladder or rectum, sometimes into the uterus ; it occasionally makes its way through the sciatic or obturator foramen ; rarely, it ruptures into the peri- toneal cavity. What are the symptoms of pelvic cellulitis ? The disease is usually ushered in by a rigor, which is often marked ; the temperature rises, 103°-105° ; the pulse is full and rapid ; the pain is not very acute ; nausea is occasionally present ; vomiting is usually absent, unless peritonitis is a complication. If pus forms,, septic symptoms become pronounced. There is often irritability of bladder and rectum. 92 ESSENTIALS OF GYNECOLOGY. Chronic cases may present few symptoms save a feeling of weight in the pelvis, irritability of bladder and rectum, and menorrhagia. What are the physical signs ? Usually, there is a tense, elastic tumor bulging into the vagina, most commonly on the left side, pushing uterus over to the right ; it is sensitive, but not acutely so. Sometimes the inflammatory process involves nearly all the connective tissue of the pelvis, and the exudation can be felt in the iliac fossae and above the pubes. When pus forms you have the physical signs of an abscess — tenderness, fluctuation, etc. From what should you differentiate pelvic cellulitis ? From— a. Pelvic peritonitis, h. Pelvic hgematocele. c. Fibroid tumor of uterus. d. Impaction of faeces. e. Ovarian tumor. / Salpingitis. How would you differentiate pelvic cellulitis from pelvic peritonitis ? In many cases it is almost impossible to difi'erentiate the two ; they frequently complicate each other. The chief points of difference are these : Pelvic cellulitis almost never occurs except after labor, abortion, or operation on the cervix ; pelvic peritonitis may arise ftom any cause of inflammation of the uterus or its adnexa, which may extend to the peritoneum. Pain and tenderness, as a rule, are less marked in cellulitis than in peritonitis. Cellulitis is more apt to bulge into the vagina than is peritonitis. CeUulitic deposits are more apt to suppurate than are peritonitic. Vomiting is less frequent in cellulitis than in peritonitis. How would you differentiate pelvic cellulitis from pelvic haematocele ? Chiefly by the history of an haematocele, i. e., sudden sharp pain, pallor, faintness, and the physical signs of a collection of fluid which afterward coagulates and hardens. The above symptoms of shock and hemorrhage are wanting in cellulitis. PELVIC CELLULITIS. 93 How would you diiferentiate cellulitic or peritonitic deposits from fibroids of the uterus ? Cellulitic or peritonitic deposits vs. Fibroid tumors. History of acute inflauimation. Slow growtli. Pain and tenderness. Insensitive. Less plainly outlined. Outlines more distinct. Less intimatel}^ connected with Closely connected with the the uterus. uterus. Perhaps menorrhagia during the Usually luenorrhagia, gradually acute stage, then irregular increasing till the menopause. menstruation. How would you differentiate impaction of faeces from pelvic peritonitis or cellulitis ? In impaction of faeces, the mass is sausage-shaped, has a doughy feel, is situated in the position of the rectum, and is less closely con- nected with the uterus than an exudation of peritonitis or cellulitis ; it is not as tender on pressure, and gives no history of acute inflam- mation. The diagnosis is made certain by clearing out the rectum. How would you differentiate a small ovarian tumor from pelvic peritonitis or cellulitis ? There are no signs of acute inflammation as in cellulitis or perito- nitis ; the ovarian cyst is usually fluctuating ; its multilocular char- acter can sometimes be felt. The menstrual disturbances common in peritonitis and cellulitis are usually absent in cases of ovarian cysts ; an ovarian cyst gradually increases in size. How would you differentiate pelvic cellulitis from salpin- gitis ? By a careful bimanual, in a case of salpingitis, you can generally map out an enlarged, tortuous tube, usually distended, extending from the side of the utems.to the region of the ovary ; if distended with fluid, you may detect fluctuation. It does not bulge into the vagina as does cellulitis. The history of the case is of value in the diagnosis. What is the treatment of pelvic cellulitis ? 1. Prophylactic : — Strict cleanliness and antiseptic precautions during labor, abortion, operations, etc. 94 ESSENTLA.LS OF GYNECOLOGY. 2. Abortive : — Put patient to bed, appl}' cold to the lower portion of abdomen. 3. When exudation has occurred : — Appb" heat to the abdomen, administer hot-water vaginal douches, move bowels, and attend to the general health. 4. If the exudation suppurates: — As soon as pus is detected, incise under antiseptic precautions and drain. The two most favorable sites for incision are through the vagina and through the abdominal wall just above Poupart's liga- ment. In doubtful cases it is sometimes advisable to open the abdomen in the median line, and then determine by tbe relations of the mass, the best mode of procedure. This, however, is rarely necessary. Pelvic Haematocele and Haematoma. Define, and give the pathology. Pelvic haematocele is an effusion of blood into the cavity of the pelvic peritoneum. Pelvic haematoma is an effusion of blood into the connective tis- sue of the pelvis beneath the peritoneum, usually between the folds of the broad ligaments. In a pelvic haematocele, the effusion is usually into the pouch of Douglas ; if this is closed by adhesions, or if the effusion is very large, the blood may flow over into the utero-vesical pouch. The former condition gives rise to the name retro-uterine, the latter to ante-uterine haematocele. The blood is at first fluid ; it then slowly coagulates and is roofed in by peritonitic exudate binding together adjacent structures : — coils of intestine, omentum, utems, etc. This blood mass, if small, may be absorbed ; usually, however, it is due to a ruptured ectopic gestation sac or a tubal abortion and under these circumstances recurrent hemorrhages into tbe mass, sufficient to burst its limiting wall are common. Occasionally, apparently from proximity to the intestine, it suppurates. What is the etiology of pelvic haematocele ? Formerly long hsts of causes were given for this condition. We now know that in most cases it is due to a ruptured ectopic gesta- tion sac or a tubal abortion. It is ])robable that exceptions to this rule occasionally occur, such as — PELVIC HiEMATOCELE AND I1^MAT03IA. 95 Rupture from traumatism of vascular peritonitic adhesions. Oozing after removal of diseased tubes and ovaries. Excessive haemorrliage from the rupture of a Graafian follicle. Rupture of an ovarian haematoma. What is the etiolog'y of pelvic hsematoma ? Here again a rupture of an ectopic gesta.tion sac is a very com- mon cause. Other causes, however, are probably more frequent than in the case of pelvic haematocele, for varix of the broad liga- ment, due to various causes of venous congestion is common, and when such a varix exists, but a slight traumatism is needed for a blood effusion. What are the symptoms of pelvic haematocele ? A sudden sharp pain, and symptoms of shock and hemorrhage. The face becomes pallid, the expression anxious ; the pulse is rapid and feeble ; temperature subnormal ; surface covered with a cold perspiration : perhaps nausea and vomiting. Later if the patient survive, we have symptoms of peritonitis and of pressure, either from the effusion or the displaced uterus. The pain and tenderness continue for several days ; there is usually painful defecation and dysuria ; usually metrorrhagia is present. In a few days, if sup- puration does not occur, the effusion diminishes in size and the symptoms abate. If suppuration occurs, septic S3^mptoms appear. The above are the symptoms of a well-marked case ; where the effusion is small the symptoms may be much less severe. How do the symptoms of pelvic hsematoma compare with those of pelvic haematocele ? In pelvic haematoma there is, as a rule, less pain and less shock. If the effusion is large, however, there may be the symptoms of shock and hemorrhage. ^ What are the physical signs of pelvic haematocele ? At first no tumor is felt ; only an indistinct sensation of fulness in the pouch of Douglas ; as the blood coagulates and is roofed in by adhesions, one can feel a boggy tumor bulging downward in the posterior vaginal fornix and pushing the uterus forward. What are the physical signs of pelvic haematoma? In this case there is felt a distinct tumor even at first ; it bulges 96 ES:5ENTIALS OF GYNAECOLOGY. down on one side of and behind the cervix ; pushes the uterus for- ward and to the opposite side ; seems attached to the side of the pelvis 'and can be felt above Poupart's ligament when it has opened out the folds of the broad ligament and lifted up the peritoneum from the pelvis. A finger introduced into the rectum will usually detect a stricture. What is the prognosis of pelvic haematocele ? The prognosis is usuall}^ that of ruptured ectopic gestation and will be discussed under that condition. What is the prognosis of pelvic hsematoma ? Usually good. If the effusion suppurates, the prognosis is less favorable. It may rupture into rectum, vagina, bladder, or rarely above the pelvic brim. How would you differentiate pelvic haematocele from acute pelvic peritonitis ? Pelvic Twematocele vs. Acute pelvic peritonitis. History of sudden, sharp pain, Less sudden in onset ; symptoms with symptoms of shock and of shock and hemorrhage hemorrhage. wanting. Absence of acute inflammation Symptoms of acute inflammation at first. at first. Uterus usually displaced for- Uterus fixed, not markedly dis- ward. placed. How would you differentiate pelvic haematocele from a fibroid tumor of the uterus ? Pelvic Twematocele vs. Fibroid tumor. History of sudden, sharp pain Of slow growth ; symptom-s and symptoms of shock and gradually developed. hemorrhage. Soon followed by signs of in- Absence of signs of inflamma- flammation. tion. Less intimately connected with More intimately connected with the utems. the uterus ; moves with it Sensitive to pressure. Insensitive to pressure. Density less. Density greater. PELVIC HEMATOCELE AND HEMATOMA. 97 How would you differentiate pelvic hsematocele from a retro* flexed or retroverted uterus ? Pelvic hcematocele vs. Retrojiexed or retroverted uteres. Acute histoiy of pain, stock and Usually a long history. hemorrliage. Fundus of uterus usually lies Fundus backward ; absent in foi-ward. front. Sensitive to pressure. Less sensitive, unless surrounded by peritonitis. How would you differentiate pelvic hsematocele from an ovarian cyst ? Pelvic hcematocele vs. Ovarian cyst. Acute histoiy of pain, shock and History of slow growth, with few hemori'hage, general symptoms. More sensitive to pressure. Less sensitive to pressure. First elastic and soft, then hard. Usually fluctuating throughout. How would you differentiate pelvic hsematocele from im- pacted faeces ? By the history, rectal examination, and thorough emptying of the rectum. How would you differentiate pelvic haematocele from retro- uterine carcinoma ? Pelvic hcematocele vs. Retro^uterine carcinoTna. Acute history of pain, shock and History of a chronic disease. hemorrhage. Uterus usually pushed forward. Uterus but little displaced. How would you differentiate pelvic hsematoma from pelvic cellulitis'? Pelvic hcernxjutoma vs. Pelvic ceUiditis. History of sudden, sharp pain, History of labor, abortion, or perhaps symptoms of shock operation on the ceiTix. and hemorrhage. Signs of acute inflammation ab- Signs of acute inflammation sent at first. from the first. Less sensitive. More sensitive. 7 98 ESSENTIALS OF GYNiECOLOGY. What is the treatment of pelvic haematoma ? Keep the patient quiet in bed : at first apply cold, later heat, both externall}^ in the form of poultices and per vaginam by hot water douches. If suppuration occurs, open and drain through the vagina. If repeated hemorrhages are added to this haematoma two courses are open according to the size of the tumor. If the tumor is small and low in the pelvis, incise through the vagina, clean out clots, etc., and drain. If the tumor is large and extends high in the pelvis, it is probably better to open the abdomen and govern the treatment by the condition found. The treatment of pelvic haematocele will be considered under ectopic gestation. MENSTRUATION. Define. Menstruation is a periodical series of phenomena, the most marked of which is a discharge of blood from the uterine mucous membrane, beginning, on an average, in this country, at fourteen, and recurring monthly till forty-five. The relation of menstruation to ovulation is still unsettled. As a rule they are simultaneously present or absent, but either may be present for a short time without the other. Describe the factors which influence the onset of menstrua- tion ; what is the average frequency and duration of each period ? In temperate climates, menstruation usually appears at 13-15 years ; it is earher in warmer climates, later in cooler ; it appears in girls who Hve an indoor, city life, earlier than in the country. The periods nonnally appear eveiy 28 days, but in this there are great variations ; some women in perfect health menstruate every 3 weeks, some only every 5 weeks. The average duration of each period is 3-4 days, but this varies between 2 and 8. The discharge of blood is usually slight at first, reaches maximum on the second or third day, then gradually dimin- ishes. MENSTRUATION— AMENORRHCEA. 99 Disorders of Menstruation. Amenorrhoea. Define. Amenorrlioea is the absence of menstraation between puberty and the menopause. It is the normal condition during pregnancy and lactation. Menstruation may be present, but "concealed," due to atresia of the lower part of the genital tract. It may be divided into : — a. Emansio mensium — Where menstraation has never appeared. b. Suppresio mensium — Where menstruation has appeared, but fails to reappear. What is the etiology of amenorrhcea ? The most frequent cause is anaemia, especially that form called chlorosis. Other causes are phthisis, or other debilitating diseases ; acute diseases at puberty ; non-development of the generative organs ; atrophy of the generative organs ; increasing obesity ; removal of ovaries and tubes by operation. What are the symptoms ? Amenorrhoea is itself more a symptom than a disease, and the symptoms which usually accompany amenorrhoea are those of the disease which causes it — most frequently anaemia or phthisis. Thus, from anaemia we have : — Pallor. Dyspnoea and palpitation of the heart on exertion. Depraved appetite. Constipation. Headache. CEdema. Murmur at the base of the heart. Neuralgic pains. Hysteria. From phthisis we get the regular symptoms of cough, emaciation and night sweats. 100 ESSENTIALS OF GYNECOLOGY. What is the prognosis ? When associated with simple anaemia the prognosis is good. When due to non-development of the generative organs the amen- orrhoea usually continues. When associated with phthisis or other wasting disease, the prognosis is that of the disease. What is the treatment of amenorrhoea ? a. When due to anaemia : — Some form of iron, as Blaud's pills; oxygen; nourishing food; fresh air ; regulation of the bowels, and attention to the mode of life. h. When due to imperfect, or non-development of the generative organs : — Determine, under anaesthesia, whether ovaries are present or not ; if absent, do not attempt to induce menstruation. If the ovaries are present, besides attention to the general health, the following methods may be employed : — Hot water vaginal douches ; Boro-glyceride tampons ; Electricity to uterus and over ovaries. c. When associated with phthisis, or other wasting disease, the treatment is that of the associated disease. In cases of acute suppressio-mensium, due to exposure to cold, etc. , hot mustard foot baths, hot applications to the pelvic region and diaphoretics internally, may be used with safety "B-nd advantage. Vicarious Menstruation. Describe. Vicarious menstruation is a periodical discharge of blood from some part of the body other than the interior of the uterus. It may occur with either amenorrhoea or scanty menstmation ; it usually appears at about the time of the regular flow. It may come from almost any mucous membrane : from the nose, mouth, etc. ; it may also come from the nipple or from an open sore ; it is usually due to a watery condition of the blood and a poor condition of the blood- vessels. Direct treatment is usually not required. MENSTRUATION — MENORRHAGIA AND METRORRHAGIA. 101 Menorrhagia and Metrorrhagia. Define. Menorrhagia is a prolonged or excessive menstrual flow. Metrorrhagia is "uterine hemorrhage occurring independently of the menses. " What is the etiology? Menorrhagia and metrorrhagia may be produced by causes acting at a distance, or local, in or about the uterus itself. Acting at a distance are : — 1. Obstructed general circulation from disease of heart, lungs or liver. 2. Low condition of blood and vessels in certain wasting diseases. Acting about the uterus are : — ■ 1. Tumors. / 2. Ectopic Gestation. 3. Disease of tubes or ovaries. The most common causes are situated in the uterus itself, and among them are the following : — 1. Subinvolution of the uterus ; 2. Ketained secundines ; 3. Submucous, or interstitial fibroids ; 4. Polypi ; 5. Carcinoma; 6. Fungous granulations of the endometrium. The last is the most common cause of all. What is the treatment of menorrhagia and metrorrhagia ? When due to causes acting outside of the uterus, the treatment is that of these causes ; at the same time, there will often be found iungous granulations of the endometrium which magnify the infiu- ence of the distant causes ; unless otherwise contraindicated, these fungosities need to be removed by the curette under antiseptic pre- cautions ; the uterine cavity is then washed out, and an application of iodine or carbolic acid or a mixture of the two may then be made to the endometrium. In mild cases of menorrhagia or metrorrhagia ergot and hydrastis canadensis are of value even without the use of the curette, and in nearly all except malignant cases after curetting. 102 ESSENTIALS OF GYNECOLOGY. Diseases of the tubes and ovaries and ectopic gestation require their own treatment. Fibroids may demand removal of the tumor or hysterectomy. Polypi require removal. Carcinoma indicates hys- terectomy. Fungous endometritis demands curetting as above. Dysmenorrhoea. Define. ' ' Dysmenorrhoea may be defined as the occurrence of pain jusi before, during or after the menstrual period ' ' (Hart and Barbour). What are the varieties of dysmenorrhoea ? The following varieties are mentioned, but seldom distinctly differentiated :— 1. Obstructive ; 2. Congestive; 3. Neuralgic; 4. Ovarian ; 5. Membranous. Obstructive Dysmenorrhcea. What is the etiology ? Both the etioi^gy and pathology of the difi'erent varieties of dysmenorrhoea are still far from settled, but the conditions usually associated with obstnietive dysmenorrhoea are : — a. Flexions of the uterus ; h. Stenosis of os externum, os internum, or the whole cervical canal ; c. Polypi ; d. Fibroids distorting uterine canal ; e. Long, conical cervix ; /. Spasmodic contraction of os internum. What are the symptoms ? Intermittent, cramp-like pains, accompanying the expulsion of blood clots which have formed above the obstmction ; this expulsion is followed by relief A sound passed between the periods usually shows hyperaesthesia of the internal os. MENSTRUATION— DYSMENORRHCEA. 103 What is the treatment ? During the intermenstrual period dilate the cervical oanal with one of the dilators of the glove-stretcher variety. If there seems to be any endometritis present, curette the uterus and wash it out. Pack the cavity with iodoform gauze, and unless the pain is severe leave it for forty-eight hours ; this will maintain the dilatation for quite a period. In order to prevent future recontraction, the occa- sional introduction of graduated sounds is of value. All this must be done under strict asepsis. The use of intra-uterine stems had better be abandoned. For the temporary relief of the several vari- eties of dysmenorrhoea the preparations of viburnum are of value. Congestive Dysmenorrhea. What is the etiology ? "Congestive dysmenorrhoea depends upon an advance of the menstrual congestion beyond the physiological limits ' ' (Keeve). The conditions associated with congestive dysmenorrhoea are the following : — a. Exposure to cold ; h. Defective general circulation ; c. Metritis ; d. Endometritis; e. Displacements of the uterus ; / Pelvic tumors ; m g. Pelvic peritonitis. What are the symptoms ? Between the periods there are usually symptoms of pelvic trouble, or defective general circulation. Just before the flow begins, there appear feelings of weight and heat in back and pelvis, headache, flushing of the face, and some rise of temperature ; the pulse is rapid. The symptoms are usually relieved by a free flow. What is the treatment ? a. During the attack — 1. Hot mustard foot-baths ; 2. Hot sitz -baths ; 3. Diaphoretics, such as Dover's powder; 4. Hot pelvic applications. 104 ESSENTIALS OF GYNAECOLOGY. h. During the intermenstrual periods — 1. Seek to remove the cause ; 2. Scarify cervix occasionally ; 3. Employ glycerine tampons ; 4. Avoid excessive coitus and exertion. Just before the flow begins, use hot-water vaginal douches. Neuralgic Dysmenorrh(ea. What is the etiology ? This frequently occurs in combination with some of the other forms of dysmenorrhoea, especially the congestive ; it is most often associated with an indolent, indoor life, anaemia, malnutrition, chronic malarial disease or hysteria. Sometimes no cause can be assigned. What are the symptoms ? Pain, sometimes referred to uterus, sometimes to ovaries, some- times elsewhere ; it changes its situation ; is often shooting in char- acter ; usually begins a little before the flow ; is sometimes relieved by a free flow. Between the periods, no pathological changes can be detected in the pelvic organs, but patient suffers from neuralgia elsewhere — facial, intercostal, etc. What is the treatment? Attention to the mode of life ; fresh air ; exercise ; tonics, espe • cially iron, arsenic and quinine ; at the onset of the pelvic pains employ hot sitz-baths and hot-water vaginal douches, and give inter- nally such anti-neuralgics as phenacetin. Ovarian Dysmenorrhea. What is the etiology ? This is applied to a class of cases associated with disease of the ovaries, but the etiology is far from settled, and the class not distinct. What are the symptoms ? Between the periods there is pain and tenderness over the region of the ovary, increased by exercise, defecation and coitus ; these symptoms are increased at the menstrual periods. MENSTRUATION — DYSMENORRHCEA. 