o LiBRAKUS :; •♦i HEALTH SCIE 'GES LIBRARY Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/textbookofgynecoOOreed A TEXT-BOOK OF GYNECOLOGY/' EDITED BY CHARLES A. L. REED, A.M., M. D. President of the American Medical Association (1900-1901); Gynecologist and Clinical Lecturer on Surgical Diseases of Women at the Cincinnati Hospital ; Fellow of the American Association of Obstetricians and Gynecologists ; Fellow of the British Gynecological Society ; Corresponding Member of the National Academy of Medicine of Peru, etc. ILLUSTRATED BY R. J. HOPKINS NEW YORK D. APPLETON AND COMPANY 1901 Copyright, 1901 By D. APPLETON AND COMPANY TO E. C. STOCKTON REED, M. D., LL. D. FORMER PROFESSOR OF MATERIA MEDICA AND THERAPEUTICS IN THE CINCINNATI COLLEGE OF MEDICINE AND SURGERY THE LABOR OF THE EDITOR IN THE PREPARATION OF THIS WORK IS DEDICATED AS AN EXPRESSION OF FILIAL AFFECTION PREFACE In the iDreparation of this work there has been held in view the three following special objects, viz.: 1. The formulation of a Text-Booh which shall serve as a wording manual for 'practitioners and students, and which shall embrace the best approved developments of gynecology, including those of later date than are, or can be, included in a work of similar magnitude by a single author. For this purpose assignment of topics was made to a considerable number of writers, but only to those who have acquired reputation in connection with the subjects upon which they Avere asked to write. This division of labour, giving to each writer a relatively small amount of work, insured a careful preparation of copy in the shortest possible time, and the issuance of a strictly up-to-date volume. 2. The co-operation of the various departments of medical science in their synthetic relation to gynecology. For this purpose contributions were invited from several writers who are not gynecologists in the strict sense of the term. Thus the various topics upon pathology were given to pathologists, while those relating to bacteriology, dermatology, neurology, hygiene, etc., were assigned with similar appropriateness. As a consequence a single chap- ter, in some instances, is based upon contributions from several writers, while the whole has been rendered consecutive, systematic, and homo- geneous by the Editor. The work is not, therefore, in any sense a mere aggregation of monographs. 3. The specific recognition of the work of investigators and oper- ators in gynecology and correlated departments. For this purpose invitations to contribute to the work were limited to those who had already contributed something to science. As a con- sequence Avriters were asked to treat their respective topics not only in a general way, but freely to express their individual views relative to the same. V yi A TEXT-BOOK OF GYNECOLOGY The Editor has rendered into the third person all references by the different writers to their own work. In this way and by reference to the table of contents, the reader is enabled to determine the authorship of each particular j^aragraph. The Editor feels a special sense of obligation to the contributors to the volume, whose clear and lucid comjDrehension of his objects and design and whose scholarly contributions have done much to lessen his task. The work of illustration has been in the hands of Mr. E. J. Hop- kins, Avhose previous special studies in anatomy as applied to art, and whose almost intuitive comprehension of the task, combined with ex- cellent technical skill on his part, has enabled him to add materially to the value of the book. Dr. Kenneth W. ]\Iillican, Assistant Editor of the New Yorh Medi- cal Journal, has kindly seen the pages through print, and it is to his vigilance, industry and scholarly supervision, that the Editor is in- debted for the elimination of errors, Avhich would have, otherwise, escaped detection. To Miss Georgia A. H. Tsaminger, secretary to the Editor, acknowl- edgments are due for efficient service in transcribing and arranging manuscript. To the Publishers, the highest praise must be given for cordial co-operation at every stage of the work. Chaeles a. L. Eeed, Editor. Cincinnati, Ohio. CONTRIBUTORS J. W. Ballantyne, M. D., F. E. C. P. E., F. R E. Lecturer on Midwifery and Gynecology, School of the Royal Colleges. Edin- burgh, Scotland. J. H. Carstens, M. D. Professor of Obstetrics and Clinical Gynecology in the Detroit College of Medicine, Detroit, Mich. Murdoch Cameron, A. M., M. D., F. E. C. S. Regius Professor of Midwifery in the University of Glasgow. Glasgow, Scotland. Henry C. Coe, M. D., M. E. C. S. Professor of Gynecology in the University of Bellevue Medical College. New York, N. Y. John G. Clark, M. A.. M. D. Professor of Gynecology in the University of Pennsylvania. Philadel- phia, Pa. F. X. Dercum, a. M., M. D. Clinical Professor of Diseases of the Nervous System in Jefferson Medical College. Philadelphia, Pa. Walter B. Dorsett, M. D. Professor of Obstetrics and Clinical Gynecology in the Beaumont Medical College. St. Louis, Mo. L. H. Dunning, M. D. Professor of the Diseases of Women in the Medical College of Indiana. Indianapolis, Ind. Frank P. Foster, M. D., LL. D. Editor of the New York Medical Journal. New Yoik, N. Y. Samuel G. Gant, M. D. Professor of Rectal Surgery in the New York Post-Graduate Medical School. New York, N. Y. Hobart Amory Hare, M. A., M. D. Professor of Therapeutics in Jefferson Medical College. Pliiladelphia. Pa. Malcolm L. Harris, A. M., M. D. Professor of Surgery in the Chicago Polyclinic. Chicago, 111. Maximilian Herzog, B. S., M. D. Professor of Pathology in the Chicago Polyclinic. Cliicago, 111. E. J. Hopkins, B. S. Artist. New York, N. Y. Joseph Tabor Johnson, A. M., M. D. Professor of Gynecology and Abdominal Surgery in the University of Georgetown. Washington, D. C. vii yiii A TEXT-BOOK OF GYNECOLOGY Wyatt G. Johnston, M. D., F. R. C. S. Professor of Bacteriology and Pathology in McGill College and University. Montreal, Canada. Matthew D. Mann, A. M., M. D. Professor of Gynecology in the Medical Department of the University of Buffalo. Buffalo, N. Y. Thomas Charles Martin, B. S., M. D. Professor of Pathology and Rectal Diseases in the College of Physicians and Surgeons. Cleveland, Ohio. Lewis S. McMurtry, M. D., LL. D. Professor of Gynecology and Abdominal Surgery in the Hospital Medical College. Louisville, Kj. Dan Million, M. D., LL. D. Former Professor of Materia Medica and Therapeutics in the Miami Medical College of Cincinnati. Hamilton, Ohio. Henry P. Newman, M. A., M. D. Professor of Gynecology in the College of Physicians and Surgeons of Chi- cago. Chicago, 111. William Warren Potter, A. M., M. D. Secretary of the American Association of Obstetricians and Gynecologists, and Editor of the Buffalo Medical Journal. Buffalo, N. Y. A. Ravogli. M. D., LL. D. Professor of Dermatology in the University of Cincinnati. Cincinnati, Ohio. Charles A. L. Reed, A. M., M. D. Gynecologist and Clinical Lecturer on Surgical Diseases of Women at the Cincinnati Hospital. Cincinnati, Ohio. Hunter Robb. A. M., M. D. Professor of Gynecology in the Medical Department of the Western Reserve University. Cleveland, Ohio. James F. W. Ross, M. D., L. R. C. P.. Eno:land. Lecturer on Clinical Gynecology in the University of Toronto. Toronto, Canada. A. W. Mayo Robson, F. R. C S. Professor of Surgery in the Yorkshire College of the Victoria University. Leeds, England. J. L. ROTHROCK, A. M., M. D. Instructor in Pathology in the University of Minnesota. St. Paul, Minn. W. Japp Sinclair, M. A., M. D., F. R. C. S. Professor of Obstetrics and Gynecology in Owen's College, Victoria ITni- versity. INIanchester, England. Horace J. Whitacre, B. S., M. D. Lecturer on Clinical Surgery and Demonstrator of Pathology in the Univer- sity of Cincinnati. Cincinnati, Ohio. E. Gustave Zinke, M. D. Professor of Obstetrics and Clinical Midwifery in the University of Cincin- nati. Cincinnati, Ohio. CONTENTS CHAPTER I PROLEGOMENA Gynecology defined ..... Historical resume Gynecology as a specialty . . Nomenclature of gynecology . Eadicalism and conservatism in gynecology PAGE Reed 1 ,, 1 ,, 2 Foster- 3 Reed 4 Prevalence Causes .... CiA'ilization . Education Personal habits . Occupation . Diseases Copulation . Prevention of conception Criminal abortion Childbirth . The social evil CHAPTER II GENERAL ETIOLOGY OF DISEASES OF WOMEN . Reed 10 10 10 10 CHAPTER III GENERAL PATHOLOGY OF THE FEMALE GENERATIVE ORGANS Local pathology conforms to general pathologic laws . . Berzog Peculiarities depending upon differentiated functions IMenstruation Ovulation in its relation to pathologic states Gestation in its relation to pathologic states The poise of the uterus and its variations . Bacterial origin of inflammatory diseases of the female genitalia Tuberculosis .... Syphilis . . . Trophic changes Neoplasms .... 1-2 12 12 13 13 15 1.5 17 17 17 18 A TEXT-BOOK OF GYNECOLOGY CHAPTER IV GENERAL THERAPEUTICS OF GYNECOLOGY General medication Serum therapy Local medication Balneotherapy . Suggestion Electricity Massage Reed PAGE 20 21 22 22 23 23 24 CHAPTER V THE GYNECOLOGICAL ARMAMENTARIUM The gynecological armamentarium . . , . . . Robb 27 CHAPTER VI DIAGNOSIS Definition and scope . Indications and contraindications for vaginal examination The gynecologic examination Physical examination The armamentarium The examination itself Inspection of the external genitals Digital examination Bimanual examination Rectal exploration . Examination under anaesthesia Auscultation, percussion, and general palpation of the ab domen .... Regions of the abdomen . Instrumental examination (n) The speculum (/>) The sound . {€) The dilator . {(}) The curette . (p) The aspirator Examination of the secretions — Urines, faeces, menstrual fluid Examination of the blood Examination of the nervous system Reed 29 „ 30 Potter . 30 „ 31 55 31 55 33 55 34 55 35 55 37 55 39 ,5 . 40 5, 40 Reed 41 ., 42 Potter . 42 ,, 45 55 45 „ 46 „ 47 Reed 47 55 49 49 CHAPTER VII SEPSIS Sepsis defined .... The bacteria of sepsis Local sepsis ..... Symptoms, pathology, treatment General sepsis Symptoms, pathology, treatment Reed 50 50 55 56 57 58 CONTENTS CHAPTER VIII ANTISEPSIS Antiseptic provisions of Natur Sterilization Mechanical means Heat .... Germicidal agents l^he nurse The room The patient Instruments and dressings Sutures and ligatures Post-operative antisepsis The surgeon Hand sterilization Gloves .... Reed PAGE GO 00 Gl 61 63 63 64 66 66 67 68 69 69 70 Definition Pathology Causes Symptoms Diagnosis . Treatment Prophylactic Restorative CHAPTER IX SHOCK Reed 12 72 72 72 73 74 74 74 CHAPTER X HEMORRHAGE AND HEMOSTASTS Hemorrhage Symptoms Diagnosis Treatment of hemorr Hemostasis Styptics Heat Pressure Angiotripsy Electric hemostasis Ligatures hage Reed Newman Reed 78 78 79 79 79 79 80 80 81 83 86 CHAPTER XI ANAESTHESIA AND ANESTHETICS IN GYNECOLOGY Definition Hare Anaesthetic agents Race and temperament in the selection of an anaesthetic . „ Indications and contraindications for the use of chloroform and ether „ 87 87 88 A TEXT-BOOK OF GYNECOLOGY Ether in its relation to bodily temperature Choice of anaesthetics in children Bromide of ethyl Ether and its administration Mixed vapours and their administration Chloroform and its administration Management of accident in anaesthesia Anaesthetic mixtures Central anaesthesia by cocaine General anaesthesia by alcohol General anaesthesia by hypnosis Local anaesthesia Hare Reed PAGE 89 91 91 92 93 94 95 98 97 97 98 98 CHAPTER XII ABDOMINAL SECTION Terminology Preliminary treatment of the patient The evils of hypercatharsis Examination of the urines Instruments Location of the incision Dii-ection and varieties . The incision itself . Closure .... Drainage .... Reed 99 •5 100 ,) 101 ,, 102 Rohh 103 Reed 103 „ 105 „ 107 „ 109 jj 114 CHAPTER XIII THE EXTERNAL ORGANS OF GENERATION IN WOMEN Definitions Reed . .117 Development „ . . 117 Malformations of — (ff) Vulva Ballantyne . 118 (h) Vagina ., .126 The hymen Reed . . 131 Malformations of the hymen Ballantyne . 131 CHAPTER XrV INJURIES OF THE EXTERNAL GENITAL ORGANS Injuries from — (a) External violence Dorsett (&) Parturition . (c) Sexual intercourse Pudendal hematocele Reed Injuries of the vagina Rupture Urinary fistulse Ross Vesico-vaginal fistulae Sims's operation Reed 135 136 136 136 139 139 139 139 144 CONTENTS Vesico-vaginal fistulae — Ross's operation Reed's operation After-treatment . Utero-vaginal fistulae Treatment Recto-vaginal fistnlae Causes . Operation (Mayo Robson's) Ra Mayo RoJiHott PAGE 145 14() 148 151 151 152 152 153 CHAPTER XV INJURIES OF THE EXTERNAL GENITAL ORGANS — {COflt 111116(1) Rape Objective evidences Local condition Injuries on other parts Condition of clothing Schedule for examination Indecent assault Prolapse .... Injuries of perineum, vagina Uterus .... W. Joh uson 150 150 157 158 158 159 160 161 162 162 CHAPTER XVI INFECTIONS OF THE EXTERNAL GENITAL ORGANS Bacteriology of the external genital organs Mixed infections .... Gonorrhoea ..... Tuberculosis Erysipelas ..... Erysipelas and puerperal infection Diphtheria ..... Aphthae ...... Aerogenous infection Bilharzia ...... Chancroid Reed Wliitacre Reed Ravogli 16.3 105 160 171 177 178 179 179 180 180 181 CHAPTER XVII DISEASES OF THE SKIN OF THE FEMALE GENITALS Intertrigo . Erythema . Oedema Eczema Folliculitis Herpes progenitalis Pruritus vulvfe I'athology Causes Ravogli . 191 „ 194 „ 195 )j 190 5» 198 )) 200 )) 202 Reed 203 l\(iro(/H . 204 XVI A TEXT-BOOK OF GYNECOLOGY Retro-displacements Reed Symptoms and diagnosis „ Treatment ........... Massage . . . „ Pessaries • „ Surgical Mann Shortening the round ligament; Alexander's operation; vaginal operation; fixation operations . . . „ Anterior abdominal cuneohysterectomy .... Beed Anterior displacements ......... Prolapsus Herzog Inversion Reed CHAPTER XXV PARTURIENT INJURIES AND FOREIGN BODIES OF THE UTERUS Parturient injuries . Rupture . . . . Laceration of the cervix . Trachelorrhaphy Instruments Vesico-uterine fistulae Reed's operation Nonparturient injuries Wounds from external causes Foreign bodies Reed RoI)l) Ross Reed CHAPTER XXVI INFECTIONS OF THE UTERUS The uterus The endometrium The secretion of the uterine cavity The myometrium Bacteria of the uterus Infections . Endometritis and metritis Pathology Causes Symptoms Diagnosis Treatment Topical Curettage Instruments McMiirtry Reed Sinclair Reed Rohh CHAPTER XXVII - INFECTIONS OF THE UTERUS — (Continued) Specific — Gonococcous infection Reed Streptococcous infection „ 372 376 CONTENTS xvii Specific — Tuberculosis infection Sj'philitic infection Echinocoecous infection Whitoore Rffd PARE 384 391 393 CHAPTER XXVni 3fEOPLAiS31S or THE rXJERtJS Neoplasms of the utenis in general Benign neoplasms Fibromyomata . Causes, pathology, histoiy Seeondaiy degenerations Diagnosis Complicating pr^nancy Treatment Medicinal and electrical Surgical Indications . Myomectomy Supravaginal hysterectomy Panhysterectomy Eeed's operation Vaginal myomotomy Extirpation of polypi Herzog . . 396 . 390 . 39G 39fj_397 ,, . 399 McMui-trij . 402 . 403 . 404 . 404 . 404 Bo-^s . 405 . 407 . 410 . 415 Feed . 417 Dunniiifj . 420 ,, . 424 CHAPTEE XXIX isEOPLASiis OF TiTE T7TERTTS — {Continued) Malignant neoplasms Syncytioma malignum Pathology Histology Causes Symptoms Treatment Adenoma . Symptoms Diagnosis Treatment Sarcoma Pathology Histology Symptoms Causes Treatment Carcinoma Pathology Histology Causes . Symptoms Pregnancy as a complication Reed . 42G Herzog . 426 . 427 . 427 Reed . 42S . 428 . 429 Rerzoy . 429 Reed . 431 . 431 . 431 Eerzofj . 432 . 432 . 433 Reed . 435 . 430 . 436 Berzofi . . 437 . 438 . 439 Reed . 440 . 442 ■! . 443 XVlll A TEXT-BOOK OF GYNECOLOGY Carcinoma — Palliative treatment . . . . . Radical treatment . . . . . Vaginal hysterectomy . . . . Instruments ...... Abdomino-vaginal panhysterectomy Extended operation . . . . . Byrne's operation of electro -hysterectomy Results of hysterectomy . . . . PAGE Carstens 444 Reed 447 Newman 447 Robb 448 GarsteiiK 453 Reed 453 1} 456 ;j 458 CHAPTER XXX C.ESAREAX SECTION AND ITS MODIFICATIONS Definition .......... Cameron Historical resmne . , . Preparations .... Position of child and placenta The operation .... Sanger's method Porro's modifications 460 460 465 465 466 470 471 CHAPTER XXXI MALFORMATIONS AND DISPLACEMENTS OF THE FALLOPIAN TUBES Absence and defective development ..... BalJanfijne . 473 Supernumerary and accessory tubes ..... „ . 474 Accessory ostia ......... „ . 474 Displacements .......... „ . 477 CHAPTER XXXII NEOPLASMS OF THE FALLOPIAN TUBES Benign neoplasms ..... . Reed . 478 Papillomata ,, . 478 Cystomata ...... „ . 480 Lipomata ...... „ . 480 Fibroniyomata „ . 481 Malignant neoplasms .... „ . 481 Carcinomata „ . 481 Sarcomata „ . 482 CHAPTER XXXIII INFECTIONS AND INFLAMMATION OF THE FALLOPIAN TUBES Infections in general ...... Bacteria of the Fallopian tubes in health . Bacteria of the Fallopian tubes in disease Relations of infections to inflammation of the tubes Catarrhal salpingitis ...... Morbid histology of salpingitis .... Acute Chronic ........ Hydrosalpinx Reed 483 Sinclair 484 „ 484 Clark 487 » 489 489 !> 489 H 491 „ 495 CONTENTS Hematosalpinx Pyosalpinx Symptoms and diagnosis of salpingitis Clark Rohh PAGE 499 499 501 CHAPTER XXXIV INDIVIDUAL INFECTIONS OF THE FALLOPIAN TUBES Infections by — Gonoeoccus . Reed 512 Streptococcus „ 516 Bacillus tuberculosis .... . Whitacre 519 Bacillus coli communis . Reed 528 Pneumococcus „ 529 Staphylococcus » 530 Saprophytes ■ 530 Septic vibrion „ 531 Actinomyces ..... . 531 CHAPTER XXXV TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES The natural course and termination of inflammatory eases of the Fallopian tubes Hygienic treatment Medicinal treatment Local treatment Massage Electricity Drainage Vaginal incision Inguinal or inguino-vaginal Abdominal and abdomino-vaginal Rectal puncture .... Aspiration Conservative operations on the tubes Radical treatment .... Salpingectomy .... Tait's operation .... Modifications of Tait's operation Abdominal panhysterectomy Doyen's operation .... Modifications, indications, and limitations dis- Clark 532 Coe 535 „ 536 ,j 537 ,, 538 Reed 539 ,, 540 „ 541 542 ,, 544 „ 546 ,, 546 Coe 546 Reed 549 ,, 549 !J 551 !1 553 „ 554 556 ■) 557 CHAPTER XXXVI MALFORMATIONS AND DISPLACEMENTS OF THE OVARIES Malformations Ballautync Absence Rudimentary development Accessory ovaries Coexistence of ovaries and testicles 560 560 560 561 562 XX A TEXT-BOOK OF GYNECOLOGY Displacements of the ovary Reed Decensus and prolapsus . „ Hernia PA6B 563 563 564 CHAPTER XXXVII INFECTIONS AND INFLAMMATIONS OF THE OVARIES Classification ......... Hyperfemia . Acute inflammation ....... Chronic inflammation ....... Bacteria of the ovaries Individual infections Streptococcous infection Reed Gonococcous infection ...... Pneumococcous infection ...... Bacillus coli communis infections .... Tubercular infections ....... Whitacre 567 Reed 567 „ 568 Whitacre 569 Sinclair 570 „ 571 Reed 571 „ 574 „ 574 „ 575 Whitacre 575 CHAPTER XXXVIII TREATMENT OF INFECTIONS OF THE OVARIES Preliminary consideration Natural terminations Palliative treatment Conservative treatment Radical treatment Oophorectomy Unilateral Effects : primary, secondary Reed 579 579 581 582 584 J. T. Joh nson. 584 Reed 585 586 CHAPTER XXXIX TROPHIC DISEASES OF THE OVARIES Atrophy Coe . . 592 Cirrhosis Whitacre . 593 Hypertrophy Coe . . 594 CHAPTER XL NEOPLASMS OF THE OVARIES Small benign cysts ........ Follicular cysts Cysts of the corpus luteum Tubo-ovarian cysts Neoplastic cysts Proliferation cysts Dermoid cysts Solid tumours ......... Fibroids . . Calcified tumours Hematoma ......... Rothrock . 597 „ . 598 , : 599 , . 601 , . 602 , . 602 , . 611 . 614 , . 614 Reed . 615 Coe . 618 CONTENTS XXI Malignant neoplasms Rothroch Carcinoma .....■•••• » ■ Sarcoma »> • Endothelioma . » ■ PAGE 619 619 622 624 CHAPTER XLI NEOPLASMS OF THE OVARIES — {Continued) Complications . . . . Symptomatology Diagnosis Treatment Ovariotomy . . . . History . . . . Indications . . . . Technique . . . . After-treatment . Incomplete ovariotomy . Ovariotomy during pregnancy Reed J. T. Johnson Reed CHAPTER XLII ECTOPIC PREGNANCY Historical resume McMurtri/ Definition Hersog Etiology " Classification » Course and termination v Histology " Symptomatology McMurtr Diagnosis ■ >' Treatment .....•■■•• " 627 632 633 637 638 638 639 639 645 646 647 649 650 650 652 654 656 660 662 664 CHAPTER XLIII NEOPLASMS OF THE BROAD LIGAMENT The bi-oad ligament . Varieties of neoplasms Cysts (parovarian) . Origin . History Causes Symptoms, complications, diagnosis Treatment ..... Hall -Hawkins operation . Hydiocele of the long ligament Fibroma and myoma Symptoms, diagnosis, treatment Dermoids Solid tumours of the round ligiuiient pelvic VMiicocclc, iineuiisMial varix, i)liIeV)olithiasis f ';i rciiioiiia, sarcoma ...... Reed 669 Zinke 669 „ 670 „ 671 )' 671 ji 674 V 674 „ 675 Reed 676 677 Zinke 677 ,, 679 Reed 681 ,, 681 Zinke . 682 . 686 A TEXT-BOOK OF GYNECOLOGY CHAPTER XLIV INFECTIONS OF THE BEOAD LIGAMENT AND OF THE PELVIC PERITONEUM Infections of the broad ligament ...... Beed Pyogenic „ Pelvic abscess — treatment „ Syphilitic infection . . . „ Tuberculous infection . Whitacre Tubercular peritonitis „ CHAPTER XLV MENSTRUATION Normal menstruation . Time of appearance Menstrual cycle ........ Quantity of discharge Character of discharge ....... The inducing cause of menstruation .... The role of the uterus ....... The role of the Fallopian tubes The role of the ovaries ....... The hygiene of menstruation ...... PAGE 688 688 689 690 691 692 MiUikin . 699 „ . 701 „ . 704 ,, . 704 „ . 705 !> . 706 ,, . 708 „ . 709 „ . 709 ,, . 712 CHAPTER XLVI THE DISORDERS OF MENSTRUATION Menorrhagia General systemic causes ...... Local causative diseases above the pelvis . Pelvic causes ........ Treatment Metrorrhagia ......... Amenorrhoea ......... Treatment Retention of the menses ....... Dysmenorrhoea ........ Intermenstrual pain ....... Vicarious menstruation The menopause ... .... MiUikin . 714 „ . 714 „ . 714 „ . 715 . 716 „ . 719 „ . 720 . 721 „ . 723 „ . 725 . 734 . 735 . 738 CHAPTER XLVII THE FEMALE URINARY APPARATUS Physical examination Harris Catheterization of the ureters „ Pawlik-Kelly method „ LTse of the uretercystoscope „ Harris's urine segregator . „ Anomalies of the kidneys „ Number „ Location „ Form 744 746 746 747 747 749 749 750 751 CONTENTS XXlll Movable kidnoy Etiology Pathologic anatomy Symptomatology Treatment Anomalies of the ureters Strictures of the ureters Nephrocytosis . Nephrydrosis Pathologic changes Symptomatology Diagnosis Treatment Harris PAGE 752 753 755 757 759 760 760 762 702 763 765 765 766 CHAPTER XLVIII THE FEMALE URiNAKY APPARATUS — {Continued) Renal infections Symptomatology and diagnosis Treatment Tuberculosis of the kidneys Pathologic changes Symptoms and diagnosis Treatment Renal calculi Pathology Symptoms and diagnosis Prognosis Treatment Tumours of the kidney . Pathology . . . Symptoms and diagnosis Treatment Operations on the kidneys Nephropexy Nephrotomy Nephrectomy Harris 770 I Id 774 775 776 778 778 778 780 780 781 785 787 787 788 788 789 CHAPTER XLIX THE FEMALE tJRINART APPARATUS — {ConUn Cystitis ..... Etiology .... Bacteriology Pathologic changes Symptoiuatology and diagnosis Treatment .... Hyperfjfjnia .... Tj'eatment .... Foreign bodies in the Ijladdcr . Treatment .... lied) Harris 790 790 791 792 793 794 795 796 796 798 XXIV A TEXT-BOOK OF GYNECOLOGY Tumours of the bladder Harris Symptomatology and diagnosis „ Treatment . ,, Urethral caruncle ........... Treatment . ,, Carcinoma of the urethra „ Treatment ........... Sarcoma of the urethra . . „ Diverticula of the urethra ........ Treatment . „ Stricture of the urethra . ■ „ Prolapse of tlie urethra . „ Treatment ........... Foreign bodies in the urethra ........ Dilatation of the urethra ........ The urachus Reed Vesico-umbilical fistula ,, Treatment „ Cysts of the urachus .......... CHAPTER L THE RECTUM Malformations ...... Examination ...... Displacements ...... General etiology of rectal diseases Relation to intra-pelvic disease in women Reed Martin Reed Gant Martin CHAPTER LI INFECTIOIS'S OF THE RECTUM Inflammation . . . . . . . . . . Gant Periproctitis .......... „ Gonorrhoea Reed Syphilis Gant Tuberculosis ............ Surgical conditions resulting from infections . . . „ Anal ulcer or fissure Martin Ulceration of the rectum „ Fistulse „ Stricture Gant CHAPTER LII MEOPLASMS OF THE RECTUM Adenoma Gant Lipoma ■ „ Fibroma „ Papilloma „ Angioma ............ Terratoma CONTENTS XXV Retention cysts Myoma . . . . Enchondroma Malignant growths . Operations . Divulsion Proctotomy . Curettage Colostomy . Excision Hemorrhoids Injection Whitehead's operation Ligature Clamp-and-cautery Gant PAGE 844 844 844 844 846 840 846 846 846 847 848 851 852 852 853 CHAPTER LIII PELVIC DISEASES AND NERVOUS AFFECTIONS Neurasthenia Dercuni . . 856 Symptoms „ . . 856 Conclusion „ . . 860 Hysteria „ . . 860 Symptoms .......... „ . . 860 Pathology „ . . 862 Conclusions . „ . . 864 Operations for the neuroses „ . . 864 Nervous symptoms of pelvic disorders ..... „ . . 865 A TEXT-BOOK OF GYNECOLOGY CHAPTER I PROLEGOMENA -Gynecology — Historical resume — Gynecology as a specialty — Nomenclature of gynecology — Radicalism and conservatism of gynecology. Gynecology. — This word (derived from ywrj, a woman, and X6yo% understanding) implies, etymologically, the study or understanding of woman; but in its applied, modern sense, it means a consideration of the names, causes, prevention, symptoms, diagnosis, pathology, and treatment, of diseases peculiar to women. Historical Resume. — The evidence revealed by numerous papyri •establishes beyond doubt that the ancient Egyptian physicians under- stood somewhat of the diseases of women, and that there were practi- tioners who devoted themselves especially to their treatment. The Mosaic writings reveal keen intelligence of the menstrual and repro- ductive functions; and the Talmud records the operation which subse- quently became known as the Cesarean. The Greeks, deriving their knowledge from the Egyptians, improved upon their inheritance, and, with the writings of Hippocrates, marked the beginning of gynecology in the sense of a systematic treatise on the diseases of women. Inflam- mations, the disorders of inenstruation, and uterine displacements, here occur for the first time in recorded science. The writers of the next five hundred years simply elaborated upon the teachings of the great master. The speculum vaginae and the speculum ani were described by •Galen, while vaginal examinations by the digital method were practised long before that epoch. In the third century b. c, Soranus wrote a book on the uterus and pudendum. Aetius, Paul of iEgina, and other writers, show active and intelligent attention to divers diseases of women, including sterility. The speculum, duck-bill and multivalvu- lar, was in use, as were the uterine sound and uterine dilators. These instruments, and a knowledge of their use, however, seem to have dropped into oblivion during the long night of the Middle Ages. It was not until 1761 that Astruc, of the medical faculty of Paris, reinvented the speculum which he describes in his writing, but which passed with- <^ut attracting the general attention of the profession. la 1801 Reca- 2 1 2 A TEXT-BOOK OF GYNECOLOGY mier introduced his really practicable instrument by that name, an event which marked the revival of the long-lost gynecologic art. From this date progress has been rapid. In 1809 Ephraim McDowell, of Kentucky, did the first ovariotomy, an event which marked the begin- ning of intrapelvic gynecologic surgery. Uterine depletion hy leeches (Guilbert); the iise of the uterine sound (Lair); topical intrauterine and intravaginal treatment (Melier); the curette (Eecamier); uterine pathology (Simpson); inflammation of the uterus (Bennet); anaesthesia (Wells-Simpson); the rediscovery of the univalve speculum (Sims); operation for vesico-vaginal fistulge (Sims); oophorectomy (Battey); pathology and operative treatment of the Fallopian tubes (Tait); infection of the upper genitalia (ISToeg- gerath); perineorrhaphy (Emmet); antisepsis (Lister); and hemostasia (Koeberle), are among the more striking events which have character- ized the evolution of modern svirgical gynecology. During this period it has been a constant beneficiary of the general development in the medical sciences. ]\Iany other names are entitled to be recorded upon a scroll more complete than is consistent with the limitations of this work. The aggregate result of such developments as are herein indi- cated comprises what is known as modern gynecology. It is obvious at a glance that the great steps that have been taken in the development of this department of medical science have been almost exclusively sur- gical; and with them, more conspicuously than any other names, must stand associated those of Marion Sims, Lister, and Lawson Tait. It must be admitted that the tendency to exclude rational therapy, in its broader and more general as well as in its local and special sense, from consideration in connection with the treatment of diseases pecul- iar to women, is an evil. The fact should be held in constant view, that gynecology is an integral and thoroughly correlated department of medical science. The gynecologist should, therefore, be grounded, not alone theoretically, but by years of actual practice, in all that per- tains to the most advanced state of the healing art, considered in its broadest sense. He should, moreover, keep himself in constant touch with medical science in the various phases of its evolution. Gynecology as a Specialty. — It is a fundamental law that progress is due to the gradual evolution of heterogeneity. This process is exem- plified, not alone in the various phases of organic life, but in complex social organisms. The medical profession, considered as a constituent element of the social fabric, is subservient to the same law. Special aptitudes and special knowledge lead to correspondingly special occu- pations. This comes as a result, not alone of the tastes and predilec- tions of the individual, but of the discrimination of those who become his patrons. It follows, therefore, that those who would assume to be specialists in any department of medical practice, but who are un- qualified for the responsibilities which they invoke, sooner or later must fail. Specialism in medicine has an ethical basis which can not be ignored. These facts render the segregation of medical science PROLEGOMENA 3 in its practical application inevitable. There is no practitioner but knows and does some things better than he knows and does others, and he is to that extent a specialist. If, however, he were to concentrate his attention exclusively upon those things which he knows best and to ignore those things of which he knows least, his intelligence would move only upon convergent lines. This is indeed the inlierent mis- chievous tendency of specialism, and one which the gynecologist, as other specialists, should never cease to resist. The sphere of the gyne- cologist's labours has already resulted in a broadening of his activ- ities. His constant experience with intraperitoneal conditions has resulted in his expansion into an abdominal surgeon, a fact recog- nised, not alone by the general consensus of the profession, but, spe- cifically, by the creation in medical schools of professorships of " gyne- cology and abdominal surgery," or of " abdominal and pelvic surgery." Nomenclature of Gynecology. — One of the chief embarrassments in the evolution of a science is an indetermined and essentially de- fective terminology. Words are but symbols, and each word, to prop- erly fulfil its office, should be easily and definitely translatable in the mind into that for which it stands. In this way alone can language subserve, in the highest degree, its legitimate function as a medium for conveying ideas from one person to another. The language of medi- cine, says Dr. Frank P. Foster, is by no means free from the defective neologisms that are to be found in the contemporary literature of the other sciences. That they are more abundant in the writings of gyne- cologists than in other medical writings he is not prepared to admit. He considers that their formation is for the most part to be attributed to the rage for designating diseases, operations, and the like, by single words. Their defects generally consist (a) in joining a Latin word to a Greek word to make a compound; (&) in adding a G-reek termina- tion to a Latin word; (c) in reversing the proper order of the terms of a compound; or (d) in retaining an aspirate which any classical Greek writer would have suppressed. The following are examples of these forms of error: (a) " rectocolporrhaphy," made up of one Latin and two Greek words; (h) " annexitis," borrowed from the annex- ite of the French; (c) " hydronephrosis," instead of " nephydrosis " ; (d) " anhydrous " for " anydrous." Most of these defectively formed words have, however, established themselves firmly in the favour of the multitude, and it would be foolish to seek to root them out at this late day; nevertheless, by pointing out their deficiencies one may hope to moderate, in some degree, the further coining of objectionable terms. Far more to be regretted than these errors of coinage, is the perverted meaning often attached to well-known words, as when we say " differ- entiate " for " distinguish," or speak of " single " and " double castra- tion "; but even such perversions, however much they may offend the fastidious, throw no real obstacle in the student's way. The same can not be said, however, of the fancy that some authors have shown for dividing retroversion of the uterus, for example, into arbitrary " de- 4 A TEXT-BOOK OP GYNECOLOGY grees." The need of the day, long since emphasized by Jonathan Hutchinson, is for the legitimate employment of well-understood words, preferably those that are short, easily remembered, and so far as possible in the vernacular. Radicalism and Conservatism in Gynecology. — The essentially sur- gical character of modern development in gynecology has led to some abuses that are the necessary incidents of all surgical evolution. The operations of tenotomy in orthopa3dics, of tonsilotomy, and of the divi- sion of the recti muscles for the cure of strabismus, were followed imme- diately after their introduction, respectively, by indiscriminate applica- tion that resulted in damage to many patients. Other examples could be cited. In gynecology each new advance has been characterized by similar experiences. The use of the sound, of pessaries, and of caustics, was in each instance attended with early abuses. Emmet's operation for the repair of the lacerated cervix was followed by its needless per- formance in many cases. Oophorectomy and the more comprehensive operations upon the uterine adnexa were followed, immediately after their introduction, by efforts to relieve by their means conditions to which, in the light of subsequent experience, they were not adapted. These abuses, if such they can be designated, are to be construed rather as evidences of conscientious efforts on the part of the profession to determine the remedial value of surgical expedients. Reactionary in- fluences can be relied upon to correct these tendencies. The actuating motive in gynecology, as in other departments of medical and surgical practice, is to preserve in a safe or entire state, or to protect from unne- cessary loss, waste, or injury, the various organs or structures that are the seat of disease. Any departure from this criterion must be attended with danger. From this point of view, conservatism in gynecology is to be commended. It should be remembered, however, that even reac- tionary tendencies may go to dangerous extremes. This is sometimes exemplified in an effort to conserve an organ at the expense of the general health of the patient. On this point it is well to be governed by the rule tersely enunciated by S. C. Gordon {Philadelphia Medical Journal, August 19, 1899) that " conservative gynecology demands saving health rather than diseased and useless organs." All the splendid achievements of modern surgery, however, have been made in violation of the other equally legitimate definition of " conservatism " — namely: " Disposed to retain and maintain what is established, as institutions, customs, and the like; opposed to innova- tion and change; in an extreme and unfavourable sense opposed to progress." In view of the fact that the term conservatism of neces- sity carries with it the meaning expressed in the last as well as in the first definition, its introduction into the literature of gynecology is to be considered unfortunate. The life-saving impulse of the medical profession, and the yet unrelieved necessities of afflicted humanity, join in a demand for every innovation that will increase the efficiency of the healing art. CHAPTER II GENERAL ETIOLOGY OF DISEASES OF WOMEN Prevalence — Causes: Civilization; education; personal habits; occupation; dis- eases; copulation; prevention of conception; criminal abortion; childbirth; the social evil. Theee is a prevailing impression that the diseases peculiar to women are increasing relatively to the population. There exist no data upon which such an affirmation can be based. The impression probably depends for its existence upon the fact that such diseases are now better understood and more generally treated than formerly. Evidence is not wanting to indicate that the Anglo-Saxon woman is not degen- erating. Bowditch has made some interesting observations on the physique of women, as follows: Of over 1,100, he found that the average height was 158.76 centimetres (5 feet 3^ inches). Sargent, in nearly 1,900 observations, the ages of the women ranging from sixteen to twent\^-six, found the average slightly higher. Galton, in 770 measure- ments of English women from twenty-three to fifty-one years of age, also found a higher average — a difference due in part, no doubt, to the younger age of a number of the American subjects. In 1,105 subjects in ordinary indoor clothing Bowditch found the average weight to be 56.56 kilogrammes (125 pounds). These observations, compared with 276 by G-alton, show that the average weight is a little greater among Americans, It would seem that while the tallest English women sur- passed the tallest American women in height, the heaviest American women exceeded the heaviest English women in weight. Specific ob- servation of this systematic character, however, is not necessary to im- press the intelligent traveller with the generally satisfactory physique of the women of England and America. It is true that many defective specimens are found, and these come with relatively greater proportion under the observation of the physician. But no one can fail to be impressed with the fact that they comprise a distinct minority of the masses. The improvement in the physique of women has been very noticeable since the sentiment for athletics has supplanted that for the cloister, and since outdoor exercises have taken the place of those seden- tary habits which, but a few decades ago, were considered the proper affectations of refinement. With that other and vastly larger class of people, who are not at liberty to choose their occupations, there has been a distinct inipr'ovcMncnt in pliysical estate. Improved habitations, A TEXT-BOOK OF GYNECOLOGY better hygiene, more humane regulation of occupation, more rational methods of education, and, with all, a more general diffusion of pros- perity, are responsible for this improvement. It is a source of regret that this more or less optimistic view must be tempered by a frank recognition of yet existing evils which, to a certain extent, retard the progressive improvement of womankind, and are largely responsible for the diseases which, in the aggregate, comprise the subject of this volume. Civilization. — The assumption has been made, and in some quarters entertained, that civilization, in the aggregate, exercises a deteriorating influence upon woman; that it develops her mind and brain and nervous system at the expense of other elements of her physical organism. There is no doubt that between the women of aboriginal peoples and those who belong to the civilized races there are certain physical dif- ferences, some of which tend to the production of sexual diseases in the latter. The reproductive function can be taken as an index. Sav- age women, as a rule, have but little difficulty in childbed, because they have large pelves and bear children with small heads. Accidents in childbirth, however, do occur among these primitive peoples with gen- erally fatal results. Currier (Medical Neivs, 1891), who has studied the physical and sexual condition of the North American Indians, says: " that pelvic disease has not been treated among Indians does not prove that it does not exist." The fact that Indian women are very generally the victims of venereal diseases establishes upon a firm basis the pre- sumption that they must suffer from the remoter physical consequences of those diseases. Menstrual habits' among many of the Indian tribes may well serve as an example to civilized women. The Mosaic rule that women during this period shall be put apart for seven days is observed in practice by these lowly people, who never heard of the records of Leviticus. JSTapheys, confirmed by Holder {American Journal of Ob- stetrics, 1892), says that " it is an inviolable rule among all these tribes for the women, when having their monthly sickness, to drop all work, absent themselves from their lodges, and remain in perfect rest as long as the discharge continues." Measurements made by Holder indicate that the average height of the Indian woman is 5 feet 3^ inches; chest, 32-| inches; waist, 39f^ inches; hips, 34|-| inches. The measure- ments of the perfect form of the civilized woman are given as follows: Height, 5 feet 5 inches; bust measure, 33 inches; waist, 26-| inches; hips, 35 inches. It would not seem from this comparison that civilization is producing the disastrous results with which it is accredited. On the contrary, there are many evidences of an improvement in the physique of women of the civilized type, in which improvement the genital organs are no doubt participating. Education. — Education of the conventional type has been held re- sponsible for many of the ills peculiar to women. This criticism had much more point and force a few decades ago when the convent, with its seclusion and sedentary habits, determined the character of GENERAL ETIOLOGY OF DISEASES OF WOMEN 7 women's education. The present, however, may be designated as the ra- tional epoch in women's education — one in which they receive the max- imum of physical, mental, and moral benefit with the minimum of in- jury. The most hopeful feature of the i^resent regime is the tendency on the part of educators to study and regard the capacities and require- ments of the individual pupil. Eecognition is given to the primary bio- logic law of the antagonism between growth and genesis; and the effort is made in all advanced institutions of learning to adjust the curricula to the needs of the growing girl at different periods of her life. The doctrines of Froebel and Pestalozzi have relieved educational methods of much of their subjectivity, with the result that more attention is given to the education of the muscular system and the special senses; the book has largely yielded to the laboratory, and the cloister to the open volume of Nature. Potter {New York Medical Journal, 1891), recognis- ing some of the yet remaining defects of the educational system, sug- gests that for girls between twelve and sixteen, study hours or school work be restricted to four hours daily; that during each catamenial pe- riod the recitation room should be avoided; that during this period girls should indulge in much mental and bodily repose; and that during the school period especially, which is also the period of most active growth, girls should be provided with an abundance of wholesome food and be instructed in the most careful dietetic habits, special stress being laid upon a full morning meal. The dress should be constructed with ref- erence to relieving the waist line of all weight and pressure. He lays great stress upon the rule that no girl should enter a boarding school where the building is more than two stories high, and that stair climb- ing, at this developmental period of life, should be reduced to the minimum. Sir J. Crichton Browne urges that there are sexual brain differences betAveen men and women which militate against the latter in higher education. While he admits that there are no trustworthy data for the estimation of the normal brain weight of healthy natives of Great Britain, he bases his conclusions upon the study of the brain of insane subjects, with the result that he finds the average excess of male over female brain weight to be 4.5 ounces, or, if allowance is made for the difference in bodily height, the excess of the male over the female brain weight is reduced to 1.05 ounces. Sir James Browne asserts that the posterior brain development is greater in woman, that the convolu- tions have a similar pattern, and that her left brain weighs relatively less than her right; but there is a marked difl^erence in the distribution of the blood to the brain in the two sexes, and from these observations the conclusion is drawn that women are not fitted for the same educa- tional tasks as are men. The whole argument is misleading, first, from the fact that the observations were made upon the brains of insane peo- ple; next, that they were not sufficiently numerous to justify a general conclusion; and, finally, that the results of higher education among women show that they improve physically as well as mentally, rather than deteriorate, under its influence. The last statement is confirmed 8 A TEXT-BOOK OF GYNECOLOGY by Dr. Mary Dixon Jones, who, as a former principal of a young ladies'' seminary, and latterly a successful practitioner with an extensive clien- tele among women, asserts that menstrual disturbances are of rare occur- rence, and that symptoms referable to the pelvis are but seldom com- plained of among young women students. The after life of such stu- dents indicates as good an average state of health and as high a degree of fecundity as among any other class. It is not apparent why intellec- tual occupation during the period of pubescence should interfere with sexual growth any more among girls than among boys. Personal Habits. — That personal habits have much to do in the causation of pelvic diseases can not be denied. Habitual errors of diet resulting in constipation; general physical inactivity inducing slug- gishness of the splanchnic circulation; and habits of dress seriously constricting the waist and imposing weight upon the pelvic viscera, are all to be taken into account. The corset, however, as an article of dress is not to be unqualifiedly condemned; on the contrary, if loosely applied, it serves as a protection rather than otherwise to the underlying viscera. More serious criticism should be directed to the deficiencies of dress of the neck, shoulders, arms, and legs. The influence of cold upon these more or less extensive areas can not but have a tendency to produce internal engorgements. Habits of outdoor exercise, now more or less prevalent, evince a hopeful tendency in the hygiene of women. Equestrian exercise, the bicycle, and golf, are all calculated to improve the physique of those who temperately participate in them. While this is true, it should not be forgotten that excessive activity in these, as in other wholesome sports, may be provocative of damage. Occupation. — The modern extension of woman's activities has brought with it more or less of a penalty in the form of genital diseases induced by her occupations. It was not to be exjjected that women could adjust themselves without damage to labours which, through generations, had been arranged for men; nor could it have been ex- pected that the several vocations could be at once so remodelled as to suit them to women's phj^sical capacities. Clerking in stores, with its long hours of uninterrupted standing, employment in offices that were not provided with proper lavatory facilities, work in factories with im- perfect ventilation, and the carrying of heavy burdens, are among the examples which illustrate the influence of occupation as a cause of pel- vic disease in women. The peasant women of continental Europe work side by side with the men in nearly all occupations, and they are espe- cially given to carrying heavj^ burdens upon the head, as is true of the American negro in the South. All these classes furnish examples of uterine displacements — especially procidentia and its attendant evils. The relative robustness of the European peasant women is largely a fic- tion. The modern household has many features that have etiological bearings upon this class of diseases. The thoughtless construction of houses, carrying with it the necessity of excessive stair climbing; the totally unnecessarily great weight of household utensils that must be GENERAL ETIOLOGY OP DISEASES OP WOMEN 9 handled by women; and the performance of overhead tasks, many of them unnecessary, are causes to be taken into account. The sewing machine, while a great mercy to womankind in general, is, by its abuse, a fruitful source of mischief to those whom it was designed to benefit. Diseases. — Aside from gonorrhoea and syphilis, mentioned in an- other paragraph, other diseases are provocative of genital disorders in women. Miiller, of Munich {C entralblatt fur Gyndkologie, 1890), has reported several cases in which miscarriages were induced by la grippe. The influence of the same disease upon the genital organs is noted by the same author, who finds that in a large number of cases it provokes either metrorrhagia, menorrhagia, or aggravation of sexual diseases already existing. Erysipelas may result in bacterial invasion and con- sequent suppuration within the pelvis and in puerperal fever. ISTeuras- thenia, a distinctly constitutional state, may occasion symptoms which Goodell appropriately designated as nerve counterfeits of genital dis- eases. Engorgements of the liver, from whatever cause arising, may produce disturbance of the portal circulation to a degree that will induce passive congestion of the pelvic viscera. Constipation is a fre- quent cause of functional disturbance of the ovaries and uterus. Copulation. — The sexual relation fulfils the meaning implied in the creation of two sexes. It is distinctly a physiologic function, yet errors in its establishment and practice frequently cause injury and disease in women. Coition, done abruptly for the first time, particularly if attempted by a male organ disproportionately large, may produce lac- erations and dangerous hemorrhage. A penis of inordinate length may penetrate a woman so far as to exercise undue violence upon the uterus and adnexa, and thereby sooner or later induce disease of those organs. If practised too frequently, or in the absence of inclination on the part of the woman, or if repeatedly completed by the man before an orgasm is experienced by the woman, it sooner or later becomes a mere source of mechanical irritation to the latter. Prostitutes suffer greatly in consequence of the nonamatory character of their sexual relations, although in such cases the constant possibility of infection as a com- plicating causative factor must be held in mind. Coitus reservatus when indulged in by the female has a tendency to increase to an abnormal degree the turgescence of the organs. Van de Warker made a critical study of forty-two women of the once notorious Oneida community, which seemed to have been organized chiefly with reference to the practice of coitus reservatus, especially by the male, but under condi- tions of promiscuity. He found no greater prevalence of sexual disease there than elsewhere, nor was he able to find diseased conditions which he could attribute to the sexual habits of the commimity. Sexual anfpMhesia, of frequent occurrence in women, is a cause of unhappiness and pbysical injury. Sexual perversions are to be considered in the light of both cause and consequence of genital disease. Masturbation is often caused by a pre-existing local irritation of the vagina or puden- fliirn, or by arlbosions of tlio clitoris to the prepuce, and it as frequently 10 A TEXT-BOOK OP GYNECOLOGY causes similar disturbances. It is highly probable that there is no form of sexual perversion that is not associated with more or less congestion of the genital organs which remains after the act, whatever it may be, is completed. Prevention of Conception. — Malthus formulated a doctrine which assumed to justify the limitation of families by the prevention of con- ception. Practices having this object in view have been known since Onan spilled his seed upon the ground. Many accessory practices, how- ever, have come into vogue in modern times, none of which are destitute of serious consequences. The use of the vaginal douche immediately after intercourse, the use of a sponge within the vagina for absorbing the semen, the " womb caps," condoms, are all damaging expedients. If it is granted that their local physical effects are not deleterious, the fact still remains that their employment implies a psychic state inim- ical to the perfectly normal performance of the copulative act. Coitus reservatus is generally more damaging to the male than to the female. Criminal Abortion. — There has been no time within the known his- tory of the human race when women have not sought to avoid mater- nity. The induction of abortion as a means of limiting reproduction was known and practised by the Egyptians, the Greeks, and the Eomans. x\lthough certain social theorists have enunciated the prin- ciple of justifiable foeticide, it remains an unproved assumption that the practice is more prevalent to-day than in previous periods. That it is prevalent to-day, however, there is no denying; nor can the dele- terious results of the practice upon the reproductive organs of women be ignored. Infections induced in this way, when not fatal, almost always destroy fecundity and render relief by surgical means im- perative. Childbirth. — j\Iany of the injuries and diseases of women have their origin in childbirth. The relatively large cranial development of chil- dren borne by civilized women, rather than any other one circumstance, tends to increase the difficulties and dangers of parturition. Infec- tion occurring in childbed, resulting in puerperal fever, or in infection of the endometrium or the Fallopian tubes, is yet of too common occurrence, although it is encountered with less frequency since the bacterial character of puerperal infections has become better under- stood. The recent great improvement in the obstetric art has already resulted in the practical disappearance of vesico-vaginal fistula and in the diminished frequency of both cervical and perineal lacerations. These conditions, however, are yet encountered as the demonstrable results of parturition. The Social Evil. — The social evil has long been recognised as re- sponsible for many of the physical infirmities of women. This evil, which has existed from the remotest antiquity and which will continue to exist as long as the race suiwives, is a necessary incident of social organization. It is properly recognised by all sociologists as an in- evitable feature of social evolution. In dealing with it, therefore, it GENERAL ETIOLOGY OF DISEASES OF WOMEN H is important at the outset to recognise it as an abiding fact rather than as an evanescent theory. In what way, therefore, does it exercise a deleterious physical influence upon society at large? The answer is that it works its mischief by the dissemination of the two great vene- real diseases, syphilis and gonorrhoea. Syphilis causes disease of the genital organs of women chiefly from the fact that it is communicated, for the most part, in the act of inter- course, and that the primary sore manifests itself in the genitalia. This, as a rule, is not an especially serious matter, although it may lead to the graver constitutional complications characteristic of the disease. In its hereditary form it is liable to manifest itself in defective develop- ments and in temperamental deficiencies, both of which may be mani- fested in defective functional capacity of the genital organs. The manifestations of this disease in relation to the difi:erent organs will be considered in their appropriate places in this work. Gonorrlicea, more than any other one disease, is responsible for those complications in women which are destructive of her reproductive ca- pacity, which produce organic disintegrations, and which demand sur- gical interference for their relief or cure. Before JSToeggerath demon- strated that the gonococcus (see Microccocus gonorrhoece under Sepsis) was the essential infectious element in the vast majority of intrapelvic suppurations, tubal and otherwise (see Pyosalpinx), gonorrhoea was looked upon as a local and comparatively trivial affection, involving the vagina and external genitalia. Since that time, however, the medical profession has come to recognise it as the most dangerous disease of frequent occurrence with which woman is afflicted, cancer, of course, being excepted. This assertion finds ample confirmation in the etiology and pathology of inflammatory diseases of women as presented in sub- sequent chapters. The social evil being recognised as a fixed and inevitable fact, and the dissemination through it of venereal disease being so destructive to women, it is the manifest duty of society to subject prostitution to the most rigorous supervision. The medical profession owes it to itself, and to the humane objects to which it stands consecrated, to use its influence to secure the legal regulation of that evil which society has proved itself unable to suppress. CHAPTER III GENERAL PATHOLOGY OF THE FEMALE GENERATIVE ORGANS Local pathology conforms to general pathologic laws — Peculiarities depending upon difEerentiated functions — Menstruation — Ovulation and gestation in their relation to pathologic states — The poise of the uterus and its variation — Bac- terial origin of inflammatory diseases of the female genitalia — Tuberculosis — Syphilis — Trophic changes — Neojilasms. Local Pathology conforms to General Pathologic Laws. — The gen- eral pathology of the female organs of generation in many respects does not differ from the general morbid anatomy and physiology of other parts of the body. Simple and specific inflammations, local bacterial infections, benign and malignant tumours, hypertrophy and atrophy, degenerations and other secondary changes, complications, and sequels, follow the same pathologic laws and types as are observed elsewhere in the organism. There may be minor differences, but these variations do not involve any fundamental change in principle. Of such slight devia- tions from the ordinary there may be mentioned unusual degrees of glandular hypertrophy, often developing after slight inflammatory irri- tation, such as we find, for instance, in the mucous membrane of the uterus. There are tumours, ordinarily very malignant in type, which in some parts of the female genitalia — the ovary, for example — may exist for a long time without involving neighbouring structures or giving rise to metastases. On the other hand, tumours histologically of a benign type may produce purely mechanical disturbances by their rapid growth, location, or otherwise, which may endanger or even take the life of the patient. There are, however, also quite a number of morbid phenomena and conditions to which the female only is subject, and which must be studied from a strictly specialistic standpoint, with- out, of course, losing sight of the great general principles of pathology. Peculiarities depending upon Differentiated Functions. — The fe- male genitalia in the human race perform such specific and well-differ- entiated physiologic functions that we should expect to find in them disturbances unknown elsewhere. Such is the case; for the functions of menstruation, ovulation, and pregnancy, are often disturbed in their exercise by underlying abnormal changes which call for particular attention. Menstruation in its Relation to Pathologic States. — Menstruation brings about a cycle of profound though transitory changes in the 12 GENERAL PATHOLOGY OP FEMALE GENERATIVE ORGANS 13 uterus. Congestion to a degree which an^^where else in the body wouhl be abnormal, and actual hemorrhage, would, of course, be pathologic in any other organ but the female genitalia. It was formerly gen- erally held that the uterus in menstruation shed its whole mucous membrane, this being regenerated from what little remained of the glandular epithelium. Herzog, who has carefully examined several menstruating uteri obtained by operation from living subjects and not post-mortem, agrees with Mandl, Westphalen, Gebhard, and others, who within the last few years have maintained that the uterus does not shed its mucous membrane in menstruation, but only loses some of the surface epithelium. It being conceded that this view is cor- rect, there are then still present during and shortly after menstrua- tion some small patches of mucous membrane denuded of surface epi- thelium. This condition certainly favours bacterial invasion whenever microbes are present, and a locus minoris resistentice is thus created periodically in the female which does not exist in the male. Morbid subjective symptoms, the disturbances of beginning menstruation, dys- menorrhoea, menorrhagia, amenorrhoea, and vicarious menstruation, are phases of pathologic phenomena necessarily peculiar to the female, and that are considered in detail in the section on Menstruation. We thus find that the function of menstruation may and does carry with it to the female, dangers and pathologic conditions from which the male is exempt. Ovulation in its Relation to Pathologic States. — ^We likewise find the same to be true with reference to ovulation. In it the physiologic processes and the accompanying tissue changes are of a type which may be well called quasi-pathologic. Paradoxical as it may appear, it may be well said that nowhere in the body do we have a physiologic process with such typical pathologic features as are found in ovulation. When a Graafian follicle has become mature and has approached the surface of the ovary there occurs at the time of ovulation a break in the continuity of the ovarian tissue, a rupture, accompanied by a hemor- rJiage, which may be more or less extensive. The gap so formed is in the normal course of events closed by the formation of cicatricial tissue, derived from connective-tissue elements. Herzog, who has studied the normal and pathologic anatomy of the corpus luteum, agrees with Clark (Archiv fur Anatomie und Physiologie, 1898), who has recently reaffirmed the view that the lutein cells are not epithelial cells derived from the zona granulosa, but connective-tissue elements derived from the theca interna folliculi. The processes of rupture, hemorrhage, and cieatri- cial-tissue formation, are, with this single exception, entirely patho- logic. (We will liere neglect uterine menstrual hemorrhage, which is of a difl'ei'ent chai'actcr altogether.) In the ovary we find them as normal features of a purely physiologic process. It is obvious how easily these fjiiaKi-|);i1 liologie y)r()(;(;ssos may overstep their physiologic limits and lead to truly morbid conditicms, such as, for instance, marked cicatri- cial contractions with general premature atrophy of the ovary. Dan- 14 A TEXT-BOOK OF GYNECOLOGY gers of ovulation to the female organism are also to be looked for in another direction. The normal living cells of the organism all pos- sess more or less the power to resist bacterial invasion. In ovulation, however, we have, formed in the female organism right in the perito- neal cavity, a blood coagulum, a focus, not consisting of living cells, but of a dead culture medium, which at the body temperature is so notoriously favourable to the development of pathogenic micro-organ- isms. It has been said above that menstruation, in consequence of slight denudation of the uterine mucous membrane, creates here a locus minoris resistentice for bacterial invasion. This is true in a still higher degree with reference to the formation of the blood coagu- lum in an open cavity of the ovary. Herzog, in studying the histology and bacteriology of a number of cases of ovarian abscess, was struck by the observation that in the large majority of cases one is able to dem- onstrate that the abscess wall contains elements of the corpus luteum. In other words, these abscesses represent an infection of the corpus- luteum cavity Avith pus formation (empyema of the corpus-luteum cav- ity). The proliferative processes in the normal adult body, as a rule, do not lead to the formation of newly organized tissues. They only sub- stitute tissue elements which in the cycle of metabolic changes have become senile, undergo dissolution, or are shed, as the case may be, and have to be replaced by younger elements. In the ovary, during sexual activity, with the ripening of the G-raa- iian follicle we have constantly a process of real new tissue formation which, as a rule, stojos onl}'^ during pregnancy, but which may even then persist (Herzog: Superfcetation in the Human Eace. Chicago Medical Recorder, vol. xv, 1898). It is not improbable that the normal new tissue formation as found in the ovary in connection with the maturing follicle, stands in a certain relation as a predisposing, or even sometimes causative, factor in the development of neoplasms so frequently found in this organ. This view is here given in spite of the well-known fact that most neoplasms of the ovary are very likely of stromatogenous and not of ovulogenous origin. Among the neoplasms of the ovary, to be considered more in detail later, there is one of a most unique patho- logic histogenesis — namely, the dermoid cyst or embryoma ovarii. Her- zog strongly indorses the view so ably advocated by Wilms that these neoplasms are always of ovulogenous origin, not merely derivatives of ectodermal inclusions, and that they represent an attempt at patho- genesis. Gestation in its Relation to Pathologic States. — The most impor- tant physiologic function of the female genital organs, gestation, leads to numerous pathologic conditions and complications. Most of these lie outside of the scope of this work, but a number of them properly fall within the domain of gynecology. Minor congenital anomalies of a type which in other parts of the organism throughout lifetime may be void of any practical moment, when found in connection with female genital organs may become of the greatest pathological impor- GENERAL PATHOLOGY OP FEMALE GENERATIVE ORGANS 15 tance. Some reference has already been made to this point when speaking of menstruation in the presence of a congenital obstacle to the catamenial flow. Of still greater practical bearing are those con- genital anomalies which become responsible for ectopic pregnancy. The etiology of the most frequent form of gestation of this kind — namely, tubal pregnancy — is as yet a good deal contested and obscure. Herzog is of the opinion that in a large percentage, if not even in a majority, of cases, congenital anomalies are indeed the cause of ectopic gestation. hSeveral cases have been reported in which there is left no doubt as to an etiology of this kind. (Henrotin and Herzog: Anomalies du Canal de Miiller comme cause des grossesses ectopiques. Revue de gynecologie et de cliirurgie abdominale, Paris, 1898. — Very Early Eup- ture in an Ectopic Gestation in a Tubal Diverticulum. New York Medical Journal, 1899.) Pregnancy also furnishes the substratum of a peculiar kind of neo- plasm found in the female, the syncytioma malignum. These tumours, developing during or shortly after pregnancy, are derived from foetal structures — namely, the chorion epithelium, comprising the layer of Langhans and the syncytium. In some way or other these foetal ecto- dermal structures acquire the properties of a malignant tumour, develop parasitic properties, invade the parental structure, primarily the sexual organs, and form distant metastases. In this manner embryonic tis- sues may become the starting point of a malignant tumour which ulti- mately destroys the life of the maternal organism. Here we have again an example of a pathologic event directly dependent upon a function of the female organs of generation, an occurrence which is of course impossible in the male. The Poise of the Uterus and its Variations. — Among the peculiar- ities of the female sexual organs must be mentioned the delicate man- ner in which the uterus is balanced and held in position by the gen- eral arrangement of the parts in the female pelvis, in connection with a complicated ligamentary apparatus. It is very obvious why such a complicated arrangement should be necessary, when we consider the changes of position and size which the fruit bearer has to go through during the sexual life of the female. The delicacy of balance neces- sary from physiologic reasons becomes a fruitful source of morbid states. A very important and voluminous chapter in the pathology of the female sexual organs is that on the malpositions of the uterus. Of course, these malpositions are usually not of a primary nature; they are, as a rule, subsequent to other morbid changes. But these morbid changes per se are often very insignificant, and a long train of patho- logic symptoms and conditions is only brought about in consequence of the changed position of the womb, its sequelae, and complications. (See Uterine Displacements.) Bacterial Origin of Inflammatory Diseases of the Female Genitalia. — If we now, from the standpoint of nosology, consider the general pathology of the female organs of generation, inflammatory diseases 16 A TEXT-BOOK OF GYNECOLOGY first command our attention. After bacteriology had solved quite a number of questions with reference to general and local infections and inflammatory conditions in various parts of the organism, it was hoped, and firmly believed, that this youngest branch of pathology would also speedily contribute much toward showing us the true etiology of the great variety of inflammatory diseases of the. female genitalia. The ana- tomic arrangement of the latter makes it a priori very probable that bacterial invasion plays a predominating role as a causative factor in all classes of inflammatory diseases. Doderlein, commenting upon this point with reference to such affections of the uterus, says: " Above any site in the body, the uterus seems to be the place favouring bacterial invasion and colonization. The open connection between the uterus, the vagina, and the outside world; the many chances for transport of germs which are so obvious, particularly during sexual life; stagnating secretions protected against desiccation and kept at a brood-oven tem- perature- — all these factors unite to a priori impress us how well adapted the interior of the genitalia is for bacterial invasion and diseases de- pendent upon them." (See Sepsis.) Yet it has been found that, in spite of all these apparently favour- able factors, the internal genital organs of the healthy woman are not easily reached by pathogenic bacteria, and are, as a rule, sterile. The vulva, according to the unanimous verdict of all investigators, is fre- quently the seat of pathogenic bacteria, particularly the ubiquitous ordinary pyogenic micro-organisms. The vagina, however, in healthy women contains pathogenic bacteria only in a small number of the cases examined under the proper precautionary measures to avoid contamination. It, on the other hand, in healthy women always har- bours a great many nonpathogenic bacteria. Yet, fully virulent patho- genic microbes, introduced experimentally, as has been done by Bumm, Menge, Kronig, Doderlein, and others, are speedily killed in the healthy vagina. Clinical and other experience has abundantly shown that the vagina under certain conditions loses its protective power of " self -purification." Particularly is this the case in parturition and immediately after delivery. A large percentage of septic inflammatory diseases of the female genitalia may be traced back to infection in par- turition. Such septic infection may, of course, also be easily induced in the nonpuerperal state by unclean instruments passed into the uterus. We know that malpositions or tumours of the uterus are responsible for hyperplastic inflammatory reactions of the endometrium. Deep lacerations of the cervix so frequently occurring in parturition, even without a manifest septic infection, may lead later on to chronic in- flammatory changes of the uterine mucoiis membrane. In other cases of endometritis we miss every tangible anatomic cause, and for an attempt at explanation we must turn to such flimsy causative factors as nutritional and circulatory disturbances of unknown origin — tropho- neurotic or vasomotor disturbances. It is, however, easy to understand GENERAL PATHOLOGY OF FEMALE GENERATIVE ORGANS 17 that in the tissues of the female organs of generation there may be ■established frequently, without the aid of bacteria, the initial stages of inflammatory processes arising directly out of a plus of the physiologic functions. Congestion and stasis, or, in other words, dilatation of ves- sels and diminution of the velocity of the current, which are among the first steps in the train of inflammatory changes, are normally found in ovulation, menstruation, and pregnancy. The inflammatory diseases of the tubes and ovaries are often of very obscure origin, just like those of the uterus. This is particularly true of the ovary. In it we meet profound pathologic changes of this type, which baffle every attempt to get at their true cause as effectually as they resist all therapeutic measures. In such inflammations of the ovary we find cases with grave vessel changes, a pathologic process which has recently been described under the designation of angeiodys- trophia ovarii (Bulius and Kretschmer). Tuberculosis of the female genital organs, which may be a primary or a secondary process, is by no means so rare as was formerly believed. Some parts of the female genitalia are invaded frequently by the tubercle bacillus. Among these must be mentioned preferably the tube. It has been found that many cases of salpingitis, formerly be- lieved to be simply septic in character, are really mixed infections in wdiich the tubercle bacillus is present. Even the ovary, formerly held to be practically free from tuberculosis, is not at all immune but is oc- casionally infected. In the uterine mucous membrane we find tuber- culosis in the acute miliary, the interstitial, and the ulcerative variety. Tuberculosis of the muscular coat seems to be rare, yet Herzog has seen a case in which the whole muscularis was literally studded with tuber- cles. (See Tuberculosis of the A^arious Organs.) Syphilis of the Female Genitalia. — Syphilitic manifestations of a primary, secondary, or tertiary type, are frequently found in the puden- dal organs, but very little is known about syphilis of the internal geni- tal organs except the occasional localization of the primary sore on the portio or cervix. Herzog, who has studied the vascular changes of syphilis (A Contribution to the Ilistopathology of Syphilis: Chicago Medical Recorder, vol. xiv, 1899), is of the opinion that certain cases of chronic oophoritis, in which no other causation can be obtained, and which present certain vessel changes very characteristic though not pathognomonic of syphilis, may be due to either the acquired or the congenital form of this affection. Trophic Changes. — Eeference has frequently been made to hyper- trophies occurring in the female genitalia. Just as we find a peculiar liability to hypertrophy in these parts, so do we meet atrophic processes, some of which have so far baffled all endeavours to solve their etiology, as is, for instance, the case in the atrophic condition known as Icraurosis vulva?. (See Cutaneous Diseases of the Vulva.) Of course all normal physiologic senile changes must be excluded from the consideration of morbid atrophies, the most interesting of which are those of the uterus. 3 18 A TEXT-BOOK OF GYNECOLOGY Normal, transitory lactative hj^Derinvolution may lead to permanent premature atrophy. This may also be brought about by a number of general infectious diseases, abnormal blood states (leucaemia), or metabolic affections (diabetes). Profound puerperal infection is the most common cause of partial or total atrophy of the uterus, and this may lead to grave local and general disturbances. (Bacon and Herzog: Fatal Perfoi'ation of a Uterus Partially Atrophied Post-partum. Amer- ican Journal of Obstetrics, 1899.) Neoplastic Changes. — The true intrinsic etiology of tumour forma- tion in the female genital organs is as obscure to us in these parts as it is elsewhere in the organism. We know, of course, that the female genitalia are in an unusually high degree liable to become the seat of neoplasms. No part of these organs is free from tumour formation, and all types are met with. Three classes of new growth stand out most prominently. The horrible frequency of carcinoma of the uterus is a fact only too well known, not only to the profession, but even to the laity. While diseases of the mamma have been left out of our considera- tion entirely, it perhaps deserves mention here that these accessory sexual organs of the female likewise belong to those organs which most frequently develop carcinoma. The second class of tumours which show a great predilection for the female genitalia is formed by the fibro- myomata. Attempts have been made to explain their frequent devel- opment in the uterine muscularis upon the ground that the structure, from its physiologic changes in pregnancy, has an intrinsic tendency toward the new formation of muscle tissue. But this seeming explana- tion disregards the fact that while we have in pregnancy an enor- mous increase in the bulk of the muscularis, it is one, as is now con- ceded, wliich does not depend upon an increase in the number of the component muscle cells, but only upon an increase in their size. The third class of neoplasms occupying a very prominent place in the pathology of the female organs of generation, is the cysto-adenomata of the ovar3^ It has been previously mentioned what physiologic reasons may possibly stand in some causal nexus to the frequency of neoplastic formations in the ovary. In the cysto-adenomata of the ovary we have epithelial neoplasms which differ greatly in some respects from ade- nomata found elsewhere. The latter, as a rule, have a great tendency to become malignant and to change into true carcinomata. This tendency in the cysto-adenoma of the ovary is rare. (Henrotin and Herzog: Carcinoma Developing in Primarily Nonmalignant Cysto- adenoma of the Ovary. Chicago Medical Recorder, vol. xvii, 1899.) Here we have an extensive epithelial proliferation, which in other parts of the body is almost sure to lead to carcinoma, but which in the ovary does not seem to carry with it any great danger of developing malig- nancy. Not only are these cysto-adenomata very common, but they also often occur in women advanced in life, and they may exist for years and decades without ever changing their benign type. Pathologic pro- GENERAL PATHOLOGY OP FEMALE GENERATIVE ORGANS 10 cesses almost unknown in other parts of the body, but fairly often seen in the female in connection with benign epithelial neoplasms, are the implantation metastases of papillomatous adenomata of the ovary. These metastases are, as a rule, entirely void of true malignant features, and they generally disappear after the removal of the main tumour. Another fact worth remembering in connection with the peculiar- ities of the pathology of the female genitalia, is the comparative fre- quency of neoplasms, particularly of a sarcomatous type, in the female infant and child. In closing the foregoing considerations, it should be said that they do not pretend to furnish a full and exhaustive general description of all the pathologic phases and problems encountered in connection with the female genital organs. What has been attempted, is to give to the student of this department of medicine an idea of the special points of view and the particular physiological considerations from which the pathology of the genital system of the woman must be ap- proached, which are considered in detail in various chapters of this book. CHAPTEE IV GENERAL THERAPEUTICS OF GYNECOLOGY General medication — Serum therapy — Local medication — Balneotherapy — Sugges- tion — Electricity — Massage. General Medication. — The lines along which modern gynecology has developed have been so distinctly surgical that relatively less attention has been given to the question of therapeutics. The error involved in this tendency is shown by the fact that the female genera- tive organs are in close vascular, nervous, and tissue, connection with the general system, of which they are as distinctly integral parts as are the eye, the ears, or other organs of special functions. They are capable of influencing and of being influenced by systemic states; and they are therefore, to a certain extent, amenable to therapeutic agencies. The medical aspect of gynecology is entitled to studious consideration. The deterioration of the blood, as manifested in the various anaemias, often finds expression in disturbance of the menstrual function; neu- rotic states not infrequently cause j^ainful coition and dysmenorrhoea, while hepatic disturbances produce pelvic hypersemias. It is appar- ent, therefore, that any therapy which will relieve the initial disturb- ance, will, to that degree, cure its results. This conception of the relation of the functional integrity of the genital organs to systemic states or to other anatomically remote diseases, must be the key to the intelligent employment of remedial agencies. Thus, a simple laxative may relieve ovarian tenderness, an active cholagogue may cure a con- gested uterus, and a course of iron and arsenic may become the most potent remedy for certain functional menstrual deficiencies. That remedies given by the stomach exercise in any important degree an elective action upon the nonpregnant uterus or its adnexa, is open to doubt. Ergot and the bromides, for example, given as rem- edies for uterine hyperplasia, have disappointed expectation. Laxa- tive agents, however, such as aloes and myrrh, which affect the lower alimentary canal, modify the functional activity of the generative organs by attracting an additional volume of circulation to the pelvis. The most valuable general remedy in the treatment of the diseases of women, is rest. This should be looked upon just as if it were a mate- rial agency, duly catalogued, and described in the materia medica. Rest in this sense implies not only physical repose, but, so far as possible, cessation from functional activity. To realize its full bene- 20 GENERAL THERAPEUTICS OP GYNECOLOGY 21 fit, the marital relations of the patient should be for the time discon- tinued, and the patient herself should go to bed. That kind of rest which patients are prone to take by donning a loose gown and lounging here and there about the house, engaging in one activity after another, amounts practically to no rest at all. The practitioner will do well always to explain in minutest detail just what he means by rest when he prescribes it. In many of the minor acute inflammations, noninfec- tious in character, this remedy is alone sufficient to cure. Serum Therapy. — The treatment of gynecologic conditions by animal extracts was introduced by Jouin in 1895, and advocated in America by Polk {Medical News, January 11, 1899). The treatment of diseases of the uterus and adnexa by these agents is under advisement. Cures of amenorrhcea due to obesity are reported as resulting from their use. Polk has advocated the administration of thyroid extract for the cure of uterine fibroids, and has reported cases which seem to be im- proved by the remedy. The treatment seems to be based upon the well- known reciprocal trophic relationship existing between the uterus and the thyroid gland. This relationship has been emphasized by Freund {CentraMatt filr Gyn'dkologie), who finds that swelling of the thyroid merely from congestion is always present in pregnancy, and also during menstruation. Wherever there is energetic or persistent irritation in- volving the uterine muscles, it will cause a persistent swelling of the thyroid. That this trophic impulse is derived from the uterus rather than from its adnexa, is shown by the fact that ovarian tumours and tubal dropsy do not cause enlargement of the thyroid, except when in rare instances they encroach upon and irritate the uterine muscle. These observations are in accord with those previously made by J. Fischer, who affirms and demonstrates not only the influence of the uterus upon the thyroid, but also that of the thyroid upon the uterus. Women with goitre generally suflier with menorrhagia and metrorrhagia; extirpation of the thyroid is followed by genital atrophy. Myxoedema in women is generally associated with amen- orrhcea. In cretins, there is a diminution and often an entire loss of sexual power. Menstrual disturbances are among the earliest symp- toms of exophthalmic goitre. These facts, long since established in America by Jenks, indicate beyond question the relationship existing between these two organs. It would seem that an extract made from the thyroid gland of the sheep and ingested into the human system exercises to some degree a modifying influence upon the uterus, its nutrition, and functions. The extent and exact character of this influence remain yet to be determined. Ovarian extract is given with the object of stimulating ovarian activity and of increasing the sexual af)petite. Favourable reports of its use have been made, but whether the alleged results are due to physical or psychic influence remains to be determined, Protonuclein, locally applied, is unquestionably a valuable antistreptococcic agent, and reports are abundant indicating that it exercises a salutary influence over the nutrient activities. 22 A TEXT-BOOK OF GYNECOLOaY Local Medication. — Local medication consists in the application of remedies directly to the part involved. This method of treatment is of great importance in many of the diseases wliich will hereafter be con- sidered. Tlie application of escharotics to an inital syphlitic sore and the topical use of an antiseptic solution in the treatment of vaginal gon- orrhoea, are examples in point. Among the remedies thus employed for antiseptic purposes, the chief are mercuric bichloride, carbolic acid, lysol, creolin, and potassium permanganate. Among the local astrin- gents may be mentioned the salts of lead, zinc, and even iron. Boric acid is a favourite with many i^ractitioners, while tannin is the vegetable salt of greatest importance in this class of cases. The action of astringents, all of which are to a certain extent antiseptic and ger- micidal, is to influence the circulation of the capillaries upon the tissues to which they are applied. They are frequently of question- able value, and always of less value than those agencies which have a more powerful iiiHuence in desti-oyiiig the micro-organisms upon which depend practically all of the inflammatory diseases in the mucous and cutaneous areas. Hydrastinine, a comparatively new alkaloid, de- rived from the hi/draslis canadensis, has been found by Falk to be a valual)le astringent, when used in ten-per-cent solution locally, for the treatment of uterine hemoi-rhage. Sedative lotions and emollient applications are frequently demanded to relieve local distress in the external genitalia. Topical a]>plicati()ns, having for their object the drainage of the pel- vis by exosmosis, should be employed in practically all cases of acute in- tlammation, of chronic engorgement, or of i)ersistent exudation within the pelvis. This treatment is made effective by virtue of the hygroscopic proi)erties of glycerine. This agent has such powerful attraction for water that it abstracts it from any underlying tissue to the surface of which it is applied. This subject will be treated more in detail in connection with pelvic inflammations. Balneotherapy. — In no department of medical practice has the use of water proved of more value than in the management of intrapelvic diseases of Avomen. Emmet, many years ago, pointed out the value of the vaginal douche and demonstrated its rationale — the water at a tem- perature varying from 105° F. to 120° F. is applied with the patient lying on her back, and continued for a period of twenty minutes at each seance. As has been demonstrated by Emmet, the primary influ- ence of the heat thus applied is to dilate the capillaries and to invite an increased supply of blood to the parts. In the course of ten min- utes, however, the secondary effect of the heat is realized. This is characterized by blanching of the parts, a contraction of the capil- laries, and a marked diminution in the volume of the local circula- tion. This treatment should be repeated at least twice daily. The results are invariably a marked amelioration of local engorgements, particularly when treatment is associated with rest and drainage by osmosis. Engelmann, of Kreuznach, has found general bathing GENERAL THERAPEUTICS OF GYNECOLOGY 23 under scientific supervision to be a remedy of great value. Asso- ciated with friction, it acts on the same principle as a counterirri- tant, attracting a considerable volume of tlie circulation to the surface, tliereby relieving splancbnic congestions, and, by stimulating the nerv- ous system, becomes an active promoter of absorption. In this way it becomes valuable as a remedy for clironic exudates, adliesions, neo- plasms, and in the treatment of amenorrhcea due to obesity. It is contraindicated in acute inllamuiatory conditions. Engelmann says that an efficacious bath ought to contain from four to six pounds of common salt or sea salt, and also from two to five pints of mother lye to four hundred pints of water. The temperature of the batli should not exceed 95° F., and its duration should not exceed half an hour. The influence of such a bath is to calm the pulse and respiration and to induce sleep, which should always be encouraged. The better time for taking such a bath, therefore, is just before bedtime. Suggestion. — Suggestion as a therapeutic agent has been in vogue since the Pastaphori of Egypt practised it in the form of a " temple sleep," and ever since the healing by words was recorded in the Mosaic writings, or in the pages of the Zend-Avesta. It is based upon the influence of mental upon physical states, and while it has never re- ceived specific recognition as a distinct agency in gynecologic thera- peutics, it is nevertheless a remedy of unconscious daily application by every tactful practitioner. That uterine and other genital disturb- ances exercise a perturbing influence upon the mind is a matter of constant observation; and that the mind diverted from the seat of dis- comfort, or thoroughly impressed with the thought of and confidence in the recovery, thereby stimulates the organism in the direction of health, is a fact long known and practised by the profession. Suggestion may be carried not only to the unconsciousness of pain due to local j)hysical disturbances, but to the degree of anaesthesia in parts that are not the seat of disease. So powerful is this agency that operations may be, and have been, performed painlessly under the hypnosis thus induced. An agent of such power should be subjected to more critical study than has yet been accorded it by the profession. (See Angesthesia.) Electricity. — Electricity, in the form of faradism, is a remedy of some value when adminstered in such a way as to bring the nervous and muscular systems under its influence, when it acts as a promoter of metabolism and an important stimulant to the nutrient functions. Ad- ministered locally, under antiseptic precautions, with the negative pole in the uterus and the other upon the surface of the abdomen, it has been found to act as a stimulant in restoring the functional tone of that organ. With one pole in the vagina and another in the groin it has been found to relieve neuralgic conditions within the pelvis. Favour- able reports have been made of its use in catarrhal endometritis. There is no doubt that, judiciously applied, it promotes the growth of the undeveloped uterus, for which purpose the intrauterine electrode should be the negative one and that placed over the abdomen or over 24 A TEXT-BOOK OF GYNECOLOGY the sacrum should be the positive one. It has been found to promote the absorption of effused products in the pelvis, but it must be recog- nised as a dangerous remedy in this class of cases, for the reason that it is practically impossible in many of them to determine when the exudation does or does not depend upon purulent infection, in the presence of which electricity should not be used. Electricity in the form of a strong current causes chemical decomposition of the tissues by the process of electrolysis, by which the acid elements are attracted to the positive pole and the basic elements are attracted to the negative pole. It was the application of this principle that induced Apostoli,, of Paris, in 1884, to attempt the disintegration and absorption of uter- ine fibroids by the use of strong electric currents. He began by using 100, which he finally increased to 250 milliamperes, the strength of the current being accurately measured by a galvanometer. While, in many cases, this treatment temporarily arrested hemorrhage and diminished the size of the growth, its general results have not been accepted as satisfactory by the profession. It proved to be painful, causing, in many instances, deep eschars on the abdominal surface, intractable peritoneal adhesions, infections of the tumour, septictemia, and, in some cases, death. Massage. — Massage is one of the most primitive of remedies, and is utilized by many aboriginal peoples. Stanley found it in iise among the hordes of Africa; Stevenson found it in use among the JSTavajos; it was a remedy among the ancient Chinese and the Hindoos; and it was employed by the Greeks and Romans. Hippocrates mentioned its use in diseases of the joints. In the great renaissance it appeared first in France, whence it spread to other European countries. Billroth, Es- marcli, von Mosetig, Thiersch, von Bergmann, von Mosengil, and others recommended it highly, first in diseased conditions of the extremities, and finally as a therapeutic measure in diseases of the internal organs. In the form of general massage it is a valuable remedy for the pro- motion of metabolism and elimination, especially in cases of the neu- rotic type. In these cases, judiciously applied, it tranquillizes the nerv- ous system, induces sleep, and, by virtue of its quality as a form of pas- sive exercise, it promotes nutrition. It is of special value as an adjunct to the " rest cure." For the realization of its greatest benefits it must be given scientifically, for the details of which the reader is referred to the various manuals on the subject. Massage is contraindicated in all febrile states and in the presence of acute inflammation. Dr. G-eorge H. Taylor has devised a method called by him vibratory massage, which is utilized by means of specially devised apparatus. The method shows great ingenuity and a scientific conception of the subject, and de- serves the most careful consideration. (See New York Medical Jour- nal, April 2, 1892.) Abdominal massage consists in the manipulation of the abdominal wall, and through it of the abdominal organs, for the purpose of pro- moting functional activity of the latter. As ordinarily employed, the GENERAL THERAPEUTICS OF GYNECOLOGY 25 patient is placed in the recumbent posture with the abdominal walls flexed, when with the hand the abdomen is kneaded. This general exercise is supplemented by manipulations beginning in the right iliac fossjB and extending upward to the hepatic flexure of the colon, thence across to the splenic flexure, and thence downward to the sigmoid, the object being to stimulate the colon to activity. As a substitute for a manual manipulation of the abdomen, Sahli places a cannon ball on the relaxed abdominal wall and rolls it around in various directions, and Ivanhoft' has suggested a substitute in the form of a hollow wooden or celluloid globe, partially filled with shot. A shot-bag has been simi- larly used with excellent results. AVhen any one of these substitutes is used, its application should be concluded by rolling it repeatedly over the track of the colon from the cscum to the sigmoid. Abdominal massage, to be most effective, should be given half an hour before breakfast and repeated half an hour after breakfast. By its employ- ment the contents of the abdominal canal are moved onward, the portal circulation is accelerated, the lymphatics are given a fresh impetus, absorption and assimilation are promoted, the production of gas is diminished and its expulsion facilitated, and the splanchnic sym- pathetics are stimulated, while all the nutrient functions participate in the benefit. Pelvic massage has been popularized chiefly through the influence of Thure Brandt. It consists in the manipulation of the pelvic organs by the bimanual method with the object of correcting displacements, of curing old adhesions, of effecting the resorption of old exudates, of stretching shortened ligaments, and of reducing hyperplasias. The patient to whom it is to be ap^jlied is given a preliminary treatment of mild laxatives to unload the rectum, and boroglyceride tampons in the vagina to lessen pelvic engorgements. The patient is placed in the dorsal position with her knees well flexed; the vagina is thoroughly cleansed; the operator inserts the index finger of his "handy" hand, thoroughly oiled, into the vagina, passing it well up behind the cervix; the other hand is placed over the suprapubic region. At this juncture, and before any special manipulations are undertaken, a careful biman- ual examination of the pelvis should be made, a precaution which should be observed at the beginning of each seance. If points of recent engorgement or of especially acute sensitiveness are discovered the operator should desist. If, however, no such contraindications are found, it is ]:)rescribed, as the first movement of the massage, to press the external hand over and behind the fundus of the uterus, while slight downward traction is exerted by the tip of the intravaginal finger, the object being in all movements to draw the uterus gently toward the symphysis pubis. The ovaries are treated, when discover- able, by subjecting them to a similar range of mobility. Special move- ments are suggested by the particular conditions that may be discov- erefl. A seance should not last over ten minutes, and the force to be employed, both in amount and direction, must be determined at the 26 A TEXT-BOOK OF GYNECOLOGY time by the conditions encountered and by the judgment of the oper- ator. After massage a boroglyceride tampon is inserted, and if the manipulations have been at all painful the patient should remain in a state of repose for several hours. The dangers inherent in this method of treatment are so many that it has been largely abandoned by those who formerly employed it, while, on theoretic grounds, it has been perhaps too unqualifiedly condemned by those who have never tried it. Its chief danger consists in the fact that the exact diagnosis of intra- pelvic conditions is extremely difficult, and that consequently massage is liable to be employed with fatal results in conditions in which it is contraindicated. iVmong the accepted, but sometimes not recognisable, contraindications to the use of pelvic massage, are acute inflammatory processes; the presence of dilated Fallopian tubes; ovarian enlarge- ments; cystic degeneration in either the ovaries or the parovarium; and, above all, the presence of pus in the pelvis. (See Diagnosis of Pyo- salpinx.) CHAPTER V THE GYNECOLOGICAL ARMAMENTARIUM The more modern principles of treating wounds have led to marked modifications in the surgeon's armamentarium, and in no part, per- haps, has the change been so pronounced as in the kind of instruments used in operative work. The day of instruments with elaborately carved wooden and ivory handles is past, and complicated trocars and tubular needles no longer have a place in our instrument cases. The present tendency is to simplify their construction as much as possible and to use no greater variety than is absolutely necessary. The choice of instruments must necessarily vary with the predilections and train- ing of the individual operator. Certain main principles, however, should always be kept in mind. The surgeon need not encumber him- self with such instruments as are seldom needed, or with a multitude of so-called " surgical conveniences " and "^ automatic appliances." He should, however, always provide himself with a liberal supply of the instruments in common use, in order to be prepared for emergencies. jSTone should be retained which do not permit of easy sterilization. Knives should have smooth metal handles, and handle and blade should be in one piece. Instruments with grooves, depressions, and notches, are to be avoided. Good hemostatic forceps with smooth blades can now be obtained, and are just as effectual as the old ones with grooved faces. All scissors, forceps, needle holders, and the like, should have simple articulations, so that the different parts are readily separable. An instrument with permanent joints can not be kept surgically clean, and should therefore not be tolerated. With our present methods of sterilization, instruments made of steel do not suffer as they did for- merly, and if properly cared for should not rust. Mckel plating has been proved to be not so valuable as was at first hoped, for, since instru- ments which are subjected to constant wear have soon to be replated, they would prove somewhat expensive. For those instruments which are but rarely used, however, nickel plating is advantageous, since it protects them from the action of the air. Instruments made of aluminum have been recommended, but they are undesirable for the following reasons: (1) They are too expensive; (3) they are too soft; (3) they will not stand repeated sterilization. In a hospital, one nurse or assistant should be given the full charge of the instruments, being held responsible for their proper sterilization and preservation. In private practice the surgeon must give the in- 27 28 A TEXT-BOOK OF GYNECOLOGY struments his personal attention; and even in hospitals he will do well to watch closely the assistant to whom they are intrusted, in order to be sure that the constant careful attention which is absolutely neces- sary is being paid to them. It is important to write out lists of instruments that are used in the different operations and to keep them where they can be easily consulted on each operation day, so that none which will be needed will be forgotten. Those lists should be divided into two parts, the first containing instruments which are sure to be required; the second, those that may possibly be needed under certain circumstances; they should therefore be prepared, although they may be set aside until they are called for. (For special lists of instruments, see the different operations.) CHAPTER VI DIAGNOSIS Definition and scope — Indications and contraindications for vaginal examination — The gynecological examination : Physical ; the armamentarium ; the examina- tion itself ; inspection of the external genitals ; digital examination ; bimanual examination; rectal exploration ; examination under anaesthesia; examination of the abdomen ; regions of the abdomen ; instrumental examination by (a) the speculum, (b) the sound, (c) the dilator, (d) the curette, (e) the aspirator — Examination of the secretions — Urine — Faeces — Menstrual discharge — The nervous system. The diagnosis of a gynecologic case consists in determining the character and location not only of the local disease, but of any asso- ciated pathologic states. The destructive character of many of the infectious diseases and of both the benign and malignant neoplasms in women, and the essentially insidious onset of many of these condi- tions, render prompt examination and early diagnosis necessary for the welfare of the patient. This fact will be emphasized in discussing the diagnosis of individual diseases. To the end that diagnosis may be made early, it is the duty of the practitioner to impress upon his cli- entele the importance of this step, and that it may be made accurately, it is essential that he should take the broadest possible survey of the patient and make the most critical investigation of even suggestive departures from health. It is better, in an effort to avoid a narrow investigation of simply the conditions complained of, to leave the examination of the genital state until all essential facts in the patient's general history have been ascertained. To this end systematic inquiry should first be made relative to the patient's age, hereditary influences, menstrual and marital histories, previous diseases, and present com- plaints. A^Tiile these interrogatories are being made and answered the physician should cultivate the habit of carefully noting the patient's appearance, with special reference to her nutrition, her nerve poise, and her temperamental characteristics. The pulse should be counted, the tongue should be inspected; in short, a general survey of the pa- tient sbould be made before strictly pelvic conditions are either in- quired into or examined. All of the facts thus gleaned should be re- corded and held in mind during the progress of the physical examina- tion, which should embrace the following steps: (a) The gynecological examination, including, if necessary, an ex- ploration of the bladder and rectum and inspection and palpation of the abdomen. 29 30 A TEXT-BOOK OF GYNECOLOGY (&) Special physical examination, including, according to the indi- cations of the case, inspection of the throat and upper air-passages, percussion and auscultation of the heart and lungs, ophthalmoscopic examination, etc. (c) Examination of the secretions — e. g., the urine, faeces, menstrual flow, and perspiration. (d) Examination of the blood. (e) Examination of the nervous system, with special reference to the determination of sensory and motor disturbances. Indications and Contraindications for Vaginal Examination. — In cases of girls and unmarried women a vaginal examination, either digi- tal or instrumental, should be undertaken only in the presence of posi- tive indications. Youth and virginity should always be looked upon as contraindications for such an exploration, unless in the presence of more than counterbalancing reasons: such, for instance, as the pres- ence of all the menstrual phenomena, the flow excepted, suggesting the possible retention of the menstrual fluid; or in the presence of an offensive discharge associated with remoter pelvic symptoms; or to investigate the origin of a persistent hemorrhage. There are numerous other conditions the importance of which will occur to the practitioner. It should be set down as a rule to which there are but few exceptions, that the examination of young girls in particular, and of many unmar- ried women of the nervous type, should be undertaken only under anaes- thesia. In this way alone can they be protected from a serious moral shock and more or less physical discomfort. AAHien the examination is being made great care should be taken to preserve as far as possible all virginal conditions; but this consideration ought not to obtain to the point of defeating thoroughness of exploration in the presence of manifest necessity. In married women less hesitancy should be manifested in under- taking an examination, although even in such cases it should not be done for trivial reasons. When, however, there are either pudendal, vaginal, or high pelvic symptoms of an obscure character and suffi- ciently severe to justify treatment at all, the practitioner owes it both to himself and his patient to insist upon an examination. Any failure to take this stand is liable to be disastrous to both parties. In women past the menopause, all symptoms of a pelvic character should be regarded with suspicion and inquired into with promptness and precision. This is especially true in the presence of hemorrhage at or about the period of the change of life — a symptom which is nearly always an evidence of malignant disease. (See Menopause.) The Gynecological Examination. — It is as important in all gyneco- logical procedures to establish accuracy of diagnosis as in any other department of medicine. The responsibility of the gynecologist is not second in this respect to that of his confreres in the other branches of medical or surgical science. The foundation of correct diagnosis lies in the thorouffhness of the DIAGNOSIS 31 examination, and to this end every known means must be invoked in discovering the real seat of the malady and the character of its possible complications. At the initial consultation a complete history of the patient's con- dition should be obtained and accurately recorded. For this purpose it will be convenient to have a book so bound as to contain one hundred histories, and so ruled and spaced that additional entries may be made at subsequent dates. It is a good plan to have the history blanks printed in sheets that may be filed temporarily and be bound after an adequate number have been filled. The form of the blank can be devised by each physician according to his own preferences, hence it is only necessary here to call attention to the essential points of the record. These are — after entering the name, age, social condition, address, and other preliminary data — to record the family history as bearing on heredity; the menstrual history; the number of children borne and the character of the labours; mis- carriages and their sequelae; condition of bowels and bladder as to func- tion; all pelvic phenomena that are abnormal; and, finally, every fact pertaining to the special condition for which the consultation is sought. After the physical examination has been made, all lesions, growths, or abnormities should be carefully entered, and the treatment advised or instituted, set forth in detail. Each physician, as he becomes impressed with the value that attaches to accuracy, will record all data shown by experience to be important. The foregoing are merely suggestive, and are, moreover, such as may not, in any case, be omitted. Physical Examination. — After having made and recorded an oral examination of the patient, the next step involves a physical investiga- tion by inspection, palpation, and pelvic exploration. The events under consideration in these pages are made applicable to office con- sultations, hence details are given adapted to that environment. Suit- able rooms are requisite, and should number three or more, en suite — one a reception room, another a consulting room, and a third solely used for the examination. In this last there should be running water, hot and cold, and a toilet room adjoining is well-nigh a necessity. The examining and toilet rooms should be presided over by a comely woman, trained as an office assistant. She need not necessarily be a nurse, but she should be a trustworthy woman competent to hold a speculum and intelligent in all that pertains to gynecological work. The armamentarium should consist of a table, specula, dressing forceps and tenacula, douche apparatus, absorbent cotton and antisep- tic wool, sounds and applicators, lubricant, protective or pad, sheet, and gown. The table should be strong and should stand solidly on its four logs. It should be capable of extension to enable the patient to lie in the horizontal position, reasons for which will be considered pres- (inily. II, need not necessarily be an expensive or complicated affair, but should be equipped with foot rests, a thin mattress, and pillows. 32 A TEXT-BOOK OP GYNECOLOGY An assortment of Sims's specula are essential, and one or two good bivalves will be convenient. Every successful g3^necologist knows the value of the Sims specu- lum, and every one Avho expects to practise the specialty must of neces- sity make himself familiar with its uses. The objection often made to it is that a competent person is required to hold it. If the beginner can not emjiloy such a person, then he must provide himself with one of the so-called self -retaining Sims instruments. Potter prefers the Emmet self -retaining attachment for this purpose. It is the simplest and can be held easily by the patient, who will grasp a piece of rubber tubing passed through the f enestrum of the buttock blade. Sounds and applicators are included in the office outfit, but it is proper to remark that they seldom will be needed. The indiscriminate use of the sound has proved harmful to many women, and should never be used by unskilful hands. Nevertheless it will occasionally be serviceable as an aid to diagnosis, hence is included in the list. Applicators, too, will rarely be employed. We need not enter into a discussion of the propriety of topical applications to the endometrium, but it will suffice to say that as a routine it is of doubtful propriety. Occasionally, however, such treatment is needful, hence the instru- ments must be at hand. The selection of a proper lubricant is a matter of considerable im- portance. Vaseline is in common use, but it is not easily removed from the hands. Dudley (Diseases of Women, second edition. Lea Brothers & Co., 1900) prefers glycerine, which is cleanly, sterile, but expensive. Some are partial to glymol, certainly an excellent agent. Potter recommends alboline in collapsible tubes, which is thus kept germ free, is cheap, and efficient. The so-called Kelly pad, really a device of Joseph Price, is a con- venient protective, but it, too, is expensive, and besides is difficult to keep clean. A piece of rubber sheeting will answer every purpose, pro- vided that it is rolled at the sides and back to prevent backfiow of water. A douche apparatus should be at command for all office examina- tions or treatment. It should consist of a reservoir that will hold at least a gallon of sterilized water, with rubber tubing attached to a vaginal douche nozzle with backfiow arrangement, and the tubing should be equipped with a gate or cut-off. Before examination the woman should be divested of unnecessary clothing, such as corsets and superffiious skirts, then placed upon the table in the dorsal posture, with feet in the foot rests, and the pad or protective properly adjusted to prevent Avetting or soiling the clothing. After covering her with a sheet, tlie douche may be administered. This should consist of an appropriate quantity of sterilized water at a temperature of about 115° F. If there is suspicion of infection, the douche should be rendered antiseptic by the addition of bichloride of mercury sufficient to make a solution of 1 to 2,000. \ DIAGNOSIS 53 Fig. 1. — " The woman is now placed upon the table, usually in the dorsal position." — Potter. The Examination. — The preparation of the patient may be made by the office assistant, who, as we have said, should be a competent woman. She shouhl ar- range the clothing of the patient, administer the donche, and, if need be, give an enema to unload the rectum. This latter is important if there is constipation, as a distend- ed lower bowel may mis- lead in diagnosis. Such a condition not only dis- places the pelvic viscera, but it may be mistaken for a tumour, new growth, or retro verted uterus. Af- ter these preliminaries the patient is ready for the examination proper, which, it is almost needless to add, in these days of asepsis, should be conducted with the utmost aseptic care. The examiner himself should prepare his hands as carefully as if he were about to conduct an abdominal section or other important surgical operation. His lavatory should be supplied with the best of soap. A number of nail brushes, too, should be at hand, and of these there is none better, or indeed so good, as those made of vegetable fibre. They are cheap, durable, and can be kept clean. We have already alluded to the administration of the douche, which should invariably precede the examination unless for some special rea- son it becomes necessary to inspect the uterine, vaginal, and vulvar fields, to study their secretions or exudates with a view to deter- mine their character, in the expectation that they may furnish an important aid to diag- nosis. But when it is used, particular care must be paid at the conclusion of the ex- amination to the dis- infection of the douche nozzle as well as of the hands of the physician and assistant and of all else that comes in contact with the patient. With these preliminaries the woman is now placed upon the table, usually in the dorsal position (I'ig. 1), as already indicated; or, accord- ing to tlio r('f|iiir('iiiciiis of the case or the preference of the operator, 4 Fig. 2.-" Or, according to the requirements of the case, or the preferences of the operator, she is placed in the left lateral prone, better known as Sims's posture." — Potter (i)age 34). 34: A TEXT-BOOK OF GYNECOLOGY Fig. 3. -" . . . Which is better appreciated if studied from the foot of the table." — Potter. she is placed in the left lateral prone, better known as Sims's, posture (Fig. 2), Adiich is better appreciated if studied from the foot of the table (Fig. 3). Occasionally it will become necessary to employ the knee- chest posture (Fig. 4), and sometimes a woman should be examined while she is standing (Fig. 5). Upon mounting the table, the woman should sit upon the end of it, which should be properly covered with protective and aseptic towels. A pillow should be provided for her head, but, as she is to lie flat upon her back, the shoulders should not be ele- vated by the pillow. A sheet or other proper covering should be spread upon her lap while she is yet sitting on the end of the table. She is now assisted to lie down, the nurse taking hold of her feet and placing her heels in the stirrups, which should be placed as close together as possible and which have been drawn out to receive them. The thighs thus become flexed, the abdominal mus- cles relaxed, and the knees widely separated. In a first examination it will often become necessary to assure the patient that she is neither to be hurt nor exposed, after which the covering may be parted and adjusted around the vulva, which is ready for inspection. Inspection of the External Genitals. — It becomes necessary, espe- cially with a strange patient, at a first examination to inspect the vulvar field with care. This is done, not only for diagnostic reasons, but for safety. A physician may become infected from a venereal sore, even on the person of an inno- cent woman, unless the presence of such a le- sion is detected before- hand. To be forewarned is to be forearmed. In the investigation of such a case, abrasions of the hand, and especially of the examining finger, should be painted with collodion. Having determined the nature of the secre- tions of the parts, and having carefully inspected tlie hymeneal orifice, noting whether the hymen has been ruptured, the examiner should next look carefully for the evidences of parturition — such as lacerations, cicatrices, and the Fig. 4.- -" Occasionally it will become necessary to em- ploy the knee-chest posture." — Potter. DIAGNOSIS like — and then he may look for tumovirs, urethral caruncles, vulvitis, urethritis, eruptions, ulcerations, cj^stocele, rectocele, inflammations of Bartholin's and Skene's glands, osdema, and pruritus. The rectum should be explored with reference to hemorrhoids, fissure, fistula in ano, pinworms, and any anomaly of anatomic configuration. The clitoris should be examined with reference to any enlargement or an adherent prepuce. The vulvar orifice, if capacious or gaping, gives token at least of marital relations, whereas the virgin vulvar orifice is small, com- pact, with a more or less perfect hymen. The absence, however, of the hymen is not considered evidence of unchastity — a fact that should always be kept uppermost in the mind of the gynecologist, especially in the commencement of his practice. The condition of the labia minora should also be noted. When these are long, flab- by, and pendulous in contour, it is prob- able that the woman is a masturbator. This condition of the minor labia, it is quite true, might arise from other causes, but this is the most probable explanation of it. While inspection is usually limited to the region and for the purposes named, it may be carried upward to include the surface of the abdomen, whereby enlarge- ment or imperfection of contour may be discovered. Inspection of the interior of the vagina through the speculum, and of the rectum by a similar instrument, does not come within the limit of this section, but will be described under its appropriate head. Digital Examination. — By far the most important method of investigation is the examination by the fingers and hands. The tactile sense is so acute, and may be so highly educated, as to supersede or take the place of every other method, provided one were limited to a single means of obtaining information. It becomes of the first importance, therefore, that it shall be employed intelligently, systematically, and thoroughly. We shall not enter into an argument as to whether the right or left index finger is the better for this investigation, but shall con- tent ourselves with saying that while the specialist will frequently prefer the left, and most of such at least will be ambidextrous, the general practitioner will usually employ his right finger or fingers for the digital examination. An advantage in using the left finger is that it leaves the right band free for instrumental use and for bimanual examination. Again, it preserves the right hand from the danger Fig. 5.—". . . Sometimes a woman should be examined while she is standing." — Pottee (page 34). 36 A TEXT-BOOK OP GYNECOLOGY of becoming an infection carrier, which is perhaps a matter of con- siderable moment in dispensary or hospital work. Sometimes it will be useful to employ two fingers in the investigation, but this will be rather the exception than the rule, limited to the capacious vagina and the short index finger. Two fingers in a narrow vagina are, to say the least, painful; but, as the index finger is sometimes short and the diagnostic reach can be increased perhaps half an inch by the con- joined use of the index and ring fingers, this expedient occasionally becomes not only justifiable but useful. There is nothing that indicates greater gynecological skill than the tactful employment of the digital examination. The clumsy, hasty, and rough manner, in which it is sometimes used, is to be strongly condemned. On the other hand, it should be employed with the great- est delicacy, but at the same time with thoroughness, precision, and aptitude. Every gynecologist should avail himself of every oppor- tunity to educate his finger tips; indeed, they should be brought to that degree of tactile perfection that a reasonable degree of accuracy in diagnosis can be obtained, in the majority of cases, without an appeal to instrumental aid. The digital examination becomes available and applicable in the horizontal, dorso-sacral, latero-prone, genu-pectoral, and standing, postures. But its chief application is in the dorsal or dorso-sacral postures. Finally, the index finger occasionally becomes of great usefulness in everting the anus by pressure through the vagina upon its posterior wall. In this manner the examiner will often detect with ease and precision rectal or anal faults that otherwise might re- main obscure. It remains for us to give the technique of the digital examination. To begin with, let us repeat, the toilet of the hands, and especially of the index finger to be employed, should be most carefully made. Thor- ough washing with soap and warm water and scrubbing with the nail brush should precede the lubrication. Then the finger tip, palmar surface dowuAvard, should be carefully passed into the vagina against its posterior wall, the fingers of the other hand being used to separate the labia and to slightly distend the vulvar orifice. In this manner it will note, first, the condition of the perineum, its rigidity or laxness, its integrity or imperfectness; secondly, the condition of the rectum, whether it contains f^ces or is empty; thirdly, the relation of the coccyx to the pelvic outlet; and fourthly, the capaciousness or narrowness of the vagina. Turning now the finger upward and passing from side to side along the vagina, its lateral surfaces are explored, until finally the cervix uteri is reached. Here is an important field for investi- gation. If the cervix is soft, like the lips, a suspicion of preg- nancy will arise; if firm or hard, like the nose, such suspicion will be dispelled. The cervix and os must now be carefully examined with reference to size and form and direction of the cervix, and the pres- ence or absence of lacerations or new growths in the os. The im- portance of thoroughness with reference to this portion of the exami- DIAGNOSIS 3Y nation is to be insisted upon, and an educated finger tip is essential to its completeness. Bimanual Examination. — A great advance in the diagnosis of pel- vic diseases was signalized by the introduction of the bimanual method of investigation (Fig. 6). The term may be defined as the examina- tion of the pelvic contents by the two hands, the index finger of one being in the vagina and the other placed on the abdomen above and beyond the pubes with which to make downward pressure. The finger within the vagina lifts up the organ or organs, and the finger tip of the other hand pressing downward upon the relaxed abdominal walls Fig. 6. — " A great advance in the diagnosis of pelvic disease was signalized by the introduc- tion of the bimanual method of examination." — Potter. engages it or them between the two. Beginning first with the bladder, its sensitiveness, distention, or emptiness, is noted. Passing upward to the uterus, its size, condition as to firmness or softness, and its posi- tion, whether in anteflexion, retroflexion, or prolapsus, is determined. Here, again, the first question upon the mind is that of possible preg- nancy. If in the digital examination a soft cervix has been felt, the inquiry as to pregnancy must be pursued bimanually, and if it is learned that the uterus is enlarged and has floating contents the sus- picion will b(! coufirrnofl, and further examination should be postponed until 1lif; f|ncstion is (lelofrriincd. It is iinjKjrtant to deal with this sub- 38 A TEXT-BOOK OF GYNECOLOGY ject first, because, in case 23regnancy exists, it stands in the way of any further 23elvic exploration lest abortion be induced.. An exception to this rule would be when tumours or new growths coexisted with sup- posed pregnancy or complicated each other in an already diagnosticated condition. Then, if there is some technical point to determine, the bimanual examination may be cautiously further pursued. Displacements of the uterus are most easily and certainly diag- nosticated by means of the bimanual examination. The normal posi- tion of the uterus, it will be remembered, is one of moderate ante- flexion, in which a line drawn through its long axis appears at the umbilicus; with the fundus, however, lying farther forward, compress- ing the bladder and impinging on the pubes, the uterine body will be easily engaged and mapped out between the two hands. It will, how- ever, require some experience to distinguish between anteversion and anteflexion — all of which will be properly set forth by another writer under its appropriate head. Retrodisplacement of the uterus may also be determined by feeling the fundus resting against the rectum in the sacral excavation, and by its absence from its appointed place as ascer- tained by pressure of the external hand. The cervix, too, in retrover- sion, will be carried upward and forward toward the pubic arch, thus resting the entire organ horizontally across the pelvis at right angles to the normal direction of the vagina. Here, again, some nicety of touch, which a little experience may soon acquire, is required to de- termine between retroversion and retroflexion. Prolapse of the uterus is more easily determined, since the index finger will come in contact with the cervix just within the vulvar orifice, or a little higher up, according to its degree. Procidentia will readily be discovered upon insiDCction, since the organ in Avhole or in part protrudes from the vagina. One of the most important functions of the bimanual is to ascer- tain the condition of the tubes and ovaries. An experienced examiner will readily discover whether the tubes are enlarged, pulpy, and soft or hardened, and whether the ovaries are unduly tender and sensitive, enlarged or atrophied, displaced, or the seat of new growths. An en- larged pulpy tube, sausagelike in shape, is suggestive of hydrosalpinx or pyosalpinx. At any rate, it means a diseased condition, which an accurate history combined with careful bimanual palpation will usually distinguish. The broad ligaments should also be carefully inter- rogated as to whether new growths lurk within their folds and if they properly support the uterus and adnexa. Adhesions, too, should be sought for, and if found, will of necessity influence further investiga- tion and treatment. If the uterus and its appendages are tender, bound down by adhesions, or if there is an abscess or pus tube, great caution must be exercised in ^jursuing further investigation. It would be in- excusable to rupture such a pus container, or to set up further inflam- matory processes by the use of force in the bimanual, or through a re- sort to instrumentation. ' DIAGNOSIS 39 It will be readily understood from the foregoing that the proper exercise of the bimanual in order to attain its greatest possibilities re- quires an experience that only long practice can give; hence, the be- ginner should never miss the opportunity of employing it under the supervision of a competent instructor. Only in this way can he learn either to bring the organs properly within reach, or to appreciate what he feels between his hands. At the outset he will often be foiled in his efforts by the nervous- ness of the patient; this he must overcome by his tact and gentleness, always giving the imjoression that he is thoroughly at home in his work. If he betrays his inexperience by suddenness of movement, inex- actitude of touch, or other evidences of the novitiate, his usefulness will be limited or destroj^ed. Complete muscular relaxation on the part of the jjatient must be obtained, and great self-possession by the examiner must exist. These two factors are conditions precedent to success. It is well to remember in pursuing the bimanual method, espe- cially when it becomes necessary to make upward pressure upon the vulvar orifice in order to reach high up in the pelvic cavity, that some- times sensitive or jDassionate women may be incited to sexual orgasm from irritation of the clitoris; hence, contact with that organ should be avoided as far as possible. It is probable that the aggregate number of such ]3atients is very inconsiderable, because illness, and especially disorders of the pelvic organs, diminish the tendency to sexual excite- ment arising from physical exploration of the genital tract. Its possi- bility, however, should not be forgotten. To recapitulate, the information to be derived from the bimanual method of examination may be grouped as follows: First, capacity, rigidity, and tonicity, of the vagina. Secondly, as to pregnancy, pro or con. Thirdly, the condition of the bladder and its relation to the other pelvic organs. Fourthly, the uterus, its size, position, presence or absence of tumours within its walls, and the condition of the cervix as to integrity or lacerations. Fifthly, the status of the tubes and ovaries as to size, location, and relationship to neighbouring parts. Sixthly, the condition of the rectum as to faecal impaction or disease of any kind, such as fistula, fissure, cancer, or hemorrhoids. Seventhly, as to the presence of any abdominal or pelvic tumour, new growth, extra-uterine pregnancy, or any abnormal condition not embraced in the foregoing classification. Finally, it may be remarked that in the case of tumours the biman- ual affords opportunity to distinguish between cystic and solid growths, and, to a certain extent, between benign and malignant neoplasms. Rectal Exploration. — It remains for us to describe examination by the rectum, which oftentimes becomes an important adjunct to the 40 A TEXT-BOOK OF GYNECOLOGY examination. The index finger in the rectum will sometimes serve to clear up a doubt or detect a hitherto undiscovered condition. It will help to diagnosticate a retroverted womb or to distinguish between that displacement and a post-nuiral fibroid growth. Again, it will serve to locate a hitherto undiscovered ovary occupying Douglas's pouch. Still again, examination per rectum may detect disease in that organ which will explain symjDtoms that otherwise would have been misun- derstood. In all cases in which careful vaginal bimanual fails to dis- cover disorder adequate to explain symptoms or to suggest a diagnosis, rectal exploration should be made. This procedure is often disagree- able, if not painful, to the patient, hence, must be instituted with great delicacy and only after thorough lubrication of the examining finger as well as the anal orifice. External hemorrhoids, even if inactive, will further emphasize the importance of careful preliminaries to the ex- ploration. (See Examination of the Rectum.) Examination under Angesthesia. — Finall}^, when all the ordinary means fail to overcome the nervousness of the patient, the rigidity of the abdominal muscles, or other hindrances to the thorough and intel- ligent employment of the bimanual method of examination, anaesthesia may be appealed to; indeed, with the full consent of the patient and with adequate assistance it should be resorted to as an important ele- ment in leading to correct diagnosis. Examination by this means should be carefully conducted with reference both to its advantages and its dangers. Its advantages con- sist in overcoming hypersensibilities, botli mental and physical, and in eliminating involuntary muscular resistance as a barrier to successful manipulation. By this means it is possible to explore with approximate accuracy the entire peritoneal surface of the uterus, both anterior and posterior. The ovaries and Fallopian tubes can be palpated; the presence and absence of intrapelvic tumours, including cysts, myomata, nodes, etc., can be determined. The presence or absence of adhesions can often be decided. The disadvantages of anaesthesia in gyneco- logical examinations centre cliiefly in the elimination of pain, which of itself possesses great diagnostic value, and is also a safeguard against injudicious and dangerous manipulation. It may be laid down as a rule, therefore, that angesthesia for purposes of examination is dan- gerous in the presence of a degree of sensibility indicative of acute inflammation. Auscultation, Percussion, and General Palpation of the Abdomen. — Of diagnostic measures, auscultation, percussion, and palpation, can be applied to the recognition and diagnosis of pelvic and abdom- inal tumours, inflammatory residues, and diseases of the appendi- csecal region, kidneys, spleen, liver, and gastro-intestinal tract. The method of applying these aids to diagnosis will be readily suggested to the examiner. Palpation of the kidney becomes important in relation to the diagnosis of diseases of that organ, and occasionally, also, in distinguishing between abdominal tumours and movable and so-called DIAGNOSIS 41 floating kidney. A movable kidney, which would escape the casual or indifferent observer, is often detected by a careful diagnostician. Hy- dronejDhrosis has been confounded with ovarian and other cysts. A detailed description of the diagnosis of kidney diseases is foreign to the purpose of this chapter, and the reader is referred to the section which deals with that subject. In examining the abdomen it is highly important, not only to hold in mind the locus of each of its contained organs, but to have an accurate conception of its regional arrangement. Regions of the Abdomen. — It has been customary heretofore to divide the abdomen anteriorly into nine different regions as a con- venient means of des- ignating either the lo- cation of symptoms or operations, or of the presumably underly- ing organs and struc- tures. This division, however, has proved unsatisfactory, because of the cumbersome- ness of its terminol- ogy, the narrowness of the areas indicated, the indefiniteness of the imaginary lines of division, and the ana- tomical variations in the location of their supposed underlying organs and structures. In accordance with the suggestion of Pro- fessor Anderson to the Anatomical Socie- ty of Great Britain (Buffalo Medical and Surgical Jour., 1893), these objections are best obviated by divid- ing the abdomen into four regions. This is done by running a line coincidently with the linea alba from the symphysis pubis to the ensi- form cartilage, and another at right angles to this at the level of the umbilicus and encircling the entire body. The median line posteriorly is indicated by the spinal column. This arrangement, which is based upon definite landmarks, and divides the abdomen into four quadrants (Fig. 7) — namely, right and left, upper and lower — will be observed in the following pages. ^^^B RI&HT ^^^H QUADRANT LEFT i UPPER 1 QUADRANT 1 f ^^m RIGHT ^V LOWER ^m QUADRANT LIJT LOWKR QUADRANT r 1 i RJ.H0PKIN3 Fig. 7. — " This arrangement, based upon detinite landmarks, divides the abdomen into four quadrants." — Keed. 42 A TEXT-BOOK OF GYNECOLOGY Instrumental Examination. — A most important adjunct to methods of diagnosis is furnished in the marvellous develoj)ment of mechanical instruments and appliances. The inge- nuity of physicians and instrument makers has presented to the gynecologist an enormous collection from which to choose. The armamentarium, however, should be simple, and such instruments as are chosen should be models of per- fection. It should never be forgotten, also, that instrumentation, no matter how dexterously applied, can never be made to supplant the educated hands and finger tips. Instruments at most are supple- mentary aids to these. We may, how- ever, enumerate some of the instruments which are considered a necessity by the g3^necologist. These are: (1) The specu- lum, (2) the sound or probe, (3) the dila- tor, (4) the curette, (5) the cystoscope, (6) the aspirator with exploratory needles, (7) the stethoscope, (8) the uterine dress- ing, forceps, (9) the spatula or depressor, (10) the tenaculum, (11) the volsella. The Speculum as a Means of Ex- amination. — Since Sims gave to the profession the speculum which bears his name the practice of gyne- cology has become an established specialty. Without this device it is doubtful if gynecology could have been enlarged, broadened, and devel- oped into the importance which it has attained at the present day. Dr. J. Marion Sims, then residing in the city of Montgomery, Ala., was engaged between the years 1845 and 1849 in the study of the opera- tive treatment of vesico-vaginal fistula. During his investigations he accidentally discovered that if a woman Avas placed upon her knees and chest, upon separating the labia the air would enter the vagina and distend it to its full capacity. Wliat was needed was an instrument to retract the perineum. This he supplied first with a spoon handle bent to the appropriate shape, and afterward, as the product of evolution, came the present speculum, which universally bears the name of Sims (Fig. 8). In the further pursuit of his investigations, and for the ap- propriate use of his speculum, a less trying posture was needed than the knee-chest. This led to further experimentation from which was evolved the semiprone, or Sims's, position. It is sometimes called the latero-prone posture, but, by whatever name it is known, its discovery and practical application are due to Marion Sims. The Sims speculum and the Sims position form the basis of the science of gynecology as at present understood and practised. Whoever, then, would attain suc- FiG. 8. — ". . . Speculum, whicli uni- versally bears the name of Siras." — Potter. DIAGNOSIS 43 cess in the art, must not only familiarize himself with the principles of this instrument and its correlative posture, but he must acqure deftness in their practical application to the patients who consult him. The beginner, therefore, should address himself to the mastery of the use of the Sims speculum in the semiprone or Sims posture. The principles are simple and the obstacles to be overcome are few. It is a mistake to suppose that a long experience is necessary to attain proficiency in the use of the speculum. It is another mistake to pre- sume that a trained assistant is necessary to its advantageous employ- ment. The physician himself must be the expert; he can then easily instruct any intelligent person to hold the speculum properly. These examinations, for obvious reasons, should be conducted in the presence of a third person. A gynecologist of large practice has an office assist- ant who performs this service. A physician whose gynecological prac- tice is limited may either avail himself of some member of his house- hold in office examinations or employ the Sims-Emmet self-retaining speculum, which has already been referred to (page 32, q. v.). In making examinations at the home of the patient the aid of some mem- ber of her family may be invoked; and this brings us to make mention of home examinations. In order to make these examinations satisfactorily and to obtain adequate information from them, the same conditions must prevail as in the consulting room. The patient must be placed upon a table, the douche must be ad- ministered, and the bimanual or instrumental examination is to be proceeded with, with the same attention to detail. Whenever the attempt is made to use the bed or couch dissatisfaction will result. It is, comparatively speak- ing, little trouble to make the home examination in the proper manner. The humblest home is furnished with a four -legged table; this can be covered with blanket, sheet, and protective; the fountain syringe can be hung on a nail near by, and if an in- strumental examination is need- ful a Sims-Emmet self -retaining speculum can be employed. Or, failing in the possession of this, the ordinary Sims instrument can be used, and an assistant to hold it may be pressed into service from the household or i)ci"'liI)oiirliood. Fig. 9. — " A good bivalve like Gau's." — Potter (page 44). 