105 Membranous Dysmenorrhcea. Describe. ' ' Membranous dysmenorrhcea is characterized by the expulsion at the menstrual periods of organized membranes either as a whole or in pieces. ' ' (Reeve. ) Fig. 13. Sketch of a Dysmenorrhoeal Membrane as seen under Water (Sir J. Y. Simpson). What is the etiology and pathology ? These are both matters of dispute, but we usually find in these cases chronic endometritis and poor general health. The inner surface of the membrane is smooth and shows the openings of the utricular glands ; its external surface is rough and shaggy (see Fig. 13). Microscopicallj^ it resembles the decidual membrane occurring in pregnancy. According to Hart and Barbour, " It is of the greatest importance 106 ESSENTIALS OP GYNECOLOGY. to remember tliat it is not a product of conception, and sliould not De mistaken for an early abortion. " It is composed of the super- ficial layer of the endometrium, with increased connective tissue ; blood accumulates under it and dissects it off. What are the symptoms ? Severe colicky pain, usually recurring at each period ; the flow is often intermittent ; thus the symptoms resemble those of obstructive dysmenorrhoea. The course is usually pvotracted. How would you differentiate membranous dysmenorrhoea from an early abortion ? By the absence of chorionic vilh and by the repeated occurrenc-e What is the treatment ? a. Between the periods — Dilate the cervix, curette the uterine canal, and apply to the endometrium iodized phenol, pure carbolic, or tincture of iodine. h. During the menstmal period — Use hot baths, hot appHcations to the pelvis, and diaphoretics. Malformations of the Vagina. What are the important varieties ? a. Atresia vaginae ; h. Double vagina ; c. Absence of vagina. d. Stenosis of vagina. Atresia YAGiNiB. Give the varieties and etiology. Atresia of the vagina may be either at the hymen, forming atresia hymenahs, or higher up in the vagina, forming atresia vaginahs. Etiology. — Atresia hymenalis is usually congenital, from mal- development. Atresia vaginahs is either congenital, or may be acquired from cicatrization following — a. Sloughing incident to parturition ; h. Adhesive vaginitis ; c. Traumatism ; d. Caustics. MALFORMATIONS OF THE VAGINA. 107 What are the symptoms of atresia vag^inae ? They are dependent on the accumulation of the menstrual blood, hence in congenital cases they are absent till puberty. The subjective symptoms of menstruation come on, but there is no appearance of blood ; at the next period the subjective symptoms are repeated. The periods then usually come more frequently, and soon a tumor forms. If the atresia is at the hymen, the latter bulges, and the vagina is distended with biood, forming a hasmato-colpos. In atresia hymenalis the cervix is usually not dilated ; in atresia vaginalis the dilatation may extend to the uterus and tubes. If the atresia is acquired, of course there will be no symptoms till the menstrual blood is retained. What are the results of atresia hymenalis if unrelieved by operation ? If the hymen is thin, it may rupture ; if thick, the vagina may rupture ; after rupture, septicaemia may occur. What are the results of atresia vaginalis ? The vagina may rupture. The uterus and tubes may become distended, forming haemato- metra or haemato-salpinx, and may rupture. The atresia may rupture. After rupture, septicaemia may occur. Where else in the genital tract than in the vagina may atresia occur ? Give the etiology and symptoms. Atresia may occur at the cervix. Atresia of the cervix may be congenital, or acquired from cicatri- zation following parturition, the use of caustics, or from a too close trachelorrhaphy. Symptoms appear when the menstrual blood ac- cumulates behind the atresia, and resemble those of atresia vaginae. The amenorrhoea and enlargement of the uterus may make one suspect pregnancy. What are the results of atresia of the cervix if unrelieved by operation ? If it is present during menstrual life, the uterus and tubes become distended, and are liable to rupture, with the danger of peritonitis and death. If it occurs for the first time after the menopause, it usually causes no trouble. 108 ESSENTIALS OF GYNECOLOGY. What is the character of the retained fluid ? During menstrual life the blood is of a brownish, chocolate color ; it is grumous and treacle-like in consistency,, kept from clotting by the mucus. After the menopause, the retained fluid is honey-like. What is the treatment of atresia of the genital tract with retention of the menstrual blood ? Aspirate slowly ; under strict antisepsis incise the obstruction, and maintain the opening by iodoform gauze or a rigid drainage-tube. What are the dangers of rapid evacuation of a haemato- metra ? The tubes are probably distended, and have formed adhesions ; the rapid collapse of the uterus would tend to tear the tubes from their adhesions, with the danger of rapture of the tubes, and perito- nitis. Stenosis op Vagina. Give its cause and describe. It may be acquired from cicatrization of the vagina or be congeni- tal. The congenital stenosis is not infrequent just in front of the cervix. It interferes with coitus and labor and gives rise to vagini- tis by interfering with the drainage of the upper part of the vagina. Malformations of the Uterus. What are the principal varieties ? 1 . Rudimentary uterus ; 2. Uterus bipartitus ; 3. Uteiiis unicornis ; 4. Uterus bicornis ; 5. Uterus didelphys ; 6. Uterus septus ; 7. Infantile uterus ; 8. Congenital atrophy of the uterus ; 9. Complete absence of the uterus, very rare. MALFORMATIONS OF THE UTERUS. 109 Describe the rudimentary uterus. In this case (see Fig. 14) "the uterus is represented by a band of muscular fibre and connective tissue on the posterior wall of the bladder. ' ' (Hart and Barbour. ) Describe the uterus bipartitus. In the uterus bipartitus (see Fig. 15) the rudimentary horns are present, and are either hollow or solid and cord-like ; they are con- nected to each other and to the vagina by the cervix, which is repre- sented by a fibrous band. The ovaries, breasts and external genitals may be well developed. Describe the uterus unicornis. The body of the uterus in this variety (see Fig. 16) is long and narrow, and is directed to one side ; its fundus has attached to it one Fallopian tube and ovaiy ; on the opposite side of the body is seen the representative of the other horn, which is either solid or hollow ; connected with this, and separated from it by the attachment of the round ligament, are the tube and ovary of that side. Describe the uterus bicornis. In this form (see Fig. 17) the division into two horns is distinctly visible externally ; the division is usually seen also in the interior o£ the uterus on section. What is the uterus didelphys? Here the two halves of the uterus are separated throughout (see Fig. 18). This condition is very rare. Describe the uterus septus. Here the division is entirely internal (see Fig. 19 ) ; beginning at the ftindus, it extends a variable distance toward the os externum, sometimes reaching it. There is no indication of the division from the outside. What is an infantile uterus ? In this condition (see Fig. 20) the cervix is 2-3 times longer than the body, the relation of cervix to body remaining as at birth. The uterus as a whole is smaller than normal. What is meant by congenital atrophy of the uterus ? The relative lengths of cervix and body (see Fig. 21) conform to those of a virgin utems, but the whole uterus is atrophied. 110 ESSENTIALS OF GYNECOLOGY. Fig. 14. Eudimentary Uterus (Veit). Sa, sacrum; U, solid rudiment of uterus; A rudi- mentary horn ; ^.bladder; 0, ovary; T, FaUopian tube ; r round ligament. Fig. 15. Uterus Bipartitus (Pvokitansky). F; vagina; fT, uterus; fc, rudimentary horn ; 0, ovary; T, tube; r, round ligament; b, broad ligament. Fig. 16. Uterus Unicornis (Schroeder). H, right side; i, left side. The left horn (h) is well developed and communicates with the uterine cavity. The right horn is in the form of an elongated band; its point of connection with the Fallopian tube is indicated by the insertion of the round ligament, which is hypertrophied. Othei letters as in preceding diagrams. MALFORMATIONS OF THE UTERUS. in Fig. 17. Uterus Bicornis Unicollis (Schroeder). r, round ligament. Fie. 18. Uterus Didelphys. a, right cavity ; 6, left cavity; c, riglit ovary ; d, right round ligament ; e, left round ligament ; /, left tube ; g, left vaginal portion , A, right vaginal portion ; i, right vagina ; }', left vagina : k, partition between the two vaginae, (From Pe Sinety, after Ollivier.) 112 ESSENTIALS OF GYNECOLOGY. Fig. 19. Fig. 20. trterus Septus in Vertical Transverse Section (Kuss- maul). [/■(uterus), placed on septum which divides cavity intotwo lateral portions ; T, Fallopian tubes ; F, vagina divided into lateral cavities by prolonga- tion of septum downward. Infantile Uterus (Schroeder). Fig. 21. Primary Atrophy of the Uterus (Virchow). DISPLACEMENTS OF THE UTERUS. 113 What is the occurrence of complete absence of the uterus? It IS veiy rare indeed, and can only be ascertained by a post- mortem examination. Many cases of supposed absence of the uterus are proved, on autopsy, to be cases of rudimentary uterus. What are the importance and danger of uterine malforma- tions ? ^ Pregnancy in such cases may endanger the patient's life. The diagnosis is difficult. Menstruation may occur from one half and pregnancy be present in the other. The pregnant cornu may be mistaken for a tumor or it may rupture with symptoms like those of ectopic gestation. Displacements of the Uterus. What do we mean by a displacement of the uterus in a clinical sense ? Changes in the position of the uterus only become displacements, in the clinical sense, when they are more or less stable. Limitation or hindrance of the normal movements of the uteras is a main characteristic of its displacements." (Schultze.) What are the principal displacements of the uterus l a. Anteversion ; h. Anteflexion ; c. Retroversion ; d. Retroflexion ; e. Prolapse. What is the difference between a "version" and a "flexion?" Ih a "version " the canals of the cervix and body are in the same straight line ; in a " flexion ' ' they make an angle with each other. Anteversion. Discuss briefly. The uterus is sometimes fixed in a position of anteversion owing to the pressure of encysted fluids, tumors, inflammatory masses or peritoneal adhesions. The symptoms are those of the causal con- dition. The anteversion, per se, gives rise to no symptoms, hence it IS not usually considered among uterine displacements 8 \ 114 ESSENTIALS OF GYNECOLOGY. Anteflexion. What is the pathology ? u In anteflexion the body of the uterus is bent fonvard on the cervix (see Fig. 22) ; in order for this to be pathological, there must be rigidity at the point of flexion. What is the etiology ? It may be congenital (puerile, Schultze) or acquired. The most common causes of the latter are a metritis occuning in V ^zz^'^.lx:; uterus, or an inflammatory process occuiTing in the utero- sacral ligaments, drawing the upper portion of the cei-yix upward Fig. 22. Anteflexion of the Uterus (Schroeder). and backward. Bandl thinks cervical catarrh the first cause, ex- tending to the cervical tissue, and then to the cellular tissue in the utero-sacral ligament. It is sometimes caused by the adhesions of peritonitis drawing the upper portion of the cervix backward. What are the symptoms ? a. Dysmenorrhoea ; b. Sterility; c. Disturbance of bladder functions — frequent micturition , DISPLACEMENTS OF THE UTERUS. 115 d. Leucorrhoea ; e. Other symptoms are those of the accompanying inflammation. What are the physical sig^ns ? The cervix lies rather high ; the os is directed downward and forward ; as you pass the finger up along the anterior wall of the cervix, it runs into a marked angle between cervix and body. The body can be felt lying in front of the cervix, just above the anterior vaginal wall. The cervix is often long and the os small. The sterility is more dependent upon the long cervix plugged with mucus than any actual stenosis of the internal os. The uterus is sometimes both anteflexed and retroverted. From what must you diiFerentiate an anteflexion ? From— 1 . A fibroid tumor in the anterior wall of the uterus ; 2. An inflammatory deposit in front of the cervix. How would you differentiate an anteflexed uterus from a fibroid tumor in the anterior wall? In an anteflexion you cannot feel the fundus elsewhere, and a sound passes when sharply curved into the body felt in front of the *'i«- 23. cervix. In a fibroid in the anterior wall (see Fig. 23) the sound does not pass into the body felt in front of the cervix, but behind it, and the fundus can be felt above and behind the fibroid. How would you differentiate an inflammatory deposit from an anteflexion ? The former is comparatively rare, l>ut when present is usually more , sensitive than an anteflexion ; in the case of an inflammatory deposit ■in front of the cervix, a careful bimanual examination will usually show the fundus elsewhere. During the acute, inflammatory period the sound is contraindicated. 1\ k ^ ( Sound passed to show that a Fibroid of the Anterior Wall is not an Anteflexion (Leblond). 116 ESSENTIALS OF GYNECOLOGY. What is the treatment of anteflexion ? First treat all existing pelvic inflammation. by means of hot-water douches, counter-imtation and glycerine tampons. When all inflam- matory symptoms have subsided, dilate the cei-vix, under antiseptic precautions, with one of the glove-stretcher dilators, and pack the cavity with iodoform gauze leaving it for forty-eight hours. Maintain the dilatation by the introduction of the graduated hard dilators, or sounds, once or twice a month for two or three months. Retroversion and Retroflexion. Define. ' ' Retroversion may be defined as the permanent dislocation back- ward of the fundus uteri, when the form of the uterus is such that axis of body and axis of cervix are identical. Retroflexion denotes the permanent backward dislocation of the fundus uteri, with simul- taneous flexion of the uterus over the posterior surface. ' ' (Harrison. ) What is the etiology and pathology ? Retroversion (see Fig. 24) may exist by itself, but with retroflexion there is always more or less retroversion. Usually the uterus is first retroverted, and then intra-abdominal pressure continuing, if the uteiTis is flexible, the fundus is pushed backward and downward. The combination of the two is thus most common, and is described as retroversio-flexio (see Fig. 25). Retro versio-flexio is most fre- quent in multiparas following parturition, where the ligaments are lax and patient lies on the back, and especially if the patient rises before involution has occurred. It may occui', however, in nulliparse or virgins, from severe blows, falls, lifting, straining, etc. ; also from inflammatoiy adhesions, drawing the utenis backward. The most common agent in pushing a movable uterus beliind the perpendicular is distention of the bladder ; intra-abdominal pressure , may then act on the anterior surface of the uterus. Relaxation of | the utero-sacral ligaments, and thickening and shortening of the utero-vesical, favor retroversio-flexio. Pathologically, we usually find the body of the uterus congested ' and enlarged, its mucosa hj^perplastic, and more or less rigidity at | the junction of cervix and body, from development of fibrous tissue. DISPLACEMENTS OF THE UTERUS. What are the symptoms ? 1 . More or less constant pain in the back ; 2. Symptoms of pelvic inflammation ; 3. Constipation ; 4. Irritability of the bladder ; 5. Leucorrhoea ; 6. Menorrhagia ; 7. Dysmenorrhoea, especially when flexion is marked ; 8. Abortion ; 9. Sterility; 10. Keflex neuroses. Fig. 24. 117 Retroversion of the Uterus (Schroeder.) What are the physical sig^ns ? On making the bimanual examination, you find the cervix nearer the vulva than normal, the fundus absent in front, and the os pointing more or less forward ; on running the vaginal fingers along the pos- terior wall of the cervix, you find a body which, in a retroversion, continues the line of this wall, in a retroflexion makes an angle with it. This body moves as a part of +he uterus ; the sound passes into it. 118 ESSENTIALS OF GYNuECOLOGY. From what must you differentiate retroversio-flexio ? 1. Fibroid tumor on posterior wall of the uterus ; 2. Faeces in the rectum ; 3. Inflammatory deposits ; 4. Prolapsed ovary or small ovarian tumor. How would you differentiate retroversio-flexio from a fibroid on the posterior wall ? Make a careful bimanual examination. In case of a backward displacement of the uterus, we find an absence of the fundus in front, the cervix points more or less forward, and the sound, when intro- duced, goes backward. Fig. 25. Ketroversio-flexio. In case of a fibroid on the posterior wall, the ftmdus may be felt in front of it, and the sound passes forward. The tumor may feel more irregular and harder than the uterus. How would you differentiate the fundus uteri from faeces in the rectum ? On bimanual examination, the fundus can often be felt forward, and the sound passes forward ; the faeces have a more doughy feel DISPLACEMENTS OF THE UTERUS. 119 than the uterus ; if doubt exists, always empty the rectum before making a diagnosis. How would you differentiate the fundus uteri from inflam- matory deposits in the pouch of Douglas ? During the stage of acute inflammation this may be very difficult, as the sound is then contraindicated. Finding the findus in front is the chief element in the diagnosis. When acute inflammation has subsided, introduction of the sound will give great assistance. How would you differentiate the fundus uteri from a pro lapsed ovary or small ovarian tumor ? By making a careful bimanual examination, the uterus is found lying in front of the prolapsed ovary or tumor. Assistance may be given by the use of the sound, or drawing down the cervix with a volsella. What are the indications in the treatment of retroversio- flexio? 1. To treat the pelvic peritonitis or cellulitis, if present, according to the regular methods ; 2. To replace the uterus ; 3. To retain it in place. What are the methods of replacing a retroverted or retro- flexed uterus when movable ? 1. Place the patient in Sims' position ; introduce index and middle fingers of the right hand into the posterior fornix vaginas ; have patient breathe deeply and slowly ; during an expiration, raise the body of the uterus with the backs of the vaginal fingers till it passes the promontory of the sacrum, then transfer one or both fingers to the front of the cervix, and push that backward ; this throws the fundus forward. 2. Another method is to replace the uterus while patient is in the dorsal position, by means of the bimanual, either vagino-abdominal or recto-abdominal. In this method the body of the uterus is raised by the fingers in the vagina or rectum until it can be grasped by the external hand, when it is then brought forward. In some cases this 120 ESSENTIALS OF GYNECOLOGY. operation is facilitated by first grasping the cervix with a volsella and puUing it downward in the axis of the vagina, thus straightening the uterine canal, making the fundus easier to reach by the examin- ing finger and easier to lift above the sacral promontory. 3. When the body of the uterus is very sensitive, so that pressure by the fingers is very painful, the uterus may be replaced by means of the sound, as follows : Introduce the sound with the concavity backward ; then make the handle describe an arc of a circle from behind forward ; then slowly depress the handle toward the perineum ; this throws the uterus forward. 4. To replace the gravid uterus, the following method is sometimes employed : Place patient in the genu-pectoral position ; draw down cervix with the volsella, and press fundus uteri toward the bladder, with the finger in the rectum. When the uterus in a retroversio-flexio is rigid at the angle of flexion, we do not expect to remove the flexion, but only to correct the version. What are the methods of replacing a retroverted or retro- flexed uterus when fixed by adhesions ? If signs of pelvic inflammation are present, treat the inflammation by hot douches, sitz-baths, wet pelvic packs, attention to the bowels, etc. When the inflammation has subsided, the uterus may gradu- ally be replaced by cautious manipulation and stretching of the adhesions, and gentle attempts at raising the utenis, a few moments at a sitting, with the fingers in the posterior fornix vaginae ; after the manipulation insert a tampon, to be worn for twenty-four hours. At first the tampons are to be pressed firmly into the posterior for- nix to exert an upward pressure on the fundus. Later, when the fundus can be nearly replaced, put the tampon in the anterior fornix to press the cervix backward and thus maintain the reposition already accomplished. The manijDulations maj?^ be assisted by hot- water vaginal douches between the sittings. It is well to have the patient assume the knee-chest position once or twice daily. ■ Schultze's method of forcible reposition consists in placing the patient under angesthesia, in the lithotomy position, inserting index and middle fingers of left hand high up into the rectum, and with these fingers forcibly, but gradually, elevating the fundus uteri and breaking up the adhesions ; the right hand is placed on the abdo- PESSARIES. 121 men, and as the uterus is elevated, it is grasped by this external hand and brought forward. This method is rarely advisable. What are the means for retaining the uterus in place after reposition ? 1. Pessaries; 2. Operative procedures. Pessaries. What are the varieties in most common use ? 1. The Albert Smith ; 2. The Emmet; 3. The Thomas. Describe them. They are usually made of hard rubber; the Thomas pessary, how- ever, is often made of soft rubber. The Albert Smith (see Fig. 26) is a modification of the Hodge pessary ; its anterior extremity is narrow, the posterior broad ; the posterior extremity curves upward behind the cervix, the anterior downward away from the urethra. The Emmet pessary is usually made of a larger bar than the Albert Smith, and the curve is much flattened. The Thomas (see Fig. 27) is long, narrow, and has its posterior bar much enlarged. How does a retroversion pessary act ? Not by pushing up the body or fundus, but by making the poste rior vaginal wall tense, thus drawing the cervix backward, and in this way throwing the fundus forward. What are the contraindications to the use of a pessary ? A pessary should not be introduced till all pelvic inflammation has subsided, and, as a rule, not until the uterus can be well brought forward; "but occasionally, when the uterus is elevated to about the promontory, the pessary may be applied. ' ' What is the proper position of a retroversion pessary after introduction ? The broader extremity should lie behind the cervix and carve upward ; the narrow in front and curve downward. 122 ESSENTIALS OF GYNECOLOGY. How would you introduce one of these retroversion pessaries? They may be introdiiced with patient either in the dorsal or in Sims' position, preferably in the latter, and in the foUowing manner : Standing at the side of the table, near the buttocks of the patient, separate the labia a little with the fingers of the left hand ; taking the pessary by the smaller end with the thumb and index and middle fingers of the right hand, introduce it between the labia, with the breadth of the pessary in the line of the labia (see Fig. 28) ; depress the perineum with the pessary as you introduce it about half way, Fig, 26, Albert Smith Pessary. Thomas Pessary. then rotate, so that the breadth of the pessary lies at right angles to the labia ; now grasp the external portion of the pessaiy with the left hand ; pass the index finger or index and middle fingers of the right hand in front of the posterior bar (see Fig. 29) and carry the pessary along the posterior vaginal wall, being careful that it does not slip up in front of the ceiTix. What are the precautions to be observed in the employment of a pessary ? A patient after the introduction of a pessary should be made to walk a little about the room, then to sit on a chair and cross one knee over the other, to ascertain if the pessary causes pain ; if it does, it should not be kept in. A patient should always be told, on PESSARIES. 