44 A TEXT-BOOK OF GYNECOLOGY Before leaving the subject of the speculum it is proper to state that the essential re- quirements for the success- ful use of the Sims instru- ment are, first, the correct position of the patient; and, secondly, the proper hold- ing of the instrument. The semiprone posture can not be described in words with sufficient clearness for a nov- ice to understand it; more- over, it is difficult to illus- trate it clearly, hence it is advised that a physician un- familiar with it should place himself under the instructions of a person who understands it thoroughly. Besides the Sims specu- lum, it is well to have at hand a good bivalve, like Miller's or Gau's (Fig. 9), which gives a good view of the cervix (Fig. 10), as well as a trivalve, the latter according to Nott's model (Fig. 11). It occasion- ally becomes necessary to examine the os or cervix uteri in the dorsal position, and these specula are well adapted to that purpose. (See Armamentarium . ) In the use of the specu- lum it is sometimes desira- ble to use reflected light or the intense rays of an electric illuminator. In cases of erosion of various character, material assist- ance in diagnosis may be derived from the use of a magnifying glass, like that devised for the pur- pose by Dr. Alexander Duke, of Cheltenham (Medical Press and Circu- lar, May 15, 1900). The lens, called a hysteroscope, is so arranged on a hinge that it can be placed at an angle by the observer. By this means the light can be di- FiG. 10.—" . Which gives a good view of the cervix." — Potter. Fig. 11. — "A trivalve . . . according to Nott's model." — Potter. DIAGNOSIS 45 rected with accuracy upon the parts under examination, and when used with artificial light it acts both as a condenser and a magnifier (Fig. 13). The Sound as a Means of Examination. — Formerly the sound was considered an essential part of the gynecological armamentarium, be- cause almost the first thing done after the in- troduction of the speculum was to pass the sound into the uterus. Nowadays, however, with improved methods of diagnosis, and especially through a more thorough understanding of the bimanual, the sound rarely is needed. Its chief purpose is to confirm the diagno- sis in doubtful cases, such as intrauterine growths and other intrapelvic abnormalities that are misleading in their character. The dangers of the sound consist in its liability to carry infection within the genital tract, and to puncture the uterine wall; the latter is, comparatively speaking, an inconsiderable danger, whereas the former is a very grave one. The sound devised by J. F. W. Eoss (Fig. 13) is best designed to obviate all dan- gers. The sound is no longer used by the experienced gynecologist to reposit a dis- placed womb, and whenever it becomes necessary to use it as an aid to diagnosis, first, it should be made thoroughly aseptic, and then it should be dipped in pure car- bolic acid rendered liquid by the addition of five per cent of glycerine, before it is passed into the uterus. With this precaution, and with gentleness in manipulation, the sound I may not do harm, and possibly it may serve I to clear up a doubtful diagnosis. The probe I is only a modified sound, lighter in con- »— I struction, and much more fiexible, and prac- tically is used for the same purpose. Appli- cators, either of whalebone or aluminum, are useful in carrying certain medicinal applica- tions within the uterine canal. If, however, the uterus is sensitive from inflammation, the use of the sound, probe, or applicator, is contraindicated, although in some instances where information is urgently needed a very light probe might possibly be introduced without harm. The rule should be never to pass the sound or probo unless it can be used without causing pain. -p ,„ The Dilator as a Means of Examination. — Dilatation a'pi^ggQu^ji^g. of the uterus is accomplished by graduated bougies, by vised by J. F. metal dilators having divergent blades, by tents, or by po'tteb. Fig. 12. " The lens called a hysteroscope." — Potter. 46 A TEXT-BOOK OF GYNECOLOGY rubber bags to be filled with air or water. The usual method is through the medium of the hard-rubber graduated bougie or the mechanical steel dilator of Goodell (Fig. 14). The purpose of dila- tation is to make the endometrium accessible to certain therapeutic measures, either medicinal or instrumental. In a narrow, or pin-hole, OS it becomes necessary to dilate the channel before using the curette or making applications to the endometrium. Where but little dilatation is required, occasionally the glove stretcher or metallic dilator can be used without an angesthetic; but usually when it becomes necessary to em- ploy the more complicated instrument of Goodell, anaes- thesia to the surgical degree should precede its use. When the os is patulous, curettage for diagnostic purposes may be made sometimes without resorting to anesthesia. Diagnostitial dilatation often becomes necessary for the purpose of admitting the finger into the uterine cavity. It is an operation, however, that should never be made when there is a sensitive uterus to contend with, or when the pelvic tissues have been invaded with inflammatory conditions; in other words, it is necessary to surround this operation with all the precautions that pertain to formidable procedures. It is not to be done in the con- sulting room and the patient allowed to make her way homeward afterward, but it should be done either in hos- pital or at home, in order that the patient may be kept entirely quiet for the next few days thereafter. This operation is to be preceded with the seizure of the an- terior lip of the cervix by the volsella, or strong tenac- ulum. The cervix is thus stretched and the dilator gradually and slowly passed into the cervical canal, the bougie with a rotary motion, the glove stretcher with a spreading of the blades in a gentle manner, just within the OS, advancing a little farther and stretching again, and so on until the work is completed. The Curette as a Means of Exam- ination. — This instrument is used to ob- tain scrapings from the endometrium with a view to determine the nature of any disease that may not otherwise be ex- dilator of Goodell."— Potter. plained. These scrapings may be sub- mitted to examination by the microscope. If malignancy is ascer- tained, the further method of procedure is readily pointed out. If there are remains of an abortion, or an endometritis that has fol- lowed abortion, then the interior of the uterus should be thoroughly cleaned, mopped with pure carbolic acid or carbolic acid and iodine, and the organ should be packed with antiseptic gauze. The curette is often used unnecessarily, and great caution should be observed 14.- i'chanieal steel DIAGNOSIS 47 in its employment. The puerperal womb is easily perforated, an accident that has often happened in unskilful hands. The Cystoscope as a Means of Diagnosis. — (See Examination of the Bladder.) The Aspirator as a Means of Examination. — This instrument is sometimes appealed to when cysts or pus pockets develop along the broad ligament. In doubtful cases these sacs may be explored through the roof of the vagina, but it is generally sufficient to diagnosticate them by the usual means, and to evacuate them by surgery through the abdomen or vagina. The stethoscope is occasionally employed to ascertain the nature of abdominal diseases, especially when pregnancy is suspected. The uter- ine dressing forceps and the depressor are an essential accompaniment to the armamentarium and need no particular description. The forceps carries cotton in wiping the tract, and the depressor holds the bladder away from the field during inspection. The tenaculum and volsella are used to seize the lips of the uterus in order to draw down the organ or to steady it while the parts are being inspected and applications are being made. These instruments should be dipped in pure carbolic acid before using. Examination of the Urinary Tract. — (See Examination of the Se- cretions and Diseases of the Urinary Tract.) With this, should be asso- ciated a systematic investigation of the various parts of the body. It is well enough for convenience' sake to begin with the upper air-passages; nose, throat, and fauces, should be investigated, 'pa.v- ticularly in cases in which there exist head or nerve symptoms, so frequently referred to as genital reflexes. A similar investigation under similar circumstances should be made of the eyes and ears. Careful auscultation and percussion of the heart and lungs should be made when there are irregularities of the former, or when the latter may be subjected to suspicion by pelvic or other symptoms suggestive of tuberculosis. It is not presumed that every practitioner is capable of making a thorough examination of each of these several organs; but any one who assumes to practise gynecology should be so thor- oughly grounded in a general knowledge of medical science that he can, with reasonable accuracy, determine departures from health in all bodily structures or functions. If it is necessary to carry an examination of any of these organs to the point of technical perfection, they can be, and should be, relegated to special practitioners for that purpose. Intrapelvic disease is a fruitful cause of perversions of practically all of the secretions. These functional disturbances, in turn, become factors in the case and need to be dealt with as such. The Urines. — In consequence of the great advance which has been made in the study of pathologic conditions of the genito-urinary tract, and in view of the fact that the urine secreted by either kidney differs from that secreted by the other, it is now important to speak, not of 48 A TEXT-BOOK OF GYNECOLOGY the urine, but of the urines, when reference is made to the secretions which accumulate in the bladder. The technique involved in securing the urine from either kidney is considered in the chapter devoted to that subject. The investigation of the blended urines, however, is still a matter of clinical importance. Care should be taken to determine their quantity, colour, and specific gravity, the presence or absence of albumin, glucose, mucus, tube casts, pus, or other morbid products. In view of the importance of xanthine and the paraxanthines in the causation of various nervous jjhenomena, an examination of the urine will frequently need to embrace a qualitative and quantitative deter- mination of these substances. Urea and uric acid are of clinical im- portance and need to be studied. In many cases it will be important, not only to study the urine from each kidney, but also to study each urine and the blended urines repeatedly. To insure completeness of examination it is important to follow the usual blanks available for the purpose. Faeces. — In many gynecologic cases, particularly in those associated with marked disturbances of nutrition, it is of great importance to investigate carefully the faeces. Their naked-eye characteristics should be noted, and microscopic studies should be made of various kinds of their constituents. Blood, fats, parasites, fungi, foreign bodies, mucin, ferments, hydatids, etc, are only mentioned to suggest the range of in- quiry which should be made in many of these cases. The reader is referred to Jaksch's Clinical Diagnosis. The Menstrual Discharge. — It is often important to determine with accuracy the quality and quantity of the menstrual discharge. To determine its character the napkins should be preserved and inspected. It should be remembered, however, that the absorption of the blood by the napkin modifies to an important degree the colour of the former. If more critical examination needs to be made, some of the discharge can be mounted upon a slide and put under the microscope. If there is occasion to ascertain the quantity passed, the napkins should be care- fully weighed before and after being used. In some cases it is impor- tant to determine whether the discharge is a true menstrual flow or a lochial discharge. For this purpose the microscopic examination is essential. It may be mentioned in this connection that in the men- strual flow immediately after its onset, there occur abundant red blood- corpuscles and prismatic epithelial cells laden with fat. These are derived from the interior of the uterus. As soon as the physiologic climax of the flow has been reached, the red blood-cells diminish and the leucocytes progressively increase until the flow disappears. The fluid which passes following a parturition, is, in the absence of hemor- rhage, thinner in consistence, with less tendency to coagulate. While it abounds in red and white corpuscles from the start, it shows, also, abundant epithelium from both the uterus and vagina. Unlike men- strual fluid, the lochia, even in the absence of septicsemia, abound in microbes. DIAGNOSIS ' 49 The Blood. — Every pi-actitioner should provide himself with the necessary instruments for the examination of the blood. These should include an apparatus for counting the blood-corpuscles, chromo-cytom- eter, and a hemometer. AVith these instruments and a good n^icro- scope, with which all modern practitioners are presumed to be pro- vided, it will be possible to determine the blood state of patients. This is an exceedingly important diagnostitial measure in gynecological practice. Thus a marked leucocytosis, taken in connection with other symptoms, is confirmatory of a suppuration which may be situated so remotely in the pelvis as to defy detection. Oligochromsemia, in vary- ing degrees, may be accepted as an index of general states of nutrition; the perturbation of which may depend, in the first instance, upon ob- scure and otherwise undetectable conditions within the pelvis. Eeed has shown [American Journal of Obstetrics and Gynecology) that many perverted conditions of the blood are caused in the first instance by disease of the pelvic organs, the disturbing influence of which is exer- cised, through the intimate nerve connections, upon the hematogenetic function. When these changes and their causation are better under- stood, the diagnostic value of blood states, considered as indicative of intrapelvic disturbances, will be greatly enhanced. The Nervous System. — The intimate relation of the entire genital apparatus with the nervous system (see ISTervous Complications in Gynecology) renders it important that the gynecologist should make a careful note of the actual state of the nerve functions. He should learn to appreciate nerve disturbances as much from the neurologic as from the gynecologic standpoint. Motor and sensory disturbances should be determined by 'instruments of precision, while the special senses should be investigated with acciiracy. Psychic states should be studied with care. Careful attention to these precautions will speedily result in reducing the now chaotic subject of " genital reflexes " to a somewhat scientific basis. CHAPTER VII SEPSIS Sepsis defined — The bacteria of sepsis — Local sepsis: Symptoms, pathology, and treatment — General sepsis: Symptoms, pathology, and treatment. Sepsis — derived from the Greek word arjifns (from o-rjirecrOai, to rot) ; French, sepsie; German, Fdulnis — is defined by Foster as putrefaction, rotting; in medicine, the morbid condition resulting from the absorp- tion of putrid or putrescent material or of germs capable of causing putrefaction. As used in this connection it implies a condition of either {a) local, or (6) general, infection by pathogenic micro-organisms. The relation of bacteria to fermentation and putrefaction Avas first demonstrated by Pasteur, from which phenomena he deduced the the- ory that suppuration in wounds was probably due to external agencies, and, by subsequent experiments, demonstrated the correctness of his analogy. The theory thus established found its first practical appli- cation at the hands of Lister, who, by a succession of careful and painstaking experiments and clinical observation, laid the foundation for the technique of antisepsis. The entire practice is based upon the now demonstrated and accepted fact that micro-organisms are the essential factors in the causation of both local and general sepsis. These micro-organisms embrace both micrococci and bacilli, a compre- hension of the identity and pathogenesis of each of which is essential to an understanding of sepsis, its prevention, and treatment. The Bactekia of Sepsis Micrococci. — Of the micrococci both the staphylococci and the streptococci play important parts, often coincidently, in producing sepsis. (A) Staphylococci, although occurring in several varieties, have a more or less common morphology in the particulars that they are (a) small, spherical cells; (b) that they vary from 0.7 /* to 0.9 /* in diam- eter; that they occur singly, in pairs (diplococci), frequently in fours (tetrads), or in masses (zoogloea). The varieties about to be considered differ from each other chiefly in colour, the character of the pigment they throw off, their behaviour in different media, their degrees of virulence, and finally in the particular of their natural habitat. While there are other varieties of staphylococci, but four will be con- sidered in this connection — viz.: (1) The Staphylococcus pyogenes aureus is the most common pathogenic micrococcus (Fig. 15). Having the 50 SEPSIS 51 morphologic feature already mentioned, it is only important to add that it multiplies rapidly at normal temperatures in nutrient media. While growing in gelatine, which these cocci liquefy, they accumulate near the surface, producing, when brought in contact with the air, a charac- teristic golden-yellow pigment which is precipitated to the bottom of the tube and from which they take their name. Sternberg gives the thermal death point in moist media at from 56° to 58° C. (132.8° to 136.4° F.), but when dried at from 90° to 100° C. (194° to 213° F.) these germs grow in either the presence or absence of oxygen, and are capable of reproducing themselves when transplanted from nutrient media at the end of a year, and they have been found alive at the end of ten days after having been dried on a cover glass. Their natural habitat on the body is the cutaneous and mu- cous surfaces, although they have been found in the salivary secretions, in the dirt under the finger nails, and in the mucus from both the pharynx and nose; they have also been found in the soil, the air and water, upon the surface of fruits, and on the petals of the rose. The pus-forming quality of this coccus is be- fig. i5.-"The titap^ylococcus yond doubt. Von Eiselberg and Netter pyogenes aureus is the most have shown that it is transported by the common pathogenic micro- T 1 T , , 1 , p , 1 , 1 , coccus." — Reed (page 50). blood to other parts of the system, but '^ ^ ' there is no conclusive evidence that it multiplies within that medium. (2) The Staphylococcus pyogenes alius is precisely like the preceding in morphology except that it is not pigmented. Surface cultures made from this coccus are milk white, from which fact it takes its name. According to Eosenbach, who discovered it, this albus occurs more commonly among the lower animals than does the aureus. Patho- logically it is often found alone in acute abscesses, but more frequently in company with other pyogenic bacteria. It is probably identical with the micro-organism next to be described. (3) The Staphylococcus epi- derm.idis albus (Welch) has physical properties precisely like those of the preceding, but differs from the aureus in colour, in the fact that it liquefies gelatine more slowly, that it is less virulent when introduced into the tissues, and that it may be present in wounds without causing pus. This latter statement is made by Welch in face of the declaration that it has been demonstrated to be the frequent sole cause of suppura- tion along the drainage tube and in stitch abscesses. Its natural habitat is the skin, into the interstices of which it is frequently buried so deep as to be beyond the reach of the agents usually employed in hand sterilization. This was interestingly demonstrated by Dr. Thomas C. Craig, United States Navy {New York Medical Journal, April 11, 1896), who, in a search for malarial organisms in a fever patient, sterilized the palmar surface of the lattei-'s finger, which he pricked deeply with a 52 A TEXT-BOOK OF GYNECOLOGY needle previously sterilized in an alcohol flame. Three drops of the resulting blood were thrown away; the top of the next drop was touched with the point of a sterilized platinum wire and a stab culture in agar made. Three cultures were thus made, two of which proved negative, while the third yielded the Staphylococcus epidermidis albus of Welch. AYhile this is an isolated observation it tends to show that, even upon a palmar surface, in the absence of sebaceous glands and hair follicles, this coccus may be situated so deeply as to elude careful antiseptic precautions. (4) The Staphylococcus pyogenes citreus, while having morphologic features in common with other micrococci, differs from them in the particulars that its coloured pigment is of a lemon yellow, that its pigment is formed only in presence of oxygen, that it is slowest of all of the micrococci in liquefying gelatine, and, finally, that al- though it is found with other bacteria in acute abscesses, its own jDathogenesis is undetermined. (B) Streptococci, like the preceding organisms, have a common mor- phology depending upon the fact that, after the cocci have multiplied by binary division in a single direction, the resulting segments arrange themselves into chains (Fig. 16). The chains thus formed may be long or short, single or arranged into bundles. While there are numerous varieties of streptococci, it is necessary for this chapter to consider only the Streptococcus pyogenes, in which the cocci are spherical — from 0.1 /A to 1 /u. in diameter — those in the same chain or in different chains varying in diameter. This strep- tococcus grows both in the presence and absence of oxygen and does not liquefy gelatine. Considered pathogenetically, it causes inflammation when injected into the tissues of lower animals, in some of which, notably in mice, with lowered vital- ity, it multiplies within the body and causes death. It is demonstrated to be the essen- tial causative factor in erysipelas, from which fact it is sometimes designated the Fig. 16.— "After the cocci have Streptococcus crysipeltttos. It is also recog- multiplied by binary division nised as the streptococcus of puerperal in a single direction, the result- ^ ^ ^^^^ ^^^.^j^ explains the noW uni- ing segments arrange them- -111 selves into chains."-EEED. versally recogniscd causal relation of ery- sipelas to the latter disease. Czerniewski found this coccus but once in the lochia of 57 healthy lying-in women, while he found it in the lochia of 35 out of 38 women with puerperal fever, and in 10 fatal cases it was present in the lochia before and in the organs after death. The inference from these observations has been abundantly conflrmed, especially by Clivio, Widal, Eiselberg, Emerich, and Bumm. It also plays an important part in the inflam- mation of mucous membranes. The Micrococcus gonorrlmce, familiarly known as the gonococcus of SEPSIS 53 Fig. 17. — "Familiarly known as the gouococcus of Neisser." — Reed. Neisser (Fig. 17), is a micrococcus occurring in pairs or in groups of four, but generally in the form of diplococci. Its elements are flattened or " biscuit-shaped." " The flattened surfaces," says Sternberg, " face each other and are separated, in stained preparations, by an unstained interspace. The diameter of an associated pair of cells varies from 0.8 ft to 1.6 /A in the long diameter — average about 1.25 fi — and from 0.6 /a to 0.8 ft, in the line of the interspace between the biscuit-shaped elements, which sometimes present a slight concavity of the flattened surfaces. Multiplication occurs alternately in two planes, and as a result of this, groups of four are frequently observed. But diplo- cocci are more numerous and are considered as the characteristic mode of grouping. Single, spherical, undivided cells are rarely seen." There are other micro-organisms with a morphology identical with the gono- coccus, which, therefore, must depend for its distinction upon other features. Among other facts to be taken into consideration in this connection are its response to staining agents; the fact that it is aerobic; that it is a strict parasite; that in culture media it is self-limiting in its vitality; that it will not develop below 25° C. (77° F.) or above 38° C. (100.4° F.); that, exposed to 60° C. (140° F.) for ten minutes, it dies; and, finally, it is distinguished by the clinical phenomena attending its occurrence. Studied pathogenetically, it has been demonstrated to cause the form of inflammation known as gonor- rhoea, upon the mucous membrane of the urethra, the cervix uteri, the corpus uteri, and the vagina of children; while the vaginal mucous membrane of adults appears to be immune. The conjunctiva is also capable of inoculation — a fact which accounts for the frequent occur- rence of ophthalmia neonatorum. Bockhart has found that the gono- cocci penetrate into the deeper layers of the urethral mucous mem- brane, even into the corpus cavernosum, although Bumm is of the opinion that, as a rule, the epithelial layer of the mucous membrane is alone involved. In its later stages gonorrhoea often becomes a mixed infection, owing to the presence of the Staphylococcus pyogenes aureus, upon which, rather than upon the gonococcus, all metastatic manifesta- tions depend. Bacilli. — The pathogenic bacilli, like the micrococci, have a com- mon morphology, in the particulars that they are spheroidal, rod- shaped, or spiral in form (Fig. 18). The ends of the rods may differ, some being square, others oval, etc., the difference existing between the ends of different rods rather than of the same rods. Of the several hundred known bacilli it is necessary in this connection to con- siflcr })nt three — viz.: (a) Bacillus coli communis, (b) Bacillus aerogenes capsvIdJ/us, iinfl (c) the liacillus tuberculosis. 54 A TEXT-BOOK OF GYNECOLOGY (a) The Bacillus coli communis, morphologically, consists of short rods with rounded ends, generally occurring in pairs (Fig. 19), about 2 /* long and from 0.4 /a to 0.6 /a broad. In some instances the diameter and the length are equal, under which circumstances they may be mistaken for micrococci. They propagate both with and without oxygen, and are both parasitic and saprophytic. They are capable of slight amceboid activity. They propagate actively in acid media of abnormal tempera- FiG. 18. — "Bacilli are spheroidal, rod-shaped, or spiral in form." — Eeed (page 53). Fig. 19.- The Bacillus coll communis. — Keed. ture. There are several varieties of this bacillus, all of them possessing a common mor^jhology though differing slightly in habitat, behaviour in similar media, and in degrees of virulence, but it is not necessary in this connection to speak of them in detail. In the normal body the habitat of the Bacillus coli communis is in the colon and adjacent por- tions of the alimentary canal. Its migration from this locus, through an infection atrium, into either the walls of the intestines or the peri- toneal cavity is fraught with serious mischief. (See Bacteriology of Fig. '20. — " The Bacillus aerogenes capsu- latus (Welch-Nuttall.)" — Eeed. Fig. 21. — ''The Bacillus tuberculosis (Koch.)" — Eeed (page 55). Appendicitis.) It has been found in common with other micro-organ- isms in puerperal fever. (&) The Bacillus aerogenes capsulatus (Welch-Nuttall, Fig. 30) oc- curs, ordinarily, as a straight but sometimes slightly curved bacillus, with ends that may be square or slightly rounded, and from 3 to 6 //. in SEPSIS 55 length. It has a transparent capsule; is without the power of spon- taneous movement; is sporeless; thrives without oxygen at noraial tem- perature; and generates gas in large quantities in all culture mediums. Animals inoculated with this bacillus sjieedily die^, the bacillus propa- gating rapidly and developing gas in the dead tissues. It is the bacillus most probably responsible for the gas which occasionally occurs in tissues in connection with suppuration. (c) The Bacillus tuberculosis (Koch, Fig. 21) consists of rods from 1.5 /A to 3.5 //. long and from 0.2 fi to 0.25 /u. broad. They are gener- ally slightly curved, but sometimes angulated, and in stained specimens exhibit unstained intervals. They are usually single, but are occasion- ally double. They are peculiar in that they do not readily take up ani- line colours, and that when once stained they do not decolourize with facility, even by strong acids. They are parasites, but under ordinary circumstances they are not saprophytic. They grow only at a tempera- ture of about 37° C. (98.6° F.), and that they develop spores in the pro- cess of growth is not established. Koch affirms that they are killed by exposure to the direct rays of light, although Sawizky states that tuber- culous sputum, u.nder the conditions of ordinary habitation, may retain infectious power for as long as ten weeks. A fact of practical impor- tance is that they develop a toxine which produces febrile reaction. Pathogenetically, it is sufficient for the present purpose to say that, introduced into the system, this bacillus causes tuberculosis both in the lower animals and man. Varieties of Sepsis. — For the purposes of this work sepsis is divided into local and general. Local sepsis implies the infection of a circumscribed area of tis.sue with pathogenic bacteria. Such infection results generally, but not always, in suppuration, which may be either superficial, as in ulcera- tion, or interstitial, as in the formation of an abscess. Suppuration consists in the conversion of normal tissue elements into a fluid called pus. Pus is of variable consistence, of high specific gravity, of alkaline reaction, and of a colour varying from grayish to greenish yellow. Any variation from yellow depends upon the presence in the pus of added elements. Microscopically, pus is found to contain leucocytes, some of which are normal in size and contour, others are dead and shrunken, while still others are very large and polynuclear, and are known as giant or pus corpuscles. There are some red blood-corpus- cles, frequent fat-laden cells, and some epithelial elements. Passet cultivated from pus eight difl^erent kinds of fungi, chief among which were the staphylococci, streptococci, and bacilli of various sorts; among the last, in different cases, were observed the bacillus of tuberculosis, the bacilli of glanders, of leprosy, and actinomyces. Filiaria and infusoria are also occasionally found. The crystalline elements of pvis are cholesterin, hematoidin, tbe ciystals of fatty acids, and the triple phosphates. The treatment of sepsis divides itself naturally into preventive and 56 A TEXT-BOOK OF GYNECOLOGY curative. Under the first head are embraced all those measures which are calculated to destroy the pathogenic bacteria existing upon the integument or upon dressings, instruments, ligatures, or sutures, and which may thence and thereby be brought in contact with such tissues as may be exposed in the course of a surgical oper- ation. They are designed to produce a condition known as asepsis. This word deserves a little consideration; its definition, as given by Foster, is as follows: Asepsis — from a privative and cnyi/^ts, putrefaction; French, asepsie; German, Asepsie — means freedom from j)utrid or putrescent material and from septic germs. It has come to be used, in surgical nomenclature, to imply an ex- alted state of ordinary cleanliness, to secure which it is not necessary to employ the usual germicidal measures and agencies. In many quarters it is accepted as true that asepsis is a very natural condition. This view is misleading and dangerous. The very contrary, indeed, may be as- serted — namely, that the condition of absolute asepsis, particularly as relates to the human integument, not only does not exist naturally, but is almost impossible of attainment. This being true, the word " asepsis " should be used only to imply such a state of freedom from septic elements as can be attained by the use of antiseptic measures and agencies. As a matter of fact, all the measures and precautions usually designated under that head are directed against septic micro-organisms and are consequently measures of anti- sepsis. This word — from avri, opposed to, and a-rjil/iatient unfit for its use. The important questions 92 A TEXT-BOOK OF GYNECOLOGY are, whether it is safe enough to justify its common use, and whether it fulfils any indications not so well filled by ether and chloroform. The answer to botn these questions is in the affirmative. The drug has been given many thousand times without ill effects and deserves a place in the hands of the gynecological operator and obstetrician. Cer- tain perfectly proper and easily taken precautions are essential for its satisfactory use (see page 95). The indications for its employment are sufficient and numerous. The first of these is met with when we desire to employ a rapidly acting, agreeable, and fleeting angesthetie for the performance of short operations, such as curetting and dilat- ing the uterus, and in making painful examinations. When properly given, bromide of ethyl produces anesthesia almost as rapidly as nitrous oxide, and when it is stopped the patient returns to conscious- ness almost as speedily as when the gas is given, and without any nausea, vomiting, dizziness, or other ill efl^ects. It lends itself, there- fore, to a large number of cases in and out of the gynecologist's office, and deserves greater use. There are two disadvantages connected with its employment — first, that there may be muscular tonic contraction or rigidity, which is annoying, and may render efforts at examination or operation difficult until it is overcome; and, secondly, that it is apt to leave a garlicky odour on the breath — two objections of compara- tively small moment, after all. The drug is not suitable for pro- longed operations. The Administration of Ether. — The anresthetizer, like the operator, knows that the simpler the instrument the easier the performance of the duty before him, and as a re- sult there are but two forms of ether inhalers commonly employed in the United States, and these meet the needs of the case so well that nothing else need be consid- ered. The one is the folded towel, turned into a well-made cone, stiffened, it may be, with a sheet of heavy paper or cardboard be- tween its folds, and fitted in the apex with a small, clean, and ster- ile sponge or piece of absorbent cotton, to hold the anaesthetic fluid. For this may be substituted the Allis inhaler, which is a cylin- drical or ovoid cover around a grated case, from the gratings of which layers of cotton cloth pass from side to side (Fig. 29). The air passes freely between the layers of cloth, which, being wet with ether, load the inspired air with anaesthetic vapour. If made of metal, so that it can be boiled after Fig. 29.—" The Allis inhaler, which is a cy- lindrical or ovoid cover around a grated case, from the gratings of which layers of cloth pass from side to side." — Haee. ANESTHETICS AND ANJllSTHESIA IN GYNECOLOGY 93 each use, and kept rigidly clean, this is the best inhaler on the market, because it gives plenty of ether and it permits a view of the face of the patient. Both the simple cone and the Allis inhaler can be employed when it is desired to give oxygen gas with the anaesthetic, since the gas can be delivered to the patient by means of a soft tube slipped under the edge of the cone close to the patient's nose. The Administration of Mixed Vapours for Anaesthetic Purposes. — • There are several somewhat complex forms of apparatus on the market for giving ether and oxygen gas or chloroform and oxygen gas. Hare considers none satisfactory in every respect. In all forms which he has seen, the oxygen is made to bubble through the ether or the chloroform, thereby vaporizing the ansesthetic, and a mixture of oxygen gas and of the anaesthetic vapour is then conveyed through a tube to the in- haler, which is placed over the patient's nose and mouth. There are several disadvantages inseparable from this method of using this valu- able combination of therapeutic agents. The first objection is that it is impossible to increase or decrease the quantity of oxygen gas supplied to the patient without at the same time increasing or decreasing the quantity of ether or chloroform, and conversely the quantity of these agents can not be verified without the supply of oxygen. Manifestly, an inability to make suitable variations in the quantity of these various agents is distinctly disadvantageous. As an illustration of how disad- vantageous it may be, Hare mentions the fact that an eminent surgeon complained to him that a grave difficulty in the use of oxygen and ether lay in the long period of time required to get the patient under the anaesthetic. The cause of this delay was without doubt due to the fact that if large quantities of oxygen were passed through the ether with the purpose of conveying considerable amounts of the anaesthetic to the patients, the individual also received such large quantities of oxygen that a condition of physiologic apnoea, or shallow or arrested breathing, occurred through sedation of the respiratory centres. As soon as this sedation took place the patient breathed less deeply than before, or she stopped breathing entirely, and under these circum- stances took but little anfesthetic vapour into the lungs, and so passed very slowly, if at all, under its influence. In Hare's opinion, therefore, the proper way to use oxygen by inhalation, in conjunction with the anaesthetic, is to place the drum upon whatever form of inhaler the physician desires to employ, and to carry into the inhaler the oxygen gas direct from the bag, which is usually attached to the steel cylinder containing the gas. Under these circumstances the patient receives both the anaesthetic and the oxygen, each of which can be increased in quantity, according to his needs, with the result that he can be speedily anaistbetized and yet receive all the oxygen that is necessary to prevent any of the disagreeable symptoms of anaesthetization and its disagreeable sequelae. Such a plan has the added advantage that it is simple and does not require any additional apparatus, the rubber tube ffoni ilio oxygen cylinder passing under the edge of the inhaler placed 94: A TEXT-BOOK OF GYNECOLOGY upon the patient's face, and the supply of gas being governed by the stopcock on the cylinder. One of the forms of apparatus which is usually sold for the simul- taneous administration of oxygen and ether consists in an inhaler which covers the patient's nose and mouth and prevents him from getting any atmos23heric air, with the result that he is forced to breathe nothing but pure oxygen, mixed with angesthetic vapour. In order to make this still more complete, a large rubber bag is attached to the inhaler, which has no connection with the outside air, and which is inflated with each expiration of the patient and dilated with each inspi- ration. After a very few respiratory movements the patient is there- fore receiving a mixture of oxygen angesthetic and devitalized air, the quantity of the latter increasing with each subsequent respiration. Manifestly this method has two grave objections: First, that the pa- tient is supplied with pure oxygen instead of with atmospheric air, whereas Nature provides healthy human beings with a mixture of oxy- gen and nitrogen. The other disadvantage is that the patient is con- tinually taking back into his lungs impurities which he ought to be getting rid of. That the administration of oxygen gas with ether or chloroform is a distinctly advantageous procedure can not be doubted. The pulse under both ansesthetics when the gas is given remains in good condi- tion in a majority of cases, and there are no complications or sequela3 in the shape of depressions, nausea, or vomiting. Feeble circulation and respiratory disorders are much less frequently met with if oxygen is given than if it is not administered. Further than this, the progress of the patient during the anji^sthetic period is usually peaceable, cyanosis being largely avoided. The Administration of Chloroform. — For the administration of chlo- roform even more apparatus has been invented than for the giving of ether. Much of it is extremely complicated, possessing this disadvan- tage in addition to others which need not be considered in the brief space devoted to this article. While it is true that many of the English ansesthetizers employ these, American physicians are usually content with much simpler apparatus. There are, practically speaking, only two chloroform inhalers that can be generally employed with advan- tage — namely, that of Esmarch and that of Lawrie. Both of these inhalers embody two essentials of every form of apparatus used for the giving of chloroform — namely, the free access of air to the patient. All the more complicated inhalers are lacking in this important char- acteristic, or depend upon valves which may get out of order. The majority of anaesthetizers in this country employ a folded napkin or one of the inhalers just named. The patient should get at least ninety per cent of air during the use of the chloroform. Great advantages in the Esmarch and Lawrie inhalers are the facts that a free supply of air is present; too much of the drug can not be poured upon the inhaler with- out escaping, so that the patient can not receive an overdose, except ANAESTHETICS AND ANAESTHESIA IN GYNECOLOGY 95 through gross negligence; and the face of the patient is readily seen. Whatever the form of inhaler used, it must never be held so tightly over the patient's face that air is cut off (Fig. 30). The Lawrie inhaler is so cheap that a new one can be used for each patient, and the thin flannel cover of the Esmarch can be boiled each time it is used, thereby insuring sterilization. When chloroform is given it must be placed on the inhaler in drops, and not poured on freely as one uses ether. Finally, the angesthetizer should re- member that the dose of the anaesthetic is not that which he pours on the inhaler so much as the amount that the patient takes into his lungs, and, therefore, that in all cases the attention of the anaasthet- izer should be centred on the respira- tion, for upon the rapidity and depth of tills function does the dose depend. Again, as the respiratory function is the first one to feel the depressing effects of the drug, it acts as a good index of the degree of influence. In a case where the heart is known to be diseased, this organ must, of course, be watched also. Should the respiratory action become irregular or stormy, the ansesthetizer should at once stop the anaes- thetic, since the irregularity indicates abnormal action of the drug, and the amount inhaled can not be estimated. The Administration of Bromide of Ethyl. — When bromide of ethyl is given, it should be placed upon a cone or inhaler which tightly fits the face, and be pushed freely until the patient passes under its effect, which will be rapidly accomplished, as a rule. Care must be taken that the bromide of ethylene is not used by mistake, and that the drug is kept in dark glass bottles to prevent its decomposition. In order to be sure of its purity, it is best to use the drug from hermetically sealed flasks. Management of Respiratory and Other Accidents in Anaesthesia. — Attention may be called to the use of two instruments commonly em- ployed by inexperienced anassthetizers, which are nearly always, abused, viz., the mouth gag and tongue forceps. The mouth gag aids, rather than prevents, the falling of the tongue back into the mouth, and increases the possibility of the inhalation of saliva or other materials into the lungs; and the tongue forceps is almost invariably so con- structed that it bruises, punches, or punctures, the tongue in a manner that is anything but wise. Inexperienced anacsthetizers are very apt Fig. 30. — Esmarch's chloroform inhaler. — Haee. 96 A TEXT-BOOK OF GYNECOLOGY to believe that these two instruments should always be in their pocket, and should be frequently employed. As a matter of fact, they are very rarely, if ever, needed, and the jDroper manipulation of the head and jaw, and grasjjing the tip of the tongue with the fingers which have been covered with a towel, are quite sufficient to produce the proper position of this organ. There is a common error in the method of manipulating the head and jaw in respiratory accidents under anesthetics. Under such cir- cumstances it is the custom to allow the patient's head to fall backward, so that the muscles in the anterior i)ortion of the neck are in a condition of great extension, and it is thought that by maintaining this posture the glottis is widely opened so that air can readil}^ pass in and out of the lungs. It is true that this position of the head does widely open the glottis, but at the same time it drops the soft palate down upon the dor- sum of the tongue in such a way that the patient is required to take all the air that he needs through his nasal chambers. These upper air- passages are nearly always obstructed by mucus, which has been brought out as a result of the local irritation produced by the anges- thetic vapour. In addition, the nasal passages of many patients are partially or totally occluded by overgrowth of the mucous membrane covering the turbinated bones or by the presence of ^oolypi, so that if any of these causes of obstruction are present it is most difficult for the patient to get air. If, on the other hand, the angesthetizer, standing at the patient's head in his usual position, places a hand upon each side of the head and jaw in such a way that the palm of the hand covers each ear and the tip of the middle finger rests under the angle of the jaw, and then draws the head toward him, stretching the neck of the patient, and at the same time carries the head forward instead of backward, the result is that the glottis is quite as Avidely opened as when the head is extended upon the neck and carried backward, with the additional advantage that the soft palate is not strapped over the dorsum of the tongue, and the patient can, therefore, obtain air both through his mouth and nasal chambers. The attitude of the head under these circumstances in relation to the rest of the body, save for the fact that the patient is prone rather than erect, is that which is taken by the athlete when running. Surely no runner desiring to fill his lungs with air would tip his head far l^ack with his chin pointed upward, but, on the other hand, would project his head forward in such a way as to make his upper passages as patulous as possible. Anaesthetic Mixtures. — There are three ansesthetic mixtures to which reference should be made before leaving this subject. One of these is the so-called A.-C.-E. mixture, which contains alcohol, chloro- form, and ether, this combination being made with the idea of securing the auEesthetic effect by three drugs; and of combating by the alcohol and ether any tendency to cardiac depression produced by the chloro- form. Theoretically this mixture has something to recommend it, but practically the rapidity of vaporization of these three drugs is so dif- ANESTHETICS AND ANJ^:STHESIA IN GYNECOLOGY 97 f erent that the patient will get first one anaesthetic and then the other, and finally the alcohol, so that in reality he does not pass under the influence of all three at once. It can not be urged that there are serious objections to this mixture, but, on the other hand, there are no material advantages in it. The same objection holds against the C.-E. mixture, which contains chloroform and ether alone. The last anaesthetic mixture which need be mentioned is Schleich's, which is made according to three formulas, differing, not in ingredients, but in the quantity of each ingredient, and which consists in a mixture of ether, chloroform, and petroleum ether. It is claimed by Schleich that the petroleum ether has no deleterious effects. He believes that the effect of chloroform and sulphuric ether, together with the addition of petroleum ether, prevents the disagreeable effects which are met with when chloroform or ether is given alone. While this mixture on its first apj^earance received considerable attention, increasing clinical ex- perience has not been favourable to its employment, and it is speed- ily dropping out of use even in the hands of those who first considered it of great value. Central Anaesthesia by Cocaine. — In 1885 spinal ansesthesia was practised by J. Leonard Corning, of New York. Tuffier utilizes it in the following way: A 2-j)er-cent solution of cocaine is sterilized by heating at 80° C, the sterilization being repeated each day for three consecutive days. This solution is thrown into the arachnoid space of the spinal cord by means of a sterilized hypodermic syringe with a long and heavy needle. To administer the injection a line is drawn from the crest of one ilium to the other. The forefinger of the left hand is placed on the spine of the vertebra immediately above the line just indicated. The detached needle of the hypodermic syringe is now inserted to the right and a little above the tip of the left forefinger, being pushed well into the spinal canal. The escape of the arachnoid fluid will indicate that the needle has entered the canal. The loaded barrel of the syringe is now attached to the needle through which the solution of cocaine is discharged slowly and without force. From 1.5 to 3 cubic centimetres of the fluid are used, the dose depending some- what upon the size of the patient. Anaesthesia from the diaphragm to the toes will develop in from ten to twelve minutes; and the insensibil- ity thus induced will last from one to three hours. The cardiac dis- turbance induced by this form of anaesthesia is less than that from either ether or chloroform. Ko fatalities have been accredited to it. A. Palmer Dudley and other American surgeons have utilized this form of central ana-stliesia with success in hysterectomy and other equally severe opei-ations. It is es])ecially eligible in kidney complications. General Anaesthesia by Alcohol. — It is practicable to bring patients itilo ;i ((itidil ion of surgical ana>sthesia by the administration of alco- hol. J. .M. Matthews, of Louisville, frequently operates painlessly for hemorrlioids and other rectal conditions in ])atients who are thus ^' dead di-imk/' 'i'lic alcohol should he given in doses of an ounce 8 98 A TEXT-BOOK OF GYNECOLOGY every few minutes until alcoholic coma is induced. It is an eligible ex- pedient in alcoholic habitues, but is liable to induce an aggravating acute gastritis with attendant vomiting in patients who are not drinkers. General Anaesthesia by Hypnosis. — The researches of Charcot, and later of the Medical School of Nancy, have established the possibil- ity of entirely destroying physical sensibility by suggestion. Reed has operated for the repair of lacerated perineum, and for pelvic abscess by vaginal drainage, in patients who had been rendered unconscious by hypnotic angesthesia. This, however, is not to be looked upon as an agent or influence of general utility, for the reason that women are not all subjective, and for the further reason that, notwith- standing there are no reflex manifestations of pain, nor any memory of the operation, it still seems that the impression registered upon the secondary or induced consciousness provokes shock to a degree that is not realized under general ana?sthesia as ordinarily practised. The subject is one pregnant with great j)0ssibilities, and should be subjected to more critical study than has yet been accorded it by the English- speaking medical profession. Local Anaesthesia. — It is sometimes desirable and even imperative to avoid the administration of general anaesthetics. Pain may be re- lieved under such circumstances by benumbing the parts with cold or with ether, or by using a subcutaneous injection of a 8-per-cent solution of cocaine. The latter remedy, however, should not be looked upon as innocuous, so far as its constitutional efl^ects are concerned, serious cardiac and respiratory complications having ensued upon the administration of but a small quantity. CHAPTER XII ABDOMINAL SECTION Terminology — Preliminary treatment of the patient — The evil of hypercatharsis — Examination of the urine — Instruments — Preparation of the field of operation — Location of the incision — Direction and varieties of the incision: Vertical median, transverse umbilical, transverse suprapubic, oblique ventral, inguinal, oblique subcostal, lumbo-iliac, lumbo-costal — General observations on making the incision — Closure — Immediate and complete by laminated suture — Where drainage is necessary by suture en masse — Drainage. Theee has been much discussion of the various terms which, from time to time, have been coined to designate the operation whereby the abdominal cavity is opened and its viscera made accessible for surgical purposes. Blancard, of Middleburg, Zealand, published a work nearly two hundred years ago in which he employed the word " gastrotomia " to designate " the cutting open of the abdomen and womb, as in sedio Ccesarea." The word comes from two Greek terms — namely, yao-r^p, meaning belly or stomach, and rofiij, meaning incision. The first of these terms was formerly employed in its ordinary and vulgar sense of belly. Since operations upon the stomach proper have come into vogue, the term has been narrowed in its significance, and is commonly used exclusively to designate the operation of making fistulse into that organ. Laparotomy (derived from Xairdpa, the flanks, and to/at; [rifivuv, to cut]; French, laparotomie; German, Laparotomie) was, perhaps, the next coinage, and had, originally, a meaning that was entirely consist- ent with its purpose. It was employed early in the nineteenth century to designate the operations in the inguinal regions, as, for instance, for hernia and colotomy. In later years, however, with the advent of what has since become known as abdominal surgery, " laparotomy " was made to mean all operations upon the abdominal wall. This was such a manifest misapplication of the original meaning of the term that the profession has largely abandoned its use. The first revolt was emphasized by Lawson Tait, who employed in its stead the expression ''abdominal section." This term, in turn, has occasioned considerable discussion. Greig Smith says that it is, perhaps, "most objcctionaljlc of all; an abdoTtiinal section," he adds, "is made 99 100 A TEXT-BOOK OF GYNECOLOaY on a frozen cadaver with a saw for anatomical purposes; it is not easy to understand how an evil chance led to the name being given to an incision made through part of the abdominal wall for sur- gical purposes." This criticism must be recognised as of doubtful accuracy. The word " section " is derived from the Latin sectio, meaning simply " to cut." A statement that " section " must imj)ly amputation or an abso- lute severance of one part from the other, is, therefore, an unjustifiable stricture. The fact remains that, by convention at least, it has come to be synonymous with incision. This has been verified through gen- erations, and for that matter centuries, in the term Csesarean section. Latterly we hear of jjeriueal section, sagittal section, and many other equally legitimate applications of the word. The word coeliotomy — from the Greek kolXm, the belly, and t€jxv€lv, to cut, and correspond- ing in significance with the French cwliotomie, the G-erman l-oilotomie and hauchschnitt — does not materially help the situation. The word coe- liotomy was brought to the attention of the profession by the late Dr. E. P. Harris, of Philadelphia, although Dr. F. P. Foster, writing on the subject, says " this term seems to have been introduced by Davies-Colley." " Some good people," continues Foster, " write it celiotomy; many consider it more expressive than laparotomy, but with its adoption has sprung up the curious term ' abdominal coe- liotomy,' an abdominal opening of the abdomen, as distinguished from vaginal coeliotomy. The term abdominal section answers every purpose, and seems to me ])referable to both coeliotomy and lapa- rotomy." The Preliminary Treatment of the Patient. — In the absence of an emergency, such as hemorrhage, acute sepsis, or strangulation, time should be taken to prepare the patient's system for the operation. This should be done by giving particular attention to the state of the secretions. Most patients, particularly those of the more chronic class, are constipated, and their systems are, as a consequence, laden with tox- ines from the hyperabsorption constantly going on from the alimen- tary canal. The condition is all the more serious because of the de- fective peristalsis which is liable to be still further weakened, if not entirely arrested, by the influence of the operation upon the sympa- thetic nervous system. It is highly important, therefore, for these two reasons, if for no other, that the bowels should be not only un- loaded, but brought to an approximately normal standard of activity. This is best done by giving the patient a small dose (one sixtieth of a grain) of strychnine with salol (three grains) three times daily associ- ated with a persistent course of salines. For the latter purpose the magnesium sulphate, the sodium sulphate, or the sodium phos- phate, may be employed, either in the form of some of the natural mineral waters, or by dissolving some of the salt in plain water. More important, perhaps, than the selection of the remedy is the manner of its administration. The best results are obtained by giving drachm ABDOMINAL SECTION 101 doses, beginning, not before, but after a meal. If the chosen remedy is continued in this way during twenty-four hours and no laxative effect is realized, it may be well to unload the bowels of their now softened contents by administering one full dose of the medicament, given this time on an empty stomach. The saline should not be dis- continued so soon as the bowels have been evacuated, although a little time should be given for the previously secured laxative effect to subside. The saline should then be resumed in half doses, given an hour or two after each meal. In this way it becomes mixed with the ingesta, and, by stimulating both secretion and peristalsis, prevents a return of the constipation. A constipation of long standing may thus frequently be broken up in the course of a week^ often with permanent results. The Evil of Hy- percatharsis. — It is highly important to urge a word of cau- tion against the prevalent habit of purging patients ex- cessively before op- erations. It is not unusual for patients to be forced to have a dozen or more de- jections during the twelve or twenty- four hours before undergoing the or- deal of an abdominal section, and during this time they are kept upon a re- duced diet, and often during the final twelve or fifteen hours are given nothing at all to eat. It should be borne in mind that such hypercath arsis (a) weakens the pa- tient, (b) still further weakens peristalsis, (c) aggravates post-operative thirst, and (d), by draining the circulation, stimulates all of the absorb- ent functions, and thus lays the foundation for systemic sepsis in the presence of unavoidable local infection. The practice is wholly wrong and should be attandoned. Fig. 31. — " Fenton B. Turck covers the abdominal wall with a sheet of rubber dam." — Keed (page 102). 102 A TEXT-BOOK OP GYNECOLOGY Examination of the urine is very important, as is the correction, by judicious medication, of an}^ error tliat may be found in that secre- tion. The condition of the skin should equally be the object of careful investigation and treatment. This latter precaution is of greater impor- tance than is generally recognised. It is only necessary to mention that failure of the urinary function, as the result of the action of the anaes- thetic on the kidneys, is one of the most frequent fatal complications following visceral operations; and that in the presence of such a com- plication the chief hope of the patient lies in the compensatory activity of the sweat glands. It is highly important, therefore, that they be piit in a state of normal activity before the operation. Baths, if necessary, with dry heat or steam and followed by friction, continued during several days, generally constitute all the treatment that is required. The digestive function should be brought to as high a state of effi- ciency as possible. Fenton B. Turck covers the abdominal wall with a sheet of rubber dam (see Fig. 31). This is stretched taut, and, being translucent, does not obscure the underlying integument; the incision is made directly »y> ■-^.^ /'— >-^^ . ■ — -^^^^^--—"'^ m He^^h ,Jf„ C^— (5^^=^ pP^^R v" r— A;s===^ ==sss^^ ^--^^s-~^ '-"^JB ^_/ ^"•*****^ '''^**TBb =^=======^ '. w^U^ Fig. S2. — " The cut edges of the rubber dam are brought forward and tucked into the wound." — Reed. through the dam just as if it were a part of the skin. After the inci- sion is completed, the cut edges of the rubber dam are drawn for- ward and are tucked into the wound, covering its margins and being retained by a clothes-pin arrangement, as shown in the drawing (Fig, 32). The rubber dam is further utilized by Turck in preventing infec- tion of the peritoneal cavity by drawing a loop of intestine to be oper- ated upon through a small hole in the rubber sheet. ABDOMINAL SECTION 103 Instruments for an Abdominal Section Aspirator. Cautery (Paquelin). Forceps : Long dressing 1 Long hemostatic 6 Medium liemostatic 3 Small hemostatic 3 Bullet 1 Rat-tooth 2 Needles, curved : Very large (No. 1) 1 Large (No. 4) 2 Intermediate (No. 3) 2 Small (No. 2) 2 Intestinal (No. 1) 2 Transfixion, right curved 1 Needles, straight 2 Needle holder 1 Retractors : Large 2 pairs Next size smaller . . 2 " Scalpels 2 Scissors : Long 1 pair Short 1 " Sound, uterine 1 Speculum, Sims's small 1 Sponge holders 4 Tenaeula : Straight 1 Curved 1 Additional Instruments for Ovarian Cysts Trocars, large and small. Two Nekton forceps. Rubber tubing. Additional Instruments for Extra-uierine Pregnancy^ Hysteromyomectomy, or Supravaginal Hysterectomy^ and Vaginal or Infravaginal Hysterectomy One dozen pairs of long hemostatic forceps. Two Museux's forceps for seizing tumours. Glassware Catheters 2 Drainage tubes, assorted sizes : Straight 3 Curved 3 Flask, sterilized, to receive fluid (contents of cysts, etc.) for examination 1 Nozzles (for irrigation) 2 Preparation of the Field of Operation. — (See Preventive Treatment of Sepsis.) Location of the Incision. — The abdominal incision is generally located in the median line for the reason that this particular situation enables the operator to more freely handle the parts of the abdominal and pelvic cavities. This rule is adopted more particularly in the old operation of Cesarean section, and in the more recent procedure of ova- riotomy. In the former instance it was manifestly to the convenience of the operator to get down directly upon the uterus. In the second class of cases it was more desirable because it enabled the surgeon to deal with either side of the pelvis with equal facility; latterly, however, the principle has gained recognition that the incision should be made directly over the organ or structure which is to be dealt with. 104: A TEXT-BOOK OF GYNECOLOGY The question of hernia resulting from the unsatisfactory restora- tion of the incised abdominal wall is also an important consideration in determining the location and character of the incision. It is generally- supposed that the cut in the median line directly through the linea alba is best calculated to avoid unpleasant consequences. Of the incision in this location, it may be said that it is the easiest to make, and, by avoiding blood vessels, is least complicated with hemorrhage. It is closed with great facility, and the union which ensues is generally very satisfactory. If infection should occur, however, the approximation of the structures, however accurately made, may be destroyed, and the margin of the wound thus become retracted. This is of very serious import when the incision is a little to one side or the other of the median line, and when the separation involves the margins of the fasciae. This — i. e., separation of the fascia — -is the underlying condi- tion of post-operative ventral hernia; to avoid this accident many oper- ators prefer to invade the abdominal cavity a little to one side or the other of the median line, some preferring to go as far to one side as the outer margin of the rectus muscle; some preferring to go di- rectly through the rectus ; while still others open the sheath of that muscle near the median line, pushing the muscle itself to one side and continuing the inci- sion through the middle of the under- lying layer of sheath and fascia. In this way it is contended that should one layer separate, the other layer, directly super- imposed, will exercise a greater retentive power, and thus pre- vent the development of hernia. This principle is one which is capable of adoption in many operations. It should be observed, especially in fat subjects, where, in consequence of the disuse of the abdominal muscles, or of the stretching incident to distention by fat. Or from the pressure due to the presence Fig. 33. — " The incision may be made in that locality which will afford the greatest facility in dealing with the under- lying internal conditions."— Reed (page 105). ABDOMINAL SECTION 105 of deposits of adipose tissue, the structures of the abdominal wall are materially weakened. It should be remembered that an incision may be made at any point in the abdominal wall, and that there are no blood vessels contained therein the hemorrhage from which is not readily controllable. As a rule, therefore, the incision may be made in that locality which will afford the surgeon the greatest facility in dealing with the underlying internal conditions (Fig. 33). Direction and Varieties of Incision. — While the foregoing is true, it is also true that there are distinct advantages to be gained by definitely and accurately arranging the direction of the incision into and through the abdominal wall. It is also true that, consistently with the object in view, the incision is best made (a) coincidently with the cutaneous folds, and (5) coincidently with the muscular fibres and fascial striw. This principle was enunciated by Kocher (Operative Surgery, New York, 1894), who definitely outlines the incisions to be made for vari- ous purposes, some of which come properly within the range of a work on gynecology, and are given herewith. The line of the median ab- dominal incision is, as already stated, the one most commonly employed. While it is made transversely to the normal cutaneous folds it is coin- cident with the recti muscles, a fact that conduces largely to the easy and permanent approximation of the deeper structures. The results, so far as the skin is concerned, are, however, often somewhat unfortu- nate, if from no other than an sesthetic point of view. The retraction of the skin that frequently ensues, notwithstanding the most careful approximation of the cutaneous margins, frequently results in post- operative widening of the cicatricial area. Frequently under this in- fluence the scar tissue undergoes what is spoken of as a keloid change. When, therefore, the cutaneous incision can be made transversely, the underlying layers being divided in any direction to suit the oper- ator, but preferably in the direction of their respective stricB, the result is always more satisfactory. There is nothing more striking than the difference between a scar made transversely to, and one coincidently with the cutaneous folds, the latter becoming practically imperceptible after a very few weeks, while the former shows a constant tendency to increase in size and to diminish in retentive power. The Vertical Median Incision. — The incision E (Fig. 33) may be called the low vertical median incision, while that designated G (Fig. 33) is the high vertical median incision. The latter should be employed in operations upon the stomach, and in other operations in which it is desirable to reach the organs lying in the upper part of either of the upper quadrants of the abdominal cavity. A vertical in- cision (//, Fig. 33) is sometimes made in the left upper quadrant for operations upon the spleen. The incision in the median abdominal line is the best in all cases in which it is necessary to deal with both siflos of the pelvis, or in those cases in which it may be uncertain as to which sifl(; of the pelvis may be the ultimate seat of operation. The median line is, as a riih-, 1lic safer locus for a genei-al exploratory in- 106 A TEXT-BOOK OF GYNECOLOGY cision. It should always be employed in the presence of surgical condi- tions lying immediately beneath it. The Transverse Umbilical Incision. — This incision is made trans- versely at the umbilicus, and may be employed in dealing with prac- tically all conditions developing in that locality. It is the ideal in- cision in the management of umbilical hernia. As a rule, a post- operative ventral hernia, occurring in this locality, or, for that matter, at any other point above or below the umbilicus, may be safely and desirably approached through a transverse incision, while the her- nia itself should be approximated in a transverse rather than a longi- tudinal line. This line of incision is of especial importance in fat people. These patients, lying upon their backs, exercise all of the gravity which is derived from the heavy and mobile abdominal walls in a spontaneous tendency to retract from the longitudinal median line, while their equally natural tendency is to hold a transverse ajDproxi- mation in continued apposition. The Transverse Suprapubic Incisio7i (C, Fig. 33). — This incision should be made transversely to the median line, immediately above the pubes, in all operations in which it is desirable to approach the bladder from the outside. This occurs with frequency in gynecological practice. The Oblique Ventral Incision (A, Fig. 33). — The oblique ventral in- cision should be employed in dealing with the common iliac artery, as sometimes becomes necessary in gynecological practice; it may be used on the right side in dealing with the suppurations about the head of the colon and in appendicitis, or in surgical conditions pertaining to the pelvic bones on that side. On the left side it is the avenue of approach to the sigmoid flexure as well as to the common iliac artery. The Inguinal Incision (B, D, Fig. 33). — The inguinal incision may be made either above or below, but coincidently with, the line of Pou- part's ligament. In the former position it may be employed in inguinal hernia or to reach conditions beneath the broad ligament in order that they may be dealt with without communicating with the peritoneal cavity. Suppuration in this locality may be evacuated and drained by an incision along this line, while retroperitoneal myotomy, or, for that matter, intraligamentary cysts, may be approached by this incision, after their true character has once been determined by the incision in the median line. This incision is sometimes made below Poupart's ligament in deal- ing with femoral hernia and with conditions connected with the fem- oral artery. The Oblique Subcostal Incision (F, Fig. 33). — The oblique subcostal incision should be made from a half to three quarters of an inch be- neath the costal margins, extending from the outer margin of the rectus muscles to as far around the side as may be necessary. This operation is sometimes desirable in making explorations for the kidney — a pro- cedure which comes within the purview of this work; it is usually em- ABDOMINAL SECTION lOY ployed, however, for operations upon the gall bladder, which are not considered in this volume. The Lumho-iliac Incision. — This incision begins near the last costo- vertebral articulation, extending downward and forward in the direc- tion of the crest of the ilium. It may be employed in the case of ne- phrectomy, or for the complete removal of the ureter. The Lumbocostal Incision. — This incision is made from a point one to two inches to the side of the posterior median line, and carried obliquely downward, forward, and upward below the costal margin. It is employed for operations upon the kidney. General Observations on making the Incision. — ^Wherever the inci- sion may be located it should be made deliberately, all attempts at haste being avoided. The layers should be incised one by one. Bleed- ing points will, of course, be encountered, some localities and some patients being more vascular than others. The blood should be speed- ily wiped away by means of a bit of dry sterilized gauze, so that the structures may be kept clearly in view. The gauze thus used should be immediately thrown away. M^ich time is often lost in needless atten- tion to unimportant bleeding. As a rule, that bleeding which is merely capillary or venous may be left to itself, while a i3ulsating jet should be at once controlled by means of a hemostatic forceps. This should not be hastily applied, and should always be adjusted with care and precision. Many careless operators and assistants simply take a large Fig. 34. — " The presenting structure should be picked up by two hemostatic forceps." — Keed. bite of ti.ssue somewhere in tlie noiglibourliood of the bleeding point, with the object, of course, of controlling the hemorrhage. The pres- sure thus imposed upon the tissue, particularly the adipose tissue, which is found in such abundance in the abdominal wall, is liable to induce 108 A TEXT-BOOK OP GYNECOLOGY necrosis, and thus interfere with primary union. A few seconds of time should he taken to isolate more or less definitely the hleeding point, which should then be picked up accurately by the point of the hemo- static forceps. As soon as the deej) fascia or the subperitoneal fat is reached, the presenting structure should be picked up by two hemostatic forceps (Fig. 34), which should be re- applied as often as may be necessary to hold the peritoneum away from the underlying viscera. The moment the peri- toneum is nicked the air rushes in and the in- testines fall away from the abdominal wall. Failure to observe this precaution sometimes re- sults in the totally un- necessary wounding of the intestines or other structures within the ab- dominal cavity. The peritoneum should be carefully incised by means of either scissors or a knife, coincidently and coextensively with the upper part of the in- cision (Fig. 35). As soon as the peri- toneum is opened, care should be taken to per- manently arrest all hem- orrhage in the abdominal incision and to remove the forceps. In the course of an operation it may be, and frequently is, neces- sary to enlarge the inci- sion; in doing so great care should be exercised to make the additional opening directly in line with the previous one, and to observe the same precautions in dealing Avith the incidental hemorrhage. It is better to employ a knife for this purpose rather than the scissors, which are generally so convenient, so expedient, and so generally utilized by the hurried surgeon. The scissors are objectionable, because in the act of cutting they produce a certain amount of cell destruction, which is Fig. 35. — "The i>fi'itiiiiciiiu should be carefully incised . . . coincidently and coextensively with the upper part of the incision." — Reed. ABDOMINAL SECTION 109 obviated by the keener edge of the knife. The incision having been made as large as necessary, the operation, whatever it may be, is car- ried to completion. The Closure of an Abdominal Incision. — There are various methods of closing the abdominal incision. The question of interrupted or con- tinuous suture, the question of suture material, and the question of sealing or not sealing the wound, are all to be considered; this is bet- ter done with reference to the necessity or not of maintaining drainage. The Immediate and Complete Closure of an Abdominal Incision. — When the operation has been successfully concluded, when the field of operation has remained free from infection, when hemostasis has been secured, and when there are no remaining doubts as to the safety of the internal conditions, the abdominal wound may be closed com- pletely and at once by one of the following methods : Closure by the Laminated Suture. — The ideal method of closure is by the approximation, edge to edge, of like structures; thus the peri- toneum to the peritoneum, the tranversalis fascia to the transversalis fascia, the superficial fascia to the superficial fascia, and the integu- ment to the integument, should be successively approximated. This may be done either by continuous or interrupted suture or chromicized or formalinized catgut. The kangaroo tendon and other tendinous materials have a certain vogue for this purpose, but they are not essen- tial to success. If a continuous suture is applied in each layer it ought to be supplemented by a number of interrupted sutures in the fascial layers, as these structures are more prone to retract than are the others, and they are likewise the chief retentive tis- 5" "^^ sues of the abdominal wall. It is not safe, therefore, to trust their approximation to a sin- gle continuous suture. The application of the sutures to the various layers is largely facili- tated by drawing up, by two small volsella for- ceps, each consecutive layer into the field of operation (Fig- 36). Volsella forceps are vastly better adapted to this ymrpose than are those used for hemo- stasis, because they exercise no pi-essure, and consequently induce no cell destruction. The skin should be closed by means of intercuta- neous suture, 1jiit before starting this suture the end should be fastened Fig. 36. — " The application of the sutures to the various layers is largely facilitated by drawing up, by small volsella forceps, each consecutive layer into the field of operation." — Keed. 110 A TEXT-BOOK OF GYNECOLOGY in such a way as to place the knot deep in the subcutaneous fat (Fig. 37) in order that its absorption may be insured. This is done by passing the needle through the subcutaneous fat from beneath, carrying it across to the other margin of the wound, and downward through the fat, bringing it out at a point corresponding to the original insertion on the other side. The suture is now tied and the short end cut close. In order to secure perfect approximation at the end of the wound, the first intercutaneous suture is passed toward the end from which the suture starts (Fig. 38). The remaining su- tures are passed in the other Fig. 37. — "The end should be fastened in such a way as to place the knot deep in the subcutaneous fat." — Eeed. Fig. 38. — " The first intercutaneous su- ture is passed toward the end fi'om which the suture starts." — Eeed. direction, the margins of the skin being carefully drawn together (Fig. 39). There are connected with this last manoeuvre certain dan- gers, for instance, the unsuccessful application of the sutures, leaving a gaping point to serve as an infection atrium; or, on the other hand, if too tightly drawn after they have been inserted, the pressure itself may be destructive of the integument and may result in a necrosis, which is disastrous to primary union. After having applied the inter- cutaneous suture there may be some retraction of the subcutaneous fat, a condition which is easily remedied (Fig. 40). This is done by taking a long curved needle, inserting it an inch or less back from the line of incision, crossing the incision itself, and bringing the needle out at a corresponding distance on the other side. The needle is then rein- ABDOMINAL SECTION 111 serted through the aperture of exit, and is carried in a more or less oblique way back to the opposite side, where it is brought out half an inch distant from the point of original insertion (Fig. 41). The suture thus buried approximates the underlying fat, and in an important degree forti- fies the cutaneous approximation. It is returned in the same manner until the whole line of incision has been brought under the influence of the suture. It is then tied under the skin by inserting the needle and working its point two or three times around the strand of catgut immediately un- der the skin. The needle is then brought out on the other side and the catgut excised under traction close to the skin. The end immediately re- tracts and the whole operation will have been completed entirely beneath the integument. It is well in the majority of cases to seal the wound by adjusting over it a little sterilized gauze fixed to the surface by means of collodion, but the impossibility of sterilizing col- lodion should prevent its application directly to the margins of the wound. After the abdomen is well cleansed and dried it should be tightly bound with a cloth bandage. That in use at the Cincinnati Hospital is probably more advantageous than others, it being held firmly in place by two flaplike elongations of the back part which are brought up between the thighs and fastened to the front of the bandage (Fig. 42). Closure where Drain- age is Necessary. — In many operations it is not possible to secure com- plete hemostasis or that degree of asepsis com- patible with safety, or to control other surgical conditions to a degree that will justify the com- plete closure of the abdominal incision. Drainage must, therefore, be employed and an orifice of exit must be provided. This is sometimes Fig. 39.— "The remaining sutures are passed iu the other direction, the margins of the skin being carefully drawn together." — Eeed (page 110). Fig. 40. — " After having applied the intercutaneous su- ture there may be some retraction of the subcutaneous fat, a condition which is easily remedied." — Reed (page 110). 112 A TEXT-BOOK OF GYNECOLOGY Fig. 41. — " The needle is reinserted through the aperture of exit, and is carried in a more or less oblique way back to the opposite side." — Reed (page 111). done by making an opening in the cul-de- sac of Douglas and carrying a self -retain- ing tube out through the vagina. In other instances this will not suffice. Many opera- tors still cling to the old glass tube and pump, while in certain other instances it is necessary to pack the field of operation with gauze and bring one end of it out through the incision. The neces- sity for the latter expedient is sometimes so great as to make it neces- sary to leave open the entire wound. Under any of these circumstances it is necessary to leave a part or all of the incision open. In such cases it is not better to employ the buried animal suture, for the reason that the drainage, how- ever established or how- ever maintained, is neces- sarily a fruitful source of infection; and infection once communicated to the continuous laminated animal suture is liable to invade all of the struc- tures that may be approx- imated by it. Closure hy the Suture En Masse. — To close the wound when drainage is required, the suture en masse should be em- ployed. This may con- sist of silk, silver wire or silkworm gut — the lat- ter on all accounts being preferable. The material, having been sterilized, of course, may be inserted from the skin to the peri- toneum, carried across from peritoneum to ]3eri- FiG. 42. — " The bandage in use at the Cincinnati Hos- pital is probably more advantageous than others." — Eeed (page 111). ABDOMINAL SECTION 113 Fig. 43.— The needle devised by Dr. J. B. S. Holmes. — Reed. toneum and through from peritoneum to skin. For this purpose many operators prefer a straight needle;, others a curved one; the most satis- factory one which the writer has encountered has been devised by Dr. J. B. S. Holmes, of Atlanta, Ga. It is a round needle bent at an angle near the point, which has a bayonet finish (Fig. 43). The needle in passing through the ab- dominal wall should be made to define an arc of a •circle, so that when drawn together the intermediate structures will be brought well forward and forced into approximation (Fig. 44). In a few in- stances it may be found necessary to bring the traction to bear more specifically upon the margins of the fascia. This is accomplished by ■a, figure-of-eight arrangement, effected as follows: The needle is in- serted through the skin and superficial fascia, brought out into the margin of the wound, inserted into the oppo- site side just below the superficial fascia, car- ried through the peri- toneum, crossed over, inserted through the peritoneum and brought out just beneath the su- perficial fascia, crossed over to the other side, inserted through the superficial fascia, and brought out through the skin. The resulting suture is a complete figure eight, which forces into approximation the fascia which, under many circumstances, is prone to retract to a degree calculated to defeat the union (Fig. 45). The sutures having been inserted, the ends are gathered together upon either side and the entire abdomi- nal wall is drawn away from the in- testines, the perito- neal margins being forced together by properly directed traction upon all the sutures. This having been done, the ends of the sutures may be permitted to lie freely while the operator ties each one seriatim. If the material is silkworm gut the preliminary loop of the knot should be accomplished by three turns, and sliouhl be, drawn tog(3tlicr with just sufficient force to effect the approxiiiiaiion of the tissues, but without force enough to interfere 9 Fig. 4A. — " The needle, in passing through the abdominal wall, should be made to define the arc of a circle." — Eeed. Fig. 45. — "The resulting suture is a complete figure of eight." — Reed. 114 A TEXT-BOOK OF GYNECOLOGY Avitli the local nutrition of the parts. A suture that blanches the skin under it is tied too tightly. This can not always be avoided, because the post-operative engorgement of the parts sometimes increases pres- sure to a dangerous degree. If the suture has been secured as already indicated — namely, by an extra whirl in the preliminary loop — it is totally unnecessary to • ajsply the usual second loop for fixation. If, then, the tension should subsequently appear to be too great, the suture can be loosened. An extra suture may be inserted to secure approxima- tion at the point occupied for drainage. If applied, this suture should be left loose until after the drainage is concluded. It may be stated, as- a rule, however, that this expedient is one of doubtful utility, and is not infrequently fraught with some danger. It is better, as a rule,, to leave that section of the wound which has been employed for drain- age open for spontaneous closure. Drainage. — Drainage was at one time considered more essential tO' success in abdominal surgery than it is at the present day. At the time when surgeons were less sure of hemostasis it was a safeguard in detect- ing internal hemorrhage, and it should yet be employed in all cases in which the operator has any doubt about having controlled the bleed- ing. In former times, when the toilet of the peritoneum was less care- fully made than at present, drainage was essential for the escape of pus, which continued to form until limited by the self-extermination of its micro-organisms. Drainage may be practised by leaving in the abdominal wound a glass tube extending to the bottom of the pelvis.. Through this tube the accumulated fluids are sucked with an appa- ratus consisting of either a syringe or a rubber bulb with a glass barrel attached to a bit of rubber tubing. The manipulation requires great care to prevent infection, the liability to which by this means consti- tutes one of the chief objections to drainage as a routine measure. In many abdominal operations in which it is desirable to promote the escape of fluid, drainage is effected by making an opening in the floor of the cul-de-sac of Douglas and inserting through that into the vagina either a small rope of gauze, or preferably a T-drainage tube. These are made of rubber after the pattern of Martin, but as found in the shops are unnecessarily expensive. Just as efficient a drainage tube can be made by taking a piece of ordinary quarter-inch drainage tubing, eight inches long, and cutting it off oval at one end. The tube is then split for a distance of an inch and a half into two flaps; an eighth of an inch below the base of each flap a small hole is cut into each side of the tube; through each of these holes the corresponding flap is drawn by means of an ordinary hemostatic forceps; the result is the formation of a T-tube of great utility (Fig. 46). Delageniere has de- vised metal drainage tubes, but their advantages are not obvious. G-auze has been used for drainage purposes, but it speedily becomes filled with the secretions, which it fails to conduct out of the cavity; its use, there- fore, should be limited to those cases in which the fluid expected to be taken out by it is not in excess of the absorbing capacity of the gauze tO' ABDOMINAL SECTION 111 be used. J. Gr. Clark investigated the general question of drainage in seventeen hundred abdominal sections at the Johns Hopkins Hos- pital {American Journal of Obstetrics, April, 1897). In approaching his investigations he proceeded upon the conclusions of Muscatello — Fig. 46. — " The result is the formation of a T-tube of great utility.'' — Eeed (page 114). viz.: (1) the surface of the peritoneum is equivalent to that of the skin; (2) it has an enormous absorbing function, taking up in an hour from 3 to 8 per cent of the entire body weight; (3) under the influence of very toxic or very irritant substances an equal transudation into the peritoneal cavity may take place. Clark, from a general study of the subject as well as from these investigations, concludes that — 1. Fluids and solids may pass through the endothelial layer of the peritoneum, the fluids in many places, the solid particles only through the spaces in the diaphragm. 2. The minute solid particles are carried into the mediastinal lymph vessels and glands, and thence into the blood circulation, by which they are distributed to the abdominal organs and lymph glands. 3. Large quantities of fluids may be absorbed by the peritoneum in an astonishingly short time. 4. The leucocytes are largely the bearers of foreign bodies from the peritoneal cavity into the mediastinal lymph glands. As the result of the experimental study of infection of the perito- neum by Grawitz, it has been shown that — 1. The introduction of nonpyogenic organi.sms into the abdom- inal cavity, either in small or large quantity, or mixed with formed par- ticles, produces no harm. 2. Great quantities of organisms, which ordinarily produce no dis- turbance, may give rise to a general asepsis if the absorptive ability of the peritoneum is impaired. 3. '^rhe injection of pyogenic organisms into tlie peritoneal cavity may be quite as harmless as injection of the nonpathogenic varieties. 116 A TEXT-BOOK OF GYNECOLOGY 4. The introduction of pus-producing cocci causes a purulent peritonitis (a) if the culture fluid is difficult of absorption; (b) if there is present irritating material which destroys the tissues of the perito- neum, and thus prepares a |)lace for the lodgment of organisms; (c) if a wound of the abdominal wall is present which forms a nidus for the infectious process. In this latter case purulent peritonitis will cer- tainly be produced. It was further found that the area drained by a tube speedily be- came limited, almost to the circumference of the tube itself; that the tube frequently acted mechanically, and thus perpetuated the peritoneal exudation; that the serum throAvn off by the peritoneum acted as the best possible culture medium for germs introduced from without; and, finally, that any agents that had any possible effect upon bacteria acted as an irritant to the peritoneum, and thus defeated the purpose for which they were employed. CHAPTER XIII THE EXTERNAL ORGANS OF GENERATION IN WOMEN Names and definitions — Development — The vulva and its malformations: atresia; infantile ; double ; persistent cloaca ; persistent urogenital sinus ; epispadias in women; precocious development; individual malformations of the labia, cli- toris, and perineum; pseudo-hermaphroditism: (a) masculine, (b) feminine — The vagina and its malformations : absence ; atresia ; stenosis ; double or sep- tate — The hymen and its malformations : atresia ; double ; absence ; anomalies in (a) form, (1)) structure, (c) anterior extension. The external organs of generation in women consist of the puden- dum and vagina. The pudendum embraces the structures known as the mons veneris, the labia majora, the labia minora, the clitoris and prepuce, the vestibule and fourchette, and the hymen. The word " vulva " applies to all of these •external structures excejat the mons veneris. For convenience of classification the perineum will be con- sidered in this same group. Development of the Genital Organs. — The genital organs, whether male or female, have their embryologic origin in the Wolffian body, Mliller's ducts, and the genital glands. From the Wolffian body, or the primordial kidney, there appear on the inner portion, and in the fifth and sixth months of utero-gestation, the genital glands, which subse- quently evolve into either ovaries or testicles. If, however, at the end of the third month, when differentiation of sex is manifested, the geni- tal glands develop into ovaries, the Wolffian body and canal atrophy, almost disappearing, and leave as their only remnant the organ of Eo- senmiiller in the broad ligament. Mliller's duct, however, persists, and from it are developed the Fallopian tubes, while the round ligament is developed from the yet persisting ligament of the Wolffian body, blend- ing, however, with Mliller's ducts at the Junction of the superior with the middle third. The external organs of generation are derived from the genital tubercle, which appears at about the sixth week of festal life and reaches its maturity during the succeeding two weeks. After the development of the genital folds and at the end of the second month there is recognisable on its posterior surface a furrow extending in the direction of the cloaca and designated the genital groove. This is the beginning of sex development, the subsequent steps of which, as outlined by Pozzi, are as follows: " The genital groove does not close more in front than behind, and thus the female lacks the clitoridian 117 118 A TEXT-BOOK OF GYNECOLOGY |)ortion of the urethra: and this canal in tlie adult opens at a point homologous Avith that where it was found in the foetus of eight weeks — a disposition which is found in the male when the proper development of the parts has been arrested (hypospadias). The corpus spongiosum of the urethra^ the product of the erectilized borders of the genital furrow, is also completely develojaed in the male and entirely sur- rounds the canal in the pendulous portion. But in the female it aborts in the intermediate or vestibular portion, being reduced below to its two extremities extending to the bulb of the vestibule, homologue of the bulb of the male urethra, but divided by the persistent genital opening; and above, it forms the glans of the chtoris, wliich covers the corpora cavernosa clitoridis, homologaies of the similar structures in the male penis. At the internal part of the bulb of the vestibule there are ves- tiges of a membranous organ, which reaches its full development in the male — namely, the bulb of the urethra; it is this which forms the hymen. Above, joining bulb and hymen to the clitoris and representing the ver- tical or cylindrical portion of the masculine corpus spongiosum, there is in the female a band with a vascular bundle running into it, the frsnum masculinum vestibuli." (Medical and Surgical Gynecology ,Yo\.ii,\:>. 4:o() .) When the ducts of ]\Iuller coalesce by the approximation of their internal thirds they naturally form a bifurcating double tube divided at the lower extremity by a septum with two divergent ends above. xVs development progresses this septum disappears, leaving the rudimen- tar})- vagina below and the rudimentary Fallopian tubes above with no intervening uterine body. At the end of the fifth month, however, there occurs at the upper end of this rudimentary vagina a deposit of tissue, which marks the beginning of the uterus. The failure of the septum to disappear from the rudimentary vagina results in the devel- opment of a double vagina; while its disappearance from the vagina, but its failure to disappear from the uterine extremity of the rudi- mentary canal, results in the development of a double, or bicornate, uterus. (See Malformations.) Malformations of the vulva may lead at the time of birth to an erroneous declaration of the sex of the individual, and later on they may disqualify for marriage; the importance of vaginal anomalies usu- ally becomes apparent when labour is in progress; and the structural irregularities of the h}Tnen commonly produce menstrual retention at the epoch of puberty, or interfere with the consummation of the act of coition some years afterward. ]\rALFOEMATIO>rS OF THE VULVA The embryology of the vulva is less clearly understood than that of the uterus; it is in consequence of this that its malfor- mations have not been so completely systematized as have those that affect the uterus. When the changes which take place at the poste- rior end of the embryo in connection with the development of the THE EXTERNAL ORGANS OF GENERATION IN WOMEN II9 ;genital tubercle, the cloaca, and the urogenital sinus, are better known, the anomalies which arise from interference with the normal course of these changes will be more easily comprehended. The complexity of the embryogenesis of the neighbourhood of the Bauchstiel is in- creased by the occurrence of transitory structures or scaffoldings which give place in time to the permanent arrangement of parts, but which may, under certain circumstances, persist more or less completely, and thus give rise to malformations. A good instance of this permanence ■of temporary scaffoldings is found in atresia ani vaginalis. Vulvar Atresia. — Complete absence of the vulva, the skin passing unbroken from the symphysis pubis to the coccyx, is a matter of tera- tological interest solely; on the other hand, apparent vulvar atresia, or atresia vulvce superficialis, has an immediate importance. On account 'of the existence of labial adhesions, there is an apparent absence of the vulvar cleft (Fig. 47). A small opening exists an- teriorly from which the urine issues sometimes "with considerable diffi- ■culty. At puberty trouble may arise through the oc- ■currence of hematocol- pus; but if the opening is large enough to permit the escape of the men- :strual fluid, the discovery ■of the anomaly is post- poned till marriage, when .attemjDts at ]3enetration iDy the husband may suc- ■ceed in breaking down "the labial adhesions or may require to be supple- mented by the knife of the surgeon. It is note- ivorthy that while this :atresic condition may pre- vent coitus, it is not a •complete obstacle to im- pregnation. The treat- ment is simple : some- times the labia can be torn apart, as was done by Jan (Indian Lancet, vol. vii, p. 123, 1896); at other times it may be necessary to pass a sound in at the anterior open- ing (Fig. 48), to direct it Imckward, and then to cut down ujwn it (Coop, Fio. 47. — "On acco\int of tlie existcnc-r nf labial adhe- sions, there is an apparent absence of the vulvar cleft." — Ballantyne. 120 A TEXT-BOOK OP GYNECOLOGY American Gynecological and Obstetrical Journal, vol. vi, p. 594, 1895). When the atresia of the vulva is associated with hypertrophy of the clitoris, doubts as to the sex of the individual may arise. An anomaly closely allied to that just described consists in the existence of preputial and labial adhesions binding down the clitoris. This leads to, or is at least associated with,, nervous derangements, both in childhood and adult life. The freeing of the clitoris from these adhesions may be fol- lowed by the disappear- ance of symptoms, in this respect resembling the effect of circumcision in the male. Infantile Vulva. — In infancy the labia majora are less developed in comparison with the other parts, and the vul- var cleft is consequently more exposed to view; the mons also is but slightly marked, and there is an absence of hair. These infantile characters may persist in adult life. In individuals, showing this persistence, there is commonly also an imperfect develop- ment of the uterus, ovaries, and mammary glands; chlorosis may be pres- ent, and the whole clinical picture may be called infantilism in woman. Double Vulva. — Only three cases (those reported by Le Cat, 1765; Suppinger, 1876; and Chiarleoni, 1891) are on record in which individ- uals, otherwise single in formation, possessed two vulvse situated side by side in the interfemoral space. In two of these there was an im- perforate condition of the anus, the rectum opening into the vulva or into the vagina. A case in which the external genital organs of both sexes were present was reported by Moostakoff in a Bulgarian Journal {Meditzina, p. 32, 1894; abstract by Ballantyne in Teratologia, vol. ii, p. 234, 1895), and a similar instance (Fig. 49) has been described by ISTeugebauer (Monatsshrift fiir Gedurtshiilfe und Gynakologie, Bd. vii, p. 550, 1898). It is probable that in both these latter cases the two sets of organs were really of the same sex, one, however, being so deformed as to resemble the appearance presented by the part of the opposite sex. The corresponding malformation in the male is diphallus, or double Fig. 48. — " It may be necessary to pass a sound in at the anterior opening." — Ballantyne (page 119). THE EXTERNAL ORGANS OP GENERATION IN WOMEN 121 penis, twenty cases of which, including one personal observation, Ballantyne and Skirving {Teratologia, Bd. ii, p. 92, 184, 255, 1895) gathered together and analyzed. Both in diphallus and in double vulva there is good reason to believe that the anomaly is truly a duplication of the lower end of the trunk — that it is, in fact, the least degree of posterior dichotomy. This view is strongly supported by the fact that in several of the cases that have been dissected there has been discovered bifidity of the lower end of the vertebral column as well as duplication of the external genital organs. Ballantyne has reported an Fig. 40. — "A caso in which the external genital organs of both sexes were present." — Ballantyne (page 120). instance of double genital tubercle (without any other trace of exter- nal genitals) in a foetus with exomphalos and sacral meningocele (Transactions of the Edinburgh Obstetrical Society, vol. xxiii, p. 36, 1898). Persistent Cloaca. — Under the various names of anus vulvalis, vul- var anus, atresia ani vaginalis, atresia ani vestibularis, and vulvo- vaginal anus, has been described an anomaly which is really due to the persistence of the cloacal stage of the development of the female gen- erative organs. There is no anal opening in the normal position, but faicos pass from the vagina (Fig. 50). Examination reveals an open- 122 A TEXT-BOOK OF GYNECOLOGY ing, which may be pinhole in size^ in the neighbourhood of the hymen or at a slightly higher level in the vagina; this is the lower end of the rectum. J. AY. Ballantyne has recently had a case brought Tinder his notice by Dr. George Elder, in which, in a girl four months •old, there were two vulvar anal openings between the posterior com- missure and the hymen; there was a dimple where the normal anus should have been. Sometimes, but rare- ly, the anomaly co- exists with a normal anal opening. It is noteworthy that in quite a number of the reported cases there was control over the motions. Under such circumstances the malformation might pass unrecognised till after marriage or the occurrence of labour. When, however, there is fascal inconti- nence, operation be- comes imperative. The time of puberty is that best suited for interference; and it is commonly rec- ommended that a probe be passed in at the vulvar end of the fistiilous tract and brought out at the spot where the anus ought to be, and that the structures be- tween the director and the surface of the perineum be divided and the rectum pulled doAvn and fixed by sutures. Buckmaster {Transac- tions of the American Gynecological Society, vol. xix, p. 275, 1894), however, advises that the rectal canal be brought down in front of the sling formed by the fibres of the levator ani muscle and fastened with- out strain; that a second operation be performed for the restoration of the perineum; and that finally the fibres of the levator ani be split so as to form a sphincter very much as has been done with the rectus muscle in gastrostomy. Persistent TJrog-enital Sinus. — The name hypospadias in woman has been given to the condition in which the urethra appears to open into the vagina at a higher level than is normal (Fig. 51); this is really Pig. 50. — " Tliere is no anal opening in the normal position, but feces pass from the vagina." — Ballantyne (.page 121). THE EXTERNAL ORGANS OP GENERATION IN WOMEN 123 persistence of the urogenital sinus, for what is called the lower end of the vagina in tliese cases is more correctly described as the urogenital sinus. It differs from persistent cloaca in the fact that the perineum and anal opening are normally formed and situated. There " " ^ is a greater or less defect in the posterior wall of the urethra. Clinically, cases of this kind will be grouped ac- cording as there is or is not in- continence of urine. If there is no incontinence, as in the case reported by W. A. Ed- wards (American Gynecological and Obstetrical Journal, vol. vi, p. 449, 1896), the individ- ual may pass through life and even give birth to children without the anomaly being de- tected. But in the other case it will be necessary to operate, and the method of Gersuny may be adopted, as was done with success by Krajewski (Bitner, Przeglad CJiirurgicz- ny, vol. i, p. 260, 1893-'94). The urethra is dissected out up to the neck of the bladder, the slit in its posterior wall is stitched, the canal is then twisted on its long axis, and fixed in position by a series of sutures. Epispadias in Women. — In women epispadias may be met with as a part of the malformation known as extroversion of the bladder, or it may exist practically alone. To the latter condition the name is best restricted. Ballantyne (EdinhurgJi Hospital Reports, vol. iv, p. 349, 1896) has described a case of this kind and gathered together thirty-two others from literature. It consists, as in Dranitzin's case (Journal ATcush., vol. viii, p. 567, 1894), in the absence of a greater or smaller part of the anterior wall of the urethra, Avith the division of the cli- toris into two parts, and the presence of a median groove in the region of the anterior commissure of the vulva (Fig. 52). There is no splitting of the symphysis pubis or anterior bladder wall. It has only one symptom — more or loss complete urinary incontinence — and in its least marked form (clitoi-idian epispadias) even this may be absent. Various plastic operations, resembling those used in hypospadias, have been employed to lengthen and narrow the urethra and to restore the anterior vulvar coiiiinissui-e and eliloi-is; but success has only been occa- FiG. 51. — " The name hypospadias has been given to the condition in which the urethra appears to open into the vagina at a higher level than is normal." — Ballantyne (page 122). 124: A TEXT-BOOK OF GYNECOLOGY sionally obtained, and most often the purely palliative wearing of a urinal has had to be accepted as the sole treatment practicable. Precocious Development of the "Vulva. — In strong con- trast to the cases of infantile vulva are those of precocious development of it, which are occasionally met with. Girls of from two to ten years ex- hibit under these circum- stances a marked growth of pubic hair; the vulva, as in the adult, is strongly devel- oped anteriorly (de Eiche- mond, Revue mensuelles des maladies de Venfance, tome xvii, p. 74, 1899); and the mammary glands may also show hypertrophy. Physio- logically there may be early menstruation or pubertas precox (Hennig, Centralblatt filr Gynakologie, Bd. xxii, p. 832, 1898), and in some in- stances (e. g., that reported by C. W. Gleaves, Medical Record, New York, November 16, 1895) there has been pre- cocious pregnancy. Malformations of the Labia, Clitoris, and Peri- neum. — The anomalies that have been described affect more or less all the structures mak- ing up the vulva, but the single parts may also be malformed. The labia minora or nymphse may be absent, or increased in number, or hypertropMed; the clitoris also may be enlarged so as to suggest doubts as to the real sex of the individual. In many of these cases of hyper- trophy there exist nervous phenomena, which are occasionally miti- gated by excision of the enlarged parts. A curious anomaly of the labia minora has recently been reported by Shoemaker {American Journal of Obstetrics, vol. xxxii, p. 216, 1895); the nymphas were unusually large, and in each there was a congenital circular perforation about half an inch in diameter, and exactly opposite each other. J. W. Ballantyne has described a case of a suspected " hermaphrodite " in which the left nympha was enlarged, pyramidal, and divided into two parts by a constriction (Transactions of the Edinlurgh Obstetrical Society, vol. xiii, p. 185, 1898). Fig. 52. — "Epispadias may lie met with as part of the malformation known as extroversion of the bladder." — Ballantyne (page 123). THE EXTERNAL ORGANS OP GENERATION IN WOMEN 125 Pseudo-hermaphroditism : Masculine. — It is not out of place in a work devoted to gynecology to refer to cases of doubtful sex in which the individual, by reason of his possession of testicles, is a male, but on account of his external organs might quite well be a woman, for such cases usually are brought to gynecologists for treatment. The anomaly most commonly met with under these circumstances is perineo-scrotal hypospadias (Fig. 53). The imperforate penis, often atrophic, re- sembles the clitoris; the ure- thra opening at the base of this rudimentary penis re- sembles the female meatus urinarius at the base of the vestibule; and the short ves- tibular canal, which may even be guarded by a hymen, simulates the vaginal orifice in a very striking fashion. Nondescent or atrophy of the testicles, enlargement of the mammary glands, and the exhibition of acquired femi- nine traits, may all combine to make the question of the sex of the hypospadic male one of the greatest difficulty. When it is added that cases have occurred in which the individual not only possessed a uterus, but also sufEered every month from a san- guineous discharge from it, the discovery of the true sex only after post - mortem microscopic examination of the genital glands can be quite well understood. It must also be remembered that the testicles in such cases often show pathologic changes. In an individual described by P. Delageniere (Annales de gynecologie, tome li, p. 57, 1899), and regarded for twenty-seven years as a woman, the testicles, which were found in the inguinal regions, showed tubules surrounded by fibrous tissue, atrophied, and containing no spermatozoa. In one of the glands there were also several nodules, "adenomata of the testicle." In this case the vulva was absolutely normal, the breasts were those of a girl before puberty, and the thorax was mascuhne in type. 'J'lie abflomon was opened, but no trace was found of uterus or Fig. 53. — " The anomaly most commonly met with is perineo-scrotal hypospadias." — Ballantyne. 126 A TEXT-BOOK OP GYNECOLOGY tubes; the atrophied testicles were removed. If such individuals are seen at the time of birth it is probably best to bring them up as boys, as Lawson Tait suggests, for male pseudo-hermaphrodites are com- moner than females, and there is less risk in bringing up a girl among boys than a boy among girls. At a later age the question of removal of the genital glands (nearly always atrophic or morbid either in structure or position) will require to be faced. C. Martin has removed the testicles from an individual brought up as a girl, with the result or sequence that the pubic hair and the breasts developed {British Medical Journal, vol. i, 1894, p. 1361); but it is doubtful to what extent we are at liberty in these cases to remove sexual glands even when these are in all probability morbid in structure and jDossibly functionally inade- quate. Pseudo-hermaphroditism : Feminine. — The most common form of gynandria or feminine pseudo-hermaphroditism, is that in which superficial vulvar atresia exists in association with hypertrophy of the clitoris. When there is also hernia of the ovaries into the labia the individual may readily be regarded as a male. In all probability, how- ever, doubts will early arise as to the true sex, and a close inspection of the parts, accompanied possibly by some slight surgical interference, will serve to make plain the matter before any harm is done. Malformations of the Vagina The embryology of the vagina is better understood than that of the vulva, and the nature of its anomalies is therefore more evident. Some doubt, however, exists as to the mode of formation of the lower end of the canal and of the hymen. The general view is that the whole of the vagina above the hymen is Miillerian in origin, being produced by canalization of the fused lower ends of the two ducts of Mliller; but Berry Hart (Transactions of the Edinburgh Obstetrical Society, vol. xxii, p. 18, 1897) looks upon it as Miillerian in its upper part only, and as developed from the urogenital sinus in its loAver third by the break- ing down of cells derived from the Wolffian bulbs (lower ends of the Wolffian ducts). ISTagel's investigations, however, do not support Hart's conclusions, and Webster {Transactions of the American Gynecological Society, vol. xxiii, p. 446, 1898) also sums up adversely to them. Nev- ertheless the anomalies of the vagina present features not easily ac- counted for by either of the two theories of origin. Absence of the Vagfina. — Cases of complete absence of the vagina, in which careful examination of the tissues lying between the rectum and the bladder reveals no trace of muscular bands, are of pathological interest solely; they occur only in connection with advanced terato- logical conditions, such as sympodia. Vaginal Atresia. — There may exist a complete or an incomplete imperforate condition of the vagina; between the bladder and rectum there may be found simply a fibro-muscular cord; in other cases the THE EXTERNAL ORGANS OF GENERATION IN WOMEN 127 vaginal canal may be present in part and imperforate in part; and in yet others there may be a membranous septum at the upper^ middle, or lower, third of the vagina. When the lower third of the canal alone is present it is surmised that it is not Mtillerian, but derived from the vestibular sinus; its upper boundary would be composed of the lower imperforate end of the Miillerian vagina, or (if the theory of Hart is accepted) of the persistent Wolffian bulbs. The malformed state of the vagina is commonly associated with anomalies in the other genital organs both internal and external; thus, the uterus may be ill devel- oped or absent, and the Fallopian tubes and vulva may, but not so frequently as the uterus, be defective. On the other hand, the uterus and the other genitals may be normal in structure. Sometimes it is stated that the ovaries are absent, but it must be re- marked that in cases in which the vagina and ovaries are both absent the sex of the individual can hardly be re- garded as female at all. If functionally active ovaries and uterus coexist with im- perforation of the vagina, the supervention of puberty usually leads to the retention of blood, in a more or less altered state, in the uterus (hematometra) or tubes (hematosalpinx), or in the perforate part of the vagina (hematocolpus) (Fig. 54). J. W. Ballantyne has recently seen a case (under the care of Dr. Alexander James in the Edinburgh Infirmary) in which the vagina was imper- forate in a great part of its extent, and in which the uterus was the size of a three months' preg- nancy (hematometra); the patient, a girl twenty-two years of age, had frequently recurring attacks of epistaxis, and a very remarkable fea- ture of the morbid anatomy was the presence of well-marked cervi- cal ribs. ('linically, an impoi-forate condition of the vagina usually begins to attract notice when the indi vicinal reaches the age of puberty. As month after month goes past without any sign of the menstrual dis- FiG. 54. — " The supervention of puberty usually leads to the retention of blood in the perforate part of the vagina (hematocolpus)." — Ballan- tyne. 128 ^ TEXT-BOOK OF GYNECOLOGY charge, but with all the signs associated with menstruation (pain and weight in the pelvis, headache, swelling of the breasts, epistaxis, etc.), the patient^s friends bring her to a medical practitioner. It is then found that the vagina is imperforate and that there is distention in the hypogastric region, and, if the case is kept under observation, it may be noted that this swelling increases suddenly at recurring monthly periods, to diminish again slowly in the intervals. The examining finger passes into the vagina to a greater or lesser distance, accord- ing as the imperforation is high up or low down in the canal, but it never touches the cervix, and by the aid of the rectal touch, with a sound in the bladder perhaps, it can be made out whether the uterus and adnexa are present or not, and whether there is menstrual retention in the uterus and tubes or not. In other cases of vaginal atresia, the first symptoms to lead to medical intervention are those arising at the time of marriage, when coitus is found to be either impossible or incomplete and painful. In these instances the internal genital organs may be functionally quiescent, a fact which accounts for the absence of monthly suffering and for the late discovery of the vaginal anomaly. The intervention of the gynecologist in cases of imperforate vagina may be rendered necessary under two sets of circumstances — at or soon after puberty, for monthly pain and for hematometra and the symp- toms associated therewith; or at the time of marriage for dyspareunia. Under the former circumstances, the object of intervention is to reach and evacuate the retained menstrual blood; under the latter, it is mainly to establish what may be called a coitional vagina by a plastic operation. If the vaginal atresia is situated near the introitus and is localized, then a simple crucial incision will serve to set free the more or less altered blood in the upper part of the canal; the evacuation should be •carried out without haste and strict surgical cleanliness observed. If, on the other hand, the atresia is extensive and the blood accimiulation is far from the surface, very careful dissection will be needed before the cervix uteri is reached. With the sound in the bladder and a finger in the rectum, and using the handle of the knife or probe-pointed scissors, the operator will work upward toward the blood accumulation (whose position has been determined by rectal touch), will incise the sac, and endeavour, with the aid of flaps derived from the labia minora and perineum, to form a vaginal canal. Possibly in the future the method of operating recommended by P. Walton (Belgique medicale, ann. 5, p. 353, September 22, 1898) will take the place of that described above as more speedy and scarcely more dangerous. He makes an H -shaped incision between the labia minora, dissects upward, and at once opens into the peritoneal cavity (instead of avoiding it, as has been the cus- tom) through the pouch of Douglas; he then passes his 'fingers in and ascertains the condition of the uterus and adnexa; the opening in the peritoneum can then be closed with catgut sutures and the construction of the artificial vagina proceeded with. In the case operated upon by THE EXTERNAL ORGANS OF GENERATION IN WOMEN 129 Walton, five mouths had elai^sed since the formation of the canal and menstruation had occurred regularly, although in small amount and with complete absence of suffering. The results recently obtained by posterior colpotomy for other conditions support Walton in his recom- mendation; certainly the operation is greatly shortened, and an accu- rate knowledge of the position and condition of the parts is obtained. It is doubtful to what extent the gynecologist is justified in recom- mending the creation of an artificial vagina when no menstrual suffer- ings exist, and when there is consequently no reason to suppose that functional internal organs are present, for the operation, which is not free from risk, is manifestly being undertaken solely to provide a coitional vagina. Should intervention, however, be decided upon, it will be best to dissect upward in the space between the rectum and bladder to a distance of about two inches, and then to line this in- vagination with tissue obtained from the nymphge and perineum. The cavity will require to be kept open for some time with a cone-shaped pessary. Vaginal Stenosis. — An abnormal degree of narrowness of the vagina may be met with and may affect the whole canal or only a part of it. When the stenosis is general, it probably means that we have to do with a half vagina derived from one Mlillerian duct, the other half being undeveloped, or at least imperforate. Then the condition may be asso- ciated with the uterus unicornis or bicornis (with one cornu rudimen- tary). In other cases the stenosis is annular, and consists of one or more perforated diaphragms, a condition which may have been pro- duced by adhesive colpitis in infancy or in foetal life, but which more probably represents incomplete canalization of the vaginal anlage. Dyspareunia may result at the time of marriage, or delay may occur during the second stage of labour, and the anomaly thus be brought under the notice of the gynecologist. It is usually recommended that a crucial incision be made and the ring stretched; but it will be more satisfactory to adopt the plan advocated by Yineberg {American Gyne- cological and Obstetrical Journal, vol. vi, p. 250, 1895), which consists in excision of the septum and the bringing together with sutures of the up])er and lower margins of the annular incision thus produced. Double or Septate Vag-ina. — The term double vagina should in strict accuracy be applied only to those cases in which there exist two uteri and two vulvar apertures in addition to the two vagina?; such cases, as has been stated already, are exceedingly rare, and must be grouped among the double monstrosities. On the other hand, septate vagina, which is usually named '' double " vagina, is much more common. It is due to want of fusion of the two Miillerian ducts in their lower part; it is not, therefore, an anomaly by excess, but by defect, an arrested development. Tlu; septum generally rims antero-]:)osteriorly, when, of course, the vagina; are situated laterally; rarely, as in a case reported by Forflyce (Teratolof/ia, vol. i, p. 72, 1894), the canals lie one in front of ilie oIIhm' aM(l tlic scpliini is transverse. The septum may be complete 10 130 A TEXT-BOOK OF GYNECOLOGY and may extend from a point above between the two cervices (there are often two vaginal portions, indicating a double uterus) to the vulvar aperture, where it may subdivide that orifice and produce what is called a hymen hiforis; on the other hand, it may exist in the upper part of the vagina alone, or in the lower part alone, or it may show a varying number of perforations. Clinically, septate vagina may give rise to no symptoms till parturi- tion occurs, when, as in a case recorded by Eanieri {Annali cli ostetricia e ginecologia, xvi, p. 473, 1894), excision of the septum may be needed during the labour to prevent laceration of it, which might entail also laceration of the uterus. When, however, one or both halves of the vagina are imperforate (a not uncommon occurrence in septate vagina, Fig. 55) symptoms will arise about the time of l^uberty in association with the retention of blood in one or both canals (unilateral or bilateral hematocolpus). When unilateral, this condition has been called atresia vagince lateralis. Since the retention of blood may cause pain in the back and difficulty in micturition and defe- cation, it will be neces- sary to incise (or better to excise) the sac, clear out its contents, and j)ack Avith iodoform gauze under antiseptic precautions. In all cases in which an elastic swell- ing is found in the vag- inal wall, the possibil- ity of its being an im- perforate half vagina communicating with a functionally active half ^ Fig. 55.-"Both halves of the vagina are impel- ^^^"^""^ '^°''^'^ ^® ^°™® " forate."— Ballantyne. in mind. In a case seen by Muret (Revue medicale de la Suisse romande, p. 280, May 20, 1895) the better devel- oped half was imperforate and the more rudimentary one was patent. Sometimes the imperforate half communicates with the patent by means of a small opening, when dysmenorrhoea may exist without com- TPIE EXTERNAL ORGANS OF GENERATION IN WOMEN 131 plete menstrual retention. In Fordyce's case {he. cit.) both halves opened into the urethra. The Hymen. — This structure, which marks the dividing line be- tween the vulva and the vagina, has been carefully studied by Schaeffer in nearly two hundred foetuses. He found, without exception, that as early as the fifth month the hymen was composed of two lamellse, the inner being derived from the vagina, while the outer appeared to be the inner margin of the vulvar fold; and that coalescence of these two layers was not infrequent. On the vaginal surface of the hymen were found transverse folds, similar to those in the vagina, between which were pockets so distinct that, in the event of their occlusion, they could easily be converted into retention cysts. Irregularities in the distri- bution of these folds account for those anomalies of the hymen which are spoken of under the names of hymen crenulatus, dentatus, carinatus, falciformis, etc. On the vulvar surface of the hymen in the foetus, he found numerous folds extending from the fossa navicularis, nymphse, clitoris, and meatus. If these observations meet with sufh- cient confirmation, it may be necessary to revise accepted theories of the embryologic development of this structure. At present it is looked upon as a remnant of the cloacal appendage. In the human embryos shortly after the coalescence of Miiller's ducts it manifests itself by an accumulation of epithelia on the posterior wall of the rudimen- tary vagina. Whether it develops entirely from the vulvar side or entirely from the vaginal side, or, as is more probable, in two lamellae, one from either side, is a matter of no practical importance. To the naked eye it presents the appearance of a mucous fold that in many instances is very elastic. The elasticity of this structure is so pro- nounced in a number of cases that it withstands repeated parturition. Microscopically, its surfaces are shown to be covered with flat epi- thelium on a network of fibrous elastic tissue, containing few or no muscular fibres. Capillary vessels and nerves are conducted by nu- merous papillse from the central connective tissues into the epithelial structures. Malfokmations of the Hymen The hymen is a developmental relic, and is, therefore, very liable to variations in form and structure. It arises from the breaking down of the tissue between the sinus urogenitalis and the lower end of the Miillerian vagina, and it is possible, as Hart asserts, that the Wolffian bulbs may contribute to its formation. In addition to the well-known part of it which forms a crescentic fold at the posterior end of the vulvar aperture, the hymen consists of a mesial band running forward toward the clitoris, and forming a collar for the meatus urinarius on the way. Attention was specially drawn to this forward extension of th(! liymen by Pozzi (A'tmales de f/yneeolof/ie, tome xxi, p. 257, 1884), and J. W. liallantyno has described the appearances presented by the mesial vestiltiiliic \)',u\(\ in rcinulo infants (Fig. 56) (Transactions of the Edin- 132 A TEXT-BOOK OP GYNECOLOGY fe!K durgh Obstetrical Society, vol. xiii, p. 188, 1888). x\nomalies may be met witii in the vestibular portion as well as in the hymen commonly so- called, and even a dis- tinct projection may exist (Fig. 57). Hymenal Atresia or Imperforation. — It is ex- tremely probable that many of the cases de- scribed as instances of imperforate hymen are really examples of atresia of the lower end of the vagina, for in some of the records the presence of a hymenal membrane hidden by the projecting vaginal sac is referred to. On the other hand, nn- donbted cases of atresia hymenalis do occur. Tlie imperforate condition of the membrane gives rise to symptoms which can scarcely be distinguished from those of atresia of the lower part of the vagina. During infancy some trouble may be caused by the retention of mucus in the canal, but it is usually not till puberty that the condition attracts notice. Every month, colicky pains recur with increasing severity; there is some difficulty with micturition and defecation, which passes off in the intermenstrual period; there may be epistaxis or vicarious hemorrhage from the bladder or bowel; but there is no discharge from the genitals. Examination of the patient at one of these epochs will reveal a fluctuating tumour i^rojecting to a larger or smaller extent above the symphy- sis jDubis, according as the condi- tion has been persisting for a longer or shorter time; and in the vulva will be seen a bulging membrane, which is the distended hymen. The HOPKINS' Fig. 56. — " The appeunmces presented by the mesial ves- tibular band in female infants.'' — Ballantyne (p. 131 ). Fig. 57. — "Even a distinct projection may exist" (section). — Ballantyne. THE EXTERNAL ORGANS OP GENERATION IN WOMEN 133 condition of hematocolpus, which has been thus produced, may be ac- companied by the accumulation of blood in the uterus also (hemato- metra). F. Neugebauer {Medycyna, vol. xxi, p. 429, 1893) has recorded an unusual case of hymenal imperforation without menstrual retention, the blood escaping through a small opening at the right side of the urethra; the hymen is described as consisting of two lamina (hymen hilamellatus) , an external incomplete and an internal complete, so that it is likely that the internal one was really the lower end of the imper- forate vagina. The first step in the treatment of hymenal imperforation consists in the evacuation of the retained menstrual blood. The membrane is incised and the fluid removed under antiseptic precautions, the latter being specially necessary if the uterus and Fallopian tubes have shared in the distention. The remnants of the hymen are then excised, and the edges are brought together with sutures. The cavity is jDacked with iodoform gauze. The removal of the more or less altered blood should be done slowly. Double Hymen. — The cases in which two (or more) diaphragms exist near the vaginal outlet should not, perhaps, be regarded as in- stances of double hymen, but rather as examples of annular vaginal stenosis. JSTeither does the existence of two openings in the hymen con- stitute a double hymen in the strict sense of the words. The term ought to be left for the very rare instances, to which reference has already been made, in which two vulvae exist side by side in the inter- femoral region. Absence of the Hymen. — The hymen is rarely completely wanting except in connection with absence of all the external genitals, as in some marked forms of monstrosity; but it may be apparently absent, being hidden from view by the bulging lower end of an imperforate vagina. In the newborn infant, it is folded together and projects from the vaginal orifice as two lateral folds, which may be taken for the labia minora. In the negro infant, it is deeply seated, and may in con- sequence be thought, on casual inspection, to be absent. Anomalies in the Form of the Hymen. — Instead of its normal cres- centic form, the hymen may be circular (Fig. 56), or notched (denticu- late), or projecting (infundibuliform), or fimbriated. Instead of bound- ing one orifice it may show two openings, which may be equal in size and situated laterally (Jiymen septus), or unequal in size and situated irregularly {hymen Ufenestratus); in rare cases there may be several openings (Jiym^en crilriformis). J. W. Ballantyne recently met with an instance of very complete hymen septus in an unmarried woman of forty upon whom he was operating for hemorrhoids; the openings were perfectly equal in size, and the septum, which was quite fleshy, extended for some distance up the vagina; the uterus was single, as was also the w])])('A- pMPt of the vagina. Anomalies in the Structure of the Hymen. — 'I'lu; hymen, especially in I'Mcrly |iriini|)ar'a', iiuiy he v<'iy tough and resistant; it may on this 134 A TEXT-BOOK OF GYNECOLOGY account delay tlie dilatation of the perineum in labour; it may even prevent the consummation of marriage, and require to be excised, as in a case seen by J. W. Ballantyne (Transactions of the Edinburgh Obstetrical Society, vol. xiv, p. 1-11, 1889). If it is very vascular, as well as very tough, the laceration it undergoes in coitus may cause alarming hemorrliage. Anomalies in the Anterior Extension of the Hymen (Urethral Hymen and Vestibular Band). — Gilliam has described two cases of what would see]u to be a persistence of the anterior extension of the hymen, which surrounds the meatus urinarius like a collar. In one of these, that of a girl of eighteen, suffering from incontinence of urine, there was an anomalous band attached to the urethra and spreading itself over the muscles of the anterior aspect of the vulvo-vaginal junction; it was clipped, and the incontinence disappeared at once. In the other case, that of a girl of twenty-one, also suffering from urinary inconti- nence, a membrane stretched from the anterior segment of the hymen and was attached like wings to the sides and under surface of the urethra; its excision gave a cure. Gilliam (American Journal of Ob- stetrics, vol. xxxiii, p. ITT, 189G) thinks that these bands set up local irritation. CHAPTEE XIV INJURIES OF THE EXTERNAL GENITAL ORGANS Injuries of the vulva from external violence, sexual intercourse, parturition — Pu- dendal hematocele — Injuries of the vagina: Rupture — Fistulae: urethro-vag- inal, vesico-vaginal — Sims's operation — Ross's operation — Reed's operation — After-treatment and dangers — Atresia of upper part of urethra — Uretero- vaginal fistulte — Recto-vaginal fistula — Mayo Robson's operation. Injueies of the external organs of generation may, for convenience of study, be classified into those involving (a) the vulva, and (&) the vagina. On account of the anatomical position of the vulva, which is protected above by the mons veneris and the underlying hard and resisting symphysis pubis, the descending rami, and the inner aspect of the thighs, injuries to this structure, except when due to parturition, are necessarily rare. The vascularity of the tissues composing the vulva predisposes the structure to profuse hemorrhage, so that, should there be a solution of continuity of the skin, the loss of blood may be considerable, even amounting to syncope in weak and debilitated individuals. In considering these injuries the anatomical construction of the surrounding and underlying parts must be borne in mind. The rami of the pubis possessing a rather sharp inner edge, a blunt instrument may be used, and yet an incised wound may be the result, the blunt object forcing the overlying soft structures against the ramus. Con- tused rather than incised wounds are, however, the rule. In instances in which the skin is not divided, hemorrhage into the abundant connective tissue here found results in hematoceles of vary- ing sizes, according to the size and number of blood vessels injured. The causes of these injuries to the vulva may be considered under three headings — viz. : (a) External violence, (&) coitus, (c) parturition. External Violence. — The patient may fall astride the back of a chair, as in the case of servants engaged in cleaning windows, hanging curtains, and pictures; or in the case of the female bicyclist being thrown from the saddle and alighting on the iron frame or handle bar. Eoss, of Toronto, reports {American Journal of Obstetrics, April, 1898) a case in which a woman, while riding her wheel, was thrown from the saddle, and alighting on the sharp portion of the frame, tore the geni- talia upward as high as the erectile tissue near the clitoris, producing copious hemorrhage. Hemorrhage from the vulva may be fatal even 135 136 A TEXT-BOOK OF GYNECOLOGY when induced by a relatively slight injury. Ford {New YorJc Medical Journal) reports a case of hemorrhage resulting in death in