123 leaving, that if the pessary causes her pain, she must introduce her finger and remove it. She should be seen in a few days after its introduction, to ascertain if the pessary is in position and is holding the uterus in place. If one is not able to insert the finger between the pessary and vaginal wall the pessary is too large and may cause Fig. 28. Introduction of Pessary, First Stage (Hart and Barbour). ulceration. The pessary should be removed and cleaned as often as once a month ; in the meantime the patient should be instructed to use a vaginal douche for cleanliness two to three times a week. Always before re-inserting the pessary examine the posterior fornix through a speculum to see that no pressure-sore is forming. 124 ESSENTIALS OF GYNECOLOGY. What are the operative procedures for holding a retroverted uterus in place after reposition? CL Alexander's operation ; h. HysteroiThaphy. or ventral fixation ; c. Intra-abdominal shortening oF the round ligaments. Describe briefly Alexander's operation. Alexander's operation for shortening the round ligaments is per- formed as follows : The skin about the pubes is shaved and prepared Fig. 29. Second Stage : Pessary carried on by Finger (Hart and Barbour). antiseptically ; the pubic spine is taken as the first landmark ; an incision is then made, 2 inches long, from that point upward and outward, in the direction of the inguinal canal ; the incision is deep- ened until the tendon of the external oblique is seen ; the external abdominal ring is now visible: the intercolumnar fascia is cut through in the long diameter of the ring ; if necessary the incision may be continued up to the internal ring ; the round ligament can PESSARIES. 125 usually now be seen, with the genital branch of the genito-crural nerve along its anterior surface. The ligament is then separated from neighboring structures and gently drawn out a little to show that it is free. Alexander then leaves this side covered with a clean sponge and operates on the other side in the same way. The uterus is then thrown forward by the sound in the hands of an assistant and the ligaments drawn out till they are felt to control the uterus ; the ligaments are then given to an assistant to hold, and they are each sutured with catgut to the pillars of the ring ; the bruised ends are cut off and the wound closed. The i)atient is kept in bed two to three weeks, and wears a pessary for several months. What are the indications for Alexander's operation? The field of the operation is very limited. Where a retroverted uterus is movable, unaccompanied by disease of the appendages, and either cannot, with comfort to the patient, be held in position by a pessary, or the patient is unwilling to wear a pessary, Alexan- der's operation may be employed. Some men employ it as a part of the operative treatment of prolapsus uteri. What are the advantag'es of Alexander's operation as com- pared with hysterorrhaphy ? In Alexander's operation the uterus itself is only held by liga- ments which normally hold it. It is therefore better fitted for growth in pregnancy than where the fundus is firmly attached. It is performed without invading the peritoneal cavity, and leaves the patient with a moderately movable uterus. What are the objections raised to Alexander's operation? It is not applicable unless the uterus is freely movable. The ligaments are sometimes difficult to find ; one or both may be poorly developed. Hernia occasionally, though rarely, occurs. The round ligaments are not true ligamentous structures, but muscular cords, and it is doubtful whether they are to be considered as normal supports of the uterus. Hence, when tension is put upon them, they are likely to stretch. -^ What are the synonyms of hysterorrhaphy ? Ventral suspension, ventrofixation, and hysteropexy. 126 ESSENTIALS OF GYNECOLOGY. Describe briefly the operation of hysterorrhaphy for retro- versio-flexio. The abdomen is opened in the median hne as for an ovariotomy ; the adhesions binding the uterus backward are broken up, the fundus bro^^ght forward and the uterus stitched to the anterior abdominal wall. The sutures are usually two in number, of either silk or chromicised catgut, and are inserted one just posterior to the middle of the fundus and the other posterior to that, so that when the sutures are tied the uterus will be slightly anteverted. These sutures pass through aponeurosis, muscle, and parietal peritoneum of one side, then through a portion of the fundus of the uterus, then through parietal peritoneum, muscle, and aponeurosis of the other side. These sutures are buried in the closure of the abdominal wound. Another method is to pass the suture through the entire thick- ness of the abdominal wall, then through the fundus and out through the abdominal wall. This suture can be removed later and avoids the possibility of later trouble from a non-absorbable buried suture. The usual antiseptic dressing is applied. A pessary is often inserted for a time. What are the indications for hysterorrhaphy ? Hj^sterorrhaphy is indicated in a retro verted fixed uterus, especially where pregnancy is improbable ; in a retroverted uterus after the removal of both appendages ; as one stage in the operation for pro- lapsus uteri. Kelly says: "Suspension of the uterus should be resorted to only in cases of persistent retroflexion which refuse to yield to simple plans of treatment through the vagina, and then only when the discomforts of the retroflexion are sufficient to inter- fere seriously with health. ' ' What are the disadvantages of hysterorrhaphy ? Experience shows that in pregnancy following hysterorrhaphy the portion of the uterine wall behind the point of suture is that which undergoes the chief distention and thinning. Although obstetric accidents due to the operation are rare, disturbances of parturition, and even rupture of the thinned posterior uterine wall, may occur. What modification has Kelly advocated to obviate the dis- advantages of hysterorrhaphy? He sutures the fundus to the abdominal wall with two silk sutures, PROLAPSUS UTERI. 127 both passed through the posterior aspect of the uterus behiiid a line connecting the inner ends of the Fallopian tubes. These only include with the fundus the parietal peritoneum and subperitoneal connective tissue. The fundus is not so firmly secured as by the former method. It gradually recedes from the abdominal wall and is connected with it by a band of adhesions. In subsequent opera- tions on patients so treated Kelly has found this band measuring three to five centimeters. What is the chief force in retaining" the uterus in a forward position after hysterorrhaphy or Alexander's operation ? It is intra-abdominal pressure now brought to bear on the posterior aspect of the uterus. Describe briefly intra-abdominal shortening- of the round ligaments. After opening the abdomen and separating the adhesions, the uterus is brought forward into normal position and held there by taking up the slack in the round ligaments. This is done by folding each round ligament upon itself and suturing the folds in apposition. Prolapsus Uteri. What is meant by the expression ? Halt and Barbour define prolapsus uteri as a downward displace- ment of entire displaceable portion of pelvic floor, uterus and ap- pendages past entire fixed portion, with coincident descent of small intestine. What is meant by the * 'entire displaceable portion of pelvic floor " ? ' ' The entire displaceable portion comprises bladder, urethra and vaginal walls. It has resting upon it the uteiTis, broad ligament, Fallopian tubes and ovaries. ' ' What is the " entire fixed portion of pelvic floor " ? That outside of the entire displaceable portion, i. e. , tissue attached to the posterior surface of the symphysis ; all outside the inner aspect of the levatores ani ; the rectum and tissue attached to the sacrum. 128 ESSENTIALS OF GYNiECOLOGY. What are the degrees of prolapsus uteri ? According to Thomas there are three : — 1. When the organ has sunk in the pelvis. 2. When the cervix is at the ostium vaginae. 3. When a part or the whole of the uterus lies between the thighs. What is the etiology ? The three elements in the etiology of prolapse are — X. Relaxation of the hgaments of the uterus, combined with lack of tone in the entire displaceable portion of the pelvic floor and " slackening of loose tissue around it. " 2. Lack of support in the entire fixed portion of the pelvic floor, especially laceration of the perineum. 3. Intra-abdominal pressure. The chief predisposing causes are parturition, laborious occupa- tions, anything increasing weight of the uterus, advanced age. Pro- lapse is sometimes produced acutely by blows, faUs, heavy lifting, etc. , but is usually the gradual result of the three elements mentioned above. What are the symptoms ? Those of the acute prolapse are sudden, severe pain, vomiting, retention of urine and signs of peritonitis. The symptoms of the gradual prolapse are a dragging sensation in lower abdomen and back, and the discomfort from the protrusion and excoriation of the parts ; difficulty in urination is sometimes present. What are the physical signs ? These depend on the degree of the prolapse. If the prolapse is partial, the anterior vaginal wall bulges at the ostium vaginse, the cervix is lower than normal, and if there is marked laceration of the perineum the posterior vaginal wall also bulges. The uterus becomes more and more retroverted as it sinks in the pelvis. When the pro- lapse is complete, the cervix and more or less of the body of the uterus lies outside of the vulva; the anterior vaginal wall and part of the lower bladder wall have prolapsed with the cervix; the posterior vaginal wall with or without part of the anterior rectal wall is also everted. The uterus is usually enlarged and the supravaginal por- tion of the cervix elongated. PROLAPSUS UTERI. 129 From what must you differentiate prolapsus uteri ? 1.' Hypertrophy of the cervix: — {a) Vaginal portion ; {h) Supra-vaginal portion ; (c) Intermediate portion. 2. Cystocele. 3. Rectocele. 4. Inversion and polypi. How would you differentiate prolapsus uteri from a cysto- cele ? • In prolapse the uterus is sunken in the pelvis ; in cystocele the uterus lies in nearly its normal position, and the protruding mass is found, by the introduction of the sound into the bladder, to consist of the anterior vaginal and posterior vesical vpall. How would you differentiate prolapsus uteri from a recto- cele? In prolapse the uterus is sunken in the pelvis ; in rectocele, pure and simple, the uterus lies in nearly its normal position, and the protruding mass is found, by the introduction of the finger into the rectum, to consist of the posterior vaginal and anterior rectal wall. Both cystocele and rectocele are common complications of prolap- sus uteri. What is the treatment of prolapsus uteri ? 1. By pessaries; 2. By operation. If the prolapse is slight in amount, the perineum preserved, and the anterior vaginal wall protrudes but a little, a pessary like that of Albert Smith may sufl&ce to hold up the uterus. If this fails, a ring pessary will sometimes answer. If the prolapse is marked, the following combination of operations or of some of them give good results : 1 . Curettage of the uterus ; 2. x\mputation of the cervix ; 3. Anterior colporrhaphy ; 4. Perineorrhaphy ; 5. Hysterorrhaphy. These can all be done at the same sitting. In some cases 1, 2, or 3 niuy be omitted, in others the plastic operations will suffice without the hysterorrhaphy, but in a well-marked case all five are indicated. Vaginal hysterectomy is very seldom indicated for prolapsus uteri. 130 ESSENTIALS OF GYNECOLOGY. Laceration of Perineum and Relaxation of Vagi- nal Outlet. What is the etiology ? The most common cause of laceration of the perineum is child- birth, either natural or instnimeutal ; rarely, however, it may arise I'rom external violence, as falling astride of some sharp object. This occasionally happens to little children. Relaxation of the vaginal outlet, aside from being produced by these visible lacerations, is also caused by submucous and subcutaneous rupture or overstretch- ing of the fibres of the levator ani muscle, or i erineal fascia ; this, too, occm'S most often during parturition. What are the varieties of perineal laceration ? 1. Median. They may be : — a. Incomplete, extending more or less deeply into the perineal body. b. Complete, extending through the sphincter ani and up the rectum for a variable distance. Complete lacerations are less likely to be followed by relaxation and rectocele than are the incomplete. 2. Lateral. These result in a separation of some of the fibres of the levator ani on one or both sides from their attachment into the tendinous portion of the perineal body. Such tears may lie entirely within the vagina, the " skin perineum " remaining intact. 3. Perineal relaxation. Cases without apparent distinct tear, but with all their results. These are cases where there has been more or less subcutaneous rupture of levator ani fibres due to over- stretching. What is the importance of laceration of the perineum ? It consists in the fact that in cases of marked laceration, the fibres of the levatores ani, the chief support of the vaginal outlet, are torn; especially those fibres which are attached to the rectum ; at the same time there is laceration of the fibres of the perineal fascia. These conditions cause relaxation of the vaginal outlet, with a tendency to rectocele, cystocele and prolapsus uteri. LACERATION OF PERINEUM. 131 If the laceration is tlirough the sphincter ani, incontinence of faeces usually results. What are the subjective symptoms of laceration of the peri- neum with relaxation of the vaginal outlet ? The patient usually feels incapacitated for any great exertion, complains of a dragging pain in the back and the feeling of weight in the pelvis. What does a physical examination show ? An enlarged vaginal orifice, cystocele or rectocele ; the anns may be drawn back toward the tip of the coccyx by the sphincter ani fibres attached to its tip and now unopposed by the torn anterior fibres of the levator ani ; the depression between the buttocks at the bottom of which is the anus may be less deep than usual owing to the relaxation and descent of the pelvic floor. How would you determine relaxation of the vaginal outlet ? Insert the thumbs or index fingers into the vaginal oiifice ; sepa- rate the labia by cariying the thumbs or fingers backward and out- ward, at the same time telling the patient to strain ; the lax condi- tion of the outlet will then be readily felt, and anterior and posterior vaginal walls will be seen to protmde. What are the principal operative procedures for repair of lacerated perineum or relaxation of the vaginal outlet ? The four following operations are in common use — 1. Hegar's operation. 2. Emmet's operation. 3. The Saenger-Tait operation. 4. Cleveland's operation. Describe the Hegar operation. (Martin suture.) In this as in all perineal operations, the patient's bowels should be freely moved and the vulva shaved. Just previous to operation, the vagina and vulva should be thoroughly cleansed with soap and water and then irrigated with an antiseptic solution. In the Hegar 132 ESSENTIALS OF GYNECOLOGY. denudation which is triangular in shape (see Fig. 30.) three points are taken, A. B. and C That which is to be the apex of* the tri- angle, A, is in the median line of the posterior vaginal wall ; this is seized with a bullet forceps or tenaculum and drawn upward and forward. The points B and C, at the extremities of the base line, are points on the labia majora which when the operation is com- pleted will form the fourchette. These points B and C are also seized by bullet forceps or tenacula and are drawn apart, thus facilitating the denudation of the triangular area A. B. C Fig. 30. A This denuded surface may either be closed by sutures introduced from side to side, or as is usually done by the author, it may be closed by a continuous catgut suture in tiers according to Martin. This is similar to the Martin method of suturing used in an ante- rior colporrhaphy. (See further on.) When the operation is completed the point A is high up in the vagina, B and C are in apposition. Hegar's operation is best suited to tears which are median or to cases where time is an important element, as in prolapse cases where the perineon'haphy is but one of several operations performed at a sittino;. LACERATION OF PEUliNEUM. 133 Describe Emmet's operation for restoration of the perineum. The patient is jorepared tor operation as usual, with antiseptic douches, etc. She is anaesthetized and placed in the lithotomy position ; a point is selected in the centre of the crest of the bulging posterior vaginal wall, and a point on each labium majus correspond- ing to the lowest vestige of the hymen. These three points are to be brought together by the completed operation. Between the central point chosen and the two lateral are two triangu- lar areas, with apices running into the vaginal sulci on each side of the columna. These triangular areas are first denuded as follows : One tenaculum is inserted into the central point chosen, and another into one of the lateral points ; these are given to an assistant, who draws the central point forward and to the side opposite the other tenacu- lum. This draws the apex of the triangle nearly in line with the two tenacula ; a narrow strip is then denuded with the scissors along this line. When the tension is relieved, the area marked off is seen to be triangular, as before. The denudation of this triangle is then completed by long snips of the scissors. The lateral point on the other side is now seized with the tenaculum, and the central point drawn toward the denuded side ; this triangle is denuded as before, also, as much of the skin surface of the perineum as is necessary. The parts are now thoroughly irrigated and the sutures introduced as follows : The two triangular areas are to be in the vagina, and are sutured with either silkworm gut or catgut. The apex of one tri- angle is first closed, the suture entering and emerging from the vaginal mucous membrane near the denuded surface ; the succeed- ing sutures of this triangle are made to enter the vaginal mucous membrane on one side, slant toward the operator, emerge at the centre of the denuded surface, re-enter, slant away from the operator and emerge from the mucous membrane of the other side a little in front of the preceding suture. This method is repeated in the other triangle. There then remains but a small external denuded area to be closed ; this is best done with silkworm gut. The upper or crown suture, entering the skin on one side, passes through the anterior extremity of the columna of the posterior vaginal wall, and emerges from the skin on the other side. The bowels are moved about the third day and the sutures removed on the eighth. This is an excellent operation for bilateral tears. The two triangles denuded 134 ESSENTIALS OF GYNECOLOGY. up into the vagina lie in two depressions formed by the separation of levator ani fibres from their attachment. Hence when the sides of these triangles are brought together the tendency is to bring the levator ani fibres into apposition with the perineal body. Students find difficulty in understanding this operation from written descrip- tions, but will find it quite simj.ile when once tliey have seen the triangles located on the hving subject. Fig. 31. Describe the Saenger-Tait operation. The patient is prepared for operation by having the bowels freely moved, the vulva shaved, and an antiseptic vaginal douche given. She is then anaesthetized and placed in the lithotomy position, with LACERATION OF PERINEUM. 3 35 knees supported hy Clover's crutch and hips resting on Kelly's perineal pad. The vagina and vulva are now scrubbed with soap- water and irrigated with an antiseptic solution, and an assistant so stationed that he can allow a mild antiseptic solution or sterilized salt solution to trickle on the wound during the operation. A tampon is inserted into the rectum, the string left projecting. The index and middle fingers of the left hand are now inserted into the rectum, as seen in Fig. 31 ; the labia are separated by an assistant, the blades of the scissors (Tait uses angular scissors and inserts only one blade; scissors curved slightly on the flat, with points rather sharp, and both blades in- serted, may be used with advantage) inserted into the recto-vaginal septum just in front of the anus, and the vaginal and rectal mucous membranes separated for some distance around the point of inser- tion. A horizontal incision is now made through the point of inser- tion, extending on either side to a perpendicular through the lower extremity of the nymphae ; an incision is made with the scissors up along this perpendicular to the lower extremity of the nymphae. The flap so marked out is then dissected up to the crest of the bulging posterior vaginal wall. See Fig. 32. The parts are now freshly irrigated, and the sutures of silver wire introduced as follows : Either a Peaslee's needle or a long, straight needle with a thread loop may be used ; the sutures, 3-4 in number, are inserted just within the denuded area on one side, and brought out just within the denuded area on the other. See Fig. 33. The tampon is removed from the rectum, the sutures twisted up and either left long or shotted and cut short. The skin is now brought into apposition by superficial silkworm-gut sutures introduced be- tween the wires, giving the result seen in Fig. 34. An antiseptic dressing and a T-bandage are applied, and the patient is put to bed. The bowels are moved about the third day, and the sutures re- moved on the eighth. This operation has no advantages over the Emmet perineorrhaphy. What is a good method of procedure when the laceration extends through the sphincter ani? Thoroughly cleanse the vagina and lower portion of the rectum. D,enude a V-shaped area with apex up the rectum, representing the torn wall of the latter, and with the arms of the V resting on the ends of the divided sphincter ani muscle. The denuded sur- 130 ESSENTIALS OF GYNAECOLOGY. Fig. 32. Fig. 33. LACERATION OF PERINEUM. 137 face had best be a little larger at these latter points. It is well to dissect out and identify the torn ends of the sphincter to insure their being brought together by the sutures. Sutures of silkworm gut or chromicized gut are now introduced as seen in Fig. 35 with ends in the rectum and tied. The ends of the silkworm gut sutures are left long and protruding from the anus. This repairs the rectal rent, and now the further restoration of the perineum may be accomplished by any of the ordinary methods of denudation and suturing. The Hegar's denudation with Martin's suture answers admirably here. Fig. 34. Fia 35 Describe the Cleveland operation. Dr. Cleveland describes his method in the following words — "The usual broad denudation, extending well into the sulci having been made, the first suture is passed in at the centre (see Fig. 39. A^ 1.) of the denuded surface on the patient's left, a quarter of an 138 ESSENTIALS OF GYNECOLOGY inch from the edge, is carried well back, deep under the tissues, to embrace the retracted muscles, across between the denuded surface and the rectum, to the centre of the denuded surface, then down Fig. 36. and out a quarter of an inch from the edge, at a point (2, Fig. 36.) midway between the centre of the denuded surface on the patient's right, and the posterior commissure D. It is then carried over without cutting, and entered at a corresponding point (3, Fig. 36.) opposite the point where it was brought out; then carried up, buried, to the centre of the denuded surface, across, and out a quarter of an inch bej^ond the centre of denuded edge (4, A, Fig. 36.), directly opposite the point where it was first introduced. The second suture, or suture B in the diagram, is introduced just below the summit of the denudation on left labium (1, ^. Fig. 36.), and LACERATION OF PERINEUM. 