a patient who, while at the theatre, in attempting to change her seat, fell against the iron partition between the chairs, inducing a lacerated wound, about a third of an inch in diameter, between the clitoris and the labium minus. If the injury to the deeper structures is induced by pressure against the ramus of the pubis and does not result in severing the continuity of the skin, the resulting hemorrhage takes the form of a hematocele. (See Pudendal Hematocele.) Among other Avounds of the vulva are those produced in children while at jjlay: A fall upon a picket fence; splinters of wood being forced into the labia while sliding upon the floor or down an incline; and falls from sleds while coasting, etc. Injuries to the vulva by sexual intercourse, aside from slight lacera- tions of the fourchette, are of very rare occurrence, except in cases of rape of children and of women of advanced age. In the former they are due to the tender and undeveloped soft parts, and in the latter to senile atrophy and consequent want of elasticity. These lacerations generally involve the hymen in the young and the fourchette in the aged, and extend thence in various directions. Baldy reported {American Gyne- cological Journal, 1891) a case of laceration due to first intercourse, the injury beginning at the hymen and extending upward on the vaginal aspect of the perineum. Spaeth records a case {American Journal of Obstetrics, 1890) of laceration beginning at the vulvar orifice, extending upward along the posterior wall of the vagina, causing a vesico-rectal fistula. Parturition is by far the most frequent cause of injuries to the pudenda. (See Pudendal Hematocele.) Here also the perineum suf- fers the greatest injury. Contusions of the labia, and sometimes of the vulvo-vaginal glands, are due, in the majority of instances, to a failure of the head to rotate into the conjugate diameter of the outlet of the pelvis. Not infrequently also does the careless use of the forcejDS cause lacerations and contusions of these parts. Treatment. — The treatment of injuries of the pudenda does not dif- fer greatly from that of like injuries inflicted elsewhere. The parts should be well shaven, washed, and antisepticized, and lacerations and incisions sewn up. If contusions only are to be dealt with, the carbolic pack is applied. This dressing is prepared in the following manner: Flakes of absorbent cotton are first saturated with a 1- or 2-per-cent solution of carbolic acid, then squeezed out almost dry and applied to the antisepticized injured |)art. Over this are applied flakes of dry cotton, and the whole is covered with rubber tissue or oil silk. The dressing is held in place by a properly adjusted T-bandage. A dressing thus applied will last from six to ten hours. Further treatment is given in the section relating to Pudendal Hematocele. Pudendal hematocele may be the result of a blow, a kick, or a fall; or, in the joregnant state, of varices preceding labour, the INJURIES OP THE EXTERNAL GENITAL ORGANS 137 pressure of the descending head, or the unskilful use of forceps. M. A. Tate, of Cincinnati, who has conducted a painstaking research on this subject {Lancet-Clinic, October 17, 1896), finds that it was first mentioned by Kueff', of Zurich, in 1647; in 1734 by Kronauer, of Basle; and again, a hundred years later, by Deneaux, from which date (1830) reports of cases have been relatively more frequent. \^1ien it occurs, from whatever cause, the clot generally forms in one labium, although in certain cases its progressive accumulation results in sepa- rating the connective tissue of practically the entire pudendum. The tumour thus formed may therefore vary in size from very small to very large, Cazeaux reporting one case in which the extravasation was so extensive that it ploughed up the abdominal wall of the right side to the costal margin. Occasionally the rupture occurs in the wall of the vagina, and only reaches the vulva by an extension of the accumulation, while in other cases the hematoma is confined to the vaginal wall. Sometimes, the distention becomes so great that the skin or mucous membrane gives way and the blood clot escapes. If the hematocele is the result of rupture of an artery, the hemorrhage resulting from the breaking down of the skin may become active, even after the clot has been in situ for a number of days. In small accumulations the clot may be absorbed; in others, where the pressure of the integument is very great, or where the contusion has been extensive and severe, gan- grene may result. In occasional cases the clot may become solidified, even to the extent of calcification. The symptoms of pudendal hemato- cele consist of swelling of the labia, with |)ain in the parts, which, even in the midst of the pains of labour, is generally sufficiently severe to attract the attention of the patient. The tumour increases rapidly in size and at first is usually without any change of colour in the skin, but later becomes pinkish and bluish, and finally, when absorption is well under way, it becomes brown or bronzed in appearance. This tumour is generally at first very tense, but later, as absorption, or sup- puration takes place, becomes softer and more fluctuating. Its forma- tion may be attended with some shock, corresponding in degree to the severity of the causative injury or the amount of the extravasated blood. The rarity of this complication of labour, says Sasonofl^ (Archives de gynecologie, November, 1884), will be appreciated when it is remembered that Winckel noted only one case out of 1,600 confinements; Hecker, two cases out of 17,200; Spiegelberg, three out of 3,000; and that, at the St. Petersburg Maternity, there have occurred only eight cases out of 19,396 labours. Generally, then, it may be said that this complication occurs but once in 2,375 labours. The prognosis of these cases, so far as life is concerned, is favourable, and hematocele is rarely, if ever, fatal from the loss of blood, unless there is secondary rupture, when the subcutaneous extravasation becomes converted into a free hemorrhage. These injuries, however, are in many instances associated with enough superficial destruction of tissue to serve as an infection air-iiim, witli the rfwiilt that the underlying clot is 138 A TEXT-BOOK OF GYNECOLOGY yery liable in the course of the next few days to become converted into a culture medium for the propagation of pyogenic bacteria. As a com- plication of labour, pudendal hematocele is looked upon by both Play- fair and Cazeaux as very serious. Tate (loc. cit.) has collected cases of pudendal hematocele occurring as a complication of labour as follows: Cases. Fatal. Playfair (collected by various French authors). . Scanzoni 124 15 62 22 19 50 44 1 Deneaux 22 Barker 3 Blot 5 Winckel 6 Total 292 81 It must be remembered, however, that in explaining the mortality of 81 in a total of 292 cases from an accident intrinsically so controlla- ble as pudendal hematocele, an important percentage of these cases occurred before the inauguration of the present antiseptic regime. It is true that of these cases, but three, those reported by Barker, were recorded as having died from sepsis; but this fact does not exclude the extreme possibility that an important number of the remaining deaths occurred from the same cause. The treatment should vary a little according as the hematocele is the result of external violence or of parturition, and according to the size of the clot. If external violence is the cause, and if the clot is large, and has developed, or is developing, with rapidity, there is strong probabil- ity that it is being fed by a severed artery, under which circumstances the patient should be anaesthetized and the bleeding points found and ligated. If, however, the clot has formed slowly, and is not large, it should be treated with rest and the application of ice bags. If, after a few days, the tumour becomes red about its circumference and the pain, of a pulsating character, shows a tendency to increase, and if there is some elevation of temperature, the clot may be considered to be the seat of incipient suppuration and should be freely incised, its cav- ity thoroughly cleansed, first with the hydrogen peroxide, and next with a l-to-2,000 mercuric bichloride solution. If a hematocele occurs as a complication of labour, rather more chances should be taken to secure its absorption; as a free incision in the presence of the probably contaminated lochia may be far from an innocent procedure. It should be remembered that there exists the reciprocal danger of liberating into the vagina, or, at least, about its orifice, pathogenic bacteria that have developed in the pus of a suppurating hematocele. A pudendal hematocele in a parturient case should, therefore, be opened only in the presence of the most positive indications, after which its treatment should be conducted on lines of the most rigorous and persistent antisepsis. INJURIES OF THE EXTERNAL GENITAL ORGANS 139 Injuries to the external genital organs due to parturition, aside from pudendal hematocele which has just been considered, occur in (a) the perineum (see Pelvic Floor and its Injuries), and (6) the vagina. Of the injuries to the vagina, the chief ones are rupture and fistulse. Injuries of the Vagina. — Eupture may occur at any place, although it is more common in the posterior than in the anterior wall. Such lacerations have occurred through the vault of the vagina into Douglas's cul-de-sac and through the recto-vaginal septum. They have occurred also in the fornices, splitting up the broad ligament and causing dan- gerous hemorrhage, by severing the important blood vessels that lie upon either side of the vaginal tract. Wlien these lacerations occur, they should be immediately cleansed, and the usually contused and roughly lacerated margins of the wound pared off and approximated by interrupted nonabsorbent sutures. Many of these lacerations pass without recognition and heal spontaneously by the formation of irregu- lar cicatrices which narrow the vagina in an irregular way, causing dyspareunia and other distressing symptoms. Enpture of the vagina is to be looked upon as a tear due to the joint influence of an expansive force and to the inelasticity of the canal. It may result in the formation of a fistula, but a rupture is to be distinguished from a fistula in the particular, that while a tear is caused as already indicated, fistula is generally the result of prolonged pressure and subsequent necrotic changes. Fistulse. — A fistula is an unnatural channel that leads from a cuta- neous or a mucous surface to another free surface, or that terminates blindly in the substance of an organ or part. The edges of such open- ings are covered with epithelium. The forms of fistula that are met with in the female genital tract are urinary and fgecal. Urinary Fistulce. Fcecal Fistulce. Urethro- vaginal. Recto-perineal. Yesico-vaginal. Eecto-vaginal. Vesico-uterine. Entero-vaginal. Uretero- vaginal. Uretero-uterine. Urinary Fistulse (Urethro-vaginal, Yesico-vaginal). — The variety most commonly met with is the vesico-vaginal (Fig. 58). It sometimes happens that a fistula exists between the bladder and the vagina, and, at the same time, that the urethra has been partially or totally de- stroyed. A vesico-vaginal fistula may vary very much in size. At times it is so large that the mucous membrane of the bladder prolapses through it and the bladder is almost turned inside out. The mucous membrane is easily recognised by its bright-red colour. At other times the fistula is only large enough to admit a small probe. The nearer to the 1iiii(; at which the fistula was caused, the larger is the open- ing. Tlic oiicnitigs Hint ai'O at first large gradually contract and 140 A TEXT-BOOK OF GYNECOLOGY close. It is then difficult to say how large the opening may have been originally. The cicatrix that is formed is generally thin and firm. When the urine discharges freely from the bladder after the formation of a fistula, contraction of the bladder, with thickening of its walls. Fig. 58. — "The variety most commonly met with is the vesico-vaginal." — Eeed (p. 139). ensues. The urethra may be contracted on account of its inactivity. The vagina around the edges of a fistula is sometimes firmly fixed to the bone. In this way the edges of the fistula are drawn apart. Vesico- uterine fistulcp are rare. They can only be recognised after the uterine canal has been opened up. Ureter o-vaginal fisttdce are situated in the fornix vaginae. They are small and admit only of the entrance of the point of a sound. They open at the point of a small papilla or else have very sharja edges. The etiology of urinary fistulaB in general must take into account the element of pressure, the duration of which, rather tban the in- tensity, determines the injury. Sometimes the surgeon produces a fistulous opening for the relief of chronic cystitis, or for the removal of a stone from the bladder, or the bladder may be accidentally wounded during the performance of the operation of hysterectomy. Ulcerations of the bladder may occasionally produce perforation of the septum, and are sometimes a consequence of the presence of a vesical calculus. A pelvic abscess may open in such a way as to give rise to a urinary fistula, which may be induced also by foreign bodies, such as the long-contin- ued use of a pessary in the vagina. Injury received during labour is generally looked upon as the most frequent cause of these fistulous open- ings. Such a condition may be produced by a tear through the septum, or, as is most commonly the case, a necrosis is produced by pressure dur- INJURIES OF THE EXTERNAL GENITAL ORGANS 141 ing tedious delivery. Whatever may cause a difficult labour, may, there- fore cause a fistulous oj^ening between the urinary and the genital tracts. It is not necessary to dwell upon these conditions, as they are well known. Cuts that will give rise to fistulous openings may occasionally be produced by the use of instruments in accomplishing delivery. Such cuts usually occur in the lower part of the vagina. The forceps is no doubt more frequently blamed for the production of fistulous openings than it should be. It is generally used in difficult labours; that is to say, those in which there is long-continued pressure on the soft parts. We may conclude, therefore, that the fistulous open- ings are due to the long-continued pressure in such cases and not to the use of the forceps. They may be due to the nonapplication of the forceps. Fistulous openings have been produced, sometimes, as a consequence of cuts made by splinters of foetal bones during the performance of the operation of craniotomy. Malignant disease frequently causes fistulous openings, not only into the bladder, but also into the rectum. Nothing can be done by surgical means to alle- viate the sufferings of these poor unfortunates, and such cases need not be considered here. A calculus is frequently formed in the vagina as a consequence of the presence of a vesico-vaginal fistula. The symptoms of urinary fistulse in general demand careful consid- eration. When a patient complains of an involuntary flow of urine, an examination should always be instituted, to ascertain the reason why siich an abnormal condition exists. After labour, the patient may be discharging the urine naturally, or she may be unable to pass it, and it may be retained in the bladder, and yet, within a few days, there may be an involuntary flow of urine due to the presence of a vesico- vaginal or one of the other forms of urinary fistulse. The pressure at the time of labour produces the necrosis, and the formation of the opening is delayed for several days until the slough separates. If the opening is caused by a tear, urine will fiow at once per vaginam.. The symptoms vary according to the situation of the fistulous open- ing. When situated high up, the bladder fills up to the level of the fistula, if the patient is in the erect posture, and there is no leak until the urine reaches so high as to overflow. When there is a urethro- vaginal fistula, the bladder may be able to hold the urine, and yet the urine will not come out through the normal opening. The patient's clothing in these cases is not kept wet. The odour produced from the urine becomes unpleasant to the patient and friends; the skin of the adjacent parts becomes excoriated, red, and irritated. Sterility is usually produced, although there have been cases of conception re- corded. The patient feels disagreeable to herself and to others. The general health frequently becomes considerably impaired, and the pa- tient is always ready to submit to operation if any promise of relief can be given. Tlie tlia/ivosis iinist be rrijidc between these flstiila^ and certain con- ditions of ilie bbiddci' llial nllow Ihf e.sca])(' of ni'ine. One of these 142 A TEXT-BOOK OF GYNECOLOGY conditions is a paralysis of the sphincter vesicae muscle, due, fre- quently, to difficult labour, and rendering the patient unable to hold her water. It may remain in the bladder while the patient lies in the recumbent posture at night, but when she rises to the erect pos- ture it comes away and wets her clothing. The irritated appearance of the genitals, and the characteristic odour, indicate that there is a fistula. To be satisfied of this, it is a good plan to inject sterilized milk, or a coloured nonirritating fluid, into the bladder. Any fluid escaping from the bladder can then be more readily detected on ac- count of its colour. This method is one of the best in vogue. Some- times the opening can readily be detected with the finger. When the milk is being used, it is better to have the patient turned on her left side with the Sims speculum in position. All discharge must be wiped away from the vagina in order that the field to be inspected may be in a cleanly condition. As the bladder is distended, we must carefully watch the anterior vaginal wall for any oozing of the stained fluid. If no fluid comes away, we must infer that the opening is below the sphincter, or that no opening exists. If no special leak occurs during the act of micturition, we must then conclude that the leakage of urine is not due to the presence of a urinary fistula, but is due to some other cause. In considering the prognosis, it is well to bear in mind that sm'all fistulse sometimes heal without any surgical intervention. Many of the small fistulse, however, and all of the large ones, require operative treatment. The prognosis is not so favourable for cases in which the connective tissue of the urethro-vaginal and vesico-vaginal fold is bound down to the bony parts in the neighbourhood. If this condition is present, it is difficult to approximate the edges without great ten- sion being placed upon the stitches. Treatment. — Eecently formed fistulous openings have a tendency to close. This tendency is one of the difficulties met with in attempting to keep up free drainage from the bladder by means of an artificially produced vesico-vaginal fistula for the treatment of chronic cystitis. Such fistulous openings will often close if they are kept clean and anointed with a little vaseline or zinc ointment, and if the bladder is kept washed with boric acid or sodium biborate (3J to Oj) solution, to remove the incrustations that are liable to form at the edges of the fistula. Operations on such cases are difficult. We must be able to reach the fistulous openings, and we must be able, when we have reached them, to bring the edges carefully together with sutures. There are two positions in which the field of operation may be brought into view. One is the position on the left side with the Sims speculum, and the other position is that in which the patient is placed on the abdomen with the knees hanging over the end of a structure raised up in the centre of an operating table. To use the latter position, Eoss proceeds as follows: The head of the patient should be lower than the buttocks, and therefore different-sized boxes should be used, carefully padded and INJURIES OP THE EXTERNAL GENITAL ORGANS 143 covered with pillows, placed upon the operating table, unless one is fortunate enough to obtain the use of a Bozeman's table. The patient's head is made comfortable, her arms are allowed to hang down on either side, parts under the chest and abdomen are carefully padded, a pillow is inserted under the crests of the ilium where they impinge upon the newly constructed platform, and great care is taken to see that the knees do not touch the table below. If the knees are allowed to press for any considerable time on the table while the patient is under an anaesthetic, sloughs may be produced that will be very tedious to heal. A rubber sheet is placed in. such a way that the water that is being used in a constant stream from the " douche can " or " bag " is con- ducted to a foot bath at the end of the table. An assistant then stands on one side of the patient and holds the Sims speculum, or some modi- fication of the same, in position on the posterior vaginal wall. The operator may use the German water speculum for this purpose. It is not easy for the angesthetist to give the angesthetic while the patient is in this position unless the pillows are properly arranged. Sims pared the edges of the fistula in such a way as to avoid the mucous membrane of the bladder. He brought together the edges of the fistula with silver wire, without allowing the stitches to pene- trate the mucous membrane. Other operators have not done this, but have cut directly through, paring all tissues evenly, and bringing the edges evenly together with sutures passing through the mucous mem- brane, as well as through the vesico-vaginal tissues. Others use the flap- splitting method in order that they may be able to make use of the larger wound surface thus produced in the healing process. Any of the three methods will answer if certain important details are carried out. The approximation must be exact and thorough; the stitches must be inserted far enough away from the edges to enable them to give the proper amount of support; precautions must be taken to prevent any contamination of the wound by urine, or other septic material, and heal- ing by first intention must, if possible, be procured. Each case must be individually considered. If the rules that are well-known to govern the healing process in this locality are adhered to, success will follow; if these rules are not adhered to, success will not follow the operation, no matter which operator's method is em^Dloyed. In every ease of vesico-vaginal fistula it is advisable to examine for vesical calculus before closing the fistula. It is not wise to operate at too early a period after the formation of the fistula. The tissues must be allowed to contract to their utmost extent and to regain their natural condition after the softening that is produced as a result of pregnancy has disappeared. Unless this is done, they are too friable and too easily torn to stand the strain of stitches. It is not wise to attempt to operate for at least eight weeks after con fin cm out, nor is it wise to do a second operation until at least a moritli oc six vvcclts kept in mind. Jiemember frequency of simulation and false accusations. IQQ A TEXT-BOOK OF GYNECOLOGY A. Examination of Victim. — General condition — scrofulous, lym- phatic. Local condition (examine on table or couch in a good light). Condition of thighs and abdomen — scratches, bruises, and nail marks. Labia majora and minora, clitoris for redness, excoriation, ecchymosis, ulcers. Vestibule and vagina (open and close thighs to squeeze out liquids). Hymen — position, form, margin, orifice, folds; defloration by penis, finger, or foreign body (assistant to draw forward labium on one side while expert does the same). Discharge — physical character, amount; microscopic, examine for semen and gonococci. Signs of mas- turbation — elongated lesser labia, large turgescent clitoris, dilated vagina, pigmentation, precocious puberty about vulva, hair, and breasts. Examination of anus and perineum. Suspicious stains on body or clothing, especially chemise or drawers. Place under seal, noting date. Examine by Florence reaction and for spermatozoa; also for evidence of other origin of stain. Absence of spermatozoa not final. B. Examination of Accused. — Physical condition, strength, cuta- neous diseases. Clothing torn. Injuries, showing resistance. Sexual organs — size and appearance. Peculiarities, tattooing, hernia truss. Stains of blood or semen about person or clothing. Urethral discharge {look for semen if seen very promptly). Chronic purulent discharge. Alleged impotence. Mental condition as to sanity or full responsi- bility. Conclusions. — A. (1) Has the person been the victim of rape or sex- ual assault? (8) How has the assault been made? (3) Has there been perineal coitus or intromission of the penis or finger? (4) Is there red- ness, contusion, or laceration of the parts or defloration? (5) Has any ■disease been communicated? Is such disease syphilitic? (6) It will be necessary to re-examine in days to note progress of wound. B. (1) Does accused show traces of recent or old venereal disease? '(3) Is such disease of same nature as that found on victim? (3) Are there traces of a struggle or of suspicious stains? (4) Is accused sub- ject to bodily infirmity making coitus impossible? (5) Is his mental ■condition normal or otherwise? Indecent Assault. — In a large proportion of cases the victim is usu- ally a little girl under ten years. The attempt is most often made with the finger. As a rule, the signs of a struggle are absent, and on this account the establishment of direct proof is often impossible. The local evidences are usually slight inflammation and reddening with or without laceration of the hymen. A slight discharge often follows. The method of examination is the same as in cases of rape. In such cases care must be taken to exclude local conditions, which frequently cause spontaneous vulvo-vaginitis in children. The pres- ence of the gonococcus is significant, but the possibility of infection from other children or from members of the family must be borne in mind. Evidences of masturbation, such as an elongated or turgescent cli- INJURIES OF THE EXTERNAL GENITAL ORGANS Id toris with pigmented labia, should be looked for. The pigmentation is usually unilateral. It must be borne in mind that children are naturally mendacious, and may either originate a story of assault themselves, or accept one suggested to them by their j^arents, or by leading ques- tions put to them by their parents, or by leading questions put to them in the course of the medical examination. Fournier's classical advice to medical men charged with the inves- tigation of these cases, that one should close his ears and open his eyes, is to be kept constantly in mind. Another excellent rule is to refuse to give a medical certificate to be used by the friends of the plaintiff as the basis of the case. The civil consequences of injuries to the female genital organs have been but little studied or described. C. Thiem was the first to sys- tematize and collate our knowledge on the subject, and since then a fair number of observations have been recorded. The disabilities resulting from injuries may be classified as follows: G-ynecological effects of injury in relation to disability and claims for damage. The effects of accident and injury upon the female genital organs may be classified as follows : 1. Malposition of uterus due to accident. 2. Injury to perineum and vagina. 3. Injury to vulva. 4. Injury to uterus. 5. Injury to uterine appendages. Occasionally the injury may be the sole cause. More often it may act by aggravating existing disease. It is important to remember that the condition must be shown to arise from a single act of traumatism or overexertion, to be considered as the effect of accident. There is no evidence to show that retroversion of the nonpregnant uterus, or that anteversion, or anteflexion, or retroflexion, is ever primarily a result of accident in healthy ^^ersons. Any of the above malpositions, if already existing, may be, however, aggravated by falls, or contusions of the pelvic region. Prolapse. — A number of cases are reported by Thiem and others where prolapse has followed accidental straining and heavy lifting. The proof needed to establish this, is sudden and painful onset with swelling, oedema, and tendency to inflammation of the prolapsed parts. This should immediately follow the alleged accident or should produce a certain amount of immediate disability. A thickened or smooth con- dition of the prolapsed portion, with signs of ulcers from attrition, and ease of reposition, should readily enable old cases to be excluded. It may be assumed that prolapse only occurs as a result of accident in per- sons locally predisposed to it. The amount of disability (loss of earning power) in the labouring classes is from ten to tweifty-five per cent, according to the success with whicli rc))osition by supports can be main- tained. Operation can not 1je insisted upon if o]jj(;cted to. The 12 162 A TEXT-BOOK OF GYNECOLOGY aggravation of an existing prolapse by accident may also require com- pensation. Injuries to the perineum and vagina occur usually through falls in a straddling position or from impalement; they generally leave no per- manent disability if the immediate effects are recovered from. Lacera- tion of the posterior vaginal wall is the most serious lesion. Indirect laceration from forcible separation of the thighs during falls has been observed. The effects are, of course, most serious when this occurs in pregnant women. In injuries of the vulva and vaginal orifice, hematoma is the com- monest result of injury. It leaves no permanent disability. Tumours of the vulva have not yet been recorded as the result of a single injury. Uterus. — The nonpregnant uterus is only liable to injury in con- nection with some very severe violence, such as fracture of the pelvis; but when enlarged from tumours or pregnancy it becomes exposed to external trauma; interruption of pregnancy, if such exists, is liable to occur, but often does not. Cases of pelvic hematocele from trauma have been reported, but in those cases where metrorrhagia ensues, the existence of pregnancy is. extremely probable. The abdominal hemorrhage from ruptured tubal pregnancies is practically never due to trauma. Torsion of the pedicle of ovarian tumours was found by Thornton to be traumatic in 16 per cent of six hundred cases. Laceration and hemorrhage of ovarian tumours from contusions of the abdomen have been observed. Hydrosalpinx and pyosalpinx never arise from trauma. CHAPTEE XVI INFECTIONS OF THE EXTERNAL GENITAL ORGANS Preliminary remarks — Vulvitis and vaginitis — Bacteriology of the external genital organs — Mixed infections — Gonorrhoea — Extirpation of the vulvo-vaginal glands — Tuberculosis; vulva; vagina — Erysipelas — Erysipelas and puerperal infection — Diphtheria — Aphthae — Aerogenous infection — Bilharzia — Chancroid — Hard chancre — Late syphilitic ulcers. Infection of the vulva, the vulvo-vaginal gland, and the vagina, de- pending upon the action of specific micro-organisms, may or may not be limited to — i. e., arrested within — the intrauterine segment of the genital tract. There is a proneness on the part of particularly the more vigorous pathogenic bacteria to progressively invade contiguous mucous areas; it follows, therefore, that infection, once established in the vulva or vagina, is liable to extend upward, involving the endometrium, the mucous lining of the Fallopian tubes, the peritoneum, and the intra- pelvic l3anphatics. A proper comprehension of the general subject of infection of the female genitalia involves, therefore, a study of the various pathogenic bacteria (see Sepsis), a consideration of the micro- organisms known to be involved in the infection of these organs, and, finally, a study of the infection, not alone of any one organ, but of the entire genital apparatus. Vulvitis, or inflammation of the vulva, and vaginitis, or inflamma- tion of the vagina, were formerly recognised as clinical entities; at present, however, vulvitis is discussed under the various forms of skin disease of the vulva, or as the result of the action of micro-organisms or of traumatism, while vaginitis can hardly longer be said to exist except as the result of either infection or injury. Inflammations of the external genital organs or of any part of them, except such as occur in the recognised forms of skin disease (see Disease of the Skin of the Female Genitals), will, therefore, be discussed under the heads of In- fections and Injuries. Bacteriolog-y of the External Genital Organs. — The bacteriology of the vulva and vagina in both health and disease has been very carefully investigated by numerous observers. Pioneer work was done by Hauss- nian, Kehrer, and Karewski, with primitive methods of investigation which naturally militated against the accuracy of their results. Stroganofl', of St. Petersburg, has investigated the bacteriology of tlie vagina of the newboiTi child, and finds tliat it is free from niicro-organ- 163 164 A TEXT-BOOK OP GYNECOLOGY isms, which, however, may enter soon after birth. Baths, washings, and esjDecially the application of oleaginous substances, such as are fre- quently used in the early toilet of newborn children, favour the entrance of germs. Yfinter {C entraTblatt fiir Gyndkologie, No. 17, 1888) found numerous organisms in the vagina and upon the j^ndendal structures, in neither of which were there any manifestations of disease. An in- teresting fact was that he found staphylococci, including the Pyogenes albus, aureus, and citretis, together Avith numerous streptococci, all of which, in morphology, pigmentation, and behaviour in culture media, were identical with similar bacteria found in other loci where they possess pathogenic properties; they differed, however, in the particular that inoculation experiments indicated that they were innocuous. All investigators agree that all pathogenic bacteria lose their virulence the nearer the}^ approach the cervix. This circumstance at once raises the question whether or not the cervical and vaginal secretions . have the effect of depriving these bacteria of their virulence. In answer to this question may be cited the observations of Doder- iein, who has found a bacillus which does not grow upon many of the usual media, but may be cultivated on sugar bouillon and sugar agar. It produces an acid, apparently lactic, upon which the usual acidity of the vaginal secretion depends. Lactic acid, which is elaborated by this bacillus in considerable quantity, is presumed to be the agent which either destroys the life or neutralizes the virulence of the pathogenic organisms. In confirmation of this theory large quantities of pus- producing organisms introduced within the vagina disappeared com- pletely within a few days. This acid-forming bacillus, which stands as a sentinel at the introitus and along the vaginal wall, does not itself produce pathologic s3^m])toms, and consequently plays no part in the causation of sepsis. Doderlein is of the opinion that this micro-organ- ism and the products of its vitality are able to resist the invasion of streptococci, which probably never reach the uterus unless either car- ried there mechanically or escorted by the more powerful pus-form- ers. These latter, notably the gonococcus, overpower the bacillus of Doderlein and march practically unopposed to the remotest reaches of the genital tract. The fact that the Bacillus aerogenes capsulatus manifests its activities upon or near the cervix indicates that it is not amenable to the influence of this micro-organism. The importance of bacteriological examination of secretions found upon the vulva and in the vagina can hardly be overestimated. The lesson taught by the investigations of Doderlein and J. Whitridge Williams is conclusive upon this point. The investigations of these gen- tlemen show that the normal vaginal secretion is of very small quantity, of whitish, crumbling material, of the consistence and appearance of curdled milk, containing no mucus, and giving an intensely acid reac- tion to litmus, while microscopically it consists entirely of vaginal epithelial cells and a relatively few large bacilli. The pathologic secre- tion, on the other hand, is of a yellowish or greenish-yellow colour. INFECTIONS OB^ THE EXTERNAL GENITAL ORGANS 165 creamlike in consistence, often containing gas bubbles (dependent upon Bacillus aerogenes capsulatus) and a little mucus, and varies in reac- tion from v/eakly acid or neutral to alkaline, while microscopically it consists of epithelial cells, numerous pus corpuscles, and all kinds of bacilli. Stroganoff found that micro-organisms seemed to increase in abundance in the vaginal secretion preceding and following menstru- ation. J. Whitridge Williams made a critical study of the secretion in the vaginse of ninety-two pregnant women, upon which he based prac- tical conclusions (Transactions of the American Gynecological Society, 1898) as follows: 1. We agree with Kronig that the vaginal secretion of pregnant women does not contain the usual pyogenic cocci, having found the Staphylococcus epidermidis albus only twice in ninety-two cases, but never the Streptococcus pyogenes or the Staphylococcus aureus or albus. 2. The discrepancy in the results of the various investigators is due to the technique by which the secretion is obtained. 3. As the vagina does not contain pyogenic cocci, auto-infection with them is impossible; and when they are found in the puerperal uterus, they have been introduced from without. 4. The gonococcus is occasionally found in the vaginal secretion, and during the puerperiurn may extend from the cervix into the uterus and tubes. 5. It is possible, but not yet demonstrated, that in very rare in- stances the vagina may contain bacteria, which may give rise to saprtemia and putrefactive endometritis by auto-infection. 6. Death from puerperal infection is always due to infection from without, and is usually due to neglect of aseptic precautions on the part of the physician and nurse. 7. Puerperal infection is to be avoided by limiting vaginal examina- tions as much as possible and cultivating external palpation. When vaginal examinations are to be made, the external genitalia should be carefully cleansed and disinfected, and the hands rendered as aseptic as if for a laparotomy. Vaginal douches are not necessary, and are prob- ably harmful. Mixed Infections. — A brief consideration of the preceding para- graphs relative to the bacteriology of the external genital organs makes it evident that they are the frequent seats of coincident infections by different micro-organisms. In cases of pelvic suppuration discharging into the genital tract, both staphylococci and streptococci are generally found, together with other pathogenic micro-organisms. In gonorrhoea the diplococcus of Neisser is never the only pyogenic organism pres- ent; and in the destructive stages of tuberculosis the tubercle bacillus is always found in association with other germs. There are cases, how- f'vcr, in which the pathologic changes and clinical yihenomena are so distinctly attrilnitable to a particular micro-organism that the infection is given its name.' rather than tliat of its congeners. Jn this category 166 A TEXT-BOOK OF GYNECOLOGY may be mentioned particularly (a) gonorrhoea, (b) tuberculosis, (c) erysipelas, (d) diphtheria, (e) aphthae, and (/) aerogenous infection. Gonorrhoea in women was once thought to be a disease restricted to the Tulva, the vagina, and tlie urethra; but since the days of Tait and JsToeggerath it is known that infection of the lower genital canal if left to itself may become a progressive invasion of the mucous tract, causing infection of the endometrium, the Fallopian tubes, the peri- toneum, and the pelvic lymphatics. (See Endometritis and Pyosalpinx.) It should be remembered likewise that the lower segment of the urethra is also, coincidently with the vagina and vulva, a seat of primary infec- tion, and that from this locus it may extend upward, involving the bladder and even the kidneys. (See Cystitis.) The cause of this infec- tion is the gonococcus of Neisser (see Fig. 17). This organism is the morbific agent that is distributed chiefly through the avenue of the " social evil," and restrictive measures have been taken in all enlight- ened communities to diminish its ravages. The prevalence of this micro-organism in the vaginal discharges of prostitutes has been a fre- quent subject of investigation. Laser, of Konigsberg, examined a number of prostitutes with the result that the gonococcus was found in the urethra 111 times in 353 cases; in the vagina 7 times in 180 cases; and in the cervical canal 21 times in 67 cases. These figures indicate that this micro-organism finds a favourable habitat equally in the ure- thra and in the neck of the uterus, and the least favourable abiding place in the vagina — a conclusion which supports the observation of Doderlein relative to the phagocytic action of the acid-forming ba- cillus of the vagina. Out of the 353 patients examined by Laser for gonococci in the urethra, four fifths of the 111 cases that revealed this micro-organism gave no macroscopical evidence of gonorrhoea. In 341 patients in whom no gonococci were discovered, there was more or less inflammation of the mucosa, often with a suspicious discharge. It follows, therefore, that while infection of the genital and urinary tracts may depend upon organisms other than the gonococcus, the latter, in a degenerated form located deep in the mucous folds and follicles, but especially in the crypts of the vulvo-vaginal gland, may be a persistent cause of the disease, even when it can not be detected in the dis- charges. It is evident from these facts that gonorrhoea in women should be classified as acute and chronic. Afanassiew (Gazette de gynecologie, No. 167, p. 173) reports the results of bacteriological investigation of the lochia of twenty-four par- turient women. Out of sixty-eight examinations, he obtained cultures in nearly all the cases. The bacteria diminished in the vagina from without inward, and were fewest at the uterine cavity — an observation confirmatory of the conclusions of Doderlein. They were living and culturable, notwithstanding daily washing of the canal with carbolized water of 2-per-cent strength. The gonococcus of ISTeisser is often demonstrable in secretions from the vagina and vulva. These organisms are frequently found in appar- INPEGTIONS OP THE EXTERNAL GENITAL ORGANS 167 'eiitly nonpurulent secretions long after the period of acute infection has passed; their virulence, however, under such circumstances is gen- 'Crally greatly reduced, often to the degree of having lost their patho- genic properties. (See Gonorrhrea in Women.) Freymuth and Pe- truschky {Deutsche medicinische Wochenschrift) have found the diph- theria bacillus in noma of the vulva. The same organism has been dem- onstrated in exfoliative vaginitis not associated with gangrenous ulcera- tion, while Eisner and others have reported puerperal diphtheria in- volving the vagina and endometrium. The Oidium albicans has been ■demonstrated in ajjlithous inflammations of the vulva and vagina in both children and adults. The symptoms of acute goiiorrhwa in women consist of a burning pain on urination located at first in the meatus urinarius, and next upon the inner and erythematous surfaces of the vulvar folds; and in a copious creamy discharge, bathing the vulva and matting the pudendal hair. On inspection the vulva reveals areas of erythema, which, after a few 'days, owing to the destruction of the epithelium, may become distinct erosions; the urethra is tender to the touch, swollen, and its mucous membrane is more or less everted at the meatus urinarius. The diagno- sis may be made presumptively upon the foregoing symptoms coupled with the fact of probable exposure to infection; but it can be made positively only upon the demonstrated presence in the discharge of the gonococcus of ISTeisser. The practitioner should be very cautious in giving a final diagnosis of suspected cases of gonorrhoea, on account •of the possible social and medico-legal contingencies that may arise. The symptoms of chronic gonorrhcea in women are more obscure. There is generally a history of a preceding acute attack, the exact character of which may not be known to the patient herself, but which can be determined, at least approximately, by well-directed interrogatories. Following the supposed cure of the acute attack there has been a per- sistent catarrhal discharge, varying in colour from a whitish to a slightly yellowish tint, and varying in quantity from slight to consider- able. If these conditions exist associated with a present or a past sup- puration of the vulvo-vaginal glands, and if there is a petechial pur- plish red area about the orifice of the vulvo-vaginal ducts, the presump- tion of chronic gonorrhoea is strengthened. If the mischief in the vulvo-vaginal glands has gone to the extent of suppuration, resulting in fistula; or cystic degeneration, the diagnosis may be considered as •confirmed. The involvement of the urethra, dark -red spots upon a yel- lowish-white streaked base upon the vulva, and venereal warts,' are com- plications of conclusive diagnostic significance. Oskar Bodenstein (I)enlsche medicinische Wochenschrift) quotes Sanger to the efl^ect that the local application of a 50-per-cent solution of zinc chloride will cause the granules in the vaginal mucous membrane to spring into vc]]('S in chronic gonorrhrxia — a convenient diagnostic expedient that is •certainly worthy of inv(!stigation. 7'///; pathology of goaorrhwa in women has been understood but re- 168 A TEXT-BOOK OF GYNECOLOGY cently. Its comprehension involves a study, not so much of the changes that occur in the vulva, vagina, and urethra, as of those occurring in the bladder and kidneys, and in the uterus and its adnexa, to the chapters upon which subjects the reader is referred. The pathology of gonorrhoeal infection of the vulva and vagina is essentially the pathology of an infective inflammation. The micro-organisms, find- ing a lodgment upon the mucous surfaces of the urethra, in the muco-cutaneous folds of the vulva, or those about the introitus vaginae, readily 23ropagate in the secretions which act as culture media. The direct irritating influence, both of the organisms themselves and of the products of their vitality, results in the establishment of the ordinary phenomena of inflammation — congestion, stasis, exudation, etc. The direct action of these organisms and their products is, to a certain extent, destructive of the epithelium, which, however, would probably withstand the assaults of the invaders if it were not for the circulatory and nutrient changes in progress in the underlying struc- ture. Through these combined influences the protective epithelium is broken down and there is more or less direct invasion of the under- lying cutictilar structure; but even here the intrusive cocci are con- fronted by other defenders of the system in the form of leucocytes. Cocci develop rapidly, however, overcome their cellular antagonists, and find their Avay into the fimbriated intercellular substance and intO' pre-existing cells of the tissue and in the vessel walls. While these changes are in progress, however, the mucous follicles are invaded, and with the first temporary recession of the local circulatory pressure these follicles are stimulated to extreme activity, manifested in that hyper- secretion which is generally designated as catarrlial. In the presence of a virulent infection these follicles and glands, including even the vulvo- vaginal glands, may suffer the loss of their epithelium and themselves become the avenues for tissue infection. Local abscesses as the result of gonococcus infection but rarely occur, except in the vulvo-vaginal gland, the efferent duct of which may become occluded, converting the gland into a suppurating retention cj^st. Tissue invasions, such as have been described, more frequently result in permitting the passage of the pyogenic organisms — for by this time the infection has generally become more or less mixed — into the lymph channels, whence they are carried to the lymphatic glands, particularly to those in the groin, where, not infrequently, the infection results in abscesses. Coincidently with these changes there occurs more or less systemic intoxication, expressed, it may be, by an initial rigour; this is followed by an elevation of tem- perature, which persists with slight but irregular vacillation until the focus of suppuration has been opened and drained. Treatment. — When gonorrhcea is limited to the vulva, the urethra, and the ostium vaginae, it should be treated by rest, and antiseptic lotions of either boric acid or bichloride of mercury emollient appli- cations. The vagina will seldom be invaded unless the infection is carried upward by mechanical means. This, however, is what unfor- INFECTIONS OF THE EXTERNAL GENITAL ORGANS 169 tiinately happens in the majority of eases long before the physician is consulted. The patient of her own accord is prone to use the douche; or, may be before she has become aware of her condition, she has indulged in repeated acts of coition. The physician is, therefore, called upon at the very outset to treat a thoroughly infected vagina. Under these circumstances there is no disease with which women are afflicted that calls for more prompt, more vigorous, and more efficient treatment than that of acute gonorrhoea. Its probable extension to the upper reaches of the genital tract, with the inevitable complications thereby engendered, should stand before the practitioner as a spectre warning him to the fullest discharge of his duty. The treatment of acute gonor- rhoea is essentially bactericidal. It should begin with a thorough cleans- ing of the parts; this can be accomplished thoroughly only by first shaving the pudendum; a douche of tepid water, either clear or holding in solution some borax or sodium bicarbonate, should be used to cleanse the vulva and the vagina; after this has been thoroughly done another douche of l-to-3,000 bichloride solution should be employed for a period of from ten to fifteen minutes. This douche should be given, as should the preceding, with the patient lying upon her back, her buttocks drawn to the edge of the bed, in which position the nurse can practise most thorough cleansing of the vagina by repeatedly holding her hand over the vulva, thus forcing the retention of the irrigating fluid in the vagina; the hydrostatic pressure thus exercised will occasion that degree of dis- tention of the vagina which will cause an obliteration of the folds and the exposure of its entire surface to the action of the medicament. Care should also be taken to bring the antiseptic solution in contact with every part of the infected area of the Yulva. An older and pos- sibly more efficacious, but certainly more severe, treatment consists in cleansing the parts as above described, and in then introducing a specu- lum, widely distending the mucous membrane of the vagina, which, with the entire vulvar surface, is cauterized with a solution of nitrate of silver, twenty grains to the ounce; this cauterization, to be effective, should be thorough and should include every part of the mucous mem- brane. After the silver nitrate has been applied, a loose pledget of cot- ton, saturated with glycerine, should be carefully inserted, not so as to pack the vagina, but to lie lengthwise in the canal, preventing the ap- proximation of the cauterized surfaces. Other remedies, such as the zinc sulphate, plumbic acetate, tannin, carbolic acid, lysol, and creolin, have been suggested and may be employed; they, however, possess vary- ing germicidal properties, none of them being so valuable as either the mercuric bichloride or the silver nitrate. When the nitrate of silver is used, it should not be reapplied under three or four days. It should be remembered that antiseptic treatment, to be effective, should be con- tinued until the symptoms of infection have subsided. It is not enough to kill an existing goneration of bacteria, even though it were possible to do so in a given case, for it slioiild be remernbored that many of these micro-organisms pr()|)agate by spores, which resist more effectively than 170 A TEXT-BOOK OP GYNECOLOGY do the parent organisms themselves the action of germicidal agents. Doderlein has emphasized the importance of repeated disinfections of the genital tract, for the purpose of securing sterilization, and his teachings should pass into an axiom of practice. The treatment of chronic gonorrhoea in women involves a much more comprehensive regimen. It must he based upon a comprehension of the pathologic changes that have occurred in the case at hand. This may involve the application of surgical expedients to the bladder, the kidneys, the uterus or its adnexa, or to the pelvic lymphatics. So far as the treat- ment of chronic gonorrhea of the lower genital tract is concerned, it will resolve itself into a persistence in antiseptic measures, or the ex- tirpation of the vulvo-vaginal gland, which is generally found to be the persistent fons et origo of the disease. The antiseptic treatment should consist in the continued practice of irrigation with strong solutions of bichloride of mercury or carbolic acid, always taken in the recumbent posture, the douche bag being elevated from four to five feet above the patient, the nurse practising forced retention of the fluid in the pa- tient's vagina. It should be kept in mind that chronic gonorrhoea of the vagina is a deep-seated process, for the successfid treatment of which vaginal distention is a necessity. Forcible tamponade of the vagina, particularly in the lateral fornices and in the upper segment of the canal, should be practised by saturating a long slender cotton tampon with sterilized glycerine. The exosmotic influence of this agent has a tendency to wash the micro-organisms out of their hiding places and to bring them in contact with the stronger sterilizing agents. In these cases it is of special value to distend the vagina to the extreme by means of a multivalvular specidum, and to cauterize the thus tense and distended mucous surface with a strong solution of nitrate of silver, followed with glycerine tamponade. The escharotic influence of the silver salt is not sufllcient to produce serious destruction of the mucous membrane, unless frequently applied — i. e., oftener than every three or four days. Extirpation of the vulvo-vaginal glands should be practised when- ever they have become the seat of gonorrhoeal infection, as evidenced by either repeated suppurations or cystic degeneration. This gland is also the occasional seat of malignant disease, the existence of which is an indication for its prompt removal. This is an operation of more magni- tude than the anatomic structures involved would seem to imply. With the patient in the dorsal position, the vulva having been completely sterilized, the labia of the affected side are retracted by the hands of the assistant or nurse, and an incision is made over the gland just at the base of the labium minus. If the gland is distended, dissection should be made with considerable care until the cyst, as the gland may be now designated, is encountered; an effort should be made to carefully enu- cleate this body, which will be found to be held in position by a sort of ligamentous structure, conveying its nerves and nutrient vessels. These are of sufficient magnitude to occasion severe hemorrhage, and INFECTIONS OF THE EXTERNAL GENITAL ORGANS lYl if they are permitted to elude the grasp of the operator, they retract along the vaginal wall to such an extent that they are re-secured with extreme difficulty. Care should be taken, therefore, to get them with- in the grasp of a hemostatic forceps before excising the gland, and to ligate the pedicle before taking off the forceps; the wound should then be closed aseptically and dressed with protective pads. If closed by the buried suture the liability of subsequent infection from external causes is minimxized. Tuberculosis of the vulva is a specific inflammatory disease of the external genitalia, caused by the presence of the tubercle bacillus and characterized by both the anatomic lesions and clinical course of lupus. It may exist as a primary disease confined to the vulvar region or a secondary manifestation of tuberculous lesions in the lung, intestine, or internal genital organs. A clear definition of tuberculosis of the vulva is extremely difficult to give in the presence of the confusing classifications of different authors, and m.ust in reality include a very extended description and differentiation of the conditions — ulcus rodens vulvae, elephantiasis, lupus vulva3, Testhiomene, and destructive ulcer. Veit, Schroder, Pozzi, and many others have described ulcus rodens vulvae as a distinct lesion, but they also state that the tubercle bacillus has often been found in such ulcers. It will certainly simplify the subject greatly and bring it more within the limits of this short article to look upon this division as suh judice, and to describe only a tuberculosis of the vulva. Etiology. — Until recent times tuberculosis of the vulva has been considered so rare that it has been given no place, or only passing mention, in the accepted text-books of gynecology; but the reported cases of Demme, Schenck, Kuttner, Karajan, Paoli, Kelly, Eieck, and others, would indicate that the disease occurs with greater frequency than is generally believed, and that this condition must always enter into the diagnosis of vulvar ulceration. Barbier {Gazette medicale) believes that a woman can be infected by a tuberculous man during coitus. Bacilli have been demonstrated in the semen as well as in the discharge attending tuberculous epididymitis. The uterus may be in- fected by extension from a tuberculous growth on the vulva, without any intermediate trace of infection in the vagina. He even admits the possibility that tuberculous infection may be transmitted by the finger of the attendant, by unclean instruments, or even through the medium of the air. It is manifest, however, that infection transmitted in this way must be taken up through some rent in the continuity of the epi- thelium. The disease occurs alike in children and adults and without refer- ence to the general nutrition. The infection would seem to be by the direct inoculation of a skin abrasion by means of the nails, by infected dust, by tuberculous stools, or by coitus. The case of Schenck occurred in a chihl who bar] two tuberculous y)laymates, and wlio had no other tiihcrciilons iiijiiiilV.'sijii ions. Prostitutes arc most frequently attacked, 172 A TEXT-BOOK OF GYNECOLOGY a fact that has its explanation in their great liabihty to direct infection, in continued irritation, and in lack of cleanliness. Masturbation serves as a predisposing cause, and syphilis also by lowering the resistance of the tissues. Koch has considered extirpation of the inguinal glands to be a predisposing cause. Morbid Anatomy. — The starting point of the tuberculous process is usually in the region of the urethral orifice or the clitoris, or in the posterior commissure. The lesion begins as a single or as multiple hard masses, of a dark-red or livid colour, which develop in an indu- rated skin and increase in size very slowly. This mass may exist for a long time as a firm nodule, or in the clitoris as a hypertrophy, or it may soften in the centre and break down to form a small, raised, un- healthy ulcer with ragged edges, which exudes a serous fluid. It is in this stage of ulceration that the patient usually presents herself for treatment. When the lesions are multiple, a number of such discrete ulcers will form on the vulva and gradually run together to form an extensive area of tuberculous granulations involving the entire vesti- bule, clitoris, labia, and lower part of the vagina. The granulations of such an ulcer are un- healthy, friable, do not bleed easily, and show no tendency to caseation. The sur- face is covered by a sero-purulent exu- date. There is a rich vascularization of the part and the tissues around and beneath the ulcer are strongly infiltrated, but not markedly indurated. These ulcers are apt to be serpiginous in character, healing be- hind as the advance is made. A very char- acteristic feature of the disease is a rough, tense, hard elephanti- asic thickening of the labia or clitoris, or both, which causes them to swell to two or three times their normal size. In fact, in the cases of Karajan and De Sinerty the operation was done for elephantiasis of the clitoris, and the tuberculous nature of the disease was revealed only by histological and bacterio- logical examination. A microscopic examination of these ulcers shows the base to be made up of a thin layer of tuberculous granulations and Fig. 68. — " A low power shows the caseous areas (5, c) in the tuberculous tissue and an occasional fistulous tract («)." — Whitacre (page 173). INFECTIONS OP THE EXTERNAL GENITAL ORGANS 1^3 Fig. 69. — " A high power picture demonstrates small round cells and giant cells around the irregular caseous areas." — Whitacre. the raised edges of solid tuberculous tis- sue containing more or less typical mili- ar}^ tubercles. A low power (Fig. 68) shows the caseous areas in the tuberculous tis- sue and an occasional fistulous tract. A high power (Fig. 69) demonstrates small round cells and giant cells around the ir- regular caseous areas. Tubercle bacilli may be demonstrated (Fig. 70) among the small round cells in the secretions or in the newly formed tissue. It must be remem- bered, however, that in the serpiginous course of such a tuberculous lesion the older parts of the ulcer may show the entire absence of tuber- cle bacilli, as is shown by the interesting case of Rieck (Fig. 71). The involyement of the urethra is progressive, its inner surface loses its real mucous-mem- brane character, is more or less exposed, and may be con- verted into scar tis- sue. The meatus ap- pears to be torn lat- erally, as Emmet has pictured it for the cervix. The process continues until the urethra is almost en- tirely destroyed and is represented by a funnel-shaped ulcer. The course of the ulcerative process is very slow, however, and the inguinal Fig. 70.— "Tub(;rcl(- hiu'illi may be demonstrated among glands remain free the small round colls."— Whitaore. ' for a remarkably 174 A TEXT-BOOK OF GYNECOLOGY long time. Cicatrization is sometimes associated with the ulceration, as an evidence of a tendency to spontaneous healing, and may lead to great deformity. Fistula? often form a marked feature of the disease, and especially in ulcus rodens vulvse. A tendency to a deep penetration of the tissues may be present from the start. They first form underneath the mucous membrane, but very soon penetrate deeply, and may communicate with the rectum high up at the upper end of the perineal triangle. Three or four sinus open- ings on the vulva may coalesce below the surface and open into the rectum as a sin- gle channel. Ulcera- tion in the perineal body may be so ex- tensive as to form a cloaca. Symptoms. — The first symptom of pri- mary tuberculosis <)f the vulva is often a stinging pain on uri- nation, caused by the urine coming in con- tact with a minute ulcer at the orifice of the urethra. At other times an ulcer giving no symptoms is discovered by the patient, or the nympha of one side, or the clitoris, is found to be increasing in size. A physical examination will reveal the presence of one or more ulcers possessing the above-named characteristics. The course of such an ulcerative process is extremely slow, and may continue for many years as a local phenomenon without affecting the general health of the patient. The dribbling of urine and rectal irritation will, of course, be present in the advanced cases as most distressing symptoms. Death will eventually result from involvement of the internal organs. A secondary tuberculosis of the vulva takes a much more rapid and malignant course; furthermore, the vulvar disease often possesses little significance in comparison with the primary lesion in the lung or other organs. Diagnosis. — The diagnosis of this condition possesses a consider- able degree of importance, first, because of the necessity of radical treatment, and, secondly, because of the difficulty experienced in ar- riving at a correct diagnosis. Askanazy has explained certain of these difficulties by the demonstration that we may meet with tumours not differing in their microscopical anatomy from typical tuberculosis, but Fig. 71. — The oa><^' uf Kicck : A. C, sinus openings ; B, F, scar- tissue ; X*, a small tumour containing typical tubercle tissue ; ^, ulcerated surface ; 6^, urethra; 7/, introitus vagina; t7,ele- phantiasic thickening of left nympha. — Whitacee (p. 173). INFECTIONS OF THE EXTERNAL GENITAL ORGANS I75 characterized clinically by an absence of all tendency to caseation, abnormally large size of tumour formation, firm consistence, and, lastly^ by a tendency to fibrous metamorphosis which may eventually lead to a complete obliteration of all specific tuberculous attributes. The association of ulceration with elephantiasic thickening of the labia, the slow development, the chronicity of the ulceration, and, most important, the demonstration of tubercle bacilli in the secretions, will serve to distinguish it from carcinoma. Simple elephantiasis is not associated with ulceration. Chancroid will usually be diagnosed by its history and clinical characteristics, by the absence of elephanti- asis, by its multiple character, by its short duration, and by the absence of extensive and deep destruction of tissue. Treatment. — The treatment of tuberculous lesions of the vulva is surgical, and a radical removal of all diseased tissue should be resorted to whenever this is possible. This will often require an extensive plas- tic operation, and it should be remembered that a considerable removal of urethral tissue can be made without impairing the function of the bladder (Kelly, Schroder, Paoli). When this is not possible, thorough curetting with a sharp spoon, followed by cauterization with strong acids, may be tried and repeated as often as the disease recurs. Deep cauterization by the electro-puncture serves as an excellent method of thoroughly removing the diseased tissue and securing good cicatriza- tion. The ulcers unfortunately heal very well oftentimes nnder such simple applications as iodine or acids, but this cure is not permanent, and the ulcers recur. Under any plan of treatment these cases should be carefully followed up and the slightest recurrence treated as radi- cally as the original focus of infection. Enlarged glands in the groin should be removed at the time of the primary operation or in the in- stance of their later enlargement. Either as an auxiliary to the ordi- nary methods of treating lupus, or as an independent method, Unna ad- vises (Monatshefte filr praMisclie Dermatologie) the following lotion: I^. Corrosive sublimate, 1 part; carbolic acid or. creosote, 4 parts; alco- hol, 20 parts. The nodules are attacked in series of tens, beginning with those at the edge of the patch. They are first punctured with an acne lance, and a minute shred of absorbent cotton moistened with the lotion is inserted by means of a sharpened stick, the cotton rotated and allowed to remain for ten or fifteen minutes. In a few days the punc- tures and lupus deposits so treated have almost disappeared, and other nodules may be then similarly attacked. This method, Unna believes, has many advantages over the somewhat similar plan of treatment by means of the nitrate-of-silver stick. Tuberculosis of the vagina is usually associated with tuberculosis of the higher portions of the genital tract, but a number of cases have been reported in which no other focus could be discovered in the genital tr-aet, and a single case is reported by Friedliinder in which a vaginal iiieer reproseutefl the only tuberculous lesion to be found in the entire \)<)(\y. 'r\\(i vagina certainly may be infected from a tuberculosis of 176 A TEXT-BOOK OF GYNECOLOGY the peritoneum or tube without involvement of the intervening organs (Opj)enheim), and it was Reynaud who first explained the usual seat of the first vaginal lesion in the posterior fornix, by the observation that it was here that virus-laden secretions from above first came in con- tact with the vagina. The infection may also be introduced from with- out by coitus with men suffering from a tuberculous disease of the sexual organs, by the hands or instruments of the physician or midwife, from the urine, from filthy bed linen or wearing apparel, from the air, from the blood (Davidsohn), and by infection in continuity of tissue from neighbouring organs, as in vesical or rectal fistulas. The infrequency of the disease in both the vagina and vulva, as compared with that of the higher organs, is probably to be explained by the natural resistance of squamous epithelium to bacterial invasion, and it is only after injury, abrasion, or the action of irritating secretions, that the tubercle bacillus can gain entrance to the tissues. The disease occurs Avith greatest frequency during the period of sexual activity (twenty to forty), yet seven and seventy-nine represent the two extremes of age in the collected cases. Morbid Anatomy. — Two cases in particular are reported where the entire lesion consisted in an eruption of perfectly typical, fresh miliary tubercles over the entire vaginal wall. These tubercles were of millet- seed size, and were made up microscopically of giant, epithelioid, and small round cells, which were supported by a delicate reticulum and showed areas of caseation. Tubercle bacilli were present. Favoured by moisture and warmth, these miliary tubercles soon break down to form minute ulcers, or by their confluence will form larger sharply defined but irregular ulcers. Such ulcers are characterized by perpendicular edges, a depressed grayish or yellowish-gray base, studded by tubercles and covered by caseous material, a size varying with the extent of the confluence, and a decided tendency to the serpiginous type. Such an ulcer is usually surrounded by an area of hyperemia, which is more or less filled with small, yellow, opaque, grainlike miliary tubercles. The usual seat of ulceration, as has already been stated, is in the posterior fornix. When the infection is from without, however, the lower por- tion of the vagina will be first involved. Tuberculous fistulse are found in the later stages of the disease and are formed, as a rule, by an ulcera- tion into the connective tissue, thence into urethra, rectum, bladder, or the skin surface of the perineum. On the other hand, fistulse may be the result of perforating rectal or vesical ulcers, and cases have been reported in which the fistula has its origin in a broken-down tubercu- lous Fallopian tube. These fistulse are peculiar only in the fact that they are lined by the tuberculous membrane. Symptoms. — The sym]3toms of tuberculous vaginitis are, as a rule, masked by those of the tiiberculous disease existing in other parts of the body. A leucorrhoea associated with painful coitus or pain in using the douche tube will usually be the first symptom that brings the patient to the physician for examination, or the symptoms of a vesico-recto- INFECTIONS OP THE EXTERNAL GENITAL ORGANS 177 vaginal or urethro-vaginal fistula may be the first that are referred to the vagina. A physical examination will reveal one or many sensitive nlcers possessing the above-named characteristics. The diagnosis of the miliary form from granular vaginitis should not present great difficulties when we remember the frequency of the latter as compared to the condition under discussion, also its usual association with pregnancy and gonorrhoea. Furthermore, the character of the ulceration, and the fact that a tuberculous lesion of the vagina is almost invariably associated with a similar lesion elsewhere in the body, will prevent confusion. A chancre can be easily distin- guished from a tuberculous ulcer by its history and clinical course; the papular or ulcerative syphilides by the history, the total lack of pain, and mainly by their disappearance under antisyphiltic treatment. The reports of many of the recorded cases state that the patient was first subjected to antisyphilitic treatment, leading to the impression that this confusion often arises. Finally, the secretion of every persistent ulceration of the vagina or vulva should be subjected to bacterial ex- amination in smear or culture preparations, or inoculated into the peri- toneal cavity of guinea-pigs. The number of bacilli is often too few for easy demonstration by ordinary staining methods, yet it will cause a tuberculous peritonitis in the guinea-pig in from three to four weeks when present in very small numbers. A microscopic examination of a snipping from the edge of the ulcer may be necessary to distinguish the condition from carcinoma. The treatment of tuberculous vaginitis should be as radical as possible when the lesion can be demonstrated to be a primary one, either in the genital tract or in the body; but it must be remembered that the condi- tion is usually secondary to a much more serious tuberculous involve- ment of the Fallopian tubes, the uterus, the intestine, or the lungs. In these cases palliative measures alone are indicated. When complete excision of the ulcers is possible this should be done, but we must very often limit ourselves to a thorough curetting and cauterizing of the ulcer, and a prompt treatment of every point of recurrence. Palliative measures will consist in local applications to the ulcers, the repair or cleaning of fistulge, the maintenance of an antiseptic condition by the use of astringent and antiseptic douches, the use of general tonics — in fact, the use of those measures which are applicable to tuberculosis in other parts of the body. Erysipelas of the external genital organs, and particularly infection of the genital tract by the Streptococcus erysipelatos (Streptococcus pyogenes), are occurrences of tragic importance. When the infection is strictly local, the streptococcus finding ingress through some abrasion in the epithelium, the resulting phenomena are those of erysipelas in- volving the pudendal structures. The virus, once admitted to the field of |)ff)pagation,spreads rapidly through the lymph capillariesof the sur- rounding skin. The symptoms that ensue are sudden attack of febrile ) The elevated papule, or ulcus elevatum, begins as a chancrous erosion with hyperplastic infiltration, and grows 1o a considerable size. It is round or oval, deep red in colour, and has a smooth, velvety surface, fiat or concave with distinctly elevated edges, and discharges a thin serous fluid. Ii'riijii ion from walking 186 ^ TEXT-BOOK OP GYNECOLOGY or from uncleanliness may provoke inflammation, causing a pro- nounced oedema of the labium on whicli it is seated. Careful pal- pation will reveal a slight induration, parchmentlike in character. This condition is essentially chronic, lasting many weeks, resolving slowly, leaving a deep red spot which is replaced by a sear. (4) Incrusted cliancre affects the cutaneous surface of the pudendum, beginning as a chancrous erosion or as an indurated nodule, and speedily developing a kind of film of a light, greenish, creamy tint, or, at other times, of a brownish red necrotic character. (5) The indurated nodule is rather rare in women and is found where the skin and mucous mem- brane join each other. It manifests itself as a sharply circumscribed mass of indurated tissue with a narrow base and sloping edges. (6) The diffiused exulcerated chancre is found in women of the lower class; it begins as a chancrous erosion, grows to an ulcus elevatum, and then spreads over an extensive area. It has an ulcerated and un- even surface, deep red in colour, but only slightly painful, although frequently associated with oedema of the part on which it is developed. The hacterial origin of syphilis, although very probable, has not been demonstrated. The analogy between syphilis and other diseases of known bacterial origin prompts the belief that the various phenomena of the disease depend upon a bacillus, not yet isolated, and its toxines. The pathologic changes occurring in indurated chancre are of an inflammatory character, and are accompanied in any stage of syphilis with a persistent involvement of the blood vessels; an infiltration of small round cells associated with those of larger size, and polyhedral in form, occurs in the meshes of the connective tissue surrounding the blood vessels. There is a constant tendency to the production of new connective tissue, especially in the initial chancre, and again in the later tertiary stage as manifested in the nervous system. The peri- vascular changes and the infiltration of the tissues beyond the chancre are the most important features of the initial sore. The lymph spaces are readily afi^ected with the peculiar infiltration, the virus speedily travelling through this channel to the inguinal glands. The peripheral perivascular lymph spaces are infected by the time the chancre makes its appearance; and the first halt in the march of the virus is shown by the swelling and induration of the inguinal glands. Microscopically, a well-developed chancre reveals a seminecrotic mass of small sphe- roidal cells which constitute the bulk of the ulcer, circumvallated by a zone of oedema and a cellular infiltration of the papillary layer of the derma. This oedema acts as a wall to protect the surrounding healthy tissues from invasion. The virus, having entered the lym- phatics, passes from one gland to another until it reaches the general circulation. This occurrence marks the transition from the secondary, or incubation period, and the disease breaks out in the ordinary form of roseola with all the accompanying symptoms of chlorosis, neuralgia, syphilitic fever, etc. The female genitals, like any other part of the integument, may INFECTIONS OF THE EXTERNAL GENITAL ORGANS 187 show every kind of eruption which results from the two morbid pro- cesses of hypersemia and infiltration. The hyperemia is mostly found in the early period of syphilis in the erythematous syphilides; the infiltration is always more advanced in the later stages. In the early eruptions, however, a slight cell infiltration is always present, giving rise to patches and nodules. In this stage of syphilis, Eavogli has repeatedly found a kind of infiltration of the skin of the labia majora and labia minora, just at their free edges, showing the epidermis slightly abraded and intermingled with superficial erosions; besides this slight thickening of the skin, the patches show a kind of dirty yellowish colour, and are accompanied with itching. Mucous patches or con- dylomata lata, are quite often found on the external genitals of women, during the first two years of the course of syphilis; this eruption is characteristic of syphilis, and when discovered settles all doubt relative to the diagnosis. Mucous patches, on account of their abundant secre- tion, are the most dangerous eruption for the transmission of syphilis. Eavogli is of the opinion that most cases of syphilis are communicated by mucous patches. They are found on the mucous membranes and on proximal surfaces of the skin which are continually moistened by perspiration. They begin on the skin as flat elevations, circular or dis- coid in form, and of different sizes, showing a depression in the centre with elevated borders; the epidermis in the centre is macerated by the moisture and is transformed into a grayish pellicle. This is soon cast off, leaving a plaque of a raw flesh-coloured appearance. This plaque secretes abundant serum, which soon becomes altered and causes an offensive smell, and by irritating the skin induces intertrigo. Eavogli has observed a kind of contagiousness in these patches, mani- fested by the development of similar lesions on proximal cutaneous or mucous surfaces. They assume a variety of appearances, accord- ing to location and the local conditions to which they are subjected. On account of the presence of urine, perspiration, etc., they may de- velop superficial ulceration, manifested by an abundance of offensive, purulent secretion. As a result of persistent irritation, the patches may become uneven with a verrucous aspect, caused by hypertrophy of the papillae of the derma, a hypertrophy which sometimes assumes a vegetating character (condylomata lata). These different appearances of mucous patches have caused authors to classify them as diphtheroid, ulcerative, vegetative, or hypertrophic. They are either round or oval in shape, according to the part upon which they are located; some- times they appear like ulcerated rhagades around the ostium vaginas or between the anal folds. On the mucous membranes, mucous patches have a kind of grayish appearance with marked edges slightly ex- coriated in the centre. The chronological period of mucous patches is the secondary stage from its beginning to its end. Eavogli (Monatshefle fiir praJdisclie Dermatologie, 1893) observes that it is not rare to see patches on the tongue and in the mouth of syphilitic patients after four or five years following the ])riinary infection, and 188 A TEXT-BOOK OF GYNECOLOGY in patients who are already manifesting tertiary symptoms. These lesions are sometimes the most stubborn manifestations of syphilis, as they show a tendency to frequent recurrence. When not properly treated, they may become hypertrophic, forming papillomatous masses which may persist for a long time. They usually disappear by a pro- cess of superficial ulceration and without leaving a scar. The anatomo- pathologic lesions of mucous patches consist in hypertrophy of the papillse, and in abundant infiltration of cells throughout the papil- lary layer and the corium. The mucous layer, of the epidermis is also affected, showing a proliferation of the cells, and a granular change of their protoplasm that gives to the cells a peculiar appear- ance. In the ulcerated patches this becomes obscure. On account of the dusky appearance of the infiltrated papillae, the mucous layer in many points being absent, and the tips of the papilla? mutilated by the ulcerative process, mucous patches when once seen and identified will always be recognised. There can be no doubt that they are an exclusive form of constitutional syphilis. We have already spoken of the acuminated cond3domata, which are . nonsyphilitic manifestations, and we have pointed out the charac- teristics which distinguish them from the condylomata, or mucous patches. It is possible to make a mistake only in cases of hypertrophic or vegetative mucous patches, but the absence of the pedicles, the characteristic ulceration, the abundant sero-purulent secretion, and the accompanying antisyphilitic symptoms, should be sufficient points of difference to establish the true diagnosis. Treatment. — It is beyond doubt that in order properly to treat mucous patches, a general antisyphilitic treatment must be adminis- tered. The choice of the antisyphilitic remedies is subject to the con- dition of the patient, to the period of syphilis, and so forth; and it would be entirely out of place to enter here into such a difficult and intricate question. The mucous patches require local treatment. Local treatment in a great many cases consists in the observance of the rules of cleanliness. The best treatment, in Ravogli's opinion, for mucous patches, is to wash the surface well with' an antisyphilitic solution of mercury bichloride, 1 to 2,000, and, after a while, to dry and powder them with calomel. In some cases the mucous patches are extremely stubborn, with a tendency to ulceration and hypertrophy, and in these cases it is necessary to use caustics. The application of a 4-per-cent solution of acid nitrate of mercury produces a super- ficial cauterization, and we may be sure that after touching the mucous patches two or three times with this solution they will readily heal. Sometimes the mucous patches resist the application of the solution of acid nitrate of mercury, and in these cases it is necessary to resort to stronger caustics; then, nitric acid in full strength is useful for the destruction of these patches. The application of salves or plasters to mucous patches is not to be recommended, because they are found where the skin forms folds and is macerated by the per- INFECTIONS OF THE EXTERNAL GENITAL ORGANS 189 spiraticn; it is better, therefore, to use antiseptic Lathing and the ajjplication of dry powder, which will prevent the accumulation of the perspiration. Late Syphilitic Ulcers of the Female Genitals. — Syphilitic ulcers of the vulva were studied in 1849 by Huguier, in his article on Esthio- mene, or Dartre Rongeante de la region vulvo anale, Paris, 1849, and by Matthews Duncan in the Edinburgli Medical Journal, July, 1881. In the venereal ward of the Cincinnati Hospital, Eavogli has had occasion to observe a great many cases of extensive and deep ulcers of the vulva in dissolute women who have been admitted into that institution. He supports the opinion of Hyde in denying that those ulcers of the vulva have anything to do with lupus vulgaris, and thinks that there can be no doubt that the women have been affected with syphilis. He admits that the extreme destruction of the external geni- tals of women which are occasionally observed may be due, not to syphilis alone, but probably to syphilis in connection with tuberculosis; and he remembers one case in his service in which a large and deep ulcer had destroyed part of the labia minora and part of the entrance of the vagina. The woman died, and at the post-mortem the peri- neum was found to be studded with tubercles. Usually, these ulcers are found in weak patients, with a system run down from misery and debauchery. The ulcers are always seated on a strong and thick induration which is confined to one or both labia. This infiltration sometimes extends to the mons veneris, and may also spread downward to the perineal tissues. It is accompanied by a kind of hypertrophy which is felt deeply situated in all the tissues. On these indurated places, ulcers are found which are deep and destructive. One or both labia may be destroyed. Sometimes, when the ulceration affects the perineum, the destruction may extend to the anus producing altera- tion of its function. The edges of these ulcers slope to the bottom, which is red or grayish from necrotic detritus, without a tendency to the formation of healthy granulations. The destruction once begun goes on very rapidly, and it is a difficult task to stop its ravages. Says Eavogli: " In my experience I have found this form of vulvar syphilitic ulcers more frequent in the negro race than in the white race. The date of infection from syphilis was from six to twelve years. Ko enlarged glands could be found in the groins or in the cervical region, yet, in many of these women, deep scars could be found on the legs, witnesses of progressed gummata, and roughness of the tibia could be found, showing progressed specific periostitis. These ulcers are the result of late syphilis. They are the result of gummatous infil- tration, but there is no doubt that the general condition of these patients has a great flea] to do with the virulence of syphilis." 'Jlic prognosis of tlicse ulcers must be given with great reserve. There are two principal elements for the production of the ulcers: First, advanced malignant syphilis; secondly, weakness of the general system. 190 A TEXT-BOOK OF GYNECOLOGY The treatment consists, first, in improving the general system with good diet, tonics, and better surroundings. Antisyphilitic treatment consists mostly in the administration of potassium or sodium iodide. Mercurials can scarcely be recommended on account of the weak and poor condition of the patients. Beneficial results follow applications of a solution of mercury bichloride, 1 to 2,000, and then covering the ulcerated and infiltrated surface with the emplastrum hydrargyri, which, producing an abundant suppuration, in a short time causes a sloughing out of all the detritus from the bottom of the ulcers. In the same way, the application of the emplastrum hydrargyri helps a great deal toward the absorption of the infiltration and oedema which form the base of these vulvar syphilitic ulcers. The washing with peroxide of hydrogen and the application of powdered iodoform have also given very good results, but only in later stages, when the em- plastrum hydrargyri had already diminished the infiltration. The curette has been used in cases where the surface has been covered with abundant ill-natured granulations. But with this exception, there is but little need for the curetting of such ulcers. The applica- tion of strong caustics, such as nitric acid and the actual cautery, has been tried only in those cases in which the destructive process had taken wide proportions. It is seldom necessary to resort to these means, particularly when good results are realized by the emplastrum hydrargyri. CHAPTEE XVII DISEASES OF THE SKIN OF THE FEMALE GENITALS Intertrigo — Erythema — CEdeina — Eczema — Folliculitis — Herpes progenitalis — Pru- ritus — Parasitic affections — Atrophy (Kraurosis) — Vulvar adhesions. The skin of the genitals of the woman is subject to all the diseases that are met with in the general integument, and, on account of their anatomical structure and position, some affections are more frequently found here than in other regions. Intertrigo. — This common affection is usually found in fleshy women. It is produced by the apposition of the surfaces of the skin of the thighs with each other and with the external portion of the labia majora, and is a result of friction. Under these circumstances perspira- tion is very abundant, and it macerates the epidermis and causes an inflammation of the skin, which in the beginning is limited to the de- gree of a simple erythema, but, continuing, reaches the degree of a true eczema. Indeed, in the beginning, the surface of the inguino-crural fold and of the labia is red and moist, and the epidermis appears slightly macerated. An itching and burning sensation is associated with the affection. If promj)tly treated the skin returns to the normal condition in a short time. If the affection is allowed to continue, then, on account of the profuse perspiration and of its chemical changes, associated with impurities and uncleanliness, the epidermis is deeply macerated, the sur- face is excoriated, oozing a serum which starches the linen, and the patient can scarcely move on account of the pain produced by the motion on the inflamed skin. Although the affection is called eczema intertrigo, Eavogli does not consider it a true eczema. Eczema may be the consequence of the intertrigo, just as it may follow any other irrita- tion of the skin. Vulvar intertrigo is caused by gonorrhoea, syphilis, or the accumula- tion of nonspecific but irritating secretions, in the cutaneous folds of the puflenda and groins. The large quantity of sero-purulent secre- tion oozing out of the vagina in cases of gonorrhoea, moistens the skin of the genitals and of the thighs, and by its irritating qualities causes intertriginous eruption. This intertrigo is also found in patients who observe strict cleanliness. In women neglectful of the principles of hygiene the intertrigo assumes a mnch more aggravated form. In the first case the affection is limited to the front part of the geiiitals, Inhiii tiinjoTM, l;ilji;i iiiinor;i, iitid clitoris with its prepuce, as a result of 191 192 A TEXT-BOOK OF GYNECOLOGY the contact of the gonorrhoeal fluid on the skin. In the second case in- tertrigo is spread more on the internal surface of the thighs and of the labia niajora in the fossa genito-cruralis, in consequence, not merely of the presence of the purulent secretion, hut also of the friction of the two surfaces of the skin, which become macerated by the purulent secretion, perspiration, and other impurities. Intertrigo in these cases is acute, the surface of the aft'ected skin is red and somewhat swollen; the epidermis is macerated, giving it a whitish, soggy ajDpearance; abrasions and small rhagades are formed on the labia majora, in an oblique direc- tion toward the fossa genito-cruralis; the surface is always moist from the discharge of serum, wliich, together with the gonorrhoeal secretion and the perspiration, jjroduces an offensive smell. A burning sensation accompanies the course of the affection, and motion makes it so painful that the woman can scarcely Avalk. Another form of intertrigo, more chronic in form but occurring under the same circumstances, was recently described by L. Brocq and Leon Bernard (Annales de dermafologie et de sypliiligraphie, 1899, fasc. 1, 3). It is limited to the genito-crural fossa, and when the woman is placed in the position used for the speculum examination, it appears like a triangle with the base at the fossa and the apex downward on the upper lateral side of the thighs. The skin is of an intensely dark-red colour, showing deep furrows in an oblique direction, and between them follicles can be seen. The pigmentation is very deep, due partly to the inflammatory process and partly to tJie chromatogenous condition of these regions. A -kind of small, flat, papillary growth can be seen on the surface like a lichenization, which is due to a proliferation of the connective tissues in the papilla with some hypertrophy of the epider- mic lavers. The pathoUxjii of this afl^ection is limited to the epidermis and to the superficial layer of the derma. They are the same as are found in any other inflammatory disease of the skin, hyperemia, overfilling of the blood vessels, which is the cause of the inflammatory redness, and swelling. In consequence, after increased pressure in the blood vessels, some exudation of serum and of the white corpuscles of the blood takes place through the walls of the blood vessels. The small round inflam- mator}^ cells and the white corpuscles of the blood infiltrate the papil- lary layer, and so increase the nutrition of their connective tissues. The epidermic cells are macerated by the presence of the exudation, and the horny laj^er is easily detached by the other epidermic layers, and in this way excoriations are formed. On the other hand, when the inflam- matory process lasts for a long time the papillae become infiltrated with cells, and their connective-tissue corpuscles may increase in their nutri- tion and proliferate, producing small flat papillary warts as a conse- quence of the irritation. The diagnosis of intertrigo by pathologic alterations from eczema and dermatitis is an impossibility. Bavogli, in reply to the ques- tion whether this affection, being of an inflammatory character, is DISEASES OF THE SKIN OP THE FEMALE GENITALS 193 to be classified as an eczema or a dermatitis, replies: It is a question of degree; it progresses from a pale rose-red colour to a deep reddish-violet colour. From a scarcely perceptible swelling it may attain a thick and pronounced oedematous condition, and in the same way there can be a thin, serous, scanty discharge, while in other cases an abundant, copious discharge exudes, which wets the linen of the patient. He believes, therefore, that the name intertrigo is well adapted. It gives the idea of the affection as the result of the friction of two cutaneous surfaces, and of the possibility of ciiring it in a short time by preventing the contact of the cutaneous surface. It is of a rather peculiar nature and has to be referred to dermatitis. Intertrigo is also found in syphilitic women, .often accompanying the presence of mucous patches in the secondary stage. The secretion oozing from syphilitic eruptions, which in that re- gion usually are ulcerated, causes the maceration of the epidermis, and intertrigo is the result. In these cases the first thing to do is to treat the mucous patches, and with cleanliness the intertrigo easily disappears. In the same way, for the intertrigo accompanying an acute gonor- rhoea, the first indication is to treat the gonorrhoea and prevent the gon- orrhoeal fluid from remaining on the skin of the external genitals. Al- though cleanliness ma}^ be maintained, and the improvement of the acute gonorrhoea be effected, yet the intertrigo left to itself will not heal, and it requires some attention and some local applications in order to bring about recovery. Treatment. — In intertrigo cleanliness must be observed, so as to re- move all impurities from the irritated surfaces of the skin. After wash- ing and drying, the surface is covered with rice powder or starch pow- der, to which may be added a small quantity of boric or salicylic acid (2 to 100). When the epidermis is excoriated, the surface is sore and there is a great deal of serous secretion. Eavogli finds of great advantage the use of bathing with some astringent solution. The solution of sub- acetate of aluminum and lead, known as Burow's solution, 3 per cent, applied on lint, in order to sej)arate the skin surfaces from each other, is very beneficial. If the patient can remain in bed, with a few appli- cations of this solution the intertrigo will easily disappear; but if the patient must attend to her occupations, then bathing may take place morning and evening, and during the day some salve may be applied, such as Wilson's ointment, or an ointment of — 3^ Zinci oxidi, ) __ ^ , Bismuth] subcarbonatis, f '' Acidi carbolici gtt. x; Vaselini oj- M. Fiat unguentum. This can be rubbed on the sin-face, and particularly upon the labia majora, which should be kept separated from the thighs by means of soft lint. 14 194: A TEXT-BOOK OF GYNECOLOGY In chronic intertrigo with papillary hypertrophy it is necessary to use more active remedies. Two or three applications of Wilkinson's ointment — ^ Sulphuris sublimati, ) Picis liquidge, > aa Svj; Saponis viridis^, ) Terrge albse oiij; Adipis suis oj. M. Fiat ung'uentiim. have given good results, for by causing the desquamation of the old epidermis we obtain a new soft epidermis. The application of a re- sorcin salve can also be recommended. I^ Eesorcini 3ss.; Acidi salicylici gr. vj; Vaselini fiavi oj- M. Fiat ungueutum. "When the epidermis has returned to its normal condition and the serous secretion has stopped, the only way to finish the treatment and prevent any relapses is to use scrupulous cleanliness, and after washing, to dust the genitals and genito-crural region with one of the recom- mended dusting powders. Erythema. — The skin of the genitals of the Avoman is often the seat of erythema, the result of various causes. Obstinate erythema affects the female genitals in consequence of glycosuria, and indeed it is the duty of the physician when he finds cases of erythema localized in the genitals to examine the urine. In these cases the labia minora are red and slightly swollen, the labia majora are red and swollen, the colour is rose-red, of an intense hue, and the epidermis, distended from the scanty exudation of serum, takes on a smooth, silky, and glossy appear- ance. This erythema sometimes spreads to the internal surface of the thighs, but in the usual cases it remains limited to the genitals. Ex- coriations are found on the reddened and swollen surface of the skin, produced by the act of scratching, because this glycosuric erythema is often accompanied by a persistent itching sensation — pruritus vulvae. Pruritius is in these cases very intense, and the patient can not restrain herself from scratching in order to stop this disagreeable itching sensa- tion. This deprives the sufferers of their sleep at night, and the con- stant scratching irritates the skin so much that it produces a persistent oedema or pustules, and superficial ulcerations. The presence of sugar in the urine, moistening the mucous mem- brane and the skin of the genitals, is the cause of the erythema. It must not be forgotten, however, that the tissues of glycosuric persons offer a good ground for the development of the pus germs, and as a result they are often troubled with persistent furunculosis. DISEASES OF THE SKIN OP THE FEMALE GENITALS 195 Treatment. — Although it is difricult to cure this erythema on ac- count of its persistent cause^ yet great benefit can be obtained from general and local treatment. For the first object, it is necessary to sub- ject the patient to the ordinary diet of diabetics, by forbidding all amy- laceous food and thus diminishing the quantity of sugar in the urine. These dietetic rules must be accompanied by the use of some mild purgative mineral waters, like Carlsbad, Apenta, Hunyadi Janos, Blue Lick, Congress, etc., taken regularly every morning in a dose of from half a glass to one glass, according to the tolerance of the patient. For local treatment the most important rule to follow is cleanliness. The external genitalia and the vagina are to be thoroughly washed with green soap and water and then irrigated with a 2-per-cent solution of carbolic acid. The patient is advised to remain in bed and apply com- presses with liniment of oil and limewater, to which may be added from 2 to 4 per cent of ichthyol. When the patient gets up she may make an application of Wilson's salve or the suggested formula of oxide of zinc and subcarbonate of bismuth. Lassar recommends the following formula: I^ Acidi phenylici 1 to 3 parts; Hydrargyri sulphidi rubri 1 part; Sul23hu.ris sublimati 25 parts; Vaselini Americani 100 " Olei bergamottas gtt. xxx. M. Fiat unguentum. This mixture, as it contains a great quantity of sulphur, without causing irritation prevents the development of the ])ns, germs which so often occur in the skin of diabetic persons. (Edema of the vulva may depend upon any of the conditions that interfere with the free circulation of the blood in the vulva, only a few of which are here considered. In cases of oedema of the legs as a con- sequence of heart disease or of general anasarca, the skin of the geni- tals of the woman is oedematous, swollen, of a waxy rose-red colour, the labia majora protrude in a round shape, and are sometimes painful on account of the acute distention of the skin. The labia minora and the clitoris are also swollen, presenting the same appearance; the tlughs, which are also in an oedematous condition, do not permit the woman to bring the legs close together. There are, however, cases of fjedcma localized in the genitals of the woman of angeioneurotic ori- gin, as described by Quincke, Jamison, and others. This oedema comes in th(' form of repeated attacks, which are often preceded by general malaise, vomiting, or diarrhoea. CEdema occurs in the form of a local- ized swelling of a whitish waxy rose-colour, with a certain brilliancy of the affected skin; it appears in different regions of the body, and the genitals may be included. Eavogli has observed a woman subject to attficks of this affection which could with propriety be called the giant iirti(iirl;i of Wilson, 'j'lie swcllinii: in this case was limited to the 196 A TEXT-BOOK OF GYNECOLOGY right labium, assuming the size of a fist, and it was accompanied by some j)ain and an itching sensation. It lasted for several hours and then gradually disappeared without leaving any trace. It is easy to understand that the swelling was due to an effusion of serum in the meshes of the connective tissues of the derma and of the subcutaneous tissue, and that the acute oedema was the result of an angeioneurotic affection, as the patient had frequently had similar localized oedema on half of her face and on her left shoulder. OKdema of the vulva as a result of passive hyperemia has been ob- served by Eavogli, in the practice of Tackier, in a case of Kaynaud's disease. One of the labia majora was bluish, red, and swollen, with a sloughing j^atch of superficial gangrene, together with the same as- phyctic symjDtoms in several toes. QEdema accompanied by stasis sometimes appears in one labium on account of a hard chancre concealed in the internal surface of the labium or in one side of the ostium vaginas. In this case oedema affects only one labium, which is of a bluish-red hue, showing the location of the obstacle to the circulation. It is scarcely necessary to say that as soon as the chancre begins to heal up the oedema dis- appears. Treatment. — In cases of oedema of the genitals accompanying ana- sarca, the treatment has to be directed to relieve the general condition, but the local disturbance must not be neglected. The application, in the form of compresses, of mild astringent solutions, like Burow's solu- tion in a strength of 3 per cent, or Goulard's lotion, has been found very beneficial. In the same way, when stopping the application of the compresses, the use of dusting powder, as starch or rice powder, with the addition of 3 per cent of boric or salicylic acid, is found of great service. The nurse should apply soft linen pieces between the folds of the skin, thus preventing the surfaces from rubbing each other and causing intertrigo, which often complicates oedema of the vulva. Eczema of the Vulva. — Like any other part of the body, the skin of the female genitals is subject to eczema in acute and chronic forms. In speaking of intertrigo it was mentioned that, in consequence of the neglect of care and cleanliness, it may be the starting point of an eczema. In the same way, in cases of pruritus vulvae, the irritation caused on the skin by the continuous rubbing and scratching may be the direct cause of eczema of this region. The propagation of the Staph i/lococcus pyogenes alhus on the deeper layers of the skin is to be recognised as the chief causative factor. Acute eczema may affect the vulva, implicating the labia majora and minora, clitoris, and the raucous membrane of the vagina, spreading along the periphery to the upper portion of the thighs. Along with the burning and itching sensation, a diffused redness and swelling affects the parts mentioned, and presently small vesicles appear, which soon break, causing a discharge of serum, which moistens the linen. DISEASES OF THE SKIN OP THE FEMALE GENITALS 197 Chronic eczema, however, is the form more often met with when locaUzed upon the female genitals. It often occurs in the form of ec- zema rubrum, affecting the labia majora, labia minora, and the mucous membrane of the vagina. The labia majora are red, swollen, and infil- trated, and, in consequence, the rima vulvEe is opened by the distention of the labia. On account of the unbearable itching sensation numerous excoriations are produced by the action of scratching and rubbing. In many cases the eczema spreads to the upper portion of the thighs and also to the mons veneris. On account of the spreading of the affec- tion to the vagina, an abundant secretion oozes out of the genitals, which increases the intensity of the affection. In order to be sure that the secretion is not of a venereal origin, Ravogli always makes a micro- scopic examination of it so as to exclude the possibility of the existence of gonorrhoea. Eczema of the vulva may, by continuity, very easily spread to the perineum and to the anus. The parts are red, thick, and excoriated, and serum oozes from the excoriations. Sometimes the excoriations are covered with crusts, but where there are opposing surfaces these become more or less glued. At other times no discharge takes place; the skin is rough, dry, and slightly scaly. It is always accompanied by a violent itching sensation, which causes great misery. This form of eczema may be the result of a local irritation, leucorrhoea and gonor- rhoea being the most effective factors; or it may be the result of the scratching and tearing of the skin incident to intertrigo. It may also be of reflex origin, or it may be referable to the presence of uterine dis- orders. Treatment. — Eavogli has always obtained good results by the appli- cation of ichthyol in diiferent formulge. First, care has to be taken to improve the condition of the vagina by means of irrigations with a solution of biborate of sodium, which the patient will repeat twice a day. Every other day Eavogli inserts into the vagina a tampon satu- rated with a mixture of 25-per-cent ichthyol in vaseline or glyc- erine, which the patient will leave in the vagina for twelve hours. Ex- ternally he directs the patient to apply for a few minutes a solution of carbolic acid, which relieves the itching sensation and sterilizes the afl'ected skin. The formula which he employs is: ^ Acidi carbolici 3j; Glycerini .lij; Alcoholis oijj Aquae rosse oi"^- M. Fiat linimentum. At first llie |)ntif'nt complains of some burning sensation, but she is soon willing to repeat the application for the relief which it affords to the itching. After this application the patient is directed to apply pieces of lint well saturated with the following liniment: 198 ^ TEXT-BOOK OF GYNECOLOGY ^ Ichth3'0lis oij; Olei amysxlalEe dulcis, t -- ^■ . ''-P. > aa oiv: Aquae calcis^ ) ^ly^^"^^' I aagj. Aquge rosge, [ M. Fiat linimentum. The use of salves is to be ayoicled in this condition, because the abundant secretion, together with the salve, makes rather an irritant mixture. After the repeated applications of the ichthyol liniment in the manner described, the surface of the skin begins to heal up, the itching sensation greatly diminishes, the swelling and the redness nearly sub- side, and at this point there may be applied a salve of oxide of zinc, which will finish the treatment. The formula for this salve is: E Zinci oxidi, ) -- ^ Bismutlii subcarbonatis, \ Acidi carbolici gtt. x; Vaselini flavi oj- M. Fiat unguentum. When the skin has returned to its normal condition it will retain some redness as the result of the past trouble, for the relief of which Eavogli advises the patient to continue the use of the lotion of carbolic acid twice a day, and, after drying the surface, to dust the skin with an innocent powder, as starch or rice powder, to which some oxide of zinc or subcarbonate of bismuth may be added. Folliculitis. — Either in consequence of an eczema or without a known cause, an inflanunatory process may invade the follicles of the hairs which cover the female genitals. The affection is rather rare, as Eavogli has met with this condition in only two cases, where the female genitals presented the exact appearance of sycosis. It is an in- flammatory affection in a subacute or chronic form, affecting the con- nective tissue of the hair follicles and also of the sebaceous glands connected with them. Bacteriological studies have recently explained that, like sycosis of the beard, folliculitis may be of double origin, either the result of the fungus of the ringworm or the result of the development of the pus germs in the follicle of the hair. In both cases which Eavogli had occa- sion to study, the pus cocci were the cause of the disease. In both cases the affection started from a superficial eczema and had developed until the surface gradually became covered with pustules, conical in shape, each one having a hair in the middle. It is easy to understand how the pus germs find their way into the follicles of the hair. The opening from which the hair passes through the epidermis is lined with epidermic cells, forming a kind of funnel around the shaft of the hair. According to Bockhart, the pus germs DISEASES OP THE SKIN OF THE FEMALE GENITALS 199 capable of producing this affection are the Staphylococcus alhus, aureus, and citreus, the same that can produce impetigo and furun- culosis. On account of an inflammatory process, especially eczema, the germs find the follicular openings more easy of access than in the nor- mal condition, and insinuate themselves into the follicles, thus causing inflammation of the tissues forming the follicle of the hair, and of the surrounding tissues. It will be seen that this is nothing more than a spreading of the process by continuity, when it is remembered that eczema is only the result of the production and development of the Staphylococcus pyogenes alius in the layers of the epidermis. The hair follicle, inflamed and swollen, is converted into a small abscess, as proved by AVertheim. A transudation of serum and white corpuscles of the blood takes place in the hair follicle, producing a hydropic condition of the membranes covering the root of the hair. The root is softened and swollen by sero-purulent infiltration, and in consequence the hair is easily removed, having no adherence. The papilla is usually spared from destruction, and this is the reason why in all cases of sycosis the hair is easily reproduced. Symptoms. — As in ordinary cases of sycosis, the folliculitis of the female genitals is revealed by the presence of pustules or papulo-pus- tules, each one being perforated by a hair. The pustules are conical in shape and contain a drop of pus at the point surrounding the shaft of the hair. The skin of the labia majora and of the mons veneris, when affected with folliculitis, is usually red and inflamed. This is accompanied by a burning and itching sensation. This aff'ection is often associated with boils in the same region or in the neighbouring parts of the thighs or abdomen, caused by the inoculation with the staphylococci effected by the finger nails in the act of scratching. This affection of the follicles of the hair of the woman's genitals, although chronic and obstinate, is not so difficult to treat as sycosis of the beard. It may be said that without the necessity of removing the hair, either by shaving or by epilation, this disease can easily be treated, yielding readily in a few weeks to the action of remedies. Treatment. — Of course the general system should not be neglected, although the disease is a local one. The condition of resistance of the organism to the development of the pus germs is very important, and when we begin the treatment it is necessary to establish a plan of gen- eral medication. If the patient is in an anaemic condition, prescribe ferruginous and tonic preparations; if she is suffering from a scrofulous condition, the use of cod-liver oil will be of great advantage. In case the woman is inclined to gout, or if she perspires a great deal, we must prescribe anti-gout remedies, such as lithia, salol, salicylates, etc. The local treatment consists in enforcing rules of cleanliness. Ravogli uses with good results an application of compresses well satu- rated in an astringent and antiseptic solution, and frequently repeated; also compresses saturated with a mild solution of bichloride of mer- cury (1 to 1,000) for half an hour twice a day, followed by the applica- 200 A TEXT-BOOK OF GYNECOLOGY tion of a salve, such as Wilson's ointment. In more stubborn cases the following formula can be used with good results: I^ Acidi carbolic! gr. v; Bismuthi subnitratis oss.; Unguenti hydrargyri ammoniati 5ij ; Unguenti aqua3 vosse oiv. M. Fiat unguentum. The application of ichythol is highly recommended. This is used in liniment form applied on lint, or in the form of salve, 10 per cent, in association with zinc ointment and 2 per cent beta-naphthol. Salves containing sulphur, from 4 to 6 per cent, are also found very useful. It can be applied in the form of Lassar's paste: ^ Sulphuris sublimati, ] Zinci oxidi, I aa oj; Amyli oryz^, ) Acidi salicylici gr. x; Vaselini 3J. M. With this treatment and without any necessity of epilating, as in the case of sycosis of the beard, we can obtain good results in a short time. Herpes Progenitalis. — An eruption of vesicles disposed in groups, in an acute form, is often found on the genitals of women. It corresponds to the herpes preputialis which, with the same frequency, occurs in the male sex. This eruption appears on the internal surface of the labia majora, on the labia minora, on the vestibule and prepuce of the clitoris, at the orifice of the urethra, occasionally on the external sur- face of the labia majora, and at times it spreads to the mons veneris. Eavogli has twice seen groups of vesicles on the cervix uteri, corre- sponding with the observations of Bergh (ttber Herpes Menstrualis, Monatshefte fiir PrahtiscJie Definatologie, 1890), who has seen similar eruptions, sometimes accompanied by herpes of the vulva. Before the outbreak of the vesicles there are in most cases slight burning and itching sensations. Only rarely is the itching very pro- nounced, and it accompanies the course of the affection. The eruption consists of a single vesicle, or of a group of vesicles closely arranged, or of vesicles scattered on the surface following the ramification of a nerve. It begins as a red patch, which in a few hours shows vesicles. These are usually small, from the size of a pinhead to that of a hempseed, round, transparent, containing clear serum. When affecting the mucous membrane, on account of the succulence and the thinness of the epithelium they soon break, while on the skin they re- main longer. Their contents become turbid and soon form brownish- yellow crusts. DISEASES OF THE SKIN OF THE FEMALE GENITALS 201 When the herpes is seated on the labia minora it may cause oedema of these parts, on account of the tenderness and laxity of their tissues. The vesicles when broken leave a superficial exulceration corresponding to the size of the vesicle. The bottom is of a rose-red colour, some- tim'es covered with yellow detritus, with the edges cleanly cut, but not deep, and never as in chancroid. They are usually arranged in a group, and when broken the remaining exulcerations coalesce into one patch with festooned edges, reminding one of the round pre-existing vesicles. The vesicles are seated on an inflammatory base and heal up usually in a few days; in some cases they are persistent; in rare cases they become ulcerated, and it is difficult to distinguish them from a chancroid. Un- cleanliness and the presence of gonorrhoeal fluid sometimes irritate the resulting exulcerations of the vesicles and make them persistent. Herpes is inclined to relapse at different intervals, but relapses in women are not so frequent as in men. The causes of herpes progenitalis are difficult to determine. Usu- ally this affection is the consequence of an irritation or congestion of the sexual organs. In neurotic women it is found in connection with menstruation, so that nearly every month it is reproduced. In puellce publico; cases of herpes progenitalis are often met with on account of frequent and forced coitus, and also on account of disproportion of the parts. Herpes often appears in cases of gonorrhoeal inflammation of the female genitals, and is often the result of endometritis, salpingitis, and oophoritis. It may be considered as an abortive zoster, proceeding from irritation and the nervous ramifications of the pudenda, and some- times it shows this clearly by the disposition of the eruptive patches. Although herpes progenitalis has been often suspected to be the result of the presence of cocci, yet so far there is nothing positive in this regard. Eohrer {Monatsliefte fiir Prahtische Dermatologie, 1888) found very few diplococci in the serum of the vesicles, and Pfeiffer (ibid., 1887) in a case of menstrual herpes could not find any micro- organisms. The diagfiosis of herpes progenitalis is easily made if the vesicles are still present. When, however, the vesicles are broken and an ulceration remains, there may be some difficulty in distinguishing herpes from venereal or syphilitic ulcerations. The superficial character of the lesion, the scanty serous secretion, the peculiar round disposition of the edges, the smoothness of the surface, are characteristics enough to show us that we have to do with a case of herpes. Sometimes, however, a hard chancre in its erosive stage has been mistaken for herpes. (See Syphilis of the Vulva). In women, in whom, especially, the hardness of the lesion is often not clear, we lack one of the most important char- acteristics for diagnosis. Tlie surface of a chancrous erosion is usually deeper in colour, round in shape, with a smooth surface, and is found in places where the lierpes floes not usually appear, as in the fourchette and in the ostium vagina). With reference to the possible confusion of herpes with chancroid. 202 A TEXT-BOOK OF GYNECOLOGY it is difficult for it to occur when we keep in mind the appearance of the chancroid lesion, which is the most reliable diagnostic by itself. Indeed, the jaunched-out, round, irregular, or ragged, often undermined ulcer, which rapidly spreads, accompanied with abundant secretion, and exhibiting an unhealthy, diphtheroid, worm-eaten surface, can not admit of confusion. At any rate, especially in the beginning, when no other diagnostic characteristics are present, in case of doubt it is better to suspend diagnosis, being sure that, on the following day, the doubt will be dispelled. Treatment. — As already stated, the use of douches with warm water, having in solution some borate of sodium or any other mild antiseptic, is advised. The general health of the patient must receive its proper care, and the use of mild saline purgatives is advisable when an- noyed with constipation, alkaline mineral waters when troubled with catarrhal conditions of the digestive organs, iron tonics and recon- structives when symptoms of anemia and general denutrition are pres- ent. Locally, the application of a wash containing lead and opium is very useful, especially when the herpetic eru^jtion is accompanied with pain and irritation. Touching the ulcerated surface with a solution of nitrate of silver, from 6 to 8 f)er cent, has given very satisfac- tory results. The surface is then covered with an innocent salve, as Wilson's ointment, or with vaseline containing some carbolic or sali- cylic acid. The application of powders is also used with some benefit. Iodoform is objectionable because of its odour; but aristol and euro- phen are applied with advantage on the exulcerated surface. The pow- ders have the disadvantage that they form crusts with the secretion, which soil the exulcerated surface. Ravogli prefers the use of powders when the surface is healing, at which time the parts may be dusted with oxide of zinc, subnitrate of bismuth, rice powder, or any other substance capable of keeping the surfaces dry and separated. The application of camphorated alcohol has been used as an abor- tive measure, and in the same way Depas, of Lille, advocates the applica- tipn of compresses of absolute alcohol, to which 2 per cent of resorcin and 1 per cent each of menthol and carbolic acid are added. Pruritus Vulvse. — In this affection there is no apparent eruption on the genitals; it is characterized only by an intense itching sensation of the vulva and of the vagina without apparent external causes. In cases of the presence of eczema, of lichen, prurigo, or of insects, the itching is due alike to the alteration of the skin and to the irritation of the insects; but in cases of pruritus vulvae the itching is the only symptom — one so persistent and so intense that it compels the woman to scratch and to rub the genitals, producing excoriations. If this condition lasts some time, then eczema, inflammation, swelling, and oedema of the skin of the genitals are often found, caused by the scratching and tearing of the skin. The continuous itching and the desire to scratch and rub the genitals makes the woman inclined to masturbation or to coitus, rendering her hysterical and nymphomani- DISEASES OP THE SKIN OP THE PBMALE GENITALS 203 acal. The irritation from scratching and the inflammatory process of the external genitals spread to the mucous membrane of the vagina and cause a catarrhal discharge from this organ, which increases the itching sensation. Pruritus vulvae is more often met with at the time of the menopause in women who are of nervous disposition or suffering from the recog- nised neuroses. At other times it is a premonitory symptom of a great many lesions of these organs, as fibroma, and sometimes of carcinoma. The pathology of pruritus vulva3 has been carefully studied by J. C. Webster. {Transactions of the Edinburgh Obstetrical Society, 1890-91.) As regards the naTced-eye appearances, there may be more or less hypertrophy, or none at all. As regards the hypertrophy in such cases, it is impossible to say whether it is to be associated with the primary pruritus or to be regarded as resulting from continued rubbing and scratching. It is not a constant factor. There are also many cases of simple hypertrophy without any accompanying itchiness. The micro- scopical changes found in the tissues removed in Webster's cases were of great interest, and were probably the cause of the disease. These changes were of the nature of a slowly progressing fibrosis, affecting chiefly the nerves and nerve endings of the clitoris and labia minora. Many of the nerves, if traced from deeper parts toward their termi- nations, were seen to acquire a dense fibrous character, some appear- ing as well-marked fibrous cords, the nerve fibres being compressed or destroyed. In some cases they could be followed to their special end corpuscles, which also showed the same changes. The changes were most marked in the clitoris. The Pacinian corpuscles did not appear to be affected, save in one instance where there were an abnormal number of cells in the central core. Some globular end bulbs showed an increased number of cells; others appeared as dense fibrous knobs. Some of the genital corpuscles showed the change in a marked degree, the windings of the terminal nerve fibres being often almost obliterated. The changes found in the connective-tissue framework of the clitoris and nymphae were different, being of a subacute inflammatory nature, and evidently more recent in origin than those found in the nervous structures. They were found most marked in the corium under the papillae, and affected especially the prepuce and nymphae, being found in the clitoris only in the glans under the epithelium, and much less marked than in the labia minora. In the corium of the latter were seen many minute vessels with abun- dant exudation of leucocytes into the perivascular lymphatics, while in many parts the subepithelial tissue was a mass of leucocytes and prolif- erating connective-tissue corpuscles. These changes were most marked in the hypertrophic nymphae. They were distinct from the chronic fibrosis aft'ecting the nervous structures, and were, no doubt, due to the long-continued irritation of the scratching. They affected chiefly the superficial parts — viz., the prepuce and nymphae — the nerve fibrosis being most marked in the clitoris, in which there were only a very few 204 A TEXT-BOOK OF GYNECOLOGY acute or subacute changes under the epithelium covering the surface of the glans. The causation of pruritus vulvse has always been shrouded in more or less mystery. While it is true that it is only a symptom, its pres- ence does not imply the existence as a cause of any of the recognised pruriginous diseases of the skin of the vulva. It is true that in these affections itching is a conspicuous and aggravating symptom, but it is one the existence of which is explained by manifest pathologic changes. In pruritus vulvae there are no such obvious changes; or, if there are, they are as liable to be consequences as causes. Bronson considers a general neurotic condition, either congenital or acquired, as a predisposing cause, and recognises a state of impaired conduction in the nerve of tactile sense as another causative factor. Though this usually occurs as a concomitant of hypersesthesia of the skin, it is pos- sible that it may exist independently of the latter, particularly in the atrophic changes of old age, while among the exciting causes he speaks of irritations transmitted from nerve centres, direct or local irritations, from irritants applied to the skin, or from intracutaneous sources, such as the lesions of trophic cutaneous diseases and their products; toxic or noxious materials deposited from the blood; effects of local nutritive disturbance or deranged metabolism in the cutaneous sensory nerves; and, finally, spastic contraction of the arrectores pilorum muscles. While this summarization of tlie etiology of the disease deals largely with more or less speculative pathology, it is still suggestive of what closer observation may prove to be the real causation of the disease. Ravogli, in common with other observers, recognises diabetes, or rather diabetic urine, as an exciting cause. Feinberg (Centralblatt fur Gynd- Jcologie) described two cases of idiopathic pruritus vulvae, occurring during the course of pregnancy, in which the aggravating symptoms subsided after parturition. Treatment consists in cold applications, alcoholic or ethereal, in the form of compresses applied on the genitals. Cold is more apt to relieve the itching than warm applications. In these solutions some carbolic or salicylic acid may be dissolved in the ratio of 2 per cent, and in these cases affords some benefit. Sitz baths with warm water, to which some bran has been added or some sodium bicarbonate, are to be rec- ommended. In the same way the application of vaginal douches with mild solution of borate of sodium, alum, etc., are beneficial; these douches should be followed by the application of tampons dipped in some ointment containing opium; but the application which in Ravog- li's hands has been most frequently successful is a tampon dipped in ichthyol (25 to 50 per cent) and glycerine. In very severe cases resort to suppositories of cacao butter with one fifth of a grain of morphine or cocaine has been recommended. Kholmogoroff reports success from the use of galvanism with the positive electrode, insulated to its distal tip, introduced 4 or 5 centi- metres within the vagina, while the negative, covered with chamois DISEASES OP THE SKIN OP THE FEMALE GENITALS 205 and moistened with a salt solution, was applied over the affected area. It should be remembered in this connection that chamois repeatedly applied to the skin may become infected and itself become the carrier of infection. Heidenhain applies compresses wet with a hot solution of a tablespoonful of tannin in a quart of water, the vagina having been previously douched with an antiseptic solution. This treatment is repeated every night. Mtrate of silver, sulphate of zinc in solution, and thymol in a 10-per-cent ointment, are recommended as valuable remedies. It is probable that for the relief of the purely functional pruritus careful attention to a hygienic regime comjDrises the best rem- edy. This should consist in frequent local ablution not attended with undue friction, in following a wholesome and laxative diet, and in relieving the generally accompanying constipation. Surgical Treatment. — When, however, pruritus vulvae ceases to be a purely functional disturbance and depends for its continuance upon the development of fibrosis in the terminal nerve filaments, as described by Webster, the change must be looked upon as permanent and topical, and constitutional remedies must be recognised as quite inefficient. Eelief under these circumstances can be given the agonized patient only by freely excising the affected area. In determining the extent of this operation it is essential first to ascertain the limits of the pruri- ginous areas. These, when ascertained and delimited, should be freely excised. The operation will generally involve the removal of the clitoris and its prepuce, the labia minora, and frequently the integu- ment from the inner aspect of the labia majora. In the performance of this operation the procedure designated in the chapter on clitoridec- tomy may be followed, the only change consisting in the extension of the area of denudation. Parasitic Affections of the Skin of the Female Genitals. — The skin of this region is sometimes affected with the vegetable parasite Tricho- phyton tonsurans in the form of eczema marginatum. On account of the condition of the skin, which is often macerated by the perspiration, the affection has so peculiar an appearance that for a long time it has been ■discussed whether it was the result of the same parasite, and for this reason Hebra called it eczema marginatum. At present it is accepted that this affection is nothing else than an ordinary ringworm, modified in its appearance by the locality. The moist condition of the epi- dermis allows the parasite to grow with more vigour, and the increased inflammation gives the different appearance to the affection. It is an affection found, not only on the genitals, but wherever two surfaces of the skin are close to each other. In this way we find eczema mar- ginatum of the axilla, of the breast, and of the cruro-genital fold. It is usually seen when fully developed. It appears as a reddish, moist, pigmented area circumscribed by a red, somewhat raised border, forming a circle or an arc of a circle. The border is formed by small papules or vesicles covered with brownish-yellow crusts. The surface is often excoriated as a consequence of scratching on account of the 206 A TEXT-BOOK OF GYNECOLOGY itching sensation accompanying tliis affection. The rings do not re- main limited to the genital sphere; sometimes when the disease is left without treatment they grow to reach the anal region, and spread on the pubis. It is rather difficult to demonstrate the presence of the Trichophyton tonsurans in the scales or in the crust, but with some patience and repeated experiments the fungus is found, in appearance like that of the ordinary ringworm. It is easily cured; sulphur is the best remedy. Ravogli directs the patient to wash the parts with green soap, and after washing and dry- ing, the affected skin is covered with a thick layer of Wilkinson's oint- ment, of which we have already given the formula (page 194). Bulkley recommends the use of sulphurous acid, applied in the form of com- presses on the surface. Many other remedies are used in trichophyton, such as chrysarobin or beta-naphthol, in the form of salves, which can also be applied with good results. The affection is easily manageable, and after six or eight applica- tions of Wilkinson's ointment, continiied until the epidermis exfoliates, we are sure of the success of our treatment. Pediculi Pubis. — A kind of pediculus called Phtheirius inguinalis may be found infesting the hairy parts of the woman's pubic region. Although the hairs of the pubes are the ordinary habitat of this insect, yet it may also find its way to the hair of the axillse, and in the man to the beard. This insect has a peculiar shape, resembling the form of a crab, and for this reason it has been called crab louse, and vulgarly crabs. It hangs to the shaft of the hair, inserting its proboscis into the follicle so as to obtain its nourishment from the sebaceous glands. To the naked eye it looks like a 3rellowish scale or a little crust. It causes a great deal of itching sensation, but this is seldom so severe as to cause deep excoriation, as in the case of the body louse. It always comes by contagion; sexual intercourse is the most common way of transmission of this insect, but it can be taken also from clothing, bed- ding, and from contact with the seat board of a public water-closet. This insect is very inactive; it hangs fast to the hair and to the skin, so that it is difficult to detach it. With its powerful claws it holds firmly to the hair, so that in attempting to remove it, it slides for some distance before loosening its hold. The eggs of this louse are small and adhere to the hair. A close inspection of the part affected will reveal the presence of the insect and of the nits. Treatment. — The old application of mercurial ointment is still to be recommended; one or two applications are sufficient to destroy the insect and the nits. This application, however, is somewhat dirty and may produce irritation and dermatitis. The ointment of white precipi- tate is also recommended. In his clinic Eavogli finds that coal oil gives good results; two applications are enough to kill the insects and nits. Oleate of mercury has also a good effect. After any one of these DISEASES OF THE SKIN OF THE FEMALE GENITALS 207 applications the patient takes a bath and changes the clothes in order to prevent a new transmission. Atrophy of the External Female Genitals (Kraurosis Vulvae). — Under the name of kraurosis vulvce there has been recently described an atrophy of the vulva. The name was given to the affection by Breisky, using the Greek name Kpavpo's, parched, hence withered. The atrophy is strictly limited to the skin and to the subcutaneous tissue, involving the labia majora, the fourchette, and sometimes the perineum. Charles A. L. Eeed {New Yorh Medical Journal, September 39, 1894) stated that he had never been able to observe either clinically or micro- scopically the extension of this disease to the mucous membrane of the ostium vaginae, and he believes that this affection is essentially re- stricted to the vulvar integument. For this reason the disease has also been given the more appropriate name of progressive cutaneous atrophy of the vulva. The first description of this disease is due to Eobert F. Weir, of JSTew York, who in 1875 described this affection as an ichthyosis vulvae. (Ichthyosis of the Tongue and Vulva, Neio Yorh Medical Journal, March, 1875.) Although he believed that he was describing a case of ichthyosis, yet the sym23toms have such an analogy with those of this affection that there is no doubt that he described a case of kraurosis. The knowledge of this disease is really due to Breisky, of Prague {Archiv filr JleiTkunde, Prague, 1885). In 1885 he reported twelve cases with a careful study of the symptomatology and of the pathologic alterations. Possibly such cases had come to the attention of the gynecologist before that time, but the condition had not been pointed out as a pathologic entity. Since the publication of Breisky the sub- ject has been brought to the attention of the Obstetrical and Gyneco- logical Society of Berlin, where, after a full consideration, the disease in question was recognised as a morbid entity. The first changes perceptible to the naked eye are small reddish areas around the ostium vaginae; they are not elevated; on the contrary, they are somewhat depressed. They are painful to the touch, and sex- ual intercourse is painful and futile. The vaginal orifice is very nar- row, and there is a diminished elasticity of the tissues. The skin and the mucous membrane have at this point lost a great deal of their pigment and have become thin and translucent, tense and glossy, so as to have lost all the normal folds of the vulva. The ostium vaginse is very narrow. The shrinkage is one of the leading features of this disease, but it is manifested, not over the whole region, but in different areas. Prom tbese centres the process gradually extends until the vulva has been entirely involved. The labia minora are fused together with the labia majora, and scarcely a trace of them is to be seen (Fig- 72). in some cases the mons veneris is also found in an atrophic con- dition, associated with complete alopecia. According to the observations of Breisky, in none of his cases had there existed symptoms of itillatnmation or of exanthematous affection 208 A TEXT-BOOK OP GYNECOLOGY in the external genitals. In some of his patients an unbearable itching sensation was present. Some of the women were pregnant and the itching sensation spontaneously disappeared at the end of the gesta- tion. In one of the gynecological cases the woman suffered with an itching sensation, which lasted only a few weeks. In two private cases he found one patient who had been afflict- ed with pruritus for several years, the af- fection being most annoying at night; she also had leucor- rhcea and menor- rhagia. In another case the pruritus had been present for nearly three years, with relapses at the time of the menstru- ation lasting from two to three days. Breisky drew his conclusions from the consideration of all his cases as follows: That chronic vaginal catarrh was present in 4 cases; that in 2 cases scars were pres- ent from progressed scrofulous abscesses of the cervical glands; not one had suffered with syphi- lis; 1 Avas sterile, 2 were multipara?, 5 had given birth to one or more children. Not one of the multipara? had had trouble with her delivery, and in no one had there been an inflammatory process of the external genitals. Al- though Breisky was of the opinion that this disease was the result of a chronic eczema, yet he never could find this affection in his cases. In the same way the pruritus seems to be one of the principal causes of this disease, and yet only in 3 of his cases was it present. Indeed, the etiology of this disease is very obscure. It occurs with- out previous existence of other diseases of the skin of the vulva. In Fig. 72 (Keeu).