139 passed, buried close to the denuded edge, around the angle in the left sulcus to the highest point of denuded surface on the columna, at C, then across, still buried, the angle of right sulcus and out at 2. B, which is a point midway between summit and centre of denu- dation on right labium : then carried over without cutting and is entered at 3. B, a point corresponding to the one where it was just brought out, then across, buried, the angle of left sulcus to the point C, and finally passed around the angle of right sulcus close to the denuded edge and out at 4. B. a point corresj)onding to 1. b:' Dr. Cleveland often introduces a third suture E. as a protection suture. They are usually of silk -worm gut. The sutures are now drawn up and tied beginning with A. Describe the operation of anterior colporrhaphy. This consists in the denudation of an elliptical piece of mucous membrane from the anterior wall of the vagina, and suturing to- gether the raw area thus formed. The ellipse should extend from a little behind the urethral prominence to a point just in front of the cervix. The denudation is usually best performed with scissors, removing the mucous membrane in long strips. The strip to be removed is held taut with toothed thumb-forceps drawn toward the operator, and the ridge thus formed is removed by scissors cutting in the opposite direction and held parallel to the surface of the ridge. The suturing is best done, according to Martin's method, by a continuous suture of catgut, as follows : A line of suture is first made longitudinally along the centre of the denuded ellipse ; this reduces its size slightly ; another tier of sutures is then inserted back over the first, uniting tissue more superficial ; thus the sutures are introduced tier upon tier, each narrowing the denuded area and causing the edges of the mucous membrane to approach each other, till finally in the last tier these edges are included. In Stoltz's method the denudation is as described above, but the suturing is done by means of a single purse-string suture which sur- sounds the denudation and, when drawn tight, puckers it together. This operation may be combined with any operation on the peri- neum and posterior vaginal wall. 140 ESSENTIALS OF GYNAECOLOGY. Hypertrophy of the Cervix. Give the varieties and etiology. Hypertrophy of the cervix may involve either the infra-vaginal or supra-vaginal portions. Some authorities mention hypertrophy of the intermediate jDortion of the ceiTrx. Little is known of the etiology. Hypertrophy of the infra-vaginal portion is usually congenital. Hypertrophy of the supra-vaginal portion usually accompanies prolapse of the uterus or vaginal walls. What are the physical signs and symptoms ? The OS is nearer vulva than normal ; it may even project beyond the vulvar opening. In hypertrophy of the infra-vaginal portion, the cervix is long, usually conical, with small os ; the vaginal fornices and fundus uteri are in their normal position. If the cervix protrudes from the vulva, it may be ulcerated, from friction. ' ' In hypertrophy of the supra-vaginal portion both anterior and posterior fornices are obliterated. ' ' ' ' In hypertrophy of the intermediate portion the posterior fornix re- mains, while the anterior fornix is obliterated . ' ' (Hart and Barbour. ) What are the symptoms ? The symptoms of hyj^ertrophj'^ of the infra-vaginal portion are chiefly mechanical : — Leucorrhoea, from vaginal irritation. Discomfort in exercise. Sense of weight in the pelvis. Sterility. The sjTuptoms of hypertrophy of the supra- vaginal portion are those of the prolapse of the uterus or vaginal walls, which it usually accompanies. What is the treatment of hypertrophy of the infra-vaginal portion of the cervix ? Amputation of the cervix. The best method is probably a circular amputation, proceeding in a manner somewhat similar to that employed in amputation of an extremity, viz, cutting through and retracting superficial strue- HYPERTROPHY OF THE CERVIX. 141 tures, go through cervix higher up, thus making the portion of cervix removed conical. The tissues retract so that the stump left also appears conical, but the superficial structures can easily be brought over it. The vaginal mucous membrane opposite the uterine canal is stitched to the mucous membrane of the cervi- cal canal both anteriorly and posteriorly, care being taken to make the sutures include a portion of the substance of the cervix so as to fasten the flaps down to the stump to prevent oozing and pocket- ing. At the sides of the cervix the flaps will usually come into easy apposition and should be sutured together, taking care as above, that the sutures include the deeper structures and prevent oozing. The lines of suture thus extend from the os a little way into each lateral fornix. Before the cervix is completely removed a few of the sutures may be introduced and used as tractors. Another very good method is that of Simon and Marckwald, in which the cervix is first divided by a transverse incision into an an- terior and posterior lip ; a wedge-shaped piece is then removed from Fig. 37. Marckwald's method of splitting the cervix into an anterior and posterior lip and then uniting cervical to vaginal mucous membrane {Schroeder). each (see Fig, 37), and the flaps of each lip are brought together with sutures, either of silk worm gut, catgut, or silver wire. 142 ESSENTIALS OF GYNECOLOGY. Stenosis of the Cervix. What is the etiolog-y ? It may be either congenital or acquu-ed. Wlien congenital, it is usually associated with a small uterus, long cervix, and anteflexion. Stenosis of the external os is more frequent than of tlie whole canal. Acquired stenosis results from cicatrization following the use of too strong caustics, endocervicitis, or a too complete closure of the cervical canal in a trachelorrhaphy. What are the symptoms ? Dysmenorrhcea and sterility Tlie stenosis results in an insufficient drainage of the cervical canal. The retained secretion gives rise to an endocervicitis which, rather than the stenosis, is to be considered the direct cause of the sterilit}'. What is the treatment ? Dilate the cei-vix with one of the glove-stretcher dilators and maintain the dilatation by the occasional introduction of graduated sounds. Iodoform gauze packing may be used for the first fcAv days foUowing the dilatation of the canal. Laceration of the Cervix. What is the etiology ? The usual cause is parturition or abortion ; it occasionally occurs as a result of mechanical dilatation of the cervix. It occurs in par- turition in about 32 per cent, of women ; especially in tedious, pre- cij^itate or instrumental deliveries. It is predisj^osed to by a rigid OS, faulty presentation or condition of the foetus, premature ruptui'e of the membranes and previous disease of the cervix. What is the pathology ? The laceration may be — 1. Complete. Penetrating the whole thickness of the cervix. 2. Partial. Including cervical mucous membrane, but not ap- pearing on the vaginal surface. It may be — (a) Unilateral (see Fig. 38). (b) Bilateral. (c) SteUate (see Fig. 39). The iinilateral laceration is most apt to occui* in the fine of the LACERATION OF THE CERVIX. 143 right oblique diameter of the pelvis, i. e. , either anteriorly and to the left or posteriorly and to the right, especially the former. This Fig. 38. Single Laceration. The flaps are held apart with a double tenaculum {Emmet), Fig. 39. Multiple or Stellate Laceration {Emmet). is supposed to arise from the greater frequency of the first position of the vertex. Bilateral lacerations are usually more dangerous than those of the anterior or posterior hp, because opening up the cellular tissue of the broad hgaments. •144 ESSENTTAI.S OF GYNECOLOGY. Stellate lacerations are more apt to be superficial. If the surfaces of laceration are kept clean, more or less union will occur. Usually there is partial union, with eversion and pro- Hferation of the cervical mucous membrane, hyperplasia of the con- nective tissue and prohferation of the glandular structure. What are the complications and results ? The most fi-equent comphcations are — 1. Celluhtis. 2. Peritonitis. 3. Endometritis, especially cervical endometritis. The common results are — 1. Subinvolution. 2. Chronic metritis. 3. Displacements of the uterus. 4. Sterihty. 5. Abortion. 6. Epithehoma. If the laceration has extended through the anterior fornix, a vesico- vaginal or vesico -uterine fistula may remain. What are the symptoms ? The symptoms are due to the inflammatory processes to which the laceration gives rise. The patient usually complains of a feeling of weight in the pelvis ; leucoiThoea, disturbances of menstruation, especially menoiThagia ; sterility ; neuralgia and various reflex neuroses, such as suboccipital headache. At the time of the laceration there may be considerable hemorrhage. What are the physical signs ? On making a vaginal examination the cervix usually feels enlarged and more sensitive than usual ; the fissure can, as a rule, be readily detected ; also, if present, the eversion of the cervical mucous membrane, which usually feels velvety, often granular or cystic. Sometimes the eversion is so extreme that one does not notice the fissure, simply feeling the velvety or granular area about the os. The latter may be so patulous as to admit the finger. On making the bimanual examination the uterus is often found enlarged as a LACERATION OF THE CERVIX. 145 whole ; cicatrices may be felt extending from the laceration iuto one of the vaginal fornices. With the aid of the speculum one sees the erosion on one side of or surrounding the os, and by drawing the edges of the laceration together with tenacula the extent of the tear is visible. Without this latter procedure, one is greatly deceived, in some cases, as to the degree of the injury. What is the treatment ? Opinions differ as to whether lacerations of the cervix, unless accompanied by hemorrhage, should be immediately repaired or not. When hemorrhage accompanies the laceration, the cervix should be drawn down to the vulva and the laceration closed with silkworm gut or catgut sutures. The treatment after the puerperium is as follows : The complica- tions, if present, are first treated, especially peritonitis or cellulitis, by counter-irritation, hot-water vaginal douches, glycerine tampons, etc. The cervical endometritis is treated by pricking the cysts, if pres- ent, and applying to the cervical mucous membrane carbolic acid, iodized phenol, or alumnol, 10 per cent, in glycerine. The corporeal endometritis is treated by the curette, if necessary, and applications as in cervical endometritis. The growth of the squamous epithelium over the erosions is stimu- lated by astringent applications, especially pyroligneous acid. Under the above procedures the uterus often returns to its normal size, and the symptoms associated with the laceration disappear. If the symptoms continue after the foregoing treatment, and neither peritonitis nor cellulitis is present, Emmet's operation of trachelorrhaphy is indicated. Describe briefly the operation of trachelorrhaphy. The patient, after the usual preparation regarding bowels, bladder, and antiseptic vaginal douche, is anaesthetized and placed in the dorsal position, with Kelly's pad beneath the hips, and legs sup- ported with a leg-holder. The vulva and vagina are thoroughly scrubbed with soap and water, and an antiseptic douche given. The perineum is retracted with a speculum ; the anterior lip of the cervix is seized with a bullet-forceps, and the uterus drawn down and steadied by an assistant. The edges of the laceration are now pared with scissors or knife, 10 146 ESSENTIALS OF GYNAECOLOGY. giving the denuded area seen in Fig. 40, and leaving enough mucous membrane in the centre for the cervical canal. Care sh.ould be taken to excise the plug of cicatricial tissue at the angle of the laceration. The parts are now irrigated with an antiseptic solution, and the sutures of silkworm gut or silver wire introduced, usually 3-4 on a side, begin- ning at the upper angle. Each is passed from the surface of the vaginal portion, through the thickness of one lip, emerging in the edge of the undenuded mucous membrane ; thence is passed into the edge of tlie undenuded mucous membrane of the other lip, through the lip's substance, and emerges on the surface of the vaginal portion. The other sutures of the same side are introduced in a similar man- FiG. 40. Trachelorrhaphy for Bilateral Laceratiou of the Cervix Uteri. Sutures introduced. ner, care being taken to bring the parts into close apposition and leave no pockets. If the laceration is bilateral, the suturing of the other side is conducted in the same manner. The parts are again irrigated, and the sutures tied or twisted up. A sterile dressing is applied to the vulva and the patient placed in bed. The sutures are left 8-10 daj'^s ; the^^ may be left longer if the peritoneum is repaired at the time of the trachelorrhaphy. ENDOMETRITIS. 147 Endometritis. Define and give the varietie3= Endometritis is an inflammation of the lining membrane of the uteras; it may be either acute or chronic. Acute endometritis usually involves both cervix and body. The chronic is often confined to either cervix or body, and called in the former case cemcal endometritis, endocervicitis, or chronic cervical catarrh ; in the latter case, corporeal endometritis. Occasionally, chronic endometritis affects the whole uterus. Acute Endometritis. What is the etiolog-y ? Before imberty it is rare. The most common causes are the fol- lowing : — 1. Traumatism and sepsis, especially from dirty instruments. 2. Gonorrhoea. 3. Catching cold during menstruation. 4. Excessive coitus near menstruation. 5. Severe types of the exanthemata. 6. It is one of the lesions in puerperal septicaemia. What is its bacteriology ? It is most often due to the gonococcus, less often to the pyogenic streptococci and staphylococci. What is the pathology ? Usually the endometrium of both body and cervix is involved, but the former more than the latter. The mucous membrane is swollen and softened ; extravasations of blood into it occur ; the epi- thehnm is in places destroyed and desciuamated. The secretion is first serous, later purulent, perhaps bloody. What are the complications ? The most comnion are — Vaginitis; Urethritis; Salpingitis; Peritonitis. What are the physical sig^s ? The cervix is enlarged, soft and slightly sensitive ; the endome- trium is veiy sensitive to the sound or probe, and these should be avoided. There is often an erosion about the os, wliich is usually filled with a ropy secretion. The cervix sometimes looks and feels like that of early pregnancy. .48 ESSENTIALS OF GYNiECOLOGY. i/yhat are the symptoms ? The characteristic symptom is the discharge, which is first watery, then creamy. In mild cases there are usually no constitutional symptoms save a feeling of weight in the pelvis and a slight malaise. In more severe cases there is a dull pain in the back and pelvic region, irritability of the bladder, and a slight rise of temperature. What is the treatment ? Put the patient to bed ; give light diet ; move the bowels freely with a saline cathartic ; administer large hot vaginal douches (water Oviij, borax 3viij), temperature 110°-115°, three or four times a day for the first 24-48 hours. Later insert glycerine tampons and con- tinue douches less frequently. Depletion by scarification of the cervix is often of value. Hot applications to the abdomen usually suffice for the relief of pain. Chronic Endoimetritis. What are the varieties ? (a) Chronic cervical endometritis. (b) Chronic corporeal endometritis. A. Chronic Cervical Endometritis. What are the synonyms ? Chronic cervical catarrh and endocervicitis. What is the etiology ? Chronic cervical endometritis is predisposed to by any low state of the system, from whatever cause produced. The most common exciting causes are — (a) Laceration of the cervix. (6) Extension upward of a vaginitis. (c) Extension downward of a corporeal endometritis. (cZ) Displacements of the uterus, especially flexions. (e) Stenosis of the cervix. (/) Traumatism, especially septic. {g) Excessive coitus. Qi) Catching cold during menstruation. What is the pathology ? In mild cases the mucous membrane alon . niay be involved, but ENDOMETRITIS. 149 often more or less of the substance of the cervix is affected. In a well-marked case the epithelium, glands, and interstitial tissue are all involved in the change. The cylindrical epithelium of the canal proliferates and replaces the squamous epithelium on the vaginal portion of the cervix. This is especially true where the cervix is lacerated, and the cervical mucous membrane is everted. The glands of the cervix are hypertrophied and proliferated, and in addition to this, according to Kuge and Yeit, the surface of the mucous membrane is thrown into numerous folds^ producing gland- ular recesses and processes, which may later form cysts. The connective tissue of the cervix is also increased. The reddened areas about the os, where cylindrical epithelium has replaced the squa^ious, and the glandular structure has increased, are called erosions, sometimes wtongly spoken of as " ulcerations. What are the so-called cervi&al erosions ? The term has been applied to a number of distinct pathological conditions : 1. Small ulcers without epithelial covering. 2. A congenital ectropion of the uterine mucosa. 3. Pseudo-erosions. They are covered by a single layer of cylin- drical epithelium and are due to two distinct processes : First, there may be an outgrowth of the mucosa of the cervical canal over the exposed portion of the cervix, gradually pressing back the squamous epithelium from the external os. These heal by a reversed process, {. f., a proliferation of the squamous epithelium, causing a receding of the cjdindrical. Second, the irritation of secretions may cause a maceration and desquamation of the superficial squamous cells of the cervix, leaving exposed the deeper cylindrical ones. Such erosions appear as red spots scattered over the cervix. They heal by a metaplasia of their epithelium. What are the physical signs of chronic cervical endome* tritis? In nulliparae the cervix may feel normal, save a little swollen and sensitive ; sometimes the neighborhood of the os has a granular or 150 ESSENTIALS OF GYNAECOLOGY. In multiparae, especially where tlie cervix is lacerated, the gran- ular area about the os is larger, and small cysts in greater or less numbers can usually be felt. What are the symptoms ? The characteristic symptom is the leucorrhoea ; this may irritate the vulva, causing pruiitus. Pain in the back and loins, especially on exertion, is usually present, but may be slight. Other symptoms are disturbances of menstruation, especially men- orrhagia, sterility and reflex neuroses. What is the treatment ? Attend to the general health and remove, as far as possible, the causes of the endometritis. In mild cases, especially in nulliparae, use hot-water vaginal douches containing an astringent, as sulphate of zinc 3j-0j. If more severe, remove the ropy mucus from the canal with a large-mouthed syringe and apply iodized phenol. When the cervix is cystic or much congested, prick the cysts or scarify the cervix. Fig. 42. Schroeder's excision of the cervical mucous membrane in cervical catarrh. Fig. 41. Line of incision in mucous mem- brane. Fig. 42. Mucous membrane excised and flap be turned in on ab {Schroeder). If the above treatment fails, dilate the cervix, curette thoroughly and drain the uterus with iodoform ganze. Schroeder's operation cr)n?:ists in dividing the cervix into an ante- ENDOMETRITIS. 1 5 1 rior and posterior lip, excising the mucous membrane by a Y-shaped incision (see Fig. 41), and turning in and uniting the hps as seen in Fig. 42. When the cervix is badly lacerated trachelorrhaphy is indicated. B. Chronic Corporeal Endometritis. What is the etiology ? It sometimes follows the acute, more often begins as clironic. The most common causes are — 1 . Parturition, especially when the secundines are not thoroughly removed. 2. Displacements. 3. Traumatism, especially septic. 4. Tumors, especially fibroids and polypi. 5. Excessive coitus. 6. Extension of inflammation from the cervix. 7. Chronic metritis. What is its bacteriolog-y ? The majority of cases are not bacterial in origin. An examina- tion of the endometrium and secretion shows no bacteria except gonococci occasionally. What is the pathology ? The term chronic endometritis as here used is a clinical one and covers two distinct processes : 1. A chronic interstitial inflammation having the features of a chronic inflammation elsewhere, i.e. , a proliferation of the connective- tissue stroma cells. Glandular changes are secondary. They may be dilated, compressed or diminished in number, due to the pressure of the new connective tissue. 2. Hyperplasia of the endometrium. This is not a true inflam- mation, nor due to bacteria, but the result of congestion and chemical irritation. The hyperplasia primarily affects the glands. The}^ may be increased in length and tortuous, penetrating the mucosa in cork- screw fashion. They are frequently dilated and may form cysts. Many new ones may be formed. If all portions of the endometrium are equally involved, then it is uniformly thickened and smooth. Often this is not the case, and 152 ESSENTIALS OF GYNECOLOGY. the unequal involvement of different portions of endometrium results in the formation of " uterine fungosities "' and " villous endo- metritis." In some cases stroma and glands are both affected. Chronic corporeal and chronic cervical endometritis are often associated. What are the symptoms of chronic corporeal endometritis ? {a) LeucoiThoea. (h) Menstrual disturbances, especially menorrhagia. (c) Dysmenorrhoea. (d) Pain in back and pelvic region. (e) Sterility. (/) Abortion. ig) Reflex neuroses. What are the physical sig-ns ? On bimanual examination the uteras is usually found more or less enlarged ; perhaps a little tender. The sound, on introduction, shows the cavity enlarged, and usually detects iiTcgularities in its mucous membrane ; it frequently causes shght bleeding. What are common complications ? Metritis. Salpingitis. Peritonitis. Displacements. Vaginitis. What is the treatment? 1. Prophylactw. — Be careful that the uterus is thoroughly emp- tied after labor or abortion. Avoid exposure during menstraation. Observe strict cleanliness and antisepsis in the use of uterine in- struments. 2. When no IrregiiJarities of the Endometrium are Detected. — Make occasional applications of iodized phenol to the endometrium. Administer internally, three or four times a day, fifteen drops each of the fluid extracts of ergot and hydrastis canadensis. 3. When Iiregularities of the Endometrium are Detected. — If no METRITIS. 