— '-The labia minora are fused together with the labia majora and scarcely a trace of them is to be seen."— Eavogli (page 207). DISEASES OF THE SKIN OF THE FEMALE GENITALS 209 the cases reported by Orthmann no sugar could be found in the urine and there was no history of syphilis. In the cases reported by Reed, in one there was a history of progressed syphilis in early life, but no later manifestations could be found. So that it has been established and confirmed by Jjcwin (Centralblatt fur Gyndlcologie, 1894) that the atrophy of the vulva is not of a syphilitic origin. Gonorrhoea and no specific chronic catarrh are considered by some observers as probable etiological factors. This disease is found only in women over forty, which would identify this atrophy with trophic changes induced by advancing age. Olshausen lays a great deal of stress on the extirpation of the uterine appendages as a cause of this atrophy, which relation was found in one of Eeed's cases. In one of Jevonsky's cases the affection had started from a cicatrix in a lacerated perineum. From the multi- plicity of the possible causes held to be factors in this disease, it seems that no one must be considered as such, and Reed prefers the theory that the peripheral trophic nerves or their ganglia are to be consid- ered as the origin of this disease. This histologic condition of the skin, as found by H. W. Bettman in Reed's cases, shows, as one of the most important features, a marked hypersemia, which in some places assumes the character of true hemor- rhage. The epi- dermis shows great changes ac- cording to the .different places ; in some points it is hardened, thickened, and hypertrophic, in other places thin and atrophic, and in other places has nearly disap- peared (Fig. 73). The corium shows two different con- ditions. One is due to the exuda- tion and infiltra- tion of round in- flammatory cells into the stroma of the corium, and the other is due to the sclerosis and atroy)hy of the tissues. These are two different condi- tions, one the consequence of the other, and due to the changes of the process. In the first condition the papillae are infiltrated, in the second 15 Fig. 73 (Eeed). — " The epidermis shows great changes according to the different places." — Ravogli. 210 A TEXT-BOOK OF GYNECOLOGY they are shrunken and have nearly disappeared. In the same case the different sections show a difference in the pathologic alterations. From the ahove observations it is plain that the anatomic lesions are of a different character, according to the stage of the disease. In the begin- ning the hypergemia and exudation predominate in the tissues, later the^ lesions consist of a thickening and shrinking of the tissues in sclerosis. The siihjedive symptoms of this disease consist at first of painful points and a painful inelasticity, which are impediments to the copula- tive act. In the later period there is a loss of 'sensation in the entire diseased area. Itching is not a constant symptom, and in most of the cases is absent. In 35 cases referred to by Ohmann-Dumesnil 13 cases were troubled with itching in various degrees. In 5 cases referred to by Orthmann {Zeitschrift filr Gehurtshulfe und Gynakologie, Stuttgart, 1890) only 1 patient complained of an itching sensation. In 6 cases re- ferred to by Reed, 2 only were annoyed in that way, and that only at the beginning of the affection. The diagnosis is often made as vaginismus in the beginning of the affection, but careful inspection will reveal the sensitive areas at the ostium vaginre and the already begun shrinkage of the vulvar integu- ment. When the areas of atrophy have begun it is possible to mistake the disease for ichthyosis, but in this disease there are adherent scales,. which are never found in kraurosis. In reference to the prognosis, Tait says that the patient should always be informed that the progress of the disease will extend over- years, that it will certainly get well in time, but that treatment from time to time will give relief. It seems that the recovery alluded to is nothing else than the disappearance of the subjective symptoms. We can not promise recovery to the patient affected with this disease under any circumstances. The treatment may be divided into palliative and curative. The first is obtained by remedies to relieve pain. Carbolic acid in the form of a lotion, on account of its anaesthetic quality, affords some temporary relief. Tait recommends the application between the small labia, at bedtime, of a piece of cotton dipped in a solution of neutral acetate of lead in glycerine, as capable of giving relief. A mixture of tannin and salicylic acid in glycerine has been used in the same way with good results. Tait condemns cocaine as useless and irritating. The appli- cation of nitrate of silver in stick to cauterize the degenerated patches, so as to obtain a good cicatricial tissue, diminishes the sufferings, but does not arrest the progress of the disease. Heitzmann tried to scrape off with a sharp curette the hard tissues involved, but the length of time this process takes, and the poor results it gives do not commend it. The general tonic treatment must be strongly enforced so as to improve the general condition of the patient. As a curative treatment Eeed mentions an operative process by excision. This he applied in an incipient case of kraurosis, which was limited to a vascular ring around the ostium vaginae. The mucous DISEASES OP THE SKIN OF THE FEMALE GENITALS 211 membrane of this locality was completely excised in the form of an ellipse, and the denuded edges were brought together by means of in- terrupted sutures. The patient had some temporary relief, but seven months after, the disease appeared on the integument. Martin, as re- ported by Orthmann, has begun the method of a complete excision, which must be applied according to the affected parts, removing the tissue thoroughly and approximating the edges. In this way eight cases operated upon by Martin completely recovered. The same operation in the hands of Eeed has given very good results (Fig. 74). It is neces- sary not to operate in the be- ginning of the affection, be- cause the process is not yet limited, and it is liable to spread, in spite of the opera- tion. But when the operation is performed at the time that the sclerotic process is lim- ited, then there is no danger of a recurrence of the disease. Vulvar Adhesions. — The vulva externally consists of integument arranged in a series of folds with proximal surfaces. The fold between the labia majora and the labia minora and that be- tween the glans of the cli- toris and its prepuce, are striking examples, while the surfaces of the labia majora lie in approximation, particu- larly in case of pudendal re- dundancy. These proximal surfaces are ordinarily pre- vented from becoming ad- herent through the protective influence of the epithelial layer of the skin. There occur cases, however, of antenatal blending of these structures (see Malformations of the Vulva); others in which adhe- sion occurs speedily after birth; and still others in which, as the result of desquamative or similarly destructive inflammation of the skin, the epithelium becomes destroyed and the now denuded and ap- proximated surfaces unite. Morris {Transactions of the American Asso- ciation of Obstetricians and Gynecologists, 1892) called attention to the frequent adhesion of the prepuce to the glans clitoridis, a condition Fig. 74. — " The same operation in the hands of Keed has given very good results." — Eavogli. 212 A TEXT-BOOK OF GYNECOLOGY which, he insists, exists, to a greater or less extent, in 80 per cent of Aryan American women. He finds it very rare among the negresses; and looks upon its occurrence as a phase of evolutional change. When preputial adhesions are extensive, the glans clitoridis and the impris- oned mucous follicles remain comparatively undeveloped, but attain their normal growth after liberation of the adhesions. When these adhesions are slight they are of practically no clinical importance, but when they embrace a considerable part, or the whole, of the glans cli- toridis, they cause profound disturbances; so much so, that Morris con- siders that preputial adhesions probably form the most common single factor in invalidism in young women. Bacon {American Gynecological and Ohstctrical Journal) summarizes his observations and experience of preputial adhesions in the female, with the statement that they are prone, by the irritation they induce, to cause masturbation and the various neuroses; and that the prevention by them of the development of the glans clitoridis frequently results in eroticism. The damaging influence of these adhesions is experienced relatively more in the child than in the adult, for the reason that in the former the reflex nervous centres are less under the control of inhibitory impulses, and peripheral irritation consequently produces disturbances that would not be ex- perienced in maturer years. The treatment of this condition consists in breaking u]i the adhesions as soon as they are found, or particularly as soon as they are recognised as causes of mischief. Bacon is of the opin- ion that every female child should be examined, and the clitoris, if found adherent, should be liberated in the earlier weeks of life. The operation for this purpose consists in peeling the prepuce off the glans by means of a grooved director or other blunt instrument, and in keep- ing the area dressed antiseptically until it heals, care being taken fre- quently to separate the proximal surfaces to prevent readhesion. In labial adhesions, partieularl}^ when these are of antenatal occurrence, the structures are frequently so intimately fused as to defy separation. In certain of these cases the labia minora will be found implanted upon the surfaces of the labia majora so intimately that upon retracting the latter the former can be detected only in outline. This condition is rarely of any clinical importance. It may, however, give rise to local disturbance from the accumulation of sebaceous matter secreted by the rudimentary follicles that are incarcerated within the adhesions. When this occurs the accumulation should be liberated by incision, while at the same time an eft'ort should be made to break up the fusion. CHAPTER XVIII HYPERTROPHIC AND HYPERPLASTIC DISEASES OF THE PUDENDAL ORGANS Hypertrophy of the clitoris — Condylomata— Elephantiasis — Polypi — Treatment. The hypertrophic and hyperplastic diseases of the pudendal organs are, as a rule, acquired. Congenital hypertrophy of the vulva is com- paratively rare and is confined to single parts of the pudendum. The parts usually found enlarged in congenital hypertrophy are the labia minora and the clitoris. In the case of the former, it is often difficult to decide at the time when the observation is made whether one is deal- ing with a true congenital condition or with one acquired by accidental pathologic processes. Manipulations are employed by certain tribes to bring about a hypertrophy of the labia minora. As is well known, the South African Hottentots, by certain methods practised on their female children, produce that enormous hypertrophy of the labia minora described as the " Hottentot apron." Hypertrophy of the clitoris, while occasionally an acquired condi- tion, is probably the most common form of congenital hypertrophy of the pudendum. A large number of cases of this kind have been de- scribed, one of the most remarkable by Fehling, who reported the case of a girl of twenty-one years with a clitoris five inches long, as thick as a thumb, and with a glans one inch long. Extensive congenital hyper- trophy of the clitoris is frequently combined with atresia of the labia minora, descent of the ovaries, and other anomalies obscuring the true sex of the individual, and bringing about the condition known as female pseudo-hermaphrodism. (See Malformations of the Vulva.) This con- dition is simply one in which, owing to anomalous development, the pudenda simulate to a certain degree the male organs of generation. Of the acquired hypertrophies and hyperplasias, there are two im- portant groups of morbid conditions which have to be considered, viz., the condylomata and elephantiasis. Both of these are more prop- erly to be looked upon, not as truly neoplastic formations, but as hyper- trophic and hyperplastic diseases, since they develop upon an inflam- mn,toi-y basis. Condylomata ai*e usually present as elevated condylomata (C. acu- minata), more I'arely as broad condylomata (C. lata). They develop on tin iiifl;iiiirii;ilory basis, which may be sim])le, gonorrhroic, or syphi- lilic ( 'ofi'lyloinuta, are, liowever, not to be considered as a specific 213 214 A TEXT-BOOK OF GYNECOLOGY process, but as a secondary hypertrophy, developing, as the case may be, on either a specific or a nonspecific soil. In an early stage these hypertrophies form small, pointed elevations, warty in character. They are found on the labia niajora and labia minora, the clitoris, the mons veneris, and they spread not infrequently over the skin of the peri- neum, around the anus, and over the inner surfaces of the thighs. They are first found united in smaller groups, with spaces between them free from excrescences. Later on, they often become confluent, forming large masses which hide entirely from view the whole of the pudendum, the latter being then covered by an uneven, irregular, ragged, papillomatous, or cauliflower mass (Fig. 75), In colour they Fig. 75. — "They become eontliunt. l^iming large masses which hide from view the whole of the pudendum." — Herzog. may vary from a grayish-white to a pink or rose-red. The surface may be dry and shiny, or it may be moist. It is usually not ulcerated, unless it has been subjected, in consequence of very improper care, to a good deal of friction or other irritation. One of the notable features of these condylomatous masses is their very rapid growth during the period of gestation. This is evidently due to the increase of the blood supply to the genital organs in pregnancy. Microscopic examination of condylomatous masses shows that they consist mainly of enormous hypertrophies of the papillary layer of the skin. The papillae, normally short and simple, become elongated and branched like a tree; they divide dichotomously or in a digitate manner. These hypertrophied papillae consist of connective-tissue fibres and round, oval, or stellate cells, supporting a network of blood vessels. The HYPERTROPHIC AND HYPERPLASTIC DISEASES 215 :finest papillary branches are mainly composed of blood vessels with only scanty connective-tissue fibres and cells as a stroma. The hyper- trophic fibrillar connective tissue frequently shows an extensive round- cell infiltration consisting of polynuclear leucocytes and mononuclear lymphocytes. The epithelial layer covering these complicated hyper- trophic papillaa is thickened. The thickening is noticeable in the Mal- pighian layer, or stratum germinativum, as well as in the older more .superficial strata. Condylomatous, cauliflower masses of the vulva, may be confounded with carcinomata of the vulva, which are also apt to form cauliflower excrescences. Besides the clinical features which have to be consid- ered, a careful microscopic examination of a series of sections, made vertically in the direction of the papillary layer, can always clear up the diagnosis. We have in carcinoma as the most prominent histological feature the great proliferation of the epithelia of the skin. These pro- liferating cells form alveolar or tubular nests which are surrounded by connective tissue. In condylomata, on the other hand, we have the great hypertrophy of the connective tissue, and the hypertrophic con- nective-tissue masses are surrounded by layers of epithelial cells. There occur also certain small excrescences on the pudendum, due to frequent masturbatory manipulations, which must not be mistaken for what is to be classified as a true condyloma of the vulva. The excrescences of this type, which may to some extent simulate an early stage of condylomata acuminata, are generally found on the mucous membrane between the margin of the hymen and the labia minora, and also in the neighbourhood of the external meatus of the urethra. They are easily distinguished from true condylomata by the fact that they are small in size, simple, and not branched. They occur on the mucous surfaces only, and do not spread to the epidermal surfaces of the vulva or neighbouring parts. They are never infectious in nature, and occur most frequently in virgins of a hysterical disposition. Keeping these points in view, one is not likely to mistake these masturbatory excres- cences for true condylomata. The treatment of the venereal warts consists in their removal. This is done either by surgical means or by caustics; the first, however, is always preferable to the second. In case of small warts on the female genitals, they must first be washed with a solution of bichloride (1 to 1,000), or with a solution of carbolic acid (1 to 100). After drying them with cotton they are soaked with a cocaine solution (5 per cent), and then they are scraped off with a sharp curette, removing the small growths completely. On ac- count of the richness in blood vessels of the warts at their points of in- sertion thoy bleed freely. The bleeding is stopped by the application of a tampon (]it)ped in a saturated solution of perchloride of iron. With this process llavogli has obtained very good results, and he states that very seldom has he seen a recurrence. In case the warts should grow up again, it is better to destroy them at once by toiu;]iing them with a 216 A TEXT-BOOK OF GYNECOLOGY solution of ehloracetic acid, lactic acid, or acid nitrate of mercury. Tay- lor recommends the use of collodion containing bichloride of mercury, 30 grains to the ounce, or salicylic acid, 1 drachm to the ounce. Caustics are used independently of the curetting to obtain the destruction of the venereal warts. A strong solution of chromic acid, from 1 to 4 drachms to the ounce of water, has been applied^ but the pain which results is absolutely unbearable, and the cauteriza- tion is not limited, affecting also the healthy skin. J. W. White re- ferred to the case of a woman who died in collapse in twenty-seven hours from the ap^olication of this solution on warts affecting the vulva and the anus. {Journal of Cutaneous and Genito-urinary Diseases, 1889.) When the condylomata have attained an extraordinary develop- ment, it is necessary to remove them with the galvano-cautery loop, by which means we can prevent loss of blood. When there are warts round the meatus of the urethra, care must be taken not to cause any laceration or wound, which may be the origin of a scar strieturing the meatus. Taylor recommends the application of a powder of equal parts of calomel and salicylic acid, whicli has often given him very satisfactory results. Caesar Boeck {Monatshefte filr prakiisclie Dermatologie, 1886) rec- ommends the application of a watery solution of resorcin on the con- dylomata, especially when they have a tendency to recurrence. He vises also a powder of resorcin, eight parts, and bismuth subnitrate and boric acid, one part each, to dust the condylomata, claiming prompt and effective results. The following formula, which is applied after the warts have been well bathed with a solution of bichloride, as above described, has been also praised: ^ Acidi salicylici, ) _. ^^^ . Chrysarobini, ) * '' Collodii flexilis §j. M. To be applied twice a day. In Ravogii's clinic he has found formaldehyde very useful, which he applies in a strength of from 8 per cent to 42 per cent, as it comes in commerce. The application of pure formaldehyde is rather painful and requires the previous us'e of cocaine to diminish the pain. One or two applications have been sufficient to cause the condyloma to become necrotic and slough off. It is necessary to direct attention to the condition of the vagina and of the womb, to be sure that gonorrhoea has entirely ceased. Elephantiasis vulvae may be defined as a pale whitish tumour for- mation, or swelling, arising from the labia majora and labia minora and from the clitoris. It is by no means an easy matter to properly classify elephantiasis vulvae. There is practically nothing known as to the true HYPERTROPHIC AND HYPERPLASTIC DISEASES 217 etiology of this affection, but it appears that most cases of elephanti- asis deyelop on an inflammatory soil. It is certain that all fully devel- oped and characteristic cases histologically represent an immense hyper- trophy of connective-tissue elements. Hence elephantiasis vulvae is here classified under hypertrophic diseases of the pudendal organs. It must, however, not be forgotten that elephantiasic formations in other parts of the skin have been shown to be true neoplasms, lymphangeiomata — i. e., tumours consisting of newly formed lymph vessels and other lymphatic elements. Elephantiasis vulvse may develop from a single place, or it may be multiple from the start, the single component parts becoming confluent later on in the course of the disease. The connective-tissue prolifera- tion in elephantiasis leads to the largest tumour formations that are found in connection with the pudendal organs. In its incipient stages, elephantiasis can not be distinguished clinically and macroscopically from any simple noninflammatory hypertrophy, but, later on, the enor- mous size of the hypertrophic for- mation distinguishes it clearly from any other known condition. In growing, the tumour gets so heavy and large that it becomes pedunculated in consequence of its own weight, the main mass often reaching down to the knees. While, with us, elephantiasis vulvge is a comparatively rare dis- ease, it is quite frequently met with in some of the Eastern and tropical countries. The different forms of this affection have been variously classified according to certain prominent morphological characters. Tumours showing even surfaces have been called ele- phantiasis phrosa, while those showing a warty surface have been called papillary elephantiasis (Eig. 76). Another classification makes three subdivisions, as follows: Smooth surfaced tumours cov- ered by skin which is not mate- rially different from the surrounding epidermis — elephantiasis qlabra; tumours showing an irregularly nodular surface — elephantiasis tuherosa; and tumours with a surface showing numerous small warts and excres- cences — elephantiasis condylowaiasa. The microscopic picture of elephantiasis vulva? varies according to I he variety of ili(! liinionr and its stage of development. In the smooth Fig. 76.—" Tumours showing a warty surface have been c&WeA papillary elephantiasis.'''' — Herzog. 218 A TEXT-BOOK OF GYNECOLOGY and tuberous forms the great mass of tlie tumour consists of a tissue composed of old fibres quite poor in nuclei. This connective tissue shows a marked oedematous infiltration and is sparingly vascularized. Capillaries and small arteries exhibit a perivascular round-cell infiltra- tion. The papillary body of the derma is poorly developed, the epi- thelial layers are thinned out, sebaceous and sweat glands are present in small numbers only, and even absent over large territories. While in the first two forms described, the papillary body is not hypertrophic, but rather atrophic, the third form, the elephantiasis condylomatosa, is characterized, like the true condylomata, by a well-marked hypertrophy of the papillae of the skin. In all three forms, when well advanced, there is also a great deal of thickening of the subcutaneous connective tissue, in which sometimes evidences of new formation of lymph vessels may be found. Pozzi and other French au- thors describe the his- tory of elephantiasis as presenting a num- ber of stages. The hypertrophied skin, according to their de- scription, first takes on an embryonal type, containing also large lymph spaces like those found in true lymphangeiomata. There occurs then, after an oedema has been established, an extensive lymph stasis and infiltration of the tissues with lymph. In this stage, there are also found in the elephantiasic tissues lymph glands in a state of fibrous de- generation. The last stage is represented by an enormous thick- ening of the skin, which, according to the French authors, from whom others differ, com- prises all the layers. According to the view now generally adopted, the thickening in most cases is chiefly confined to the subpapillary and sub- cutaneous layers. Superficial ulcerations not infrequently occur when the tumour Fig. 77.- -" The prepuce, now divided into two flaps, is cut away." — Eeed (page 220). HYPERTROPHIC AND HYPERPLASTIC DISEASES 219 has attained a larger size, and sometimes the l5rmph vessels are so greatly enlarged and dilated that they produce a lymphorrhoea from the ulcerating portions. Tlie etiology of elephantiasis is still very obscure. Patients suffer- ing from elephantiasis vulvse not infrequently present the cicatrices of inguinal buboes or scars on the vulva. Frequently a history of syphilis may be obtained, and undoubted syphilitic manifestations may coexist with elephantiasis. The latter, however, can not be eradicated by an antisyphilitic treatment, though one sees occasionally a transitory im- provement after the free exhibition of the iodides. Polypi of the vulva, which authors frequently classify under neo- plasms of the pudendal organs, belong more properly, if one excludes the true fibromata, to the hypertrophic and hyperplastic diseases. These polyps, usually found in the neighbourhood of the external meatus, rep- resent hypertrophies of the mucous membrane of the vestibule. They vary from the size of a pea to that of a hazel- nut, are soft and pinkish in colour, smooth or mulberry- like, sessile or pe- dunculated. Micro- scopically, they show a loose fibrillar con- nective tissue with round - cell infiltra- tion, are covered by squamous epithelial cells, and often con- tain glandular spaces lined with columnar epithelium. They are due to inflammatory irritations, and it has recently been found that they sometimes contain gonococci. The treatment of hypertrophic and hy- perplastic diseases of the pudendal organs is almost exclusively surgical. Polypi should be treated in the same manner. Acquired enlargement of the clitoris, when a source of persistent local or constitutional disturbance, should be treated by extirpation. (See Clitoridectomy.) E. C. Dudley looks Fig. 78.- -" The exposed raw surfaces are closed by a series of fine catgut sutures."— Keed (page 220). 220 A TEXT-BOOK OP GYNECOLOGY upon acquired hypertrophy of the clitoris, and more particularly its prepuce, as being ordinarily the result of masturbation. Those cases in which the clitoris is moderately enlarged and surrounded by an abundance of loose, flabby, redundant preputial skin, he treats by what he calls circumcision. The prepuce is slit up on the dorsum of the cli- toris, as would be done in a similar operation on the male, or as is done in the initial step of clitoridectomy. The prepuce, now divided into two flaps, is cut away by seizing first one flap and then the other with a forceps and cutting it ofl^ at its base with the scissors (Fig. 77). The exposed raw surfaces are closed by a series of fine catgut sutures (Fig. 78). CHAPTEE XIX NEOPLASMS OF THE EXTERNAL. GENITAL ORGANS (A) Benign neoplasms of the pudendum: Varices, fibrorayomata, pure myomata, myxomata, lipomata, enchondromata, neuromata, cysts — Benign neoplasms of the vagina: Cysts, fibromata — Treatment — (B) Malignant neoplasms of the pudendum: Carcinomata, sarcomata, melano-carcinomata — Malignant neo- plasms of the vagina : Sarcomata, carcinomata — Treatment : Excision — Clitori- dectomy — Extirpation of the vagina. Benign Neoplasms The pudendal organs, like other part.s of the female genitalia, may become the seat of neoplastic diseases. These neoplasms, from a histo- pathological standpoint, are to be divided into connective-tissue tumours and epithelial new growths. For practical purposes it seems advisable here to separate the nonmalignant from the malignant new growths. Among the former there will be included in this consideration some pathologic conditions which, strictly speaking, do not belong to the tumours at all. Benign Neoplasms of the Pudendum. — It is a matter of doubt whether true hemangeiomata — i. e., tumours developing from and char- acterized by a new formation of blood vessels — have been observed in the pudendal organs. There are to be found, however, in literature very few reports according to which true neoplastic angeiomata have been observed in the vulva. The condition frequently found and described as varicose tumour of the vulva is not a genuine neoplasm, but represents varicosities due either to local or to general disturbances of circulation (Fig. 79). All circulatory disturbances of the lower half of the female body have a tendency to lead to marked manifestations in the vulva, its great sup- ply of blood vessels favouring very much venous stasis and the for- mation of varicosities. Pregnancy is a most fruitful cause of enlarged congested veins in the pudendal organs. We then find the veins of the labia majora greatly congested and dilated, and they rise as promi- nent purple swellings over tbe level of the surrounding skin. Large tumours of the ovaries, as well as fibromyomata of the uterus, may produce similar swellings. Valvular lesions of the heart, as well as nephritis, cause enormous o'deiria of the vulva and produce swellings of 1lic hi bin iii;ijor;i that attain at times great dimensions. Chronic 221 222 A TEXT-BOOK OP GYNECOLOGY inflammatory conditions in the pelvis also lead occasionally to vari- cosities of the piidendiun. The greatly dilated and enlarged veins may imdergo secondary changes, as phlebitis and fatty or calcareous de- generation, when there may occur, even in the absence of any appre- ciable force or insult, spontaneous hemor- rhage into the tis- sues ; a hematoma vulvce is thus estab- lished. (See Inju- ries of the Vulva.) Among the be- nign true tumours of the vulva the fibromata and filro- myomata are prob- ably the most com- mon, though they are by no means fre- quently met with. These new growths take their origin from the subcuta- neous connective tis- sue of the labia ma- jora and labia mino- ra, more rarely from the clitoris. They form hard, somewhat nodular, roundish, oval, or elongated masses, covered by normal skin. Histo- logically these tumours consist of newly formed, wavy, fibrous, connect- ive tissue, very poor in nuclei, which is surrounded by a capsule made up of a condensed tissue of the same type. The skin is generally somewhat movable over the capsule and is not much changed in its structure and appearance. The tumour proper frequently contains, besides fibrous connective tissue, nonstriated involuntary muscle fibres or cells, so that the neoplasm assumes the character of a fibromyoma. Pure myomata of the vulva are very rare, though they have been observed occasionally. Wliile the tumours of the fibromyomatous group are, as a rule, firm, hard, and solid, there may occur in them, in con- sequence of lymph stasis, lymphangeiectatic spaces of large extent. In a case of this kind, diagnosis between fibromyoma and elephantiasis- may be impossible without the aid of a microscopic examination. The latter, however, will clear up the diagnosis. The fibromata show a Fig. 79. — ''The coudition frequently found and described as varicose tumours of the vulva." — Herzog (page 221). NEOPLASMS OP THE EXTERNAL GENITAL ORGANS 223 well-circumscribed proliferation and new formation of connective tis- sue, while in elephantiasis the hypertrophic processes of the connective tissue are diffuse and infiltrating, and there are also characteristic changes in the skin, which is practically unchanged in fibroma and fibromyoma. These tumours, as has been shown recently, frequently do not arise from the pudendal organs proper, but from the round ligament, and only later on in their growth and development descend into and en- croach upon the pudendum. Fibrous tumours starting primarily from the fascia of the pelvis may likewise in the course of their development and growth descend into the pudendum and present as tumours of the latter. The fibromata and fibromyomata of the pudendal organs have been observed at all ages from about the age of puberty until long after the climacteric period. They may be single or multiple. Their growth is usually slow, but they may become very large in size, reaching down to the knees, and weighing as much as fifteen pounds and more. When these fibrous tumours attain a large size they have a tendency to become pedunculated. Some fibromata show a pedunculated character from the start, forming small, elongated projections from the integument of the labia majora. They have been described as fibroma molluscum or mol- luscum pendulum of the vulva. The larger fibromata of long standing are apt to become ulcerated on the surface by pressure and lack of proper care and cleanliness. They are also liable to undergo calcareous degeneration. Another sec- ondary change to which they may become subjected, consists in an extensive oedematous infiltration, in consequence of which the fibres composing the neoplasm become pushed apart. Such tumours are not hard, but rather soft; they may even show pseudo-fluctuation, and microscopically their tissue looks very much like a myxoid degenera- tion, though it really only represents an extensive oedematous infiltra- tion. Fibromata so changed have frequently been reported as myxo- mata or myxofibromata. Lipomata of the vulva are rare. They are occasionally found in the mons veneris or in the labia majora and form well-differentiated round- ish tumours. They are very much softer than fibromata, and, like them, are sometimes pedunculated. Like the fibromata, the lipomata of the vulva have a tendency to increase rapidly in size during pregnancy, to again somewhat decrease after the termination of gestation. A very few cases of congenital lipoma of the labium majus have been reported. Enchondromata and neuromata of the vulva have been described, but since these reports are not based upon a microscopic examination, they can not be accepted as valid evidence of the actual occurrence of such tumours. C't/.s/.s of the vulva may here receive some mention, although they are almost without exception not true neoplasms, but mere retention cysts. The cysts found most frequently in the region of the vulva are 224 A TEXT-BOOK OF GYNECOLOGY developed from the glands of Bartholin, either from the gland proper or from its secretory duct. (See Vulvo-vaginal Gland.) Other cysts similar in character to those of the vulvo-vaginal gland take their origin from Gartner's duct, which, as is well known, occa- sionally extends downward into the vulva. There are also sometimes found in the labia majora atheromatous cysts and dermoids. They are lined internally by squamous and some- times by cylindrical epithelium; acinous glandular structures have been described in connection with such cysts. Small, yellowish, translucent cysts, observed not unconmionly on the hymen, are, as their structure and contents show, retention cysts of sebaceous glands. There have also been observed on the hymen small multiple cysts of the character of lymphangeiectatic formations. Aside from the cysts of the vulvo- vaginal glands due to gonorrhoeal infection, cysts of the pudendal organs, as before described, have no important practical bearing; they are generally discovered only accidentally, not giving rise to any symp- toms. In rare cases larger cysts of this type may give rise to slight in- conveniences in consequence of their size. Benign Neoplasms of the Vagina. — Cysts of the vagina are not so very uncommon. According to the statistics of Neugebauer, they are found in one of every six hundred women presenting themselves for examination. They are usually solitary, and when multiple rarely more than three or four are present, which tend to arrange themselves in rows. Most frequently they are found in the upper part of the vagina, especially growing from the anterior wall, though they may develop in the lateral walls, as well as in the lower part of the vagina. They vary in size from a pea to a hen's egg, though Yeit has reported a case in which the cyst reached the size of a foetal head. In most instances, however, they tend to grow slowly, and rarely reach a large size. Age appears to have no influence in their etiology, as they occur in virgins as well as in women who have borne children. Many the- ories have been advanced in explanation of the origin of these cysts. Huguier and Guerin thought they always grew from glands which were present in the walls of the vagina. In later years the tend- ency has been to regard all cysts of the vagina as having their origin in the remains of the WolflHan bodies. While a certain proportion of cysts no doubt originate in this manner, this theory fails to explain the origin of many cysts which develop in locations remote from such embryonal structures and which are very superficial. More recently Preuschen was able to demonstrate the actual existence of ductlike glands in a number of cases examined post-mortem, which were lined with columnar epithelial cells, from which fact he attributed to those cysts occurring in locations other than the anterior or lateral walls of the vagina a glandular origin. It is evident, therefore, that we must admit the glandular theory as explaining the origin of a certain propor- tion of smaller cysts, while most of the larger cysts develop from the NEOPLASMS OF THE EXTERNAL GENITAL ORGANS 225 •embryonal remains of the Wolffian bodies. In addition to these theo- ries, the possibility of dislocation of islands of epithelium which become embedded in the subcutaneous tissue, the result of trauma — as, for •example, childbirth, or operations on the vagina, which afterward give rise to cysts — must always be borne in mind. Finally, dermoid cysts may develop in the wall of the vagina, usually in the recto-vaginal .septum. Cysts of the vagina are rounded tumours, frequently biscuit-shaped, hemispherical, or fusiform, with tense elastic walls encroaching on the lumen of the vagina. Earely they may assume a polypoid shape, having protruded to such an •extent as to form a pedicle (Fig. 80). The cyst wall varies much in thick- ness. In case the ■cyst is large the wall may be very thin and the contained fluid of a clear col- our, giving the cyst a bluish translucent appearance. The cyst con- tents are usually a thin, clear, yellow- ish, transparent fluid, though they may be viscid, tur- bid, and even of a dark - brown colour from the presence •of disorganized blood. Microscopic- ally, the cyst con- tents are poor in organized elements, , . , , ,^ , • 11 ^i"^- 80 (Keed).— " They may assume a polypoid shape hav- thOUgJl occasionally j^^^ protruded to such an extent as to form a pedicle."- there are to be found Rothrock. mucous corpuscles and groups of desquamated epithelial cells, cylindrical and squamous, together with cholesterin crystals and fatty detritus. Should the cyst become infected by y)yogenic micro-organisms, suppuration takes place, and the contents will then consist largely of pus. Vaginal cysts are usually simple, though occasionally the remains of septa may still be observed. Earely, multilocular cysts have been •desci'ibed, Poupinel having met with one composed of fifteen small 16 226 -^ TEXT-BOOK OF GYNECOLOGY cysts. On microscopic examination the cyst wall is made up largely of fibrillary connective tissue, though in a certain number of cysts, smooth muscle fibres are present, more or less uniformly distributed. Great difference is noted in the epithelial lining of vaginal cysts. Usually it consists of a single layer of columnar epithelial cells, which may be ciliated. Occasionally the epithelial lining is polymorphous, consisting of cuboidal, cylindrical, and squamous cells, or the cylindrical cells may be entirel}' replaced by the squamous type. Veit attributes this change, especially when the cysts are large, to the pressure of the cyst contents. In a few instances invaginations of the epithelial lining into the cyst wall have been observed, the occurrence of which has been advanced as. proof of the glandular origin of such cysts. Fibroids are the rarest of all neoplasms of the vagina. They are usually rounded, very rarely reaching a size larger than an orange,, tliough tumours weighing as much as two pounds have been observed. They are almost invariably solitary and usually sessile, only exception- ally forming a pedicle. Their favourite location is the upper portion of the anterior vaginal wall. The etiology of these tumours is still obscure. They are most frequently met with in middle life, though they have been observed in children. Von Eecklinghausen has advanced the the- ory that these tumours are in reality adenomyomata, which have their origin in the remains of the Wolffian ducts, which view, however, still lacks confirmation. These tumours grow from the fibrous or muscular coat of the vagina, and are usually embedded in a fibrous capsule. Their histologic struc- ture is identical with that of fil:)roids of the uterus, consisting largely of connective-tissue bundles with a rather sparse intermixture of smooth muscle fibres. Striped muscle fibres are occasionally to be seen, in which case the tumour must be classed as sarcoma, especially when occurring in children. The mucous membrane covering the tumours is usually in- tact, unless destroyed by pressure, when they will present ulcerated surfaces. Fibroids of the vagina may become oedematous, or gangrenous and sloughing, and may be cast off in this manner. Polypi are simply fibroids which have become pedunculated. They do not differ essen- tially in structure from fibroids. The treatment of benign neoplasms of the external genital organs represents some of the least difficult problems in surgery. Varicose tumours of the vulva, when they exist simply as enlargements of the veins and are not associated with extensive hypertrophy of the con- nective tissue, should be treated by obliteration of the veins. This to be effective must be done thoroughly. AVhen the varices are restricted to the vulva, the larger trunks of the veins are easily detectable and may be tied by subcutaneous ligature. The ligatures should be applied at intervals along the same vessels, and the vessels themselves should be divided between the ligatures. The same principle of treatment may be applied to perivaginal varices, although the technique is rather more difficult. When pudendal varices are associated with extensive hyper- , NEOPLASMS OF THE EXTERNAL GENITAL ORGANS 227 trophy, the hypertrophied area may be excised. In many of these cases the varicose condition of the external veins is but an index of the condition of all the veins surrounding the vagina and extending far up into the pelvic structures. The control of such extensive conditions is very difficult, if not impossible. Pibromyomata and cysts of either the vulva or vagina should be treated by extirpation. Malignant Neoplasms Malignant Neoplasms of the Pudendum.^Malignant tumours of the vulva are comparatively rare. If we remember how frequent these neo- plasms are in other parts of the female genital organs this must excite our comment. Schwartz collected 1,177 cases of carcinoma of the uterus and the vulva. Of these, only 30' cases belonged to the latter class; the rest were all carcinomata of the uterus. We are not, however, in a position to account for the comparative rarity of malignant neo- plasms of the pudendal organs. Carcinoma, which we will consider first, is much more frequent than sarcoma. Nothing definite is known as to any predisposing cause, except the advanced age of the patient. Winckel, who has seen 8, and collected from the literature 54, cases, found that 6 cases occurred in women under forty years: 16, between forty and fifty; 20, between fifty and sixty; and 20 cases in women over sixty years. It can not be shown that simple inflam.matory processes or gonorrhoea and syphi- lis exert any predisposing influence with reference to the develop- ment of carcinoma of the vulva. ' The starting points for these tumours are the clitoris, labia majora and labia minora, the perineum, and rarely the glands of Bartholin. In the case of the latter the carci- noma has a glandular, in all other cases a squamous, epithelial-celled type. These tumours are generally characterized by an extensive new formation of tissue, by their inclination to early superficial ulceration, hard diffuse infiltration of the surrounding tissues, and involvement of the neighbouring lymph glands, particularly those in the inguinal re- gion. The glandular involvement, however, in some cases does not seem to supervene early. The carcinomata of the vulva, from certain macroscopic features, may be divided into several groups, which are, however, not distin- guished by fine microscopic differences. One form is characterized by a prominent tumour formation. The affected portion of the vagina presents a roundish tumor, generally of moderate size, usually not larger than a hen's Qgg or an apple. It is firm and hard in consistence, situated in the upjior layers of the integument, and more or less mov- able on the subcutaneous tissues. The surface is formed by an epi- dermis, which has a tendency to form warty prominences and papillary excrescences. If these tumours are seen somewhat later they are not 80 freely movable and llieir surface has become ulcerated. A second 228 A TEXT-BOOK OP GYNECOLOGY form takes on from the start the shape of a diffuse infiltration, which does not project materially above the level of the surrounding skin. On palpation of the neoplasm its site is found to be hard, and it is not freely- movable, but, on the contrary, is firmly fixed to its surroundings. This variety likewise soon begins to ulcerate; its surface either shows a mass of shallow, uneven granulations, or a ragged tissue covered with a bloody, dirty, purulent exudate. The third form from the beginning has a marked tendency to ulceration, and presents a deep craterlike ulcer with hard, infiltrated^ overhanging edges. Microscopically, carcinoma of the vulva presents a typical squamous epithelial-celled cancer. The epithelia of the stratum germinativum proliferate into the underlying connective tissue in the form of pegs or cylindrical masses, and these have a tendency to become branched. The proliferating cells speedily undergo cornification, and one therefore finds in carcinoma of the vulva epithelial pearls or " onion bodies " in great number and very typical in appearance. The younger epithelia, which have not undergone cornification and have preserved a columnar type, together with the somewhat tubular branched character of the cell nests, may, on superficial examination, create the impression of a glandular, tubular carcinoma. This impression is, however, erroneous, for carcinomata of the vulva are true squamous-celled neoplasms, not glandular carcinomata, but " cancroids." When after removal of the original tumovir a recurrence takes place, the latter frequently loses the characteristic structure of a cancroid, and presents a tissue composed of a fibrillar stroma with only small epithelial nests in which epithelial pearls are absent. There are fre- quently found in the neighbourhood of carcinoma of the vulva, near the primary tumour or near recurring metastasis, whitish patches of epidermis, which condition is known as leucoplalcia. These spots microscopically show a thickening of the epidermis. They are not characteristic of carcinoma of the vulva, since they are also found in other conditions. Carcinoma of the vulvo-vaginal glands, of which a few cases have been reported, forms a hard tumour situated under the unchanged labium majus. Microscopic examination shows an alveolar carcinoma with remnants of normal glandular tissue of the organ. Carcinoma of the vulva after it is once well established generally spreads quite rapidly and has a tendency to grow around the urethra into the vaginal walls, into the pelvic fascia, and into the perineum. Involvement of the other labium majus from the opposite one originally affected has likewise been several times observed. The prognosis of carcinoma of the vulva appears to be somewhat better than that of cancer of the vagina, but recurrence and final death is the rule even after thorough removal. G-offe has reported a case of primary epithe- lioma of the clitoris followed by speedy lymphatic involvement. A sec- tion taken from a case of Whitacre's shows a typical microscopic picture of epithelioma of the clitoris (Fig. 81). NEOPLASMS OP THE EXTERNAL GENITAL ORGANS 229 Sarcoma of the vulva is very rare. The number of cases of this kind which have been reported is very small. These connective-tissue neo- plasms are, as a rule, very malignant, and there are few well-authen- ticated cases on record of permanent cure after the removal of a sar- FiG. 81. — "A section taken from a case of Whitacre's shows a typical microscopic picture of epithelioma of the clitoris."— Herzog (page 228). coma of the pudendal organs. The sarcomata of this region usually present themselves as large spherical tumours arising from the labia, the clitoris, or the region of the external meatus of the urethra, or they may first be observed as deeply pigmented warts on the labia. There have been described round- and spindle-celled sarcoma, myxosarcoma, and melanosarcoma. The latter is the form most frequently observed on the vulva. Winckel, among ten thousand female patients, saw only two cases of sarcoma of the vulva. One case was that of a pregnant woman, twenty-five years old, with a tumour the size of a man's head, which was hanging down from the vulva, suspended on a pedicle the size of a child's arm. This tumour had not been very malignant, since it had been present and growing for eight years. Its microscopic ex- amination showed it to be a round-celled sarcoma. Winckel's second case was a myxosarcoma. Bruhn operated in two cases of fibrosarcoma, and claims that he obtained a permanent cure. Wernitz reported a case of spindle-celled sarcoma. Robb has described a myxosarcoma. Ehren- 230 A TEXT-BOOK OF GYNECOLOGY dorfer has seen a small round-celled sarcoma springing from the anterior part of the meatus urinarius and protruding between the labia. Older reports have been furnished by G. Simon and a few others. There have been reported altogether about a dozen cases of this kind. Somewhat more numerous are the reports of cases of melanosarcoma. It is a well- known fact that the vulva is freqiiently the seat of pigmented spots and pigmented ngevi. These occasionally become the starting point of mela- notic sarcoma, which is generally of a most malignant type. Other mela- nosarcomata of this region do not begin in superficial pig- ment spots or nsBvi, but in the deeper layers of the mucous membrane. They are first noticeable as a purplish spot, which spreads, be- comes deeper in col- our, and then as- sumes the shape of a simple wart or of a branched papil- lomatous growth. ITaeckel reported a melanosarcoma of a deep bluish - black colour springing from the labia mi- nora and the cli- toris. Miiller de- scribed a tumour of this kind arising from the clitoris. Most cases reported took their origin from the labia ma- Jora. All the mela- nosarcomata of the vulva observed were characterized by a deep pigmentation; they were moderate in size. As a rule, they soon reappeared after removal and speedily led to the formation of multiple metastases. Sometimes general sarcomatosis, cachexia, and death, soon '- .%,v Fig. 82. — " Reeil lia-^ k mnved a trilobiilar nielnnosarcoma from the meatus urinariu=? of a young girl." — Herzog (page 231). NEOPLASMS OP THE EXTERNAL GENITAL ORGANS 231 follow operative procedures. Reed, however, has removed a trilobular raelanosarcoma from the meatus urinarius of a young girl with complete success (Fig. 83). Histologically, these new growths generally are composed of round cells; occasionally spindle cells are found. The cells contain in their protoplasm a great amount of a brownish granular pigment, which is also found free between the cells composing the tumour (Fig. 83). Melano - carci- nomata of the vulva, likewise very malignant in character, have been described. Dr. Balfour Mar- shall has reported (Glasgow Medical Journal) the case of a widow, aged tifty-seven, in whom the site of the clitoris was occupied by a dark-bluish and bluish-red, slightly lobulated tumour, of the size of a small walnut. The growth was removed and was found to have origi- nated in the clitoris and prseputium clitoridis, being " a melanotic sar- coma with some hemorrhage into its substance." Dr. Marshall was able to find records of only nineteen cases of sarcoma of the vulva, of which two started in the clitoris. Malignant tumours primarily situated elsewhere in the body not infrequently form metastases in the vulva. Carcinomata and sarcomata of the uterus lead to metastases in the pudendal organs, as also, at times, do malignant neoplasms of the ovaries and of the urinary bladder. Syncytioma malignum of the uterus, which so frequently forms metas- tases in the vagina, is also liable to form metastatic tumour masses in the vulva. Aschoff reports a case of syncytioma where the original tumour has made a metastasis in the left labium majus. Malignant Neoplasms of the Vagina. — (a) Sarcoma in Childhood. — Primary sarcoma of the vagina occurs at any period, in infancy as well as in adult life, and, since there is a very great difference in its appear- ance and mode of development in the two ages, allowing a sharp subdivi- sion, it is customary among writers to treat these subdivisions separately. Fig. 83 (Eeed). — " A brownish granular pigment, which is found free between the cells composing the tumour." — Hebzog. 232 A TEXT-BOOK OF GYNECOLOGY In children, as in adults, it is a rare disease, and usually manifests itself during the first two or three years of life. Granicher observed a case in a newborn child, which, however, advanced very slowly and did not prove fatal until the seventh year of life. Sarcoma in children commonly appears in the form of polypoid or grapelike protrusions, usually springing from the anterior wall of the vagina. In the beginning, the tumour is rounded or hemispherical with a broad base, but it tends to become polypoid as the disease ad- vances. It is generally of a cherry-red colour, but it may be dark brown if very vascular. Soon the surrounding mucous membrane becomes infiltrated and here and there in the surrounding structure secondary nodules begin to develop. Sarcoma shows a marked tendency to infil- trate the vesico-vaginal septum and invade the bladder, and may, from pressure on the urethra, or infiltration of the neck of the bladder, cause urinary stasis with resulting dilatation of the bladder and nephydro- sis. In advanced cases the tumour is very prone to undergo ulceration or necrosis with resulting infection of the genito-urinary tract, which ultimatel}' reaches the kidneys, terminating in pyelonephritis. Earely,, the infection may extend to the uterus, and even to the peritoneal cavity. The recto-vaginal septum may also be involved. Metastasis to distant parts of the body has not been observed, though regional metastasis to the inguinal glands and ovary has been met with. Histologically, the tumour may consist largely of connective tissue,. or it may assume the type of myxosarcoma. The sarcomatous ele- ment may consist of round or spindle cells, or both may be present. Occasionally giant cells are observed, and not infrequently striped muscle fibres are to be seen. According to Kolisko, striped muscle fibres are usually present, but other observers have failed to confirm this view. The etiology is unknown. However, since it begins in infant life, Veit (HandbooJc, p. 355) regards it as probable that in some cases at least it is congenital. Kolisko also regards the presence of striped muscle fibre as evidence of congenital origin. (h) Sarcoma in Adiilfs. — Primary sarcoma of the vagina occur- ring in adults belongs to the rarer tumours. Up to the present time but thirty-one cases have been reported. They have been observed be- tween the ages of fifteen and eighty-two, though the larger proportion has occurred in persons under forty years of age. They most frequently grow from the anterior wall and are rather more frequent in the lower third of the vagina. They appear as more or less circumscribed tumours, which is the most common form, less frequently as a diffuse infiltration of the mucous membrane of the vagina, which tends to ulceration. In the circumscribed form the tumour is usually smooth, rounded or hemispherical in shape, and sometimes is encapsulated. The integrity of the mucous membrane covering the tumour is usually maintained until pressure from its increasing size produces ulceration. NEOPLASMS OF THE EXTERNAL GENITAL ORGANS 233 Metastases to distant parts of the body have been observed, notaljly to the lungs and skin. Of the etiology of these tumours we know as little as of sarcoma in general. They usually have their origin in the perivaginal connective tissue, or in the submucosa. Occasionally they originate in the blood or lymph vessels, when they are termed endothelioma. Cases of this kind have been reported by Klein, Kalustow, and Waldstein. Histologically, sarcoma of the vagina in the adult may consist of spindle, round, or mixed cells, and occasionally giant cells are present. Sarcoma of the vagina is especially characterized by the tendency to recurrence after removal, and, according to Jung {Monatsschrift fiir Gehurtshillfe und Gynakologie, Bd. ix), only three cases are on record which have passed without recurrence a sufficient length of time after removal to be denominated cured. The vagina may be secondarily involved by sarcoma, which pri- marily has its seat in some other region of the body, as, for example, the uterus. Especially is this so in sarcoma of the cervix, where sec- ondary involvement of the vagina is almost the rule. (c) Carcinoma. — Primary carcinoma of the vagina is not common. Gurlt, among 59,600 patients, found 114 cases. Unlike sarcoma, it is a disease of later life, and has not been met with under the age of twenty-five. It appears mostly as an ulcerating excrescence, with sharply circumscribed borders, and is most frequently located on the upper portion of the posterior vaginal wall. The surrounding mucous membrane is usually involved in a catarrhal inflammation, and is fre- quently eroded and bleeds on the slightest touch. ISTot infrequently a marked thickening of the mucous membrane in the neighbourhood of the carcinomatous involvement appears as a diffuse infiltration, manifested as a thickening of the vaginal walls encroaching upon the lumen of the vagina. At first it may involve only a segment of the vagina, encircling its entire circumference like a band. In these cases ulceration is only observed after a considerable length of time. In the diffuse variety the growth is at first slow, but eventually infiltration of the perivaginal connective tissue takes place and the growth may invade the bladder or rectum, or extend into the parametrium, involv- ing secondarily the iliac and retroperitoneal glands, or, in case the growth is confined to the lower third of the vagina, the inguinal glands may become involved. The etiology is obscure. In a few instances it has been observed to develop at the point of pressure from pessaries, especially where their long-continued use has caused ulceration. These cases have many points in common with carcinoma of the skin, which some- times develops in the border of indolent ulcers. In the present state of our knowledge concerning the etiology of carcinoma, it is difficult to say just what influence the pessary has had as an exciting cause of the carcinoma, and whetlier the irritation following its use, or tlie ulceration by jorodiicing an atrium of infection, has been chiefly 234 A TEXT-BOOK OP GYNECOLOG-Y instrumental we do not know. Microscopically, primary carcinoma of the vagina presents the characteristics of carcinoma growing from the skin and consists of squamous epithelial cells. Secondary Carcinoma. — Secondary carcinoma of the vagina is of much more frequent occurrence, and may result from direct exten- sion or metastasis. Most frequently it is secondary to carcinoma of the uterus, especially to involvement of the portio vaginalis. In carcinoma of the body of the uterus the vagina may be secondarily involved by implantation metastasis. Carcinoma of the rectum or bladder may secondarily invade the vagina, and occasionally metas- tasis to the vagina has been observed to follow primary carcinoma of the ovary. Secondary carcinoma of the vagina partakes of the nature of the primary growth and is identical in its histologic structure. Treatment of malignant neoplasms of the external organs of gen- eration resolves itself into radical and palliative. The radical treatment consists in the extirpation of the malignant growth whenever it is so situated that its removal can be accomplished with reasonable safety to the life of the patient and with a reasonable prospect of complete- ness. Malignant tumours of the vulvo-vaginal glands, those involving either labium, the vagina, or the clitoris, should be freely excised, care being taken to dissect out all indurated neighbouring lym- phatics. Clitoridectomy, or excision of the clitoris, may be de- manded for the cure of either malignant or tuberculous dis- ease of that body; also for the removal of a malformed or hy- pertrophied clitoris, or for the relief of extreme nervous dis- turbances due to hyperes- thesia of that organ. The technique of the operation is as follows: Divide the tissues around the base of the gland by means of scissors, one blade of which is inserted beneath the integument, at the inner duplication of the preputial fold, and is carried entirely round the organ; the prepuce is then slit toward the pubis (Fig. 84); the clitoris is dissected out, but, before being excised, its base is clamped by a slender-bladed Kocher hemostatic forceps (Fig. 85); after which it is cut away, the vessels being controlled by ligatures. The flaps are approximated by buried Fig. 84. — " The prepuce is then slit toward the pubis." — Keed. NEOPLASMS OP THE EXTERNAL GENITAL ORGANS 235 animal sutures and the margins of the wound are closed by the inter- cutaneous method. (See Figs. 38, 39.) Extirpation of the vagina is sometimes practised in cases of primary carcinoma or of tuberculosis of that canal. Very satisfactory reports of the operation have been made by Olshausen, Diihrssen, Martin (of Greifswald), and others. In the performance of this oper- ation it may be necessary, as a preliminary step, in cases of narrow or indurated va- ginae, to incise the perineum, or even to carry the incision entirely through the peri- neum, round the anus, and up to the coccyx. As a rule, however, the operation may be done, as Martin directs, by making a preliminary inci- sion round the hymenal ring at the introitus vaginae. Af- ter this has been done, but little difficulty is experienced in enucleating the vagina by means of the finger, separat- ing the entire canal from its underlying connective tissue clear to its Juncture with the cervix. If the disease has not gone beneath the mucous membrane, the resulting disturbance of the blood vessels will not be so marked as to occasion serious difficulty in controlling the hemorrhage. If, however, the incision must be made through the perineum, round the rectum, and up to the coccyx, the hemorrhage from the hemorrhoidal plexus may be controlled only with some difficulty. After the vagina has been enucleated in the manner indicated, the remainder of the operation consists in the re- moval of the uterus and adnexa according to the technique described in Vaginal Hysterectomy. The proposition has been made by P. Miiller to extirpate the vagina, leaving the senile uterus in situ; but as even the senile uterus is the source of some secretion which will accumulate above the tract of the vagina, which now becomes occluded, it is essen- tial that even in these cases the uterus should be removed. Partial extirpation of the vagina has been practised by Fritsch and Asch, but the results have not been satisfactory. The method of Martin, as before described, is probal)ly the safer, the operation being concluded l)y drawing down the peritoneum and stitching it all round at the introitus. After this step has been taken the vulvar orifice closes itself l)y transverse obliteration. Fig. 85.—" The clitoris is dissected out, but before being excised its base is clamped." — Reed (p. 234). 236 ^ TEXT-BOOK OF GYNECOLOGY The palliative treatment of malignant neoplasms of the external genital organs consists in making the patient as comfortable as pos- sible during the persistence of the disease, and should be adopted as a line of practice only in cases that are either awaiting operation, or that have ceased to be suited to it in consequence of the extension of the disease. Of the latter class may be mentioned as examples car- cinoma of the vagina invading and penetrating the recto-vaginal sep- tum, thereby causing a recto-vaginal fistula, or other cases, again, in which the disease has perforated the bladder. These are distinctly hopeless conditions, entirely beyond the reach of surgical art, their comfort, or the little that may be secured for them, depending on vari- ous palliative measures. Cleanliness is of the first consideration; douches of lysol or creolin are cleansing, antiseptic, and are better borne than the more irritating solutions of either carbolic acid or the mercuric bichloride. Excoriated surfaces may be dressed with steril- ized white vaseline or other oleaginous product, a little lysol or creolin being incorporated with this agent if desired. Opiates in the form of rectal suppositories, or hypodermic injections of morphine, should be given whenever they are not contraindicated by the idiosyncrasy of the patient. These are cases for euthanasia. CHAPTER XX DISPLACEMENTS OF THE VAGINA The vagina — Varieties of displacements — Cystocele — Rectocele — Urethrocele — Col- porrhaphy, anterior and posterior. The vagina is a canal lined with a mucous membrane partaking largely of the histologic elements of the integument, and is surrounded by some muscular stria3 that are designated as the sphincter vaginae muscle. The tube thus constituted extends from the vulva to the uterus and is sur- rounded by more or less loose cellular tis- sue. It is slightly curved, being concave anteriorly and convex posteriorly. It is held in position, not alone by its attachment to its surrounding cellu- lar tissue, but more particularly by its at- tachment to the uterus and the pelvic diaphragm, and by the support which it de- rives from the perine- um. This canal is liable, in whole or in part, to displacement. Upward displacement may occur, as in the case of a large fibroid tumour, the growth of which carries it above the pelvic brim, caus- ing it to drag the vagina upward. This upward displacement may occur to such a degree as to exercise more or less tension, even upon the lower segment of the canal. Downward displacement, or a prolapse of the vagina or some part of it, is the condition more frequently encoun- 237 Fig. 86. — "Sacculations may occur from the urethra, a con- dition called urethrocele." — Eeed (page 238). 238 A TEXT-BOOK OP GYNECOLOGY tered. The causes of prolapse of the vagina, or of one or the other or both of its walls, may exist either in the pelvic diaphragm or in the pelvic floor. Weakness of the pelvic diaphragm — a condition which depends upon the loss of the retentive power of the pelvic fascia — is generally manifested primarily by descensus uteri. When this condi- tion occurs it is always and necessarily associated with more or less descent of, at least, the upper segment of the vagina. This is gen- erally specially marked in relaxation and descent of the floor of Douglas's pouch. Occasionally this condition of the pelvic diaphragm, with its associated hysteroptosis, is sufficient to cause more or less descent of the anterior vaginal Avail. Eelaxation of the pelvic floor or the enlargement of the vaginal orifice by laceration of the perineum may, by removing the support from the superimposed structures, in- duce a similar prolapse of the vaginal wall. When the anterior vagi- nal wall folds inward it forms a sort of pouch from the bladder and is, therefore, designated a cystocele ; when the posterior wall folds into the vagina and forms a pouch from the rec- tum, the condition is designated a rectocele (Figs. 86, 87). Simi- lar sacculations may occur from the ure- thra — a condition called urethrocele (Fig. 86). The pathology of these displacements, particularly of cysto- cele and rectocele, shows them as con- sisting essentially in an atrophy of the perivaginal rnuscu- laris, with a corre- sponding loss of its retentive power; and in a distention with resulting redundancy of the vaginal mu- cosa. The symptoms of these sacculations are very characteris- tic. In cystocele the patient is conscious of more or less distention of the vaginal orifice when she attempts to urinate; she experiences difficulty in completely emptying the bladder, often being forced to push that viscus upward with the finger before being able to empty it. When Fig. 87. — " There is always more or less residual urim- remain- ing in the adventitious pouch." — Eeed (page 239). DISPLACEMENTS OF THE VAGINA 239 this sacculation is extreme she may be unable to completely empty the bladder, even though she assists herself by the means indicated; under these circumstances there is always more or less residual urine remaining in the adventitious pouch (Fig. 87) — a condition which sooner or later results in inflammation of the bladder, with the usual pain and tenes- mus. On inspection, a globular mass, which can be readily re- placed by the finger and which increases in size and tension if the patient strains, will be seen present- ing at the vulvar ori- fice. A curved sound, introduced through the urethra into the bladder, can be readily felt on the inside of this pouch, thus ren- dering certain the di- agnosis of cystocele. In rectocele the pa- tient when straining at stool feels as if she were about to defecate through the vagina, and finds it necessary sometimes to replace the protruding mass before she can empty the rectum. If the finger is introduced into the rectum in such a case as this it can be brought for- ward into the pro- truding pouch, which presents at the vulvar orifice as a globular mass, having the colour of the vagina and presenting the half-obliterated rugge upon its sur- face. If the patient strains or coughs the protruding mass increases in both size and tension. The treatment of displacements of the vagina consists primarily in correcting, so far as possible, the causative conditions. When these Fig. 88.