153 acute inflammation is present in the neighborhood, dilate tlie cervix and curette the uterus under antiseptic precautions ; wash out the uterus with an antiseptic sohition, making use of a double-current catheter. The curetting, if thorough, is best done under anaesthesia. It is well to confine the patient to bed for a week, and occasional applications of iodized phenol to the endometrium may be necessary. Drainage of the uterus with iodoform gauze for twenty-four hours after the curetting is often of value. Metritis. Describe and give the varieties. Metritis is an inflammation of the parenchyma of the uterus, as distinguished from that of its mucous lining or serous covering. The two varieties are the acute and chronic. Acute Metritis. What is the etiology? Acute metritis rarely if ever exists as an independent condition ; it is almost always associated with an endometritis or peritonitis ; especially the former. The chief causes are — 1. Septic infection during or soon after labor, abortion, or opera- tion ; 2. Gonorrhoea. Acute metritis occasionally arises from exposure to cold during men- struation or sexual excess, but these usually first produce endome- tritis, secondarily metritis. What is the pathology ? The uterus is enlarged, especially antero-posteriorly, infiltrated with serum, soft and tender. The endometrium is also thickened and congested. The peritoneal investment is often covered with lymph. " Microscopically the muscular bundles are infiltrated with pus corpuscles " (Hart and Barbour). Circumscribed abscesses oc- casionally, though rarely, occur in the uterine walls. These often prove fatal, but sometimes are absorbed, sometimes become encap- sulated and cheesy, and sometimes empty into the uterus, bladder, rectum, vagina, intestines, peritoneum, or through the abdominal walls. 154 ESSENTIALS OF GYNECOLOGY. Acute metritis may resolve at the end of a week ; it may pass into the chronic form ; if a result of puerperal infection, it is often fatal. What are the symptoms? They usually resemble those of acute endometritis, but are more severe. The disease is often ushered in with a rigor ; temperature and pulse rise ; there is pain in the hypogastrium and in pelvis. The uterus is very tender on pressure ; there is nausea, usually vesi- cal and rectal tenesmus, and menstruation, as a rule, is disturbed, sometimes suppressed ; more often menorrhagia is present. What is the treatment? If due to sepsis, try to remove the cause ; giving, if necessarj^ intra-uterine irrigations of bichloride (1-5000). Keep the patient quiet in bed ; apply poultices or turpentine stupes to the hypogas- trium ; if temperature is very high, use the ice coil. Empty the bowels with saline cathartics ; if pain is very severe, allow opium by suppository. Later, employ long hot-water douches and glycerine tampons. When intramural abscesses form, hj^sterectomy may be necessary. Chronic Metritis. What are common synonyms? Areolar hyperplasia (Thomas). Chronic parenchymatous inflam mation of the womb (Scanzoni). Diffuse interstitial metritis (Noeg- gerath). What is the etiology? According to Hart and Barbour, the causes may be divided as follows : — (a) Causes which operate through interference with the normal involution of the puerperal uterus. (b) Causes which operate through the production of repeated or protracted congestion of the uterus. (J.) Frequent causes of subinvolution are— 1. Retained secundines. 2. Laceration of the cervix. 3. Pelvic inflammation following parturition. 4. Rising too soon after parturition. 5. Non-lactation. 6. Repeated miscarriages. METRITIS. , 155 {B) Causing repeated or protracted congestion are the following — 1 . Chronic endometritis. 2. Displacement of the uterus. 3. Tumors near the uterus. 4. Chronic pulmonary, cardiac, hepatic or nephritic disease. 5. Excessive coitus. Chronic metritis sometimes follows the acute but usually begins as chronic. What is the pathology ? The pathological changes may be divided into three stages — 1. Hyperaemic; 2. Hyperplastic; 3. Sclerotic. In the first or hyperaemic stage the uterus is enlarged, soft, tender, and contains more blood than normal. In the second or hyperplastic stage there is an increase of the intermuscular connective tissue, with or without a slight increase of the muscular tissue. The vascularity is decreased by the growth of connective tissue around and compressing the blood vessels. The third, or sclerotic stage is a result of the former, the uterus becoming more dense, less and less vascular and finally atrophied. What are the symptoms ? Most of the symptoms are either due to the increased size of the uterus or to the complicating endometritis. The symptoms usually date from parturition or abortion. The following are common — A feeling of weight in the pelvis. Pains radiating to the back, limbs and different parts of the body. Irritability of bladder and rectum. Leucorrhoea. Menstrual disturbances, especially menorrhagia, due to the endo- metritis. Abortion in the early stages. Sterility, later. Reflex neuroses. What are the physical signs ? The uterus in the early stages is uniformly enlarged, soft and tender ; later harder, and in the late stages irregularities of shape 156 ESSENTIALS OF GYNECOLOGY. maj^ be detected. The canal is enlarged in all its dimensions and the sound passes easily. The os is usuahy patulous ; the cervix may be large and nodular. What are common complications of chronic metritis ? (a) Chronic endometritis. (b) Salpingitis. (c) Peritonitis. (d) Ovaritis. (e) Vaginitis. (/) Displacements. What is the treatment of chronic metritis ? 1. Prophylactic. — Care during and after confinement. 2. Curative. — First treat the complications, if present, especially endometritis and displacements, in the usual manner. Attend to the general health, bowels, exercise, etc. Let the patient rest a part of each day, especially at menstruation ; limit coitus. Weir Mitchell's treatment of rest, over-feeding and massage is sometimes of value. Local treatment. — Prolonged hot-water vaginal douches; glycer- ine or boroglyceride tampons ; tincture of iodine to cervix and fornices of the vagina ; scarification of the cervix with Buttle' s spear. Emmet's operation of trachelorrhaphy, or amputation of the cervix by the Simon and Marckwald method is sometimes indicated. Atrophy of the Uterus. What is the etiology ? It is the natural condition after the menopause, and is produced artificially by the removal of ovaries and tubes. It is sometimes associated with phthisis and other exhausting diseases. It occurs as a superinvolution after childbirth, especially as a result of metritis, peritonitis, ovaritis or salpingitis. This superinvolution is the variety of most importance. What are the symptoms ? Amenorrhoea. Sterility. Keflex neuroses. FIBROID TUMORS OF THE UTERUS. 157 What are the physical signs ? ^ The utems is small, both in body and cervix, and the canal is shortened. What is the treatment ? Attend to the general health. Before the menopause, galvanism of the uterus and ovaries may be tried. The treatment is generally unsatisfactory. Fibroid Tumors of the Uterus. What are common synonyms ? Fibro-myomata and myomata. Strictly speaking, fibro-myomata is the more correct designation, as the tumors are composed of both fibrous and muscular tissue. What is the etiology ? Little is known of the cause of fibroids- They are much more common in the African than in the white race ; are most frequently found between the ages 30-45, and are said to be more common in manied than in unmamed women. They rarely, if ever, begin be- fore puberty, and never after the menopause. What is their structure ? Fibroids, or fibro-myomata of the uterus, are tumors composed of both fibrous and muscular tissue, either of which may predominate over the other. The fibrous tissue is usually in excess. Those composed chiefly of fibrous tissue are usually more or less encapsulated and of slow growth. Those composed chiefly of muscular tissue are rare, not encapsu- lated, and are of rapid growth.' They derive their blood-supply from a network of vessels in their capsules, the central portions being without large vessels. What are their situations ? They are much more fi'equent in the body of the uterus than in the cervix. They are most often found on the posterior wall, next in frequency on the anterior wall, rarely on the lateral waUs. The soft, rapidly-growing fibroids are more fi'equent in the fundus. The tumors always begin in the substance of the uterine walls ; 158 ESSENTIALS OF GYNAECOLOGY. tliey may continue their growth there ; may extend into the uterine cavity, hfting up tlie mucous membrane, or outward, Ulting up the peritoneum. Hence the tliree varieties : — 1. Interstitial. • 2. Submucous. 3. Subperitoneal. Fig. 43. IM. Interstitial fibroids. SM. Subiuuooud. (Schroeder.) Describe the three varieties. The interstitial or intramural fibroids (see Fig. 43) are usually multiple and are situated in the substance of the uterine wall. The submucous fibroid (see Fig. 44) may be either sessile or attached by a long pedicle. In the latter case it is called a fibrous polypus. FIBROID TUMORS OF THE UTERUS. 159 The subpcrituiieul or subserous fibroids (see Figs. 45 and 46) are jften multiple ; may be sessile or pedunculated ; may grow upward nto the abdominal cavity and draw uterus up, or grow downward nto the pelvis, and perhaps become incarcerated. They may form idhesions with other organs, get their nutrition through the adhe- sions, and become detached from the uterus. These are the most ibrous, least vascular, and slowest-growing fibromyomata. Fig. 44. Fig. 45. Submucous fihroid. {Schrocder.) Suliperitoiical Fibroid. What changes may occur in fibroids ? 1. They may undergo softening due h) oedema or myxomatous degeneration, rarely fatty degeneration. By this softening fibro- cysts may be formed. 2. They may undergo hardening, due to {n) atrophy, especially after the menopause, or removal of ovaries and tubes. The mus- cular tissue degenerates, and the fibrous tissue ccmtracts. ijj) Calci- f cation, with the deposit of lime salts, beginning usually in the centre, sometimes at the periphery. 3. Tliey may suppurate. This occurs most often in submucous fibroids, especially after instrumental traumatism ; rarely in the subperitoneal variety after torsion of the pedicle. 160 ESSENTIALS OF GYNECOLOGY. | 4. Submucous fibroids may become more and more pedunculated, forming polypi. They are sometimes extruded from the uterus.' Sometimes the capsule ruptures, and spontaneous enucleation occurs. 5. Cysts are formed by the softening of tissue and by the dilation )f lymph-spaces. J 6. Fibromyomatous uteri are occasionally the seat of carcinomJ i)f their mucosa. I What changes occur in the uterus ? The muscular wall hypertrophies, especially in the submucous or mterstitial varieties. The mucous membrane also hypertrophies, both in glands and connective tissue. Over the tumor the mucous membrane sometimes ulcerates. Fig. 46. Subperitoneal Fibroid. Changes in the position of the uterus are often produced :— 1. It may be drawn up into the abdomen. 2. It may be prolapsed. 3. It may be inverted, especially from submucous fibroids attached to the fundus. Describe briefly fibroids of the cervix. They, too, may be either interstitial, submucous or subperitoneal ; they are usually hard and single. The subperitoneal often grow out between the folds of the broad ligament. FIBROID TUMORS OF THE UTERUS. IGl The submucous and interstitial are apt to become pedunculated and form polypi. The interstitial fibroid of the cervix is sometimes mistaken for inversion of the uterus. What are the symptoms of fibroid tumors of the uterus ? 1. Hemorrhage. — First, monorrhagia, later metrorrhagia ; delayed menopause ; these occur especially in the submucous variet}^ 2. Pain. — (a) Dysmenorrboea, chiefly in the submucous variet3^ (b) Pain due to pressure on the pelvic nerves or to peritonitis around the tumor. 3. Symptoms due to pressure : — On bladder, causing : — Irritability. Retention. Cystitis. On urethra, causing: — Difficulty in micturition. Perhaps retention. On ureter, causing : — Hydronephrosis. On rectum, causing: — Constipation. Diarrhoea. Sometimes tenesmus. Piarely complete obstruction. On pelvic nerves, causing : — Neuralgia. Numbness. On veins, causing : — Varicosities. 4. Sterility. 5. Abortion. What are the physical signs ? Except in the case of some subperitoneal fibroids, the uterus is enlarged. If within reach, a tumor is felt, harder than the muscular sub- stance of the uterus, and movable with the uterus unless it is attached with a very long pedicle. If it is a small fibroid in the cervix it may bulge into the vagina and resemble inversion of the uterus. \ If it is a submucous fibroid, high up in the uterus, the sound may 11 162 ESSENTIALS OF GYNAECOLOGY. detect it, but often it is necessary to dUate the cervix and introduce the finger. If it is subperitoneal and on the anterior wall, a hard mass is felt in the anterior fornix moving with the uterus ; the fundus may be felt behind it, and the sound on introduction does not pass into it. If on the posterior wall, a hard mass is felt in the posterior fornix ; the bimanual shows fundus in front of it, and the sound passes in front of it. If it is a large fibroid extending into the abdomen, it is flat on per- cussion unless intestine overlies it ; auscultation may detect the ute- rine souffle, especially at the sides, and the mass seems to belong to the uterus. From what must you differentiate a fibroid tumor of the uterus ? Chronic metritis. Flexions of the uterus. Pregnancy. Ovarian cyst. Ectopic gestation. Pelvic h^ematocele. Inflammatoiy deposits. Inversion of the uterus. How would you differentiate a small fibroid tumor from chronic metritis ? Small Fibroid vs. Chronic Metritis. Enlargement not uniform, usually Enlargement uniform. hard irregularities. Less sensitive. More sensitive. Os usually unaffected. Os usually everted. Both conditions may co-exist. The difi'erential diagnoses between fibroids and flexions of the uterus have already been given (see page 115, Fig. 23). How would you differentiate a fibroid tumor from pregnancy ? Fibroid Tumor vs. Pregnanqj. Menstruation continues ; usually Ameuorrhcea is the rule. increased. Cervix not softened. Cervix softened. FIBROID TUMORS OF THE UTERUS. 16^ Later. Absence of positive signs of preg- Positive signs present, nancy. How would you diJBferentiate a fibroid tumor from an ovariaik cyst? Fibroid Tumor vs. Ovarian Cyst. Hard and firm. jMore intimately connected with uterus. More central. Menorrhagia common. Soft and elastic. Less intimately connected with uterus. More lateral. MenstiTiation normal or irregu- lar ; menorrhagia rare. How would you differentiate a fibroid tumor from an ectopic gestation ? Fibroid Tumor vs. No menstrual period skipped. Grows less rapidly. More central. More intimately connected with uterus. No decidual membrane cast oif. Absence of attacks of very severe sharp pain, with symptoms of collapse. Ectopic Gestation. Menstrual period or periods usually skipped. Grrows more rapidly. More lateral. Less intimately connected with uterus. Decidual membrane cast oif. Such attacks occur. How would you differentiate a fibroid tumor from a pelvic haematocele ? Fibroid Tumor Gradual development. Absence of acute symptoms. Insensitive to pressure. Hard and firm. Moves with uterus. vs. Pelvic Hoimatocele. Rapid development. Symptoms of sudden sharp pain, shock and hemorrhage. Sensitive to pressure. First soft, later harder. Does not move with uterus. 164 ESSENTIALS OF GYNECOLOGY. How would you differentiate a fibroid tumor from a pelvic inflammatory deposit ? Fibroid Tumor vs. Injlammatoiy Deposit. Slow growth ; no history of acute History of rapid development, inflammation. and acute inflammation. Moves with uterus, and seems a Usually does not move with part of it. uterus, and seems less a part of it. Insensitive to pressure. Sensitive to pressure. What is the prognosis of fibroid tumors ? It will depend on nearness to the menopause, rapidity of growth, pressure symptoms, and endometritis ; the size of the tumor is of comparatively small importance, as a large one may produce few symptoms. Death results from anaemia, sepsis, urinary disease complicating pregnancy, or intestinal obstruction. What is the treatment ? A fibroid if small may give rise to no sj^mptoms and need no treatment. Treatment, if needed, may be (1) paUiative or (2) curative. Palliative Treatment. — [a) Drugs. — The administration of ergot alone or in combination with hydrastis may control the symptoms until the menopause is reached, when the tumor usually diminishes in size ; the menopause, however, is often considerably delayed. (b) Curettage. — If the symptoms are chiefly menorrhagia or metrorrhagia, a thorough curettage of the uterus, followed at inter- vals by astringent applications to the endometrium, will often give marked relief. (c) Diminution of blood-supply. — Ligation of the uterine arteries ftom the vagina has proven of value in some cases, but is uncertain. Tait's operation of removal of the, ovaries and tubes has in many cases been not only palliative but curative ; of late, however, it has been abandoned in favor of h5^sterectomy. Curative Treatment. — This consists of either myomectomy or hys- terectomy. FIBROID TUMORS OF THE UTERUS. 1 G5 Describe the operation of myomectomy. M3'omectom3' consists in exposing the tumor in the uterus, ehher from the abdomen or vagina, incising the capsule, enucleating the tumor, and closing its bed with catgut sutures. This operation is indicated where the tumor can be easily removed without serious mutilation of the uterus. The operation is gaining in favor and may be employed even when the tumors are multiple. What are the varieties of hysterectomy ? Hysterectomy, removal of the uterus, may be performed : (a) Through the vagina — vaginal hysterectomy^ indicated when the uterus and tumor are small. [h) Through the abdomen — ahdommal hysterectomy, indicated when the uterus and tumor are large. Describe the operation of vaginal hysterectomy for fibro- myoma uteri. This differs from the operation described under carcinoma uteri only in the fact that in cases where fibro-myomata are large enough to cause symptoms the uterus with its tumors is often too large to come through the vagina without removing it piecemeal, ■?'. e. by morcellation. After thorough disinfection of vulva and vagina, the uterus is curetted and in'igated with a sterile solution ; the cervix is drawn down and separated from its vaginal attachments ; the peritoneum is opened anteriorly and posteriorly and the uterine arteries are tied on both sides. If the uterus is too large to be removed as a whole, wedge- or disc-shaped pieces are removed from its centre or the uterus is divided in the median line and each half removed separately, care being taken to keep up traction on the uterus by volsellse placed above the part to be removed. The broad ligaments are either ligated in section, or if more convenient during the operation, they may be clamped, and after the uterus is removed these clamps may or may not be replaced by ligatures according to the judgment of the operator. After the removal of the uterus, the pedicles are inverted into the vagina and sterile or iodoform gauze placed against them. Describe the operation of abdominal hysterectomy for fibro- myoma uteri. The preceding operation, owing to the amount of technical skill 166 ESSENTIALS OF GYNECOLOGY. required and the difficulty in safel}^ handling intestinal adhesions, has largely fallen into disrepute and given place to one of the two following forms of abdominal h3'sterectomy : a. In one the cervix is removed — total extirpation. With this are associated the names Eastman, Martin, Chorbak, Polk. h. In the other the cervix is left in the abdominal cavity — supravaginal hysterectomy. This is called Baer's method. In both of these methods, after opening the abdomen, the broad ligaments are tied in section and cut close to the uterus. In the total extirpation this ligation and cutting is continued down to the vagina : this is freed from the cervix and the whole uterus removed. In the supravaginal hysterectomy (Baer) the ligation and cut- ting of the broad ligaments is continued until the cervix is reached and the uterine arteries are tied and cut ; the uterus is then ampu- tated at the cervix, and the latter is left, the vagina not being opened. In each of these methods flaps of peritoneum are taken from the anterior and posterior surfaces of the uterus before its removal, and before closing the abdomen these flaps are brought together over the pedicles in the bottom of the pelvis. Inversion of the Uterus. What is the patholog-y? In inversion, the utenis is turned more or less completely inside out (see Fig. 47). It may be either — 1. Partial — where the depressed uterine wall does not extend beyond the os externum ; or 2. Complete — where the inverted body, covered with mucous membrane, hes outside of the os externum, either in the vagina or between the labia. The mechanism of production of the inversion is as follows : — A portion of the uterine wall loses its tone, is depressed into the uterine cavity, usually by traction from below or abdominal pressure from above ; the depressed portion is then grasped by the unde- pressed portion and forced toward or through the cervix. INVERSION OF THE UTERUS. 167 The peritoneum follows the depression of the uterine wall, and lines the cup thus formed. The appendages may or may not lie within the cup. The inversion occurring during the puerperium usually begins at the placental site ; when produced by intra-uterine tumors, it usually begins at the attachment of the tumor. The uterine mucous mem- brane is usually congested ; it may ulcerate ; sometimes it becomes gangrenous. Occasionally it becomes covered with squamous epi- thelium, and resembles skin. Fig. 47. Inversion of Uterus (half-size, Barnes from Orosse's essay). The fundus lies in the vagina; the cervix is not inverted; the lips are flattened out to a swelling seen below the angle of inversion. The ovaries (seen from behind) are not in the peritoneal cup. What is the etiology ? Inversion is predisposed to by — {a.) Parturition. (6.) Distention of the uterus from any cause. (c.) Intra-uterine tumors. id. ) Degeneration of uterine walls. According to the time and cause of production, two varieties are recognized : — 1. Puerperal. — Produced during the puerperium, either by ab- 168 ESSENTIALS OE GYNECOLOGY. dominal pressure or mismanagement in the delivery of the placenta, especially the latter, traction on the cord being one of the most fre- quent causes. 2. Non-puerperal. — Secondary to intra-uterine tumors ; especially pedunculated fibroids growing from the fandus. The puerperal variety is much more common than the non-puer- peral. The former is usually rapid in development ; the latter gradual. When the inversion is developed and reduced during the puer- perium, it is called acute ; otherwise, chronic inversion. What are the* symptoms ? At the time of the occurrence of acute inversion, there is pain, hemoiThage, shock, a feeling as of something giving way, and of full- ness in the vagina. This belongs especially to obstetrics. The symptoms of the chronic inversion are hemorrhage, dragging pain in the pelvis, discomfort from the foreign body in the vagina, leucorrhcea, anaemia and general malaise. Rarely inversion exists with very few symptoms. What are the physical signs ? These depend on whether the inversion is partial or complete, acute or chronic. In the partial variety the cupping may be felt by the hand on the abdomen, and the inverted portion detected by the use of the sound in the uterus. In the acute, complete inversion, one feels a soft, bulging tumor in the vagina or between the labia ; it bleeds easily, is sensitive and smaller above where it is encircled by the cervix ; it may or may not have the placenta attached to it. The sound passes around the tumor, but only a short distance into the ceiTix. The hand on the abdomen detects the absence of the fundus and the presence of the cervical ring. The physical signs of the chronic inversion are similar, save that the mass in the vagina is smaller, harder, and in the non-puerperal variety perhaps has attached to it the tumor which was its cause. From what must you differentiate inversion of the uterus ? From polypi and prolapsus uteri. INVERSION OF THE UTERUS. 169 How would you differentiate inversion of the uterus from a polypus ? The diagnosis of a complete inversion (see Fig. 48) from a polypus lying in the vagina (see Fig. 49) would be made as follows : — Inversion Fundus not felt in the abdomen ; cervical ring felt. Sound passes all around tumor, but only a short distance into the cervix. vs. Polypus. Fundus felt in the abdomen. Sound passes into the uterus, at the side of the tumor, more than 2J inches. Fig. 49. Fig. 48. Inversion of Uterus (after Thomas). A cup-shaped depression is in the place of the uterus. Sound ar- rested at angle of flexion. Uterine Polypus (after Thomas). The uterus in its normal position. Sound passes into uterine cavity. The differential diagnosis between a partial inversion and an intra- uterine polypus (see Figs. 50 and 51 ) is often quite difficult. Careful examination by the ordinary bimanual and by the abdomino-rectal method may detect the cup-shaped depression of the partial inver- 170 ESSENTIALS OF GYNECOLOGY. sion. Enlargement of the uterus rather favors the diagnosis of polypus. Both of these conditions may rarely coexist. How would you differentiate inversion of the uterus from complete prolapse ? This rarely causes difficulty. It is made by finding in the latter the external os, the obliteration of the fornices, and by passing the sound into the uterine canal. What are the results of an untreated inversion ? Yery rarely it reduces itself Rarely the patient suffers little inconvenience from it. Usually the patient dies from hemorrhage or sepsis. Fig. 51. Fig. 50. Partial Inversion of Uterus (after Thomas). Polypus still Intra-uterine (after Tliomas). What is the treatment ? The object sought is the reposition of the fundus uteri. Emmet's method (see Fig. 52) consists in inserting the right hand into the vagina, grasping the fundus in the palm, inserting the fingers into the cer^^x and pushing upward ; at the same time sepa- rating the fingers as much as possible. The left hand meanwhile exercises through the abdomen counter-joressure on the cervical ring. Noeggerath begins the reposition by dimpling in one horn of the uterus, and then uses this as a wedge to dilate the cervix. POLYPI. ITl Instead of the hand alone, cup-shaped repositors are often made use of. In all these methods the patient is usually best prepared for the manipulation by the administration of prolonged hot-water douches, and the introduction of a vaginal elastic bag, to be distended with air or water, and worn twelve to twenty-four hours. The manipulations are best jierformed under anaesthesia. When the above methods fail, hysterectomy probably offers the best result. Fig. 52. Reposition of the Inverted Uterus with the Hand alone (after Emmet). Polypi. What is meant by the term '* uterine polypus," and what are the varieties? A polypus is a pedunculated tumor attached to the uterine mucous membrane. The following varieties are recognized :— 1. Fibrous polypi. 2. Mucous polypi. 3. Pedunculated Nabothian follicles. 4. Placental polypi. 5. Papillomata of the cervix. 172 ESSENTIALS OF GYNECOLOGY. Describe briefly the fibrous polypi. Fibrous polypi are submucous fibroids whicb bave become pedun- culated ; at first lying witbin tbe uterus ; later, dilating tbe cervix and becoming vaginal (see Fig. 53), sometimes even projecting beyond tbe vulva. They spring from tbe muscular wall of tbe utems, more often Fig. 53. Intra-uterine Submucous Fibroid whicb is becoming Yaginal {Sir J. Y. Simpson). from tbe body tban cervix ; tbey are composed cbiefly of fibrous tissue witb few blood vessels. Tbeir presence sets up uterine con- tractions, wbicb gradually expel tbem. Tbeir sbaj^e is usually pyriform or ovoid. Describe the mucous polypi. These spring from tbe uterine mucous membrane, cbiefly that of the cervix. There are usually more than one (see Fig. 54) ; they are POLYPI. 173 small, soft, vascular, and on section present tlie structure of mucous membrane. What are the pedunculated Nabothian follicles ? They are the glands of the cervical mucous membrane which have become obstructed, formed retention cysts and assumed the polypoid shape. What are placental polypi ? They are portions of undetached placenta which have received nutri- FlG. 54. Group of Mucous Polypi growing in the Cervix Uteri {Sir J. Y. Simpson). ment from theh attachment to the uterus, have become coated with fibrin and so increased in size. By the uterine contractions they are made more pedunculated, and may be extruded from the cervix. Describe the papillomatous variety of polypus. Papilloma of the cervix is almost always either a malignant new growth or tends soon to become so. It is often called a ' ' cauli- flower excrescence" (Clarke), (see Fig. 55), is usuaUy soft, friable, and bleeds easily. 174 ESSENTIALS OF GYNECOLOGY. What are the symptoms of polypi ? 1. Hemorrhage. — First menorrhagia, then metrorrhagia, the source of the blooa being the mucous membrane, which covers, or in the mucous variety forms, the substance of the polypus. 2. Leucorrhoea. — Due to the accomi)anying endometritis. 3. Pain. — Due to the efforts of the uterus to expel the tumor. 4. Sterility. — Due to the mechanical obstruction and to the endo- metritis. Fi®- ^■5- 5. Anaemia and general malaise. — Resulting from the foregoing condi- tions. What are the physical sig^ns ? When the polypus has passed the os externum, the finger in the vagina de- tects a pyriform or ovoid body, hard or soft according to the variety; it is movable and seems to come from the OS. The use of the speculum deter- mines its appearance. If it is a fibrous polypus, the bi- manual examination usually shows the uteiTis enlarged, and the sound proves the cavity elongated . When the polypus is intra-uterine, the sound in some cases will detect its presence ; in other cases dilatation of the cervix and introduction of the fin- ger is necessary. What is the treatment ? When the polypus is of considerable size and lies within or external to the OS, the best treatment is removal by the wire ecraseur, putting the wire loop as near the uterine attachment of the pedicle as possible. Small polypoid projections may be scraped away with the curette ; cervical polypi may usually be twisted off with the forceps. When the polypus lies within the uterus, dilate the cervix and apply the ecraseur. Cauliflower Excrescence growing from the Cervix Uteri {Sir J. Y. Simpson). CARCINOMA UTERI. 175 If the pedicle is small, blunt, dull scissors may be substituted for the ecraseur. If the pedicle is large or dilatation of the cervix is necessary, anaesthesia is to be employed. All antiseptic precautions are to be used. Carcinoma Uteri. What is the pathology ? Carcinoma may begin in the cervix or body, being five times more frequent in the former. That of the cervix is of several forms. It may begin in the squamous cells of the vaginal surface ; this is the epithelioma or cauliflower excrescence of the cervix. Microscopically it consists of plugs of epithelial cells extending deeply into the cervical tissue. Epithelial pearls, common in epithelioma of the skin, are rarely seen here. Carcinoma of the cervical canal originates from the epithelium lining the canal or from that of the glands. These growths break down, forming necrotic ulcers with indurated edges. The vagina and body may become involved by direct extension and, through the agency of the lymphatics, the musculature and broad ligaments are involved. Involvement of lymph-nodes is a late occurrence. Carcinoma of the uterine body arises from the lining epithelium of the cavity or from its tubular glands, and presents the appearances common to adeno-carcinomata. The occurrence of primary squa- mous-celled carcinoma of the body of the uterus is admitted by Amann and others. Carcinoma of the body is diffuse, circumscribed, or polypoid. What is the etiology? The etiology of cancer of the uterus is still unsettled. The factors which favor its development are age, heredity, parturition, laceration of the cervix, with erosion and depreciation of the vital powers- 1. Age. — It occurs most frequently between the ages of 40-50, but may occur as early as 25. 2. Heredity. — Although regarded as of less importance than for- merly, its influence seems to be exemplified in some cases. 3. Parturition. — Frequent child-bearing apparently creates a marked predisposition. 176 ESSENTIALS OF GYNECOLOGY. 4. Laceration of the Cervix,. — Cancer of the cervix seems often to arise from a laceration, with erosion and cervical endometritis. 5. Depreciation of the Vital Powers. — Poor surroundings, poor food and ah and hardships of any kind seem to predispose to cancer. What are the symptoms ? 1. Hemorrhage. — This is usually the first symptom. If hemor- rhage occurs after the menopause, always suspect cancer, 2. Offensive Discharge. — Does not occur until ulceration begins. 3. Pain. — When the cervix is alone involved, pain is usually ab- sent. When the disease has extended to the ceUular tissue or peri- toneum, or involves the body of the uterus, pain is common. 4. Cachexia. — This is always present to a greater or less extent in the later stages. What are the physical signs ? If the disease affects the vaginal portion of the cervix, the exam- ining finger detects a rough, ulcerated and indurated area, or perhaps a fungoid mass. On withdrawal, the finger is usually stained with blood and emits a foul odor. The speculum gives us the appearance of the growth. Wlien the cervical canal is the point of origin one may feel a nodular cervix or more commonly a hollowed out canal, the walls of which break down under the examining finger. Carcinoma of the body of the uterus enlarges it and may be detected by the sound. What is the prognosis ? It is better in cancer of the corpus uteri than of the cervix, but is bad in both. Many have passed the operable stage when first applying for treatment. It can be improved by earlier diagnosis made by microscopical examination of curettings in all suspected cases. What is the treatment of carcinoma of the uterus ? 1. Radical. — When the disease is limited to the uterus, either cervix or body, vaginal hysterectomy is indicated. Aside from the appearance of the diseased area viewed through a speculum, the mobility of the uterus largely determines whether or not the disease has extended CARCINOMA UTERI. 177 beyond it. If the uterus is fixed in the pelvis, hysterectomy is usually contraindicated. The combined abdominal and vaginal method offers some advan- tages. Werder ligates both broad ligaments through the abdomen, and continues his dissection downward till the upper part of the vagina is separated from its attachments. The patient is then put into the lithotomy position, a circular incision is made through the vaginal wall some distance below the cervix, and the mass, consisting of uterus, appendages, and part of the vagina, is- removed through the vagina. 2. Palliative. — When a radical operation is contraindicated, the following methods of treatment are of value : — If hemorrhage is a marked symptom, and sloughing masses are present at the seat of ulceration, thoroughly curette the surface and apply carbolic acid, iodized phenol, or a solution of chloride of zinc. Frequent insertions of iodoform gauze soaked in a 4 per cent, solu- tion of chloral will be found to act as an antiseptic and anaesthetic to the ulcerated surface. For the foul discharges, vaginal douches of a weak solution of creo- lin are valuable. The pain and distress in the later stages demand opium. Attention to the general health is of course indicated. Describe briefly the operation of vaginal hysterectomy. Different operators differ somewhat in the details of the operation. The main features of the operation are as follows: The vulva is shaved, and the vagina and vulva thoroughly disinfected. The uterus is drawn down and held by an assistant; a semicircular incision is made around the cervix in the anterior fornix, and the cervix is separated from the bladder up to the utero-vesical pouch of the peritoneum. The cervix is drawn forward and the po&terior fornix opened by a semicircular incision about the cervix, w^hich is then freed up to the pouch of Douglas. The pouch of Douglas may now be opened, and a clean sponge with a long piece of silk attached, introduced to keep back the intestines. The uterus is I'reed from the lower portion of the broad ligaments by ligaturing in section, and then cutting with scissors close to the uterus. The latter may now be retroverted through the opening in the pouch of Douglas, and freed from the upper portion of the broad ligaments 12 178 ESSENTIALS OF GYNECOLOGY. by ligaturing, and cutting close to the uterus. It is well to draw the ovaries into the ligature, so that they will be removed with the uterus. The anterior reflection of peritoneum may now be divided, or, as practiced by many operators, this may be done before retro- verting the uterus. All hemorrhage is checked and the parts are cleaned ; the peritoneum is stitched to the vaginal wall ; and a single suture unites the anterior and posterior vaginal walls in the median line. Two small strips of iodoform gauze are placed in contact with the stumps of the broad ligaments and their ends brought out through the vagina. Some use clamps throughout the operation instead of ligatures. Sarcoma of the Uterus. What is the pathology ? Sarcoma of the uterus is a growth usually originating in the con- nective tissue of the mucosa and early appearing as a diffuse infiltra- tion of it, and later extending to the uterine muscle. It may, how- ever, begin as a nodule in the musc-uiar wall. It usually affects the body of the uterus, being rare in the cervix. The masses are usuallj'- grayish in color, soft and brain-like ; occasionally the circumscribed masses are firm and resemble fibroids, but have no capsule. They usually do not ulcerate as rapidly or deeply as carcinoma, but form larger tumors, and metastases are less common. What is the etiology ? Little is known concerning it. It is most frequent between the ages forty to fifty, but, unlike carcinoma, often occurs in nulliparous women. What are the symptoms ? 1. Hemorrhage. 2. Watery discharge. 3. Pain. 4. Cachexia. Thus the symptoms are similar to those of carcinoma. Some authors claim, however, that the discharge is less offensive than in carcinoma, because there is less tissue necrosis. DEGIDUOMA MALTONUM. 179 What are the physical signs ? The uterus is usually enlarged ; the sound, when introduced, detects great irregularity of the endometrium, and usually causes bleeding. If the curette is used, a grayish, brain-like material is removed. With what are sarcoma and carcinoma of the hody of the uterus most likely to be confused, and how is the diagnosis made ? They are chiefly to be confiised with villous endometritis, sloughing polypi or retained secundines. The diagnosis is made by removing fragments with the curette, knife or scissors, and subjecting them to microscopical examination. Marked angemia and emaciation would lead one to suspect malignant disease, yet severe endometritis or a vascular polypus may cause similar symptoms. What is the treatment ? Hysterectomy gives us the only prospect of cure. The palliative treatment consists in curetting and applying caustics to the interior of the uterus, keeping the vagina clean with anti- septic douches, as weak creolin, and relieving pain with opium. Deciduoma Malignum. What are its synonyms ? Chorio-epithelioma, decidual celled sarcoma, and syncytial car- cinoma. These terms have been applied to a fairly well defined group of cases of malignant uterine disease, whose pathological appearances have varied somewhat in different cases. Give its pathology. The tumors consist of masses of cells often surrounding spaces filled with blood and fibrin. The cells are round, spindle, or polyg- onal, depending on how closely they are packed together. Further- more they contain irregular masses or streaks of protoplasm with nuclei scattered through them, but with no division of the proto- plasm into cells. Different writers have thought that they originate in the following structures : IgO ESSENTIALS OF GYNECOLOGY. a. Decidual cells ; hence a tumor of maternal connective tissue origin ; a deciduoma. b. Langhans' layer of cells of the chorionic villi ; hence foetal m origin ; a chorio-epithelioma. c. The syncytial layer of the villi. This is the prevalent view and is based on the close resemblance of the protoplasmic masses in the tumor to syncytium. Syncytium is an epithelial structm-e, but whether maternal or foetal is disputed. Give its course and symptoms. It occurs most often between the age of twenty and thirty-fave years. It always follows a pregnancy, and in nearly half the cases has followed hydatidiform mole. Hemorrhage, watery discharge, and pain rapidly appear. Metastases are early and numerous. The vagina and valva are often involved by extension or metastasis and before death a number of abdominal and thoracic organs will show tumors whose microscopic appearances closely imitate those of the uterine growth. Death will follow, as a rule, within six months of the termination of the preceding pregnancy. What is the treatment ? If a diagnosis can be made, with the help of the microscope, before metastases have occurred, immediate hysterectomy is indi- cated. Salpingitis. What is the pathology "? In salpingitis there is usually first a catarrhal or suppurative inflammation of the mucous membrane of the tube ; this, extending to the peritoneum, sets up a localized peritonitis which usually closes the fimbriated extremity, and often by adhesions distorts the tube. From the closure of the outer extremity and the narrowing of the lumen in difi'erent places by the traction of peritonitic adhesions, the secretions are retained and distend the tube. This distention is favored by the softening arising from the inflammation. Other portions of the tube may be thickened, partly from inflammation of the tube itself and partly from the neighboring peritonitis. The closure of the abdominal ostium is accomplished either by an SALPINGITIS. 181 adhesion to adjacent structures or the swelhng of the muscular rin.ij at the outer end of the tube constricts it ; the swollen fimbriae are thus compressed, then adhere and retract into the tube, or rather they remain of the same length and the swollen muscular wall extends out over them. The uterine ostium, as a rule, is made com- pletely impermeable by the swelHng of the tube, but is not obliterated. The varieties of salpingitis, named according to the tubal contents, are — 1. Hydrosalpinx. 2. Haematosalpinx. 3. Pyosalpinx. What is the etiology of salpingitis? It usually arises from an extension to the tube of an inflammation of the endometrium, and its etiology is that of the endometritis, especially — 1. Sepsis during parturition or abortion. 2. The use of septic instruments. S. Gonorrhoea. What is the bacteriology of salpingitis ? The normal tube is free from bacteria. The most frequent inciter of salpingitis is the gonococcus, after this organism and about in the order of frequency in which they are found are the tubercle bacillus, streptococcus, staphylococcus, bacterium coli commune, and pneumo- coccus. Mixed infection is very rare. After a time bacteria die out in a pyosalpinx, so that a majority of such tubes examined have been found sterile. What are the characteristics of a hydrosalpinx ? In a hydrosalpinx the tube is distended with serum, the result of a catarrhal inflammation. The softening of the walls easily allows the distention, which varies in position according to the traction of peritonitic adhesions. Hydrosalpinx is occasionally associated with fibroids of the uterus and is probably not then of bacterial origin. What are the characteristics of a haematosalpinx ? Here the tube is distended with blood, which may have one of three sources: — 1^2 ESSENTIALS OF GYNECOLOGY. 1. It most often occurs as a result of a tubal pregnancj'. 2. It ma}^ be exuded from the tubal mucous membrane as a re- sult of the catarrhal inflammation. 3. It may occur as an extension of a hpematometra due to atresia of vagina or cervix. The tube is usually first hypertrophied, later thinned, and it may rupture ; this accident is usually delayed by peritonitic thickening about the tube. The blood is generally thick and tarry. What are the characteristics of a pyosalpinx? The tube is usually more thickened and surround id by more peri- tonitic adhesions than is hydrosalpinx. The pus may be slight in amount, or the tube may be immensely distended with very fetid pus. The mucous membrane of the tube maj^ be fairly well preserved and the seat of suppurative inflammation, or may be replaced by granulation tissue. Pus-tubes may be drained b}^ rupture into hol- low viscera or intraperitoneal rupture may occur, resulting in pelvic abscess or general peritonitis. What are the symptoms of salping^itis ? The patient usually suffers from a burning and dragging pain in the region of the affected tube, especially on standing and walking. Dysmenorrhoea is common ; repeated attacks of peritonitis are not infrequent. In the case of pyosalpinx septic symptoms may be pres- ent. There is tenderness on pressure in the lateral vaginal fornix, and on making a bimanual examination an elongated cystic mass can usually be detected at the side of the uteras. What are the results of salpingitis ? A hydrosalpinx or hoematosalpinx occasionally subsides so as to cause few symptoms ; they may become purulent and form pyo- salpinx. A haematosalpinx may rupture into the peritoneum or into the broad ligament, forming an hgematocele in the former case, and a hasmatoma in the latter. A pyosalpinx if unrelieved by operation may continue for years, producing chronic invalidism, or may rupture and cause septicaemia or peritonitis. TUBERCULAR SALPINGITIS. 183 What is the treatment of salping-itis ? 1 . Fi'ophylactic. — Cleanliness and antisepsis during the puerperium and in the use of all instruments. 2. Palliative. — During the acute stage of invasion, rest in bed, poultices, laxatives, and, if much pain is present, allow opium. When the case becomes subacute, i. e. , when fever has entirely subsided, applj^ counter-irritation to vaginal fornix over the affected tube or tubes, and employ tampons of boric acid and glycerine and hot-water vaginal douches. 