—". . . Transverse denmhitinns, so tliat the resulting line of approximation may be coincident with the normal folds of the vagina."— Keed (page 242). 240 A TEXT-BOOK OF GYNECOLOGY exist in the pelvic diaphragm, as when they depend upon prolapse of the uterus, the remedy is to be found in relieving the vagina of the abnormal pressure. This is generally accomplished by one or other of the recognised operations for the cure of prolapsus uteri. (See Surgical Treatment of Uterine Displacements.) Pessaries are, as a rule, more mischievous than otherwise; although their use may afford the patient a sense of temporary comfort. Those pes- saries, however, which by their con- struction distend the vagina, or impinge forcibly upon any part of its walls, have a tendency to dilate the canal still further and render the original mischief more troublesome. In the place of pessaries it is usually better to employ tamponade with some astrin- gent and antiseptic medicament. In cases of extreme rec- tocele or cystocele, or both, either com- bined or not with complete procidentia uteri, temporary comfort is derived from wearing a firm perineal support. Protruding vaginal surfaces frequently become excoriated, in which case they t;, „„ a rn, , ■ 1 • , 1 • should be treated by ±iG. 89. — inere are cases, however, in which the anterior ^ i i • j sacculation of the recto-vaginal septum exists without ap- Caretul Cleansing and. parent injury to either layer of the pelvic floor."— Eeed emollient applica- (page 242). tions. Such mcthods of treatment are, however, but tentative, cure depending upon such correction of the un- derlying cause and acquired morbid changes as can be effected only by surgical intervention. If the condition depends upon relaxation or en- DISPLACEMENTS OF THE VAGINA 241 largement of the vaginal outlet, the latter resulting from laceration of the perineiim or injury to the pelvic floor, the joroper remedy is to be found in a restoration of the perineum or pelvic floor, associated, it may be, with a narrowing of the lower segment of the vagina. (See Perineor- rhaphy.) This may need to be associated with the operation for either eysto- cele or rectocele, or both. The operation for cys- tocele consists in narrow- ing the anterior wall of the vagina and, conse- quently, is called anterior colporrhaphy. It is ac- complished, in general terms, by removing a disk of the redundant mucous membrane from tlie pro- truding vaginal wall, and in approximating the margins of the wound. The disk of membrane thus removed may be el- liptical or circular in form, and may vary in dimensions according to the size of the cystocele. Fritsch removes a circular piece of membrane, from an inch to an inch and a half in diameter, from the most prominent part of the presenting pouch; this denudation is then encircled by a single tobacco-pouch suture which is drawn up and tied, the cystic wall being pushed upward into the bladder as the suture is tightened. The technique is very simple, and in cases of small cystocele the operation is very effective. It is not practicable, however, in very large protrusions, in which there is marked redim- dancy of tissue. In such cases it is better to remove an ellipse of tissue closing the wound by careful linear approximation of its margins. Operators differ as to the direction that should be given to the long axis of this elliptical denudation. They formerly made the long axis of tlie denudation coincident with the long axis of the vagina; but an increasing number of later operators prefer to make one, or 17 f^THUPKlNS Fig. 90.- -" In such cases the vaginal wall should be denuded." — Eeed (page 242). 242 A TEXT-BOOK OP GYNECOLOGY perhaps two, transverse denudations, so that the resulting line of approximation may be coincident with the normal folds of the vagina (Fig. 88). Experience seems to warrant the latter innovation, as there is less tendency to retraction and the results seem to be more permanent. The closure can be effected either by the interrupted, or the buried animal, suture. When the interrupted suture is em- ployed it should be removed on the eighth or ninth day. (See Opera- tive Treatment of Prolapsus Uteri.) The operation for redocele consists in narrowing the posterior wall of the vagina and, consequently, is called posterior colporrhaphy. It differs from the operation on the anterior wall, chiefly because rectoeele as a rule exists as a complication of such conditions as call for the repair of the perineum or the restoration of the pelvic floor. The re- dundancy of tissue is reduced by removing one or more ellipses trans- versel}^ from the vaginal wall and approximating the edges with inter- rupted sutures. (See Perineorrhaphy, Fig. 107). There are cases, how- ever, in which the anterior sacculation of the recto-vaginal septum exists without apparent injury to either layer of the pelvic floor (Fig. 89). In such cases the vaginal wall should be denuded as indicated in Fig. 90, which is drawn from a patient in whom the conditions varied slightly from those in the case Just mentioned. The mucous margins are then approximated by interrupted sutures, beginning first with one tri- angle, then with the other, thus forming the expanded arms of a Y. The remaining area is then approximated by passing the interrupted sutures from side to side. CHAPTEE XXI THE VULVO- VAGINAL GLAND Anatomy — Gonorrhceal infection — Abscess — Cysts — Carcinoma. The vulvo-vaginal glands, or glands of Bartholin, are two small rounded or oval bodies from 15 to 20 millimetres in length, varying greatly in size and shape, and situated in the posterior third of the labia majora, one on either side of the lower end of the vagina, immediately below the bulb and in front of and near the upper margin of the perineal septum (Fig. 91). They are racemose glands the acini of which are lined by a single layer of high co- lumnar epithelial cells with basal nuclei. They secrete a muco-serous fluid which is emptied through two slender ducts of about 2 centimetres in length and terminating in small openings in the vestibule about 1.5 centimetre from the posterior median line just out- side the hymen. These ducts are lined by low cuboidal epi- thelial cells and their mouths are plainly visible on close in- spection, being of sufficient size to admit the passage of a fine probe. Functionally, the secretion of these glands serves to moisten the mucous mem- brane of the vestibule, and dur- ing sexual excitation or coitus it is discharged in considerable quantities. These glands become fully developed at the age of puberty, and maintain their full function until the climacteric, when they begin slowly to undergo atrophy and their function gradually ceases. The location of the mouths of these ducts renders them peculiarly liable to infection which may, by extension 343 Fig. 91. — " The vulvo-vaginal glands . . . are situated in the posterior third of the labia majora." — Kotheock. 244 A TEXT-BOOK OF GYNECOLOGY through the dnct^ involve the gland and result in a series of inflamma- tor}' conditions constituting the chief diseases to which it is liable. Inflammation must be regarded as invariably due to bacterial infec- tion, and eases apj^arently the result of trauma, as for example those following on childbirth, are now generally explained by the pre- existence of pathogenic bacteria in the duct, the trauma having served merely to afford an atrium of infection. While various bacterial flora of the vulva may gain entrance to these ducts, inflammation is almost invariably of gonorrhoeal origin. The one possible exception to this is the staj)hylococcus, which, it appears, may produce inflammation either alone or in association with the gonococcus. All other bacteria, therefore, which may at times be present, must be regarded in the light of secondary invaders. Pure gonorrhoeal inflammation usually remains confined to the ducts, rarely involving the parenchyma of the gland, and then only slightly. Gonorrhoeal Infection of the Ducts. — Infection of the ducts may occur directly, but in the majority of cases it is secondary to infection of other portions of the genital tract. A well-developed case of gonor- rhoeal inflammation of the vulvo-vaginal gland has been observed four- teen days after exposure to infection (Bumm), but this is exceptional, and frequently Aveeks or months may elapse before the mouths of the ducts become infected although constantly bathed meanwhile with vulvar or vaginal secretions. In most instances both ducts are in- volved, frequently from the beginning, but almost invariably in cases of long standing. The ducts are usually involved throughout their entire lengtli, though oftentimes the involvement is not uniform throughout, but some portions of the duct are more severely attacked than others. To C. Herbert {Inaugural Disse7iation, Leipsic, 1893) we are in- debted for a description of the histological changes which take place in gonorrhoeal inflammation of the gland and its duct. They consist essentially of desquamation of the epithelial cells, with a small round-celled infiltration of the intercellular substance and subepithelial connective tissue. At first the epithelium lining the duct becomes swollen, and even- tually loosened, by the infiltration of leucocytes, then desquamation begins. In cases of long standing, the desquamated epithelial cells are replaced by cells more cuboidal in character, often approaching the squamous type. The lumen of the duct will be found filled with pus and desquamated epithelial cells in which gonococci may be demon- strated. The gonococci may penetrate to the subepithelial connective tissue but are not found in the infiltration cells themselves. Gonorrhoeal inflammation of the ducts either begins as a chronic process, or, after a brief and ill-defined acute stage, becomes chronic. It may persist for months, and even years, an ever-fruitful source of infection, and, indeed, together with infection of Skene's glands, THE VULVO-VAGINAL GLAND 245 may constitute the only points of localization of the infection in women. It usually occurs some time during sexually active life, though Fischer {Deutsche meclicinische Wcclienschrift, 1895) has observed it in children. Symptoms. — In the beginning, gonorrhoea of the ducts gives rise to few or no symptoms, so that the patient may be totally unconscious of its presence. Occasionally, there is a sensation of itching and burn- ing and perhaps some slight sensitiveness on pressure, or the patient may complain of a dull pain increased on walking or sitting. These symptoms when they occur are of short duration, and the patient may be conscious of nothing more than a slight muco-puru- lent discharge. Even this is often so slight as to escape notice. On examination, if the labia are separated so as to bring the mouths of the ducts into view, these appear, in cases of recent infection, in the form of dark-red, glistening, moist, spots resembling small ulcers, this appearance being due to ectropion of the inflamed and swollen mucous membrane lining the duct. If pressure is made along the course of the duct, a thin yellowish pus may be made to exude from its mouth, often in considerable quan- tities, which examination with the microscope shows to consist of pus and desquamated epithelial cells in which gonococci may be demon- strated in large numbers. Occasionally a nodular swelling, or induration, due to an infiltra- tion of the subepithelial connective tissue by small round cells, may be felt along the course of the duct. When the disease becomes chronic, similar signs may be observed though less pronounced. The secretion now becomes more mucoid in character, and while gonococci may still be demonstrated they are present in diminished numbers. Frequently the only remaining sign of infection is the appear- ance of the mouths of the ducts, which Sanger has compared with flea- bites and has named " maculae gonorrhoeae," since he regards them as an infallible sign of gonorrhoea. Gonorrhoeal inflammation of the ducts may terminate in abscess of the glands or in cyst formation, and these two conditions constitute the chief diseases of the viilvo -vaginal glands, inasmuch as gonorrhoeal disease of the ducts is so devoid of symptoms that the patient is seldom conscious of its existence, and frequently it is only discovered by the examination of a physician. Abscess. — Inflammation of the parenchyma is invariably due to in- fection by pyogenic bacteria, most frequently the Staphylococcus pyo- genes aureus, occasionally the Staphylococcus pyogenes alhus, either in association with the gonococcus or alone, and in a few instances the Streptococcus pyogenes has been found present (Dujon). In addition to these, various other bacteria are sometimes present in the pus, fre- quently the Bacterium, coli commune; and in one case of relapsing abscess, examined by Kothrock, the Bacillus pyocyaneus was present. 2i6 A TEXT-BOOK OF GYNECOLOGY together Avitli the Staphylococcus pyogenes aureus and other undeter- mmed bacilli. The pus has frequently a foul odour similar to that so often raet with in abscesses occurring about the anus, and in all probability due to the associated presence of the colon bacillus or putrefactive bacteria. Inflammation of the gland is almost always secondary to inflam- mation of the duct, though Eothrock recalls a case which had been under observation for some time, in which there was no evidence of disease of the ducts, old or recent. In this case the Staphylococcus pyogenes aureus was found in pure culture and no gonococci were demonstrable in the ^dus. Abscess of the gland may occur at any stage in the progress of disease in the duct, and, according to Bumm, it occurs in about one third of all cases of gonorrhoeal infection of the diict. It is frequently met with in prostitutes, in whom gonorrhoeal infection is unusually common. In this class of patients the traumatism incident to the abuse of coitus seems to be a fruitful exciting cause. Not infrequently it is met with immediately following menstrua- tion in the absence of any history of traumatism. Abscess usually develops unilaterally and may occur on either side, appearing to have no predilection for one side over the other. In case the disease runs a very acute course, the parenchyma of the gland is quickly destroyed, and the infection may pass through the mem- brana propria into the surrounding cellular tissue, with a resulting phlegmon which terminates in suppuration with the formation of an abscess. Usually, however, the inflammation runs a less acute course and remains confined to the capsule of the gland, which quickly be- comes distended with pus. In such cases the cellular tissue outside the gland becomes oedematous, and this in a large measure accounts for the swelling which is present. Symptoms. — Abscess of the vulvo-vaginal gland as a rule begins abrujjtl}', and manifests itself by swelling of the labia majora accom- panied by the usual signs of acute inflammation — redness, heat, and pain. On examination, there may be felt in the posterior third of the labia majora, and often extending into the vagina, an irregular-shaped swelling the size of a pigeon's egg, and extremely sensitive on pressure. After a few days, during which the .symptoms increase in severity, the swelling becomes boggy indicating beginning suppuration, and fluc- tuation may soon be felt. During this time the j)atient will usually find locomotion difficult on account of the swelling. The pain will have increased in severity, and have become throbbing in character. In severe cases there is usually a slight elevation of temperature reach- ing 101° or 102° F., and the onset of suppuration may be ushered in by a chill. There is usually some swelling of the inguinal glands on the affected side, which always indicates infection by pyogenic bac- teria, as it is never present in pure gonorrho?al infection (Sanger). With the accumulation of pus, a gradual thinning of the skin and sub- THE VULVO-VAGINAL GLAND 24T cutaneous tissue takes place, and the abscess, if not opened, points and ruptures spontaneously. Perforation usually takes place on the inner surface of the labia majora, hut the pus may be conducted forward between the layers of the ischiopubic fascia, and point in the fold between the labia majora and labia minora. In some cases, the abscess may be evacuated through the duct by pressure made in that direction; but this is exceptional, as the duct is usually occluded, or at least does not communicate with the main abscess cavity. Earely the pus may burrow, and the abscess may be evacuated through the perineum, or even into the rectum with resulting fistulge. The pus may be yellow, dirty-green, or chocolate- coloured from altered blood. It frequently has a foul odour, and may contain gangrenous shreds. Well-defined abscesses are usually sharply limited by a thick pyo- genic membrane, the inner surface of which may be smooth, or irregu- lar from necrotic shreds, or from trabeculae-like septa which separate the lobes of the gland. Inflammation of the vulvo-vaginal gland almost invariably terminates in sujDpuration, though occasionally cases are met with in which it is characterized by marked induration with little tendency to the accumulation of pus. In these cases, the induration may remain for a long time, and may serve as a focus of infection for renewed attacks under the stimulus of traumatism. Cysts. — Cysts of the vulvo-vaginal gland are invariably the result of occlusion of the duct, and are therefore retention cysts. The vast majority are secondary to gonorrhoeal infection of the duct. According to Sanger, they are an almost certain indication of pre-existing gonorrhoea, while Winter maintains that they may result from occlusion of the duct by traumatism, as, for example, in child- birth. Cysts may be located in the duct or in the gland. Those of the duct are sm.all, superficial, and may remain for a long time without the patient's knowledge, being only discovered accidentally by exami- nation. They are situated in the lower part of the labia majora and at first are fusiform, but later they tend to become spherical. Cysts of the gland proper are larger, and are more deeply situated. From the beginning, they are spherical in shape, and may develop in one lobule, or the entire gland may be converted into a cyst. The wall of the cyst is usually thin and consists of connective tis- sue, and, occasionally, the remains of the epithelial lining of the gland may still be observed. The cyst contents vary in character ranging from a thin clear serous fluid, to a thick, tenacious, or colloidlike, accumulation, vary- ing in colour, sometimes clear or yellow, and, again, brown or chocolate coloured from the presence of altered blood. Microscopically, they may contain blood corpuscles, leucocytes, epitbelial cells, cholestcrin crystals, and detritus, and frequently the presence of gonococci may be dctnonstrated. 248 ^ TEXT-BOOK OF GYNECOLOGY As a rule, the older the cyst, the clearer will be its contents. In case the duct is not altogether occluded, pressure over the cyst may force out some of its contents, and occasionally cysts are met with which empty themselves spontaneously or during coitus, and which refill again after a time. In a few instances, cysts have been described which contained a fatty substance similar to that of sebaceous cysts. It is probable, however, that these were cysts which had their origin in the sebaceous glands of the vulva. Occasionally, cysts are met with which contain gonorrhoeal pus, the result of occlusion of the duct. Such collections have been termed pseudo-abscesses, as the usual signs of acute inflammation, such as are observed in staphylococcus infection, are wanting, except perhaps slight swelling which is due to cedema. Cysts of the vulvo-vaginal glands may become secondarily infected by pyogenic bacteria, following on which, suppuration ensues and the cyst is transformed into an abscess, with the usual accompanying symptoms. Cysts of the gland proper rarely reach a size as large as a hen's egg; and those especially large ones which have been described, the contents of which were clear and limpid, were probably in reality vagi- nal cysts from the remains of Gartner's ducts. Treatment. — Gonorrhoea of the ducts usually runs a very chronic course if left to itself, and, owing to the difficulty of access of the localized points of infection, often proves most obstinate to treatment. First of all, cleanliness of the external genitals should be secured by antiseptic douches. The duct should be systematically evacuated each day by gentle pressure made along its course from within out- ward, after which an application of an 8-per-cent solution of nitrate of silver should be made by means of cotton wrapped on a slender probe. Good results also follow the use of a 2-per-cent solution of formalin applied in the same manner. "When the lumen of the duct is very narrow or obliterated, it is sometimes best to lay it open along its entire length, and this is most conveniently done by a Weber's canaliculus knife such as is employed by oculists for division of stric- ture of the lachrymal duct. When the duct has been laid open it should be washed out with an antiseptic solution, after which, either of the above-mentioned solutions of silver nitrate or formalin may be applied. Pozzi recommends the application of a 2-per-cent solution of chloride of zinc or cauterization by a crayon of nitrate of silver, while others recommend cauterization with pure carbolic acid. Inflammation of the gland is to be treated as is acute inflammation elsewhere, namely by rest in bed and by cold applications until sup- puration, as is the almost invariable rule, occurs, when the abscess should be freely opened, washed out with an antiseptic solution, and packed with iodoform gauze to encourage granulation from the bot- THE VULVO-VAGINAL GLAND 249 torn. As a rule the incision should be made over the most superficial point, which, in most cases, is the internal surface of the labium. Kelly prefers, however, to make the incision over the skin surface so as to avoid a painful cicatrix which sometimes follows an incision made over the mucous surface. As a rule, general anaesthesia will not be necessary for the opening of these abscesses, but local anaesthesia by chloride of ethyl, cocaine, or the application of ice, will be quite sufficient. Cysts are best treated by extirpation, after which the opening should be immediately closed by interrupted sutures. In case this is not possible, after thoroughly laying the cyst open, an attempt should be made to obliterate its cavity by cauterization and packing with iodo- form gauze. Examination should, at the same time, be made of the duet, and, if found diseased, it should also receive attention; otherwise it may remain as a source of infection. Carcinoma. — One other disease of the vulvo-vaginal glands deserves mention, and that is carcinoma. While of rare occurrence, the num- ber of cases which have been reported in recent years renders it certain that carcinoma may originate in the epithelium of the gland. Clini- cally, it appears to develop in middle or advanced life, as a rounded tumour of the labium which does not tend to ulcerate. Microscopically, the tumour frequently follows the type of adeno-carcinoma. Cases have been reported by Geist, Martin, Mackenrodt, Wolf, and Kelly. The treatment here, as for malignant disease in other regions of the body, is its early recognition and complete removal. In Martin's case the patient died of recurrence four years after the operation. CHAPTER XXII THE PELVIC FLOOR AND ITS INJURIES The pelvic floor — The "pelvic diaphragm" — Injuries of the pelvic floor — Lacera- tions of the perineum — Restorations of the pelvic floor — Immediate operation — Instruments — Operations for incomplete lacerations, superficial — Emmet's operation, Reed's method of suture ; modifications — Operations for complete lacerations; Tait's operation; modifications — Repair of deep injuries of the pelvic floor — Harris's operation. The pelvic floor consists of those structures which hy their muscu- hir elements are attached to the lowest plane of the pelvic bones and which occupy the outlet of the pelvis. These structures considered in their entirety include integumentary, aponeurotic, and muscular ele- ments, and are penetrated by three canals, namely, the vagina, the ure- thra, and the rec- tum. The function of the pelvic floor is to serve as a basis of support for the superimposed vis- cera. This power of support is exer- cised by virtue of the aponeurotic, and, particularly, the muscular elements of the floor; and it is to these elements that special atten- tion is invited. The muscles of the pel- vic floor are ar- ranged in two layers, (a) external, and (b) internal. The external layer of muscles embraces the bulbo-cavernosus, the trans versus-peringei, and the sphincter-ani-externus muscle, with fibres from the pubo-coccygeus and the obturator-coccygeus muscles. These muscles meet at a central point of convergence, which may 250 Fig. 92. — " These muscles meet at a central point of conver- gence, which may be designated the nidus perincei.'''' — Eeed (page 251). THE PELVIC FLOOR AND ITS INJURIES 251 Fig. 93. — " The internal layer, as described by M. L. Harris, is composed of four paired muscles." — Eeed. with propriety be designated the nidus perincei (Fig. 92). Tlie perineum proper is a pyramidal structure the base of which lies between the fourchette and the anus, while its apex blends with the recto-vaginal septum; its essential structures are derived from, and constitute a part of, the external muscular layer of the pelvic floor. The internal muscular layer of the pelvic ^ ■■"■ " ' ^ floor occupies a plane about 1.5 centimetre above the external layer, and, as de- scribed by M. L. Har- ris (Journal of the American Medical As- sociation), is composed of four paired muscles (Fig. 93). Harris says that " it is not always easy in a human subject to draw sharp lines of demarcation between some of these muscles at all points, and some knowledge of comj)arative anatomy is necessary to a clear un- derstanding of them. Comparative anatomy teaches us that these muscles are the representatives of well-developed, clearly defined mus- cles, which, in the lower animals are concerned in the movements of the caudal appendage, and which, owing to the loss of the caudal appen- dage and the assumption of the erect posture through evolution, have somewhat readjusted their character and attachments, to conform to their new function of closing the pelvic outlet and supporting the pel- vic contents. These four muscles are called the ischio-coccygeus, the ilio-coccygeus, the pubo-coccygeiis and the pubo-rectalis. The ischio- coccygeus which arises from the spine of the ischium and is inserted into the lateral border of the lower part of the sacrum and the upper part of the coccyx; and the ilio-coccygeus, which arises from the iliac portion of the obturator fascia and in inserted into the lateral border of the lower part of the coccyx, have comparatively little remaining physio- logical importance or surgical significance." The remaining two muscles, however, are of extreme importance. " Tlio pvibo-coccygeus arises from the lower border of the symphysis ossis pubis, from the posterior surface of the os pubis, and from the obturator fascia as far back as the ilio-pectineal eminence. From this somewhat extensive origin the fibres pass meso-dorsad, passing by tlio uretlira, tlie vagina, and the rectum, lying cephalad of the lower porlion of the ilio-coccygeus, and arc inserted with those of its fellow 252 , A TEXT-BOOK OF GYNECOLOGY from the opposite side by means of a tendinous expansion into tlie ven- tral surface of the coccyx and the lower part of the sacrum, the more ventral fibres interlacing directly with those of its fellow as a girdle posterior to the rectum. The pubo-rectalis lies beneath, or caudad of, the ventral portion of the pubo-coccygeus, from which it is separated ventrally by an intermuscular fascia. It arises from the lower jDortion of the symphysis ossis pubis, or from the beginning of the descending ramus and the cephalic surface of the urogenital fascia. Its fibres usually form a well-defined muscular loop which passes dorsad, encir- cling the rectum at the perineal fiexure where it becomes continuous with its fellow. In jDassing by the rectum, some of its fibres enter the wall of the rectum, gradually become tendinous, and pass caudad as far as the cutaneous surface. A few fibres also pass anterior to the bowel between it and the vagina, some of them eventually becoming con- tinuous with the transversus-perinsei muscle of the opposite side. The jjubo-coccygeus and the pubo-rectalis together form what is generally termed the levator-ani muscle, and are the most important muscles of the pelvic floor. They produce the characteristic perineal flexure of the rectum and vagina and form the chief support of the pelvic viscera. They must undergo the greatest elongation during the dilatation of the pelvic outlet for the passage of the child, and, therefore, are most liable to suft'er rupture or laceration, as will be shown later. The more ventrally placed fibres pass almost directly ventro-dorsad, while on frontal section the muscular plane slopes from the periphery toward the centre and cephalo-caudad. In the space between the opposite muscles ventrally pass the vagina and urethra, and it is extremely im- portant to clearly understand the relations of these muscles to the lateral wall of the vagina. The normal virgin vagina is not a simple straight tube. In passing from without inward the general direction of the vagina, for a distance of 1.5 to 3 centimetres within the hymen is dorso-cephalad. At this point a distinct change in direction takes place and the vagina passes almost directly dorsad. The point of angu- lation lies opposite, and corresponds, to the perineal flexure of the rectum, and is produced by the pubo-coccygeus and the pubo-rectalis muscles encircling these canals at this point and drawing them for- ward, or in a ventral direction. With the finger introduced into the vagina, one is able easily to recognise the point of angulation, and distinctly to feel the edge of the pubo-rectalis muscle through the lat- eral wall of the vagina, as it passes in its course toward the symjjhysis. " An incision through the lateral wall of the vagina 1 to 2 centi- metres to the inner side of the hymen or its remains will expose the median edge of this muscle. It may easily be dissected up almost from its origin from the symphysis ossis pubis to the rectum, and in passing by the vagina its fibres do not enter or form an attachment directly to the vaginal wall. The muscle varies from 3 to 6 millimetres in thick- ness and extends in connection with the pubo-coccygeus laterally to the wall of the pelvis, the plane in the transverse direction being oblique THE PELVIC FLOOR AND ITS INJURIES 253 to the wall of the vagina. That portion of the vagina lying internal to the point of angulation or perineal flexure, and which composes by far the major portion of the canal, lies in its ventro-dorsal plane almost parallel with the muscular plane, and rests on it, the rectum alone in- tervening. Contraction of the muscles of this layer tends to increase the perineal flexure of the rectum and vagina by drawing the parts in a ventro-cephalic direction, and the opening through the muscular floor is thereby maintained ventrad of the line of gravity. The weight of the pelvic organs is thus brought to bear on the muscular layer of the pelvic floor; that mass of tissue ordinarily called the perineal body lying be- tween the rectum and the vagina, and extending from the inner muscu- lar floor of the pelvis to the cutaneous surface, has little or nothing to do with sustaining the pelvic organs." (Harris, ibid.) The pubo-coccygeus and the pubo-rectalis muscles, considered joint- ly as the levator-ani muscle, are graphically described by Dickinson {American Journal of Obstetrics) as resembling a horseshoe. Without reference to accurate anatomical details he says that " it is like a sling attached to the pubes in front, its sweep reaching horizontally back- ward to encircle the rectum and vagina like a collar. It sustains the re- lation of an independent encircling constrictor to the rectum and vagina, both of which are drawn by it in the direction of the pubes. It is a vohmtary muscle with the capacity of lifting from 10 to 27 pounds. In cases in which it is inordinately developed it may be a serious barrier to the sexual relations while its spasmodic excitation is the frequent cause of dyspareunia and vaginismus." Meyer designated the internal muscular layer of the pelvic floor as the diaphragma pelvis proprium., and there has been a disposition among other writers to speak of this layer as the pelvic diaphragm. But this nomenclature is both erroneous and misleading. The word diaphragm, whether employed in mechanics or biology, conveys the meaning of " a partition or septum which separates one cavity from another." The most extravagant license can not conjure into existence a cavity below the internal muscular layer of the pelvic floor. If the term pelvic dia- phragm is to be employed at all, it shou.ld be restricted to that parti- tionlike arrangement of structures at the utero-vaginal junction which divides the recognised cavity of the pelvis from the cavities of the vagina, rectum, and, in part, of the bladder. Injuries of the pelvic floor may embrace any of the recognised varieties of wounds, such as contused, incised, or lacerated. They may be restricted to the skin, or they may involve the external muscular layer (perineum), or only the deeper muscular layer, or, to a greater or less extent, the whole of the structures of the pelvic floor. In this chapter we shall confine attention to those injuries which affect (a) the external muscular layer (perineum), and (&) the internal muscular layer. Lacerations of the Perineum. — Injuries of the external muscular layer are cliicfly restricted to tlie /lerineum and are ordinarily discussed under the title of lacerations of the perineum. These injuries rarely 254 A TEXT-BOOK OF GYNECOLOGY result from external violence, but the traumatism upon which they depend is generally an incident of parturition. The traumatisms inflicted in this region are generally considered and treated as lacerated wounds. Still, there are instances in which the injury may be classed both as a contusion and a laceration, and upon a proper conception of the true nature of the trauma the treat- ment will, in a great measure depend. Varieties. — The varieties of these lacerations, or tears, must be con- sidered from the standpoint of the direction taken by the tear. This will be governed by the presenting part of the child that comes in con- tact with the least resistant or most inelastic structure, the force of the labour pains, and the anatomic construction at the point of impinge- ment. It must be remembered that the perineal structure, as a whole, is a complex arrangement of muscles, ligaments or tendons, fasciae, and ves- sels and nerves, so interwoven and superimposed as to resist a great amount of force. One of the functions of the perineum being to close the introitus vulva^ by the contraction of the sjshincter vagint"B and levator-ani muscles, it is drawn or held forward by them, pro- ducing an abrupt angle with the lower portion of the birth canal; so that, in the process of descent, the presenting part comes into contact with a de- cided obstruction, and, should it be wanting in elasticity or resiliency, the structure is sure to be injured. A tear occurs at the point of least resistance, whether at this point be situ- ated a muscle, tendon, or fas- cia. This tear will take the direction of the course of the fibres composing the integral part at which the force is spent (Fig. 94); for the rea- son that it does not require so much force to split such a structure as it does to sever it at right angles. Should a tear occur along the course of the central tendon it may be de- nominated a central tear; if along the fibres of the transversus peringei muscle or the transverse fibres of the triangular Hgament, a lateral tear, with the prefix "right" or " left," as the case may be. The central rupture is regarded by most au- FiG. 94—" This tear will take the direction of the course of the fibres composing the integral part at which the force is spent." — Doesett. THE PELVIC FLOOR AND ITS INJURIES 255 thors as far the more frequent, but this is not the experience of Dorsett. Out of 1,006 ruptures of the perineum occurring at the St. Louis Female Hospital from July 15, 1887, to March 3, 1892, there were 296 central ruptures, 237 left lateral, 199 right lateral, and 10 ruptures of the third degree, or into the rectum, being more or less central. The remainder were of a superficial nature, or ruptures of the first degree. So great is the tendency for the line of tear to follow the fibres of the different tissues forming the perineum, that there are instances in which the tear, starting at the raphe, runs along the central tendon, here and there breaking a fibre and getting a little farther to one side until the sphincter ani is reached and penetrated; which muscle, on account of its peculiar circular form, may lead the tear around the anus, almost or completely enucleating the lower rectum from the surround- ing structures, or it may pass on backward to the fibres of the coccygeal ligament and split them till it reaches a point at or near the tip of the coccyx. Two cases of enucleation of the lower rectum from these severe tears have been observed by Dorsett. A laceration may start at the fourchette and take a straight back- ward course, following the raphe for a short distance, when, on ac- count of a particularly strong fibre or set of fibres of the triangular liga- ment or transversus peringei muscle, it may take a different course, pro- ducing a very irregular wound. Lacerations sometimes take a shape not unlike the letter L or an inverted Y or T. When the head is in the first or second obstetrical position and there is not a great disproportion between the child's head and the maternal parts, and when the patient is tractable and can be controlled, the levator-ani muscle, as a rule, escapes injury. When an occiput posterior position is met with, the deeper perineal structures are apt to suffer, whether the delivery is instrumental or not. This is due to the fact that flexion can not take place and the occiput engages the posterior wall of the vagina and ploughs its way through the perineum, tearing the levator-ani and other deep muscles on its way outward. Occasion- ally, these posterior positions may cause what is known as perforating rupture. In other words, the perineum may be perforated by the child's head in such a way that the fourchette and sphincter ani may remain intact. Such injuries are, however, fortunately rare. A most remarkable case of perforating rupture of the perineum is related by Liszt (Monatsschrift fiir GehurtsMilfe unci Gynakologie). The subject was a primipara, aged twenty years, who had a normal pelvis and was in labour thirteen and a half hours. A swelling the size of a goose's egg appeared over the perineum and gradually increased in size until it ruptured two hours later. The child, which presented by the breech, was expelled through the opening, but the head had to be extracted. The fourchette and rectum were uninjured. For the purpose of description, lacerations of the perineum may be described as degrees of injury, according to the extent of solution of oriliriiiity. As, for example, a laceration through the skin, mucous. 256 A TEXT-BOOK OF GYNECOLOGY submucous, and subcutaneous cellular tissue, and as far as the muscle but not into it, may be termed a laceration of tlie first degree; if through the skin, mucous membrane, submucous and subcutaneous cellular tissue, and the muscular structures to, or into, the external sphincter- ani muscle, a laceration of the second degree; if through all the previ- ously mentioned tissues, and also through the anal sphincter into the rectum, a laceration of the tliird degree. Prophylaxis.- — In the conduct of a case of labour it should be a matter of the utmost concern to the obstetrician to guard against a rupture of the perineum, the time for the most watchful attention being at the close of the second stage of labour; for, when the present- ing 23art is pressing uj)on the perineum, the tenesmus becomes so great that the inclination to strain, as at stool, becomes almost irresistible. Still, in many instances, if the patient is directed to " breathe out " and to " take short breaths," she may control herself to such a degree that the head may, even in a primiparous woman, slip over the peri- neum Avithout injuring it beyond a slight tear of the fourchette. Yet it must not be forgotten that the maintenance of flexion of the child's head is the desideratum, and it is the duty of the obstetrician, by con- stant manual effort, so to press the occiput downward toward the hollow of the sacrum, that, by the proper amount of moulding of the head, the occiput can come well up under the pubic arch. When this stage is reached, the force now to be exerted is in exactly the opposite direction — that of extension — and is exercised by placing the palm of the right hand, not u^jon the mother's perineum, as was taught by the older writers, but upon the part of the child's head that shows in the cleft of the vulva, till the parietal eminences are about to escape, when the left hand relieves the right, and the index and middle fingers of the right hand are carried into the rectum and hooked under the supra- orbital arches. Gentle traction is now made with the two fingers of the right hand upward toward the pubic arch, while the left hand holds the head well against the arch. As soon as there is shown to be some progress, the two fingers, already in the rectum, are carried farther upward, and the lower border of the superior maxillary bone (in the child's mouth) is reached, when traction is made upon it, and latterly the child's chin is substituted for the maxilla. During this pro- cess of " shelling out the child's head," very effective assistance can be rendered by the nurse or assistant, by the insinuation of the fingers between the child's occiput and the pubic arch, and by pushing down the upper vaginal commissure which engages the back of the child's neck, like a collar. This rule should be followed whether the forceps is used or not. In the great majority of instances the forceps is only necessary to bring down the head into the vulva and is then taken off; the remainder of the delivery can be accomplished in the manner indi- cated above. In the delivery of all cases, irrespective of presentation or position, traction, manual or instrumental, should be in the direction of the axes of the birth canal for the preservation of the perineum. This THE PELVIC FLOOR AND ITS INJURIES 257 rule should be strictly adhered to at the outset. Still, with the utmost care and good judgment, the perineum will be ruptured in a certain proportion of cases. J. W. Bullard (Western Medical Review, Novem- ber 16, 1898), after having consulted Byford, Munde, Martin, Hirst, Baldy, Coe, and Montgomery, as to proportion of lacerations during first labours, has found it to be about 30 per cent. Consequences. — The immediate consequences of laceration of the perineum are according to the degree of injury sustained. If the lacera- tion is of the first degree, the consequences are trivial. If of the second ■or third degree, the normal involution of the vagina and vulva is more or less interfered with, and the danger of sepsis greatly augmented. On account of the resulting torn and lacerated open wound, pathogenic organisms gain ready access. If the laceration extends into the rec- tum through the sphincter-ani muscle, the inability to retain the faeces iind gas will render the patient a miserable sufferer. The remote consequences, when the laceration is of the second or third degree, are many and not confined to the site of injury. For it must be remembered that the perineum is the support upon Avhich rest the internal organs of generation as well as a part of the weight of the bladder; so that an impairment of this structure necessarily disqualifies these organs from performing their functions in a normal manner. When the laceration extends to the anal sphincter and is deep ■enough to involve the levator ani, the transverse muscles, and the transverse fibres of the triangular ligament as well as the different layers ■of fascia, the anterior wall of the rectum and the posterior wall of the bladder are robbed of their natural support, and a sagging of these organs is the consequence. As soon as the solution of continuity takes place, the divided ends of muscles retract, and, in time, by the pro- cess of healing, will be covered by mucous membrane, which does not give strength but allows a pouching downward of these organs. Strain- ing in the act of defecation or micturition augments the trouble, and, in the case of the bladder, a cystocele — in the case of the rectum, a rec- tocele — is formed. These abnormal pouches grow progressively larger and progressively give more and more trouble. In the case of the blad- der, the loss of its posterior support, viz., the perineum, together with the tearing away of its natural moorings from their normal attachment around the internal aspect of the pubis by the passage of the child through the birth canal, leaves nothing to hold it up, and a sagging of the viscus is the result. This sagging down prevents the organ from emptying itself completely, and a decomposition of the residual urine soon sets up an often intractable cystitis. A division of the structures composing the greater portion of the perineum, leaving only the sphincter-ani muscle, allows the rectum to pouch forward, thus forming the condition known as rectocele. This tiirnoTir is increased in size by the efforts at defecation, for the reason that tlio anterior wall of the rectum forms almost a right angle to the .anus, and, at each attempt to defecate, this angle is increased, and 1H 258 A TEXT-BOOK OP GYNECOLOGY the pouch or sac is consequently likewise increased in size. On account of the inability to evacuate thoroughly the contents of the rectum, a constipation is inaugurated, which tends still further to increase the size of the tumour. jSTot alone to the bladder and rectum, is the mischief done by a rupture of the perineum. The vagina, uterus, and uterine adnexa, also suffer. The lack of support given the vaginal walls causes them to drag the uterus downward, stretching its suspensory structures — viz.,. the broad ligaments on either side, the two utero-sacral ligaments pos- teriorly, and the two round ligaments anteriorly. Nature only intended these ligaments to act as " guy ropes," to poise the uterus in the pelvic cavity, and not as supports. The consequence is a giving way of these ligaments, resulting in either descensus or retro-deviations of the uterus and adnexa. The restoration of the pelvic floor is demanded in all cases when the injury is sufficient to cause either destruction or serious deteriora- tion of the functional power of this structure. When injuries are restricted to the external muscular layer (perineum) the impairment of function may consist, either in a mere enlargement of the vaginal out- let, with a consequent tendency to rectocele and cystocele, or, if the laceration has extended through the recto-vaginal septum, dividing the sphincter-ani muscle, the consequent loss of function finds expression in fgecal incontinence; the indication, therefore, is for the repair of what are ordinarily designated the perineal structures. If, on the other hand, the injury involves the internal muscular layer of the pelvic floor, the resulting impairment of function eventuates, not only in a tendency to rectocele and cystocele, but in general ptosis of the pel- vic viscera; the manifest indication is, consequently, for a restoration of integrity and tone in the impaired deep muscles of the pelvic floor. When both layers of the pelvic floor are damaged, as is the case in prob- ably the majority of instances, the resulting operation, to be curative, must comprehend a restoration of all the injured parts. It is needless to say that the necessary prelude to correct treatment must consist in careful examination and accurate diagnosis. The immediate operation for external injuries of the pelvic floor, otherwise called lacerations of the perineum — i. e., the operation for restoration of the parts immediately after parturition — is one the expe- diency of which must be determined by the character of the laceration and the condition of the patient. If the laceration is not associated with much contusion, if the line of cleavage is direct and the surface smooth and of easy approximation, and if, moreover, the patient's condition is such as to admit of the operation, sutures may be applied at once and the wound closed. If, however, the laceration is of the eccentric variety, if the tissues are bruised and the proxim.al surfaces seem to be infiltrated with blood, and particularly if, in the presence of these conditions, the laceration is complete, attempt at imme- diate repair may be set down in the vast majority of cases as a mere THE PELVIC FLOOR AND ITS INJURIES 259 unnecessary and fruitless infliction of pain. The practitioner in Justice alike to himself and his patient should, before attempting the imme- diate repair of these injuries, explain that the majority of such opera- tions are failures. Union may be said to occur in less than 50 per cent of even favourable cases. When the practitioner deems the case in Fig. 95. — Hemostatic forceps. — Kobe. Fig. 96.— Scalpel. — Kobe. Fig. 97. — Emmet's left- angled, right-curved scissors. — EoBB. Instruments for Catheter, glass 1 Forceps, hemostatic : Long 2 Intermediate 2 Small (Fig. 95) 2 Long dressing 1 Needles, as for abdominal sections (omitting the largest). Needle-holders 2 Needle, Reed's curved 1 Nozzle, Edebohls's 1 PerineorrJiapliy Packer, vaginal 1 Retractor, small 1 Intermediate 1 Scalpels (Fig. 96) 2 Scissors, right-angled 1 pair. Emmet's left-angled (Fig. 97).. 1 " Straight-pointed 1 " Sound, uterine 1 Tenaculum, straight 1 Tenacula, curved 2 hand a proper one for immediate repair, he should recognise that every step of the operation should be done with the strictest antiseptic precautions. The patient should be put in position on the table and the vagina should be carefully irrigated, preferably with lysol or car- bolic-acid solution; if the mercuric bichloride is used the solution should not be stronger than 1 to 4,000, because a stronger solution coming into 260 A TEXT-BOOK OF GYNECOLOGY contact with the raw surfaces of the wound is liable to cause tissue changes that will interfere with the union. After cleansing the vagina, the upper part of that canal should be carefully packed with sterilized gauze, to prevent the escape of the lochia during the progress of the operation. After having again cleansed the wound, interrupted sutures of sterilized silkworm gut should be inserted, with careful observance of the principles governing their application, as set forth in the paragraph relating to the elective operation of perineorrhaphy. Operations for Incomplete Laceration of the Perineum. — The opera- tion for the repair of superficial lacerations of the perineum is very simple. A V-shaped area is denuded at the site of the former four- chette (Fig. 98), and is closed by interrupted su- tures (Fig. 99), the re- sulting line of approxi- mation representing the letter Y. Emmet's Operation. — The patient, after having been antiseptically pre- pared and anassthetized, is placed u]3on her back, her buttocks at the edge of the table, her legs thoroughly flexed and in- trusted to assistants, or preferably, to the me- chanical appliances which constitute a part of the modern operat- ing table (Fig. 100), the clothing worn during operations being omitted from the picture in order to show better the posi- tion of the legs. To hold the legs in a flexed position is both difficult for the assistant and not destitute of danger to the patient, for injuries have happened to the hip joint by injudicious pressure upon the flexed leg. Clover's crutch is not a desirable appliance for the reason that its mechanism is calculated to interfere with respiration and to become an embarrassment to anaesthesia. As soon as the patient is Fig. 98. — "A V-sliaped area is denuded at the site of tlie former fourehette." — Eebd. THE PELVIC FLOOR AND ITS INJURIES 201 put in this position and the labia are retracted, the posterior wall of the vagina will appear as a projecting mass within the vagina (recto- cele, Fig. 86). A tenaculum is fixed in the middle and at the apex of this mass, which is now drawn forward and up- f ~ ^ T^^ ward toward the pubes; as this is done the trac- tion thereby induced will make apparent two folds, one on either side, lead- ing from the point of the tenaculum to each lateral sulcus of the vagina. A tenaculum is then hooked into the caruncle caused by muscular retraction on either side of the vag- inal outlet, and upon the tenacula thus placed lat- eral traction is made by assistants. A gutterlike fold is thus formed, the external end beginning at the caruncle and ex- tending upward into the lateral sulcus where it coalesces with the fold from the central point of traction maintained by the tenaculum drawn up- ward toward the jDubes, and another tenaculum is now placed at the site of the fourchette, midway between the two last named. The traction made in this way indicates the area to be denuded, while the approximation of the two lateral tenacula and the final infolding and Fig. 99. — " . . . Closed by interrupted sutures, the re- sulting line of approximation representing the letter Y."— Reed (page 260). the one in the vaginal wall will show approximation of tissue that is to be accomplished by the operation. Again separating these three points, and re-establishing the upward and lateral tension, the operator can see, in clear outline, the area which is to be denuded. The margins of the folds induced by the traction are the indications for the incision, which is carried along the crest of one lateral fold to 202 A TEXT-BOOK OF GYNECOLOGY the bottom of the sulcus on the same side, and from the bottom of that sulcus to the central tenaculum, on the posterior vaginal wall; it is then carried from this same central point to the bottom of the sulcus on the opposite site of the vagina, and along the crest of that lateral fold to the vulvar margin; the two ends of this really continuous in- cision are now united by carr3dng an intermediate incision from one lateral tenaculum directly across to the opposite lateral tenaculum. The territory thus outlined is next de- nuded, after which the me- dian tenaculum on the pos- terior wall of the vagina is Fig. 100.—" The patient is placed upon her back, her clrawn down to a level with legs thoroughly flexed."— Keed (page 260). the lateral carunculse. Su- tures of silver wire are em- ployed and are inserted first into one lateral triangle and next into the other lateral triangle of the wound. They are passed an eighth of an inch back of the margin, and traverse first the mucous membrane and then the underlying muscularis; are crossed over to the other margin of the same triangle and are passed out from beloAv upward, including first the muscularis and then the mucosa. The sutures are inserted about one fourth of an inch apart and, in passing from one side to the other of the respective triangles, they are made to define a V-shaped course, the apex of the letter pointing downward (Fig. 101). This is accomplished by inserting the needle and bringing it downward to the median line of the triangular space, drawing it out, reinserting it at the point of exit, and directing it upward and inward. After the sutures have been placed in first one and then the other lateral triangle, the "crown suture" is inserted (Fig. 101). This suture is recognised by Emmet as the one of principal importance in the entire operation and is inserted at the point of the carnncular depression on one side, deeply enough to embrace within its sweep the levator-ani muscle. It is brought out on the denuded surfaces, passed over, and is inserted through the cellular tissue underlying the tip of the central mucous tongue. It is then crossed over to the other side, is inserted deeply enough to include within its sweep the levator-ani muscle, and is brought out Just back of the caruncular depression of that side. A second suture an eighth of an inch from the foregoing may be similarly inserted if deemed expedient. Interrupted sutures are now passed from one side to the other, between the " crown suture " and the median perineal tenaculum, at intervals of about one fourth of an inch. The sutures are now tied, beginning with those at the apex of THE PELVIC FLOOR AND ITS INJURIES 263 first one and then the other triangle, the resulting approximated wound resembling the letter Y. Care should be taken in tying the sutures; for, if tied too tightly, they may induce necrosis from pressure. It may be taken as a safe rule that a suture is too tight whenever it blanches the tissues that it compresses. The foregoing description is intended to convey a conception of the technique as employed by Enunet, and as yet practised by him and his numerous fol- lowers. Many of the lat- ter, however, while fol- lowing practically every other detail of Emmet's technique, substitute other suture material; McMurtry, for instance, closes the lateral trian- gles with formalinized catgut, using silkworm gut for the " crown su- tures " and for the extra- yaginal sutures. From the fact, however, that formalinized catgut en- dures within the tissue from fourteen to twenty- one days- — a longer pe- riod than the interrupted sutures are ever retained — the^ expediency of in- serting buried " crown sutures " of this material is well worthy of consid- eration. Reed's method of su- turing is as follows: The denudation is made in the same way as in Em- met's operation — but the closure is effected en- tirely by means of the buried formalinized catgut suture. The crown suture is first in- serted. A heavy curved needle armed with strong catgut is passed from left to right through the cellular layer of the mucous tip; it is then inserted a little to the right of the median line and carried deep enough to catch in its sweep the levator ani on the patient's left side. It is brought out beneath the cutaneous surface, and is carried to the opposite side and inserted beneath the cutaneous sur- FiG. 101. — " After the sutures have been placed in first one and then the other lateral triangles, the crown suture is inserted." — Eeed (page 262). 264 A TEXT-BOOK OF GYNECOLOGY face, being made to embrace in its sweep the levator ani of the patient' s-- right side (Fig. 103), when, being drawn taut, it will show the lines of approximation (Fig. 102). If the laceration is very deep and the separation is very pronounced, another crown suture of the same ma- terial is inserted in the same way; the ends of the crown suture, or of both of them if two are used, are left long and, for the present, untied. The wound is then closed by beginning on the inside near the apex of the left triangle, inserting the suture through the deep connective tissue and the muscularis, and bringing it out through the edge of the mucosa; it is then carried across and m- FiG. 102.- serted through the edge of the mucosa, through the muscularis, and the deep connective tissue. The suture is now tied and the short distal end alone is cut away. This gives the suture its an- chorage. (See Abdomi- nal Section.) After this- the needle is made to de- fine the same circuit at in- tervals of one quarter of an inch, or less, until the lateral triangle is closed. The needle is then carried through the submucous connective tissue to the apex of the other triangle, when, without further preliminary fixa- tion, it is made to approximate the margins of the wound as in the pre- ceding triangle (Fig. 103). When both lateral triangles have thus been closed to the crotch of the Y, this suture is fixed by tjdng it in the deep cellular structures. The crown suture is now tied, the knot being on the inner surface of the approximated tissue. The remaining peri- neal wound is then closed by an intercutaneous suture (see Abdominal Section), forming the stem of the Y. In some cases it is well to fortify the approximation with a supplementary serpentine suture, passed sub- cutaneously (Fig. 109). The advantages of this method of closure are that it insures the best possible approximation of the parts; it gives the -" Being drawn taut it will show the lines of approximation." — Reed. THE PELVIC FLOOR AND ITS INJURIES 265 patient less pain after operation; it is less liable to infection; and there is no occasion to remove sutures. Various modifications of Emmet's operation have been made, many of them, unfortunately, ignoring its sound philosophic principles; others, however, while observing the principles of Emmet, differ from, his operation chiefly in the manner of execution. One of the most valuable of these innovations is the procedure of A. Palmer Dudley, the essential point of which is to take a stitch which will draAV up all the posterior mucous mem- brane at the middle of the posterior wall, so that none of it can interpose itself afterward when the parts containing the tendinous centre of the muscular floor of the pel- vis are drawn into ap- position. This elimi- nates the downward-pro- jecting tongue of mucous membrane left by Em- met in his denudation. When a rectocele is present, the denudation is extended upward to the crest of the pre- senting pouch, forming a triangle the apex of which is in the medi- an line of the posterior vaginal wall. The wound is closed by a series of interrupted cat- gut sutures, the ends of which are tied externally. In passing these sutures in cases not complicated with rectocele, the nee- dle is inserted through the cutaneous margin and carried back coinci- dently with the long axis of the denudation for a distance of, perhaps, half an inch; it is then drawn through, reinserted at right angles, and brought out at the mucous margin, the buried portion of the suture making a lottor L; tlie snture, next carried over to the opposite side at Fig. 103. — "The needle is carried through the submu- cous connective tissue to the end of the other trian- gle when ... it is made to approximate the margins of the wound as in the preceding triangle."— Keed (page 264). 266 A TEXT-BOOK OF GYNECOLOGY a corresponding point and inserted through the mucous margin at a distance of half an inch, is brought out in the midst of the tissue, and the needle reinserted at the point of exit and brought out through the cutaneous margin, the buried portion of the suture on this side making the letter L precisely as did the same suture on the other side. The second suture is passed in precisely the same way, the horizontal and perpendicular lines being parallel with those of the preceding stitch, from which it is distant about one fourth of an inch. Four or more such sutures are inserted and the ends are tied externally. In cases in which rectocele is present, the sutures are applied beginning at the apex of the upper triangle. The needle is inserted through the mucous membrane, pointing downward and inward toward the median line, at which point it is brought out; reinserted at the point of exit and passed through the tissues upward and outward, it is brought out through the mucous membrane on the opposite side of the triangle at a point directly opposite that of entrance. The buried portion of the suture thus intro- duced is in the shape of a letter V. Other sutures are applied in the same manner, the arms of the V gradu- ally widening until, in the middle of the area of denuded tis- sue, the suture is di- rectly horizontal, while those inserted below this point are parallel with it. The sutures are now tied, beginning with the upper intra vaginal one, the wound when closed making a straight line along the raphe of the peri- neum, the fourchette, and the median line of the posterior vag- inal wall. Lawson Tait adapted the flap- splitting operation to incomplete lacera- tions of the perineum, but with results less satisfactory than those following the Emmet operation, and vastly inferior to those which follow the adoption of the flap-splitting jDrinciple in cases of complete Fig. 104.—" The condition that is presented at examination." • — Keed (page 267). THE PELVIC FLOOR AND ITS INJURIES 267 laceration. The Emmet operation may be accepted as a safe work- ing method in incomplete tears of the perineum. Operations for Complete Lacerations of the Perineum. — When the laceration of the perineum is complete, involving the separation of the recto-vaginal sep- tum and a division of the sphincter-ani muscle, the resulting condition is much more embarrassing to the patient and much more difficult for the sur- geon. In these cases there is a much more complete retraction of the perineal structures, a much wider gaping of the vaginal orifice, and an incontinence of the fgeces. The condition that is pre- sented at examination (Fig. 104) is that of a sep- tum with only a narrow cicatrized margin which, if denuded by the ordi- nary trimming process, would afford but narrow surfaces for approxima- tion. This, indeed, was a cause of failure in the ma- jority of the older opera- tions. To obviate this dif- ficulty and to secure wider margin for approxima- tion, Lawson Tait hit upon the expedient of splitting, rather than trimming, the septum. By this means, turning the rectal side of the flap into the rectum, and the vaginal side of the septum into the vagina, he secured, without the loss of tissue, approximating surfaces varying from half an inch to as much more as might be deemed desirable. Lawson Tait's Operation. — The technique of the flap-splitting operation is as follows: The patient is carefully prepared with due antiseptic precautions and with careful attention to the condi- tion of the bowels. This latter point is of extreme importance and should consume several days in its proper accomplishment. The bowels should be relaxed by repeated doses of salines given in small quantity and at frequent intervals. The Hunyadi or Apenta water or a mild solution of sulphate of magnesium may be given every few hours Fig. 105.— "The three incisions form the letter H."- Reed (page 268). 268 A TEXT-BOOK OF GYNECOLOGY until the bowels are relaxed, after which the saline should be kept up at longer intervals for the next couple of days. In the meantime the diet, while abundant, should be chiefly of the liquid variety. Catharsis should cease at least twenty-four hours before the operation. On the morning of the operation one or two high enemas should be given, washing out, not -ROTlIPHIfi3| o^ly ^^l^e rectum, but the sigmoid and the colon. No opiates are given to restrain the bowels either be- fore or after the op- eration. The vagina is now thoroughly sterilized and the pa- tient is placed on the operating table. A bistoury or, prefer- ably, a pair of keen- edged scissors curved on the edge or bent at an angle, may be employed to divide the septum. This is done by carrying the incision from one side to the other, be- tween the vaginal and rectal layers of the septum, to the depth of about half an inch. The inci- sion is next carried out to either side to the outer margin of the distinctly cica- tricial area. Another incision is now made, beginning a little below, and a trifle to the outside of, the um- bilicated point, indicating the location of one end of the retracted sphincter-ani muscle. The incision is carried upward along the outer margin of the cicatricial area to its upper angle. A similar incision is now made on the opposite side. The three incisions unite to form the letter H (Fig. 105). It will now be discovered that by bringing the two upright lines of the H into approximation with the median line there is a restoration of the original contour of the parts. In the act of bringing them together, the vaginal flap and the rectal Fig 106. — " Other operators pass these sutures through the cutaneous margin." — Keed (page 269). THE PELVIC FLOOR AND ITS INJURIES 269 flap of the septum separate, approximating the broad proximal sur- faces. Before