3. Radical. — If the distention and thickening of the tube fail to subside under the foregoing treatment, remove the tube and ovary of the side affected. Often both sides are involved and require removal. A salpingitis is often favorably effected by curetting the uterus. Tubercular Salpingitis. Give its pathology. The infection may reach the tube either through the blood, lymph- channels, endometrium, or peritoneum. It is usualh^ secondary to a general, pulmonary, or peritoneal tuberculosis. Rarely the bacilli enter through the vagina and thus cause a primary genital tuber- culosis. The tubes are much more frequentl}' affected than other parts of the genital tract. The tubercular lesions are most marked near the abdominal ostia, and both tubes are, as a rule, affected. Williams describes three varieties : 1 . Miliary tuberculosis. 2. Chronic diffuse tuberculosis. 3. Chronic fibroid tuberculosis. The abdominal ostia may or may not be occluded. The tubes vary in their degree of distention with pus or cheesy material. The lesion may be confined to the mucous membrane or involve the entire thickness of the tubal wall. What are the predisposing" causes ? The disease occurs from infancy to old age, but is most frequent between the ages of twenty and forty, and seems predisposed to by child-bearing and the puerperal state. It has followed sexual inter- course when the male genitals were tubercular. 184 ESSENTIALS OF GYNECOLOGY. Upon what would you base a diagnosis of tubercular salpin- gitis ? Absence of other causes of pj^osalpinx, as gonorrhoea or infection following labor or abortion. Evidence of other tubercular lesions. Pallor, emaciation, and cough. Physical examination, as a rule, reveals two large sausage-shaped masses lying close to the uterus, firmly adherent and less sensitive than is the rule with pyosalpinx. Presence of tubercle bacilli in the uterine discharge. What is the treatment ? The usual climatic and medicinal treatment of tuberculosis. In many cases this is the only treatment. If, however, the tube or tube and peritoneum alone arc tuberculous, cceliotomy is indicated. The ovaries and tubes are removed and with them the uterus. The cervix may be left, as it is rarely diseased. The abdominal incision is closed without drainage. Affections of the Ovaries. Hemorrhage into the Ovaries. Discuss briefly. A small amount of hemorrhage into a follicle at the time of rapture is normal. Interstitial hemorrhage or apoplexy of the ovary, as it is called, results from congestion due to general circulatory dis- turbances or local inflammations. When hemorrhage occurs there is pain, and if hemorrhage is excessive, which is rarely the case, the symptoms may resemble those of a ruptured ectopic gestation. Ovaritis. What is the pathology ? Ovaritis or inflammation of the ovary may be acute or chronic. Tubercular ovaritis is usually described separately. Acute ovaritis may be follicular or interstitial ; the two are often combined. In the follicular form, the epithelium of the follicles degenerates, the liquor folliculi becomes purulent, and the ovum is destroyed. AFFECTIONS OF THE OVARIES. 185 In the interstitial form, tlie stroma is infiltrated witli serum and leucocytes and the connective tissue cells are increased ; abscesses often form between the bundles of fibers ; sometimes gangrene occurs. Chronic ovaritis, often the result of the acute, may exhibit 3 forms — 1. The atrophic. 2. The hyperplastic. 3. The cystic. In the atrophic form the ovary is small, hard, and nodular ; the tunica albugiuea is much thickened. In the hyperplastic*" form, the ovary is enlarged, hard, and com- paratively smooth ; it usually prolapses from the increased weight. In the cystic variety, the change is not confined to the follicles, but the stroma is involved as well. The atrophic form maybe present in one part of the ovary and the hyperplastic in another ; the tunica albuginea is thickened and prevents rupture of the cysts. Ovaries the seat of ovaritis are often more or less surrounded by peritonitis. What is the etiology of ovaritis ? It occasionally occurs in severe cases of the infectious diseases or metallic poisoning, but is most often secondary to disease of the tubes or peritoneum. It is predisposed to by anything causing con- gestion of the ovary, such as displacement of the uterus, or ovary or excessive veneiy. A salpingitis with its own etiology is the most frequent c?Mse of ovaritis. Among individual causes, the following are especially to be mentioned : — iSepsis during labor, abortion or operations. Gonorrhcea. Catching cold during menstruation. Whac are the symptoms? The symptoms of acute ovaritis are usually mingled with those of the accompanying salpingitis or peritonitis. There is generally sharp pain in the ovarian region or regions, radiating to the back ; often pain in micturition and defecation, and various reflex neuroses. If an abscess forms, septic symptoms may be present. In the chronic form the symptoms are usually less marked ; there 186 ESSENTIALS OF GYNAECOLOGY. .1.5 dull pain in the ovarian region, increased by walking. There is dyspareunia and, especially if the ovary is prolapsed, painful defe- cation. What are the physical sig^ns ? These may be obscure, from the fact that the ovary and tube are bound together by peritonitic adhesions into one indistinct mass. When definable, we feel, on making a bimanual examination, a round body at the side of the uterus, but separated from it by a slight interval ; it is sensitive to pressure, producing pain of a sick- ening character ; it may or may not be movable. When the ovai-y is prolapsed, this round, tender mass may be felt in the pouch of Douglas. From what must you differentiate an inflamed ovary ? From — Salpingitis. Peritonitic deposit. Exudation into the broad ligament. Fibroid tumor. Faeces in the rectum. How would you differentiate ovaritis from salpingitis ? This is often very difficult, from the fact that the two conditions frequently coexist. The chief features in the differential diagnosis are found in the phj^sical signs, as follows : — Ovaritis vs. Salpingitis. Lies farther fi'om the uterus ; Lies nearer the uterus ; more more globular in shape. elongated. The ovary cannot be felt else- The ovary can often be felt sepa- where. rate from the mass. More sensitive. Less sensitive. How would you differentiate an ovaritis from an exudation in the broad ligament ? Ovaritis vs. Exudation in Broad Ligament. More circumscribed. Less circumscribed. Less closely related to vaginal More closely related to vaginal vault. vault. Less fixity of the utems. More fixity of the uterus. AFFECTIONS OF THE OVARIES. 187 How would you differentiate ovaritis from a lateral uterine fibroid ? Ovaritis vs. Lateral Fibroid. Sensitive to pressure. Insensitive to pressure. Less intimately connected with More intimately connected with the uterus. the uterus ; moves with it. Density less. Density greater. Menorrhagia less common. Menorrhagia more common. How would you differentiate ovaritis from faeces in the rectum? Ovaritis vs. Fceces. More sensitive. Less sensitive. Globular. Elongated in shape. Does not indent on pressure. Lidents on pressure. Found after emptying rectum. Disappears on emptying rectum. What is the treatment of ovaritis ? During the acute stage keep patient quiet in bed; apply hot poultices to the lower abdomen ; keep bowels open and faeces soft ; give an anodyne, if necessary. Later, apply counter-irritation by means of iodine to the vaginal fornix over the affected organ, and support the ovary with a tampon. An excellent method is to soak a roll of gauze in a solution of iodoform 1 part, chloral 1 part, and glycerine 4 parts, and place this about the cervix, especially on the affected side. After the withdrawal of this support, which may be left in twelve to twenty -four hours, a hot-water vaginal douche may be used with advantage. As a last resort, after a faithful trial of the above palliative measures for months without avail, and if the patient is a great sufferer, removal of the offending organ is indicated. If abscess of the ovary is present, early operation is indicated. An ovary the seat of ovaritis may be removed through the vasrina. 188 essentials of gynecology. Prolapse of the Ovary. What is the etiology and pathology ? Prolapse of the ovary may occur either as a result or cause of disease. From the increase in size, due to congestion or inflamma- tion, the ovary is aj)t to prolapse. In a retroversion or retroflexion of the uterus, the ovaries also are usually drawn backward, and from their disturbed circulation become congested and diseased. In their descent they usually first lie on the retro-ovarian shelves, and may then further descend, especially the left, into the pouch of Douglas. What are the symptoms ? They are those of ovaritis and of ovarian compression ; the latter being most marked, viz. : painful defecation and dyspareunia. (The differential diagnosis has been given under ovaritis. ) What is the treatment ? {a) PaUiatwe. — If due to a displacement of the uterus and both uterus and ovaries are movable, replace the uterus and maintain it in position by means of a pessary. When the ovaiy alone is displaced, if movable, support it at first with a tampon ; later a pessary may perhaps be worn. When the ovary is fixed by adhesions, an attempt should be made to cause resolution of the adhesions by counter-in-itatiou, glycerine or boroglyceride tampons, hot- water douches and gentle massage. (5) Radical— h t\^Q palliative measures fail and the symptoms are severe, operation is indicated, either to remove the prolapsed ovary, or, if the uterus is displaced backward, to break up the adhe- sions and fasten the uterus forward by hysterorrhaphy or by short- ening the round hgaments. Tumors of the Ovary. What are the chief causes of enlargement of an ovary? [a] Inflammation. [d) Carcinoma. [1] Cysts. (e) Fibroma, (c) Papilloma. (/) Sarcoma. [g] Tuberculosis. Discuss ovarian sarcoma and fibroma. Sarcomata are chiefly of the round-celled variety, but may be AFFECTIONS OF THE OVARIES. 189 spindle-celled. They occur at all ages, and not infrequently in children ; both ovaries are often affected, and they frequently give rise to ascites. Hemorrhagic cysts may be formed in the large ones. Fibromata, as a rule, are not so large as sarcomata, grow slowly, and do not cause ascites. Discuss ovarian papilloma and carcinoma. Papillomata occasionally originate on the surface of the ovary, but more begin in the wall of a cyst, whose wall they penetrate and then spread over the ovary and peritoneum. They resemble warts else- where, and may be the starting point of carcinoma. The ovaries become the seat of carcinoma rarely primarily, but often from extension or metastasis. A cyst-adenoma or ovarian papilloma may become carcinomatous. What are the varieties of ovarian cyst ? Describe them. The varieties of ovarian cyst are — ol \jiaAk ^.^""^^''^ ^"^^""' ''^^^• I Simple follicular. %/) ji /I ( Cyst-adenoma. <^^^^^^-'^'^-] Proliferating papillary. Dermoid. Corpus luteum cysts rarely attain the size of a child's head. They have no epithelial lining and contain thick brown fluid, whose color is derived from blood-pigment. The simple follicular cysts are often multiple, and originate in distended Graafian follicles. They are lined by a single layer of epithelium and contain clear serous fluid. The cyst-adenomata of the ovary form its largest cysts. They are the ordinary multilocular cysts, and may attain a very great size. ^They are adenomata whose alveoli become distended with fluid, and by breaking through of partition walls, cavities of several quarts' capacity are formed. Protruding into the larger loculi several smaller "secondary" or " daughter " cysts are often seen. Their fluid is viscid, gelatinous, sometimes blood-stained, and contains pseudomucin. The proliferating papillary cysts : Any ovarian or parovarian cyst may have warty growths on its inner surface, but there is a variety of cyst which usually contains them and is thought to originate in the portions of the Wolffian ducts which are imbedded in the hilum 190 ESSENTIALS OF GYNAECOLOGY. of the ovary. The presence of ciliated epithelium in many of them makes this origin probable. The dermoid cyst on its interior seems lined with skin. It may contain hair, sebaceous matter, teeth or irregular fragments of bone, etc. The present accepted idea as to the origin of dennoid cysts is that they are caused by an abnormal inclusion of the epiblast ; i. e. , that certain misplaced embryonic cells grow within the ovary and produce the tissue to which they were destined. What is the etiolog'y of ovarian cysts ? Concerning this little is known. They occur most freciuently be- tween the ages of 20-50, but are found both in the young and old. Simple ovaritis or injury of the ovary are said by some to predis- pose to the formation of a cyst. What changes may occur in an ovarian cyst ? The principal changes are the following : — It may rapture, usually from traumatism. Hemorrhage may occur into it. It may become gangrenous or may suppurate. The hemorrhage, gangrene and suppuration are usually the result of torsion of the pedicle. Supi3uration may also arise from the introduction of sepsis if the tumor is tapped, as formerly practiced. What are the symptoms of an ovarian cyst ? They are chiefly those of pressure. There may be difficulty in urina- tion and defecation ; in the later stages the patient is greatly ex- hausted by the great weight, and often suffers with dyspnoea. What are the physical signs of an ovarian cyst ? These vary with the location. When small and in the pelvis we get a tense elastic mass, usually fluctuating and insensitive to pres- sure. The multilocular variety may seem hard. The uteras is dis- placed by the tumor. When the cyst has extended to the abdomen, we get distention of the abdomen and dullness on percussion over the tumor. Fluctua- tion can usually be detected. What is the relation of ovarian cysts to the uterus ? When small the cyst prolapses from its own weight into Douglas' AFFECTIONS OF THE OVARIES. 191 cul-de-sac ; hence the uterus will lie in front of the tumor. When the tumor is too large to lie in the pelvis it rises into the abdomen, the uterus then retroverts and lies under the tumor. Double ovarian cysts, even of large size, may continue to lie behind the uterus and displace it forward. From what must you differentiate an ovarian cyst when small and situated in the pelvis ? From (a) Distended tube. (b) Peritonitic exudation, (c) Inflammatory exudation into broad ligament. (d) Extra-uterine gestation. How would you differentiate a small ovarian cyst from a dis- tended tube ? Ovarian Cyst vs. Distended Tube. No inflammatory history; gradual History of acute inflammation: development ; little if any pain. pain usually prominent. More globular. More elongated. Less intimately connected with More intimately connected with the uterus. the uterus. Insensitive to pressure. Sensitive to pressure. Less fixity. More fixity. How would you differentiate a small ovarian cyst frem a peri- tonitic exudation ? Ovarian Cyst vs. Peritonitic Exvdatiov. No history of acute inflammation. History of acute inflammatiDn. Insensitive. Sensitive to pressure. More mobile. Fixed. More lateral. Usually in pouch of Douglas. How would you differentiate a small ovarian cyst from an in- flammatory exudation into the broad ligament ? Ovarian Cyst vs. Inflammatory Exudation. Absence of history of inflamma- History of inflammation follow- tion. ing labor, abortion, or opera- tion. If a haematoma, history of sharp pain, shock, perhaps symptoms of hemorrhage. 192 ESSENTIALS OK GYNAECOLOGY. More mobile. Induration of parametrium want- ing. Insensitive. Bulges less into vagina. Fixed. Induration present. Sensitive to pressure. Bulges moi'o into vagina. How would you differentiate an ovarian cyst from an extra- uterine pregnancy ? Ovarian Cyst vs. Extra- uterine Pregnancy . 81ow growth. No symptoms of pregnancy. Menstruation usually not far from normal. More mobile. Uterus usually not enlarged. Pain only from pressure ; acute attacks. no Grrowth more rapid. Constitutional symptoms of preg- nancy. Amenorrboea usually followed by menorrhagia. More fixed. Uterus enlarged. Attacks of pain ; finally a severe attack, symptoms of shock and hemorrhage. From what must you differentiate a large ovarian cyst occupying the abdomen? From (rt) Pregnancy. (6) Ascites. (c) Fibroid tumor of the uterus. (cZ) Distended bladder. (e) Heematometra. How would you differentiate a large ovarian cyst from a pregnant uterus ? Ovarian Cyst vs. Pregnant Uterus. More lateral. Menstruation continues. Positive symptoms of pregnancy absent. Uterus small, separate from tumor ; cervix not softened. Fluctuating. More central. Amenorrhoea the rale. Positive symptoms of pregnancy present. Uteras forms the tumor ; cervix softened. Less fluctuating ; foetal parts felt. AFFECTIONS OF THE OVARIES. 193 Intermittent contractions absent. Intermittent contractions present. Growth less rapid. Growth more rapid. How would you differentiate a large ovarian cyst from ascites ? Ovarian Cyst vs. Ascites. Patient on back : — Patient on back : — Swelling central or unilateral. Swelling bilateral. Dullness in front. Tympanitic in front. Tympanitic on the sides. Dullness on the sides. Percussion note varies httle on Percussion note varies greatly in turning patient from side to turning from side to side. side. Circumscribed. DiiFuse. How would you differentiate a large ovarian cyst from a large fibroid tumor of the uterus ? Ovarian Cyst vs. Fibroid. Fluctuating. Firm, non-fluctuating. Less intimately connected with More intimately connected with the uterus. . the uterus ; moves with it. Menorrhagia uncommon. /^: Menorrhagia common. Uterus usually not enlarged. ' litems usually enlarged. How would you differentiate a large ovarian cyst from a distended bladder % Ovarian Cyst vsT Distended Bladder. More lateral. Central. Enlargement slow. Enlargement rapid. Remains after patient is cathe- Disappears when patient is terized. catheterized. How would you differentiate a large ovarian cyst from a hsematometra ? Ovarian Cyst vs. Hcematometra. Menstrual flow appears. Menstrual blood retained. More lateral ; separate from the Central ; tumor formed by the uterus. distended uterus. Pain only from pressure. Periodical attacks of pain, due to 23 increase of contents. 194 ESSENTIALS OF GYNAECOLOGY. Atresia absent. Atresia of vagina or cervix present. What is the treatment of an ovarian cyst ? The onl}'^ treatment is removal. If large, through abdominal coeliotomy ; if small, it can often be easily removed through the vagina. Parovarian Cysts. Describe briefly. They are cysts developed in the broad ligament from the parova- rium, the remains of the Wolffian body. These cysts are usually unilocular ; the contents colorless, thin and waterj^ The cyst wall is usually thin, and fluctuation very distinct. As the cyst grows, it opens up the folds of the broad ligament, and obliterates the meso- salpinx. The Fallopian tube lies stretched out over its upper sur- face. How would you distinguish between an ovarian and par- ovarian cyst? Ovarian Cyst vs. Parovaman Cyst, Has a pedicle. No pedicle. Somewhat movable. Deep-seated in pelvis and immovable. Uterus in front when small ; behind Uterus pushed to opposite when large. side when small ; forward against sj^mphj^sis when large. What is the treatment ? Removal by coeliotomy is the best treatment. The broad ligament, which is spread out over the tumor, is incised near to and parallel to the tube, and the tumor is enucleated from its bed. The cavity in the broad ligament is then either closed so as to leave no pockets, or the edges of the broad ligament are brought to and stitched in the lower angle of the abdominal wound and the cavity drained. The former practice is usually preferable. AFFECTIONS OF THE OVARIES. 195 What are the chief points in the technique of an abdominal cceliotomy for the removal of the uterine appendages or a cyst ? Have the bowels of the patient thoroughly emptied and let her take a thorough warm bath. On the evening before the operation, place upon the abdomen a towel soaked in a solution of soft soap to be left until the following morning. On the day of the operation, the abdomen and pubes are shaved, scrubbed with soap and water, washed with alcohol, and then with bichloride 1-1000. All antiseptic precautions must be observed in regard to instru- ments, hands, sponges, etc. The patient having been anaesthetized, a final cleansing of the abdomen with alcohol and bichloride is performed. An incision, about three inches long, is made in the median line, beginning just below the umbilicus ; this incision is deepened to the peritoneum and bleeding points are clamped. The peritoneum is raised with thumb forceps, one held by the operator, the other by an assistant, and the peritoneum cut between the forceps ; the incision is length- ened with the scissors, cutting on the finger to the length of the abdominal wound. The latter may be lengthened, if necessary. If the operation! is for the removal of the appendages, the fundus of the uterus is felt for as a landmark ; the ovary and tube of the afiected side are brought into the abdominal wound and surrounded by warm sponges or pads. The broad ligament is tied in section beneath the aiDpendage and the parts outside the ligature cut away, leaving just enough to prevent the ligature from slipping. The first ligature should be placed external to the ovary including the infun- dibulo-pelvic ligament, which contains the ovarian artery. The liga- ture placed at the proximal end of the tube should include the anasto- motic branch between the uterine and ovarian arteries. The ligature is then cut short and the stump dropped back into the abdominal cavity. The other side is treated, if necessary, in the same way; If the operation is for an ovarian cyst, after opening the abdomen the cyst is punctured with a trocar, the emptied sac drawn out of the abdominal wound, the adhesions separated, if necessary, the pedicle tied, and the stump treated as before. If pus has gotten into the abdominal cavity, the latter is freely irrigated with warm sterilized salt solution ; drainage may or may not be indicated. 196 ESSENTIALS OF GYNECOLOGY. The abdominal wound is closed by one of several methods. An ideal method is that which sutures each laj^er of the abdominal wall separately. A continuous catgut suture is used for the peritoneum, another for the aponeurosis, interrupted catgut sutures unite the subcutaneous fat, and the skin is united by any desired method of suture. The wound is then cleansed, a sterile dressing is applied and held in place by plaster strips and an abdominal binder, and the patient is transferred to bed. The bed should be warmed with hot- water bottles, but great care should be taken that the patient is not burned by them. What is the after-treatment of the case ? The patient receives no food by the mouth for twelve to twenty- four hours, nutrient enemata being used if needed. After vomit- ing, due to the anaesthetic, has subsided, thirst is quenched by the repeated administration of small doses of hot water ; later cool or carbonated water is given. The urine is drawn with a catheter. As little opium as possible is used. The bowels are moved on the third day by enema, calomel gr. iv (gr. j every half hour) or salines. If tympanites occurs at any time, the bowels are moved. If silk or silk-worm gut sutures have been used they should be removed within a week. The patient is allowed up on the four- teenth to twenty-first day. Describe the vaginal operation for the removal of a diseased appendage or an ovarian cyst. The same joreliminary preparations are observed as for an abdom- inal coeliotomy. At the time of the operation the vulva and vagina are thoroughly disinfected, the patient being in the lithotomy posi- tion and on a Kellj^'s pad. The perineum is retracted with a spec- ulum. If endometritis is present the uterus is first curetted. The posterior lip of the cervix is then seized with a volsella and drawn forward. The vagina is grasped with a toothed thumb-forceps about where it joins the rectum, and drawn downward. Between this point and the junction of vagina and cervix a cut is made with scis- sors directed toward the uterus ; first going through the vagina, then into the pouch of Douglas. This incision may be enlarged laterally. Two fingers are inserted into this opening and the pelvic AFFECTIONS OF THE OVARIES. 197 contents examined. If a diseased tube and ovary are found, a gauze pad or sponge, each with a long silk attached, is inserted above the mass to be removed, to keep back intestines or omentum ; the ap- pendage is freed, brought down into the vagina, ligated and re- moved. The gauze pad or sponge is now removed and the vaginal opening may either be closed or the pelvic cavity may be drained with gauze, according to the indications. If an ovarian cyst is to be removed, after opening the pouch of Douglas the cyst is tapped and emptied ; the sac drawn down into the vagina, ligated, and removed. What are the advantages and disadvantages of the vaginal as compared with the abdominal operation ? In the vaginal operation the shock is less and the abdominal cicatrix with its tendency to hernia is avoided. The vaginal operation requires greater skill in operating ; there are greater possibilities of injuring gut in separating adhesions, and greater difficulty in repairing the damage ; it may be hard to locate and control bleeding. In some cases the appendages cannot be removed by vagina until after the removal of the uterus. Hence if there is doubt as to the diagnosis and a possibility that the whole or a part of an ovary or tube may be allowed to remain, the abdominal route is to be selected as favoring conservative surgery. What are the indications for a vaginal operation ? In those cases in which the patient's condition will not warrant a severe operation, a pelvic abscess, pus-tube, or ovarian abscess may be drained through the vagina. Later, after recovery from sepsis, an abdominal operation may be performed with safety. A small ovarian cyst or prolapsed ovary may be removed with advantage through the vagina, as may also a small fibroid in the lower uterine segment through either anterior or posterior fornix. The vaginal route is to be selected for the drainage of any large collection of blood, serum, or pus in the pelvis, which is well walled off by intestinal adhesions. Vaginal hysterectomy is the operation usually done for carcinoma of the uterus. What operations are performed through the anterior fornix ? Small fibroids of the cervix or anterior uterine wall are removed through the anterior fornix. This route is also employed for short- ening the round ligaments. 198 ESSENTIALS OF GYNECOLOGY. How would you prepare catg-ut for ordinary ligature and suture ? One of the best methods is that by means of boihng alcohol. This is conveniently carried out by Dowd's apparatus a cut of which is here given. It consists of a coil of block tin tubing en- FiG. 56, Dowd's Apparatus for Sterilizing Catgut. cased in a copper C3'linder. The lower end of the coil is straight- ened out and projects through the rubber cork of the jar in which the bottles of catgut are to be sterilized. The upper end of the coil is bent into a convenient shape for suspension and during use ECTOPIC GESTATION. 199 is closed with a cotton plug. On one side of the cylinder are two taps, the lower for the entrance, the upper for the exit of cold water from a faucet which condenses the alcoholic vapor which rises in the coil. The catgut, wound on glass spools, is placed in small bottles (pre- ferably with screw tops) which are filled with strong alcohol. These bottles are placed in the large jar and covered with strong alcohol. The jar is then attached to the condenser, and placed in a vessel of water on a gas or other stove. The boiling is kept up for an hour. Another good method is the following : — 1. Soak the gut in ether for 1 hour. 2. Wipe with a bichloride towel. 3. Soak in bichloride 1 : 1000 for 8 hours. 4. Wipe with a bichloride towel. 5. Store it in absolute alcohol. How would you prepare the chromicizlB%(3fficEwen's) catgut ? Soak the gut for 48 hours in the following solution : — R. Acidi chromici, ^iij-^vss Aquae, q. s. ad Oj M. et adde Glycerini, Ov. Then store the gut in carbolized glycerine 1-5, Wipe with a bichloride towel before using. Ectopic Gestation. Ectopic gestation may be considered as primarily tubal. Three varieties are recognized : 1. Tubal proper, (free tubal). 2. Tubo-uterine, (interstitial) ; in that portion of the tube em- braced by the uterine wall. 3. Tubo-ovarian. — Between the tube and the ovary, originally tubal. Abdominal pregnancy was originally tubal. Ovarian pregnancy never occurs. 200 ESSENTIALS OF GYNECOLOGY. What is the etiology ? It has long been recognized that tubal inflammation, peritoneal adhesions, and pressure upon the tube predispose to tubal pregnancy. In the case of inflammations, however, not until the tubal mucosa has become practically^ normal is tubal pregnancy likely to occur. Hindrance to the passage of a fertile ovum into the uterus will not of itself cause tubal implantation of the ovum. An hypothesis has been advanced that under normal conditions the tube will not undergo the decidual change necessary for pregnancy, but that the tubal mucosa of a few women possesses the property, common in many of the lower animals, of responding to the stimulus which the fertilized ovum offers by forming a decidual membrane. In such individuals, if the passage of the ovum into the uterus is interferred with, tubal pregnancy results. What are the symptoms ? There is usually a history of previous sterility ; then symptoms of early pregnancy ; usually amenorrhoea at first, later irregular men- struation or menorrhagia, with passage of portions of the uterine decidual membrane. Attacks of pain with sj^mptoms of shock may be present ; then when the sac ruptures, symptoms of hemorrhage, severe shock, and collapse. What are the physical signs ? Before rupture occurs, the uterus is felt to be enlarged and soft- ened, and at the side is found a mass formed by the distended tube. At the time of rupture, if it has occurred with hemorrhage into the peritoneal cavity, very few physical signs may be present ; simply an indistinct feeling of fluid in the pouch of Douglas. Later, as the blood coagulates, a tumor is formed behind the uterus. If the rupture has occurred into the broad ligament, a tumor is formed at once by the blood-distended ligament. This tumor pushes the uterus forward and toward the opposite side. It tends to bulge into the vagina, and a finger introduced into the rectum detects a narrowing of it. What is the course and result ? Ectopic gestation is primarily tubal. At about the third month, either a rupture of the tubal wall may occur, with the escape of the foetal products, or the escape may take place through the fimbriated ECTOPIC GESTATION. 201 extremity, constituting a tubal abortion. When a rupture of the tubal wall occurs, it ma.y take place (1) through a portion covered by peritoneum, i. e., into the peritoneal cavity, or (2) through a portion not covered by peritoneum, i. e., down between the folds of the broad ligament. The intraperitoneal rupture may prove fatal, although often not until several hemorrhages have occurred. In an extra- peritoneal rupture the hemorrhage is usually hmited. The foetus usually dies when it escapes from the tube. When the rupture, however, is extraperitoneal, i. e. , between the folds of the broad liga- ment, the foetus may survive, being nourished by a placenta attached to the floor and walls of the pelvis or broad ligament, and go to term. At any time after the middle of pregnancy the foetal sac may rupture and the foetus lie free in the peritoneal cavity. This con- stitutes secondary rupture and explains the cases of so-called ab- dominal pregnancy. Primary rupture may be delayed in the cases of interstitial pregnancy until the sixteenth week ; hemorrhage is then likely to prove fatal. When the blood effusion is small it may be absorbed. Sometimes suppuration occurs. From what must you differentiate extra-uterine pregnancy? Suppurative cellulitis. Fibroid tumor. Ovarian cyst. Dermoid cyst. Parovarian cyst. Salpingitis. Retroversio-flexio. What is the treatment ? If a diagnosis is made before rupture occurs, the best treatment consists in the removal of the tube with its contents. At the time of rupture, if this has taken place into the peritoneal cavity, open the abdomen, hgate and remove the sac from which the hemorrhage comes, also, the foetal remains and blood clots. Drainage is rarely necessary, unless the foetal sac has become infected. If the rupture has taken place into the broad ligament and the resulting h^ematoma is small, this may be left with the hope of its absorption. If repeated hemorrhages occur, surgical interference 202 ESSENTIALS OP GYNECOLOGY. is indicated. If suppuration take place, the mass should be opened from the vagina and drained. If the life of the foetus continues after the rupture, and the case is seen during the early months, the life of the foetus should be disregarded in the interest of the mother. The foetus and mem- branes should be removed and the sac drained. If the case is first seen after the viabilitj^ of the foetus, an attempt should be made to save both lives. Fistulae. What are the chief varieties met with in gynaecology ? They may be either urinary or fecal. Urmary fistulae present the following varieties (see Fig. 57) :— 1. Urethro-vaginal. 2. Yesico-vaginal, 3. Vesico-uterine. 4. Uretero-vaginal. 5. Uretero-uterine. The most common is the vesico-vaginal. The fecal fistula which especially concerns us is the recto-vaginal. What is the etiology of a vesico-vaginal fistula ? The most common cause is sloughing following long-continued pressure, usuaDy in parturition, but occasionally from a pessary. It may be produced by direct laceration through the septum. It is predisposed to by a tedious labor. What are the symptoms ? The involuntary escape of urine. A urinous odor about the person. Irritation and excoriation of the vulva and parts around. How is the diagnosis made ? If the fistula is not evident on exposing the parts with a Sims' speculum, the patient being in Sims' position, the bladder may be distended with some colored antiseptic fluid, like creohn solution, and by the exit of the latter the fistula may be detected, and then verified by a probe. What is the treatment? The treatment usually pursued in this country is the operation of FISTULA. 20S Sims, which is performed as follows : The patient is anaesthetized, an antiseptic vaginal douche given, and all antiseptic precautions observed during the operation. She is placed in Sims' position and Sims' speculum introduced. The edges of the fistula are pared with the knife or scissors, the mucous membrane not being included in the incision. Silkworm-gut or silver-wire sutures are then intro- duced, about one-fifth to one-fourth inch apart, not penetrating the mucous membrane. The parts are brought into apposition by tying or twisting the sutures, and then a self-retaining catheter is intro- duced. The sutures are left for eight days. The operation for a urethro- vaginal fistula is similar to the above. Fig, 57. To REPRESENT THE CHIEF VARIETIES OP URINARY FiSTULA — URETHRO-VAGINAI., Vesico-vaginal and Vesico-uterink.— Those with the ureters are not seen. The seat of a recto-vaginal fistula is indicated {De Sinety). What are the chief steps in the operation for the cure of a vesico-uterine fistula ? Emmet regards the condition as due to a laceration of the cervix extending into the bladder, the laceration healing only below. The operation is based on this idea, viz. : The cervix is split up to the fistula ; the edges of the latter are denuded, and the whole brought together in a manner similar to a trachelorrhaphy, especial care being taken with the upper sutures. 204 ESSENTIALS OF GYNECOLOGY. Recto- vaginal Fistula. What is the etiology? This, like the vesico-vaginal fistula, is usually due to sloughing caused by long-continued pressure in parturition, or may be produced by laceration through the septum, either by the unaided efforts of nature or by instrumental delivery. Cancer or syphilis may, of course, cause fistula, but this will not concern us here. What is the treatment ? It is similar to Sims' operation for vesico-vaginal fistula. The edges are denuded and brought together by silkworm gut or silver wire, the rectal mucous membrane being uninjured. If the fistula is near the vulva, it is usually best to divide the sphincter ani and perineum up to the fistula, to dissect this out, and then close the parts as in a laceration of the perineum through the sphincter ani. INDEX. Alexander's operation, 124 Amenorrhcea, 99 Anterior colporrhaphy, 139 Applicator, uterine, 59 Atrophy of the uterus, 156 Bacteria of endometritis, 147 of salpingitis, 181 of vagina, 84 Bimanual examination, 46 Bladder, 36 Bui hi vestibuli, 20 Carcinoma, ovarian, 189 uteri, 175 Catgut, preparation of, 198 Cellulitis, pelvic, 91 Cervical erosions, 149 Ciliffi, 32 Clitoris, 18 Coccygodynia, 81 Condylomata, pointed, 77 syphilitic, 78 Corpus luteum cyst, 189 Curette, 64 Cysts of ovary, 189 Deciduoma malignum, 179 Development of the pelvic organs, 43 Dilators, 59 elastic, 63 graduated, hard, 61 Displacements of the uterus, 113 anteflexion, 114 retroversion and retro- flexion, 116 Dysmenorrhoea, 102 Ectopic gestation, 199 Eczema of the vulva, 75 Emmet's operation, 133 Endometritis, 147 acute, 147 chronic, 148 villous, 152 Erosions, cervical, 149 Erythema of the vulva, 75 Fallopian tubes, 31 Fibroid tumors of the uterus, 157 ovarian, 188 Fistula, recto-vaginal, 204 Fistulte, 202 Follicular cysts, 189 Fornix, anterior, operations through, 197 Fossa navicularis, 20 Fourchette, 20 Fungosities, uterine, 152 GoNococcus, 66 Gonorrhoea, 67 Hematocele and haematoma, pelvic, 94 pudendal, 73 Hemorrhage from vulva, 74 Hernia, pudendal, 72 Hymen, 21 Hyperesthesia of the vulva, 80 Hypertrophy of the cervix, 140 Hysterectomy, 165 vaginal, 177 Hysterorrhaphv, 126 Kelly's, 126 205 206 INDEX. Instruments, 48 Inversion of the uterus, 166 Irritable urethral caruncle, 82 Ischio-rectal fossa, 42 Kelly's hysterorrhaphy, 126 Kraurosis vulvae, 80 Labia majora, 17 minora, 18 Laceration of the cervix, 142 of the perineum, 130 Malformations of the uterus, 108 of the vagina, 106 atresia of, 107 stenosis of, 108 of tj^e vulva, 83 Menstruation, 98 disorders of, 99 amenorrhoea, 99 dysmenorrhoea, 102 congestive, 103 membranous, 105 neuralgic, 104 obstructive, 102 ovarian, 104 menorrhagia and metror- rhagia, 101 vicarious, 100 Mesosalpinx, 30 Metritis, 153 acute, 153 chronic, 154 Mons veneris, 17 Myomectomy, 165 New growths of the vulva, 77 Ovaries, 32 affections of, 184 cysts, 189 enlargement of, 188 hemorrhage into, 184 prolapse of, 188 tumors of, 188 Ovaritis, 184 Papillomata, ovarian, 189 simple, 77 Parovarian cysts, 194 Parovarium, 35 Pelvic floor, 40 Perineal body, 41 Perineum, muscles of, 42 Peritoneum, pelvic, 87 Peritonitis, pelvic, 88 Pessaries, 121 stem, 63 Physical examination of pelvic organs, 43 Polypi, 71 Probe, uterine, 59 Prolapse of urethral mucous mem- brane, 83 Prolapsus uteri, 127 Pruritus vulvae, 78 Pudendal hsematocele, 73 hernia, 72 Rectal examination, 47 Rectum, 38 Round ligaments, intra-abdomi- nal shortening of, 127 Saenger-Tait operation, 134 Salpingitis, 180 tubercular, 183 Sarcoma of the uterus, 178 ovarian, 188 Skin diseases of the vulva, 75 Sound, uterine, 55 Specula, 48 Brewer's speculum, 52 Pergusson's speculum, 51 Kelly's speculum, 53 Simon's speculum, 51 Sims' speculum, 49 Stem pessaries, 63 Stenosis of the cervix, 142 of the vagina, 108 Tents, 58 Theca folliculi, 33 Trachelorrhaphy, 145 Urinary tract, 35 I INDEX. 207 Uterine applicators, 59 fungosities, 152 Uterus, 23 mucous membrane of, 25 changes of, 26 Vagina, 21 bacteria of, 84 diseases of, 84 secretions of, 22 stenosis of, 108 Vaginal examination, 44 Vaginismus, 80 Vaginitis, croupous, 87 gonorrhoeal, 86 simple catarrhal, 84 Vaginitis, ulcerative, 86 Vestibule, 20 Vicarious menstruation, 100 Volsella, 54 Vulva, malformations of, 83 Vulvitis, 65 acute simple catarrhal, 65 chronic catarrhal, 66 croupous, 69 follicular, 70 gangrenous, 69 gonorrhceal, 66 phlegmonous, 68 Vulvo-vaginal glands, 21 cyst and abscess of, 71 Catalogue tt Medical Publications OF W. 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This latter method, while not so profitable to the publisher, offers to the purchaser many advan- tages which will be appreciated by those who do not care to subscribe for the entire work at one time. This American edition of Nothnagel's Encyclopedia will, without question, form the greatest System of Medicine ever psoduced, and the publishers feel confident that it will meet with general favor in the medical profession. i8 NOTHNAGEL'S ENCYCLOPEDIA VOLUMES JUST ISSUED AND IN PRESS VOLUME I Editor, William Osier, M, D., F.R.CP, Professor of IMedicine in Johns Hopkins Unive7-sity CONTENTS Typhoid Fever. By Dr. H. Curschmann, of Leipsic, Typhus Fever. By Dr. H. Curschmann, of Leipsic. Handsome octavo volume of about 600 pages. Just Issued VOLUME n Editor, Sir J, W. Moore, B* A„ M, D., F,R,CPJ., of Dublin Professor of Practice of Medicine, Royal College of Surgeons iji Ireland CONTENTS Erysipelas and Erysipeloid. By Dr. H. Lenhartz, of Hamburg. Cholera Asi- atica and Cholera Nostras. By Dr. K. VON LiEBERMEiSTER, of Tubingen. "Whooping Cough and Hay Fever. By Dk. G. Sticker, of Giessen. Varicella. By Dr. Th. von Jurgensen, of Tiibingen. Variola (including Vaccination). By Dr. H. Immermann, of Basle. Handsome octavo volume of over 700 pages. Just Issued VOLUME m Editor, William P. Northrtjp, M, D. Professor of Pediatrics, University and Bellevue Medical College CONTENTS Measles. By Dr. Th. von Jurgensen, of Tiibingen. Scarlet Fever. By the same author. Rotheln. By the same author. VOLUME VI Editor, Alfred Stengel, M,D, Professo}- of Clinical Medicine , University of Pennsylz'ania CONTENTS Anemia. By Dr. P. Ehrlich, of Frank- fort-on-the-Main, and Dr. A. Lazarus, of Charlottenburg. Chlorosis. By Dr. K. VON Noorden, of Frankfort-on-the-Main. Diseases of the Spleen and Hemor- rhagic Diathesis. By Dk. M. Litten, of Berlin. VOLUME vn Editor, John H. Musser, M. D. Professor of Clinical Medicine, University of Pennsylvania CONTENTS Diseases of the Bronchi. By Dr. F. A. 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M. and Therapeutics, 15 Saunders' Pocket Medical Formularj^ . 11 Sayre — Essentials of Pharmacy 15 SoUmann — ^Text-Book of Pharmacology, 22 Stevens — Modern Therapeutics, .... 13 Stoney — Materia Medica for Nurses, . . 13 Thornton — Prescription- Writing, ... 13 20 MEDICAL PUB Lie A TIONS 21 MEDICAL JURISPRUDENCE AND TOXICOLOGY. Chapman — Medical Jurisprudence and Toxicology 5 Golebiewski and Bailey — Atlas of Dis- eases Caused by Acciderits, 17 Hofmann and Peterson — Atlas of Legal Atedicine, 16 NERVOUS AND MENTAL DIS- EASES, ETC. Brower — iManual of Insanity, 22 Chapin — Compendium of Insanity. ... 5 Church and Peterson — Nervous and 5 Mental Diseases 5 Jakob and Fisher — Atlas of Nervous System, 17 Shaw — Essentials of Nervous Diseases and Insanity, 15 NURSING. Davis — Obstetric and Gynecologic Nurs- ing, Griffith— The Care of the Baby, . . Hart — Diet in Sickness and in Health, Meigs — Feeding in Early Infancy, . Morten — Nurses' Dictionary, . . . 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An American Year-Book of Medicine and Surgery, 3 Anders — Practice of Medicine 4 Eichhorst — Practice of Medicine, ... 6 Lockwood — Practice of Medicine, . . . 9 Morris — Ess. of Practice of Medicine, . 15 Salinger & Kalteyer — Mod. Medicine, n Stevens — Practice of Medicine, .... 13 SKIN AND VENEREAL. An American Text-Book of Genito- urinary and Skin Diseases, 2 Hyde and Montgomery — Syphilis and the Venereal Diseases, 8 Martin — Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . . 15 Mracek and Stelwagon— Atlas of Dis- eases of the Skin, 16 Stelwagon — Essentials of Diseases of the Skin, 15 SURGERY. An American Text-Book of Surgery, 2 An American Year-Book of Medicine and Surgery, 3 Beck — Fractures, 4 Beck — ^vlanual of Surgical Asepsis, ... 4 Da Costa— IManual of Surgerj', 5 International Text-Book of Surgery, . 8 Keen— Operation Blank, 8 Keen — The Surgical Complications and Sequels of Typhoid Fever, 8 Macdonald — Surgical Diagnosis and Treatment, 9 Martin— Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . . 15 Martin — Essentials of Surgery, 15 Moore — Orthopedic Surgery, 10 Nancrede — Principles of Surgery, ... 10 Pye — Bandaging and Surgical Dressing, 11 Scudder — Treatment of Fractures, ... 12 Senn — Genito-Urinarj' Tuberculosis, . . 12 Senn— Practical Surgery, 12 Senn — Syllabus of Surgerj', 12 Senn — Pathology and Surgical Treat- ment of Tumors, ... 12 Warren — Surgical Pathology and Ther- apeutics, 14 Zuckerkandl and Da Costa — Atlas of Operative Surgery 16 URINE AND URINARY DISEASES. Ogden — Clinical Examination of the Urine, 10 Saundby — Renal and Urinar>' Diseases, 11 Wolf — Handbook of Urine Examination, 22 Wolff — Examination of Urine, 15 MISCELLANEOUS. Abbott^Hj'giene of Transmissible Dis- eases, 3 Bastin — Laboratory Exercises in Bot- any, 4 Golebiewski and Bailey — Atlas of Dis- eases Caused by Accidents, ... . . 17 Gould and Pyle — Anomalies and Curi- osities of Medicine, 7 Grafstrom — Massage, 7 Keating — Examination for Life Insur- ance, 8 Pyle — A IManual of Personal Hygiene, . 11 Saunders' Medical Hand-Atlases, . 16,17 Saunders' Pocket Medical Formularj', . 11 Saunders' Question-Compends, . . 14. 15 Stewart and Lawrence — Essentials of Medical Electricity, 15 Thornton — Dose-Book and Manual of Prescription-Writing, 13 Van Valzah and Nisbet — Diseases of the Stomach, 13 THE LATEST BOOKS, Bergey's Principles of Hygiene* The Principles of Hygiene ; A Practical Manual for Students, Physicians, and Health Officers. By D. H. Bergey, A.M., M. D., First Assistant, Laboratory of Hygiene, University of Pennsyl- vania. Handsome octavo volume of about 500 pages, illus- trated. Brower^s Manual of Insanity^ A Practical Manual of Insanity. By Daniel R. Brower, M, D., Professor of Nervous and Mental Diseases, Rush Medical Col- lege, Chicago. i2mo volume of 425 pages, illustrated. Gorhatn's Bacteriology. A Laboratory Course in Bacteriology. By F. P. Gorham, M. A., Assistant Professor in Biology, Brown University. i2mo volume of about 160 pages, fully illustrated. Gradle on the Nose^ Throaty and Ear. Diseases of the Nose, Throat, and Ear. By Henry Gradle, M. D., Professor of Ophthalmology and Otology, Northwestern . University Medical School, Chicago. Handsome octavo volume of 800 pages, profusely illustrated. SoIImann^s Pharmacology. A Text-Book of Pharmacology. By Torald Sollmann, M. D., Lecturer on Pharmacology, Western Reserve University, Cleve- land, Ohio. Royal octavo volume of about 700 pages. Wolffs Examination of Urine. A Handbook of Physiologic Chemistry and Urine Examination. By Charles G. L. Wolf, M. D., Instructor in Physiologic Chem- istry, Cornell University Medical College. i2mo volume of about 160 pages. 22 5r -v 90/ ^^ c/rKcctV^ 0^ Qw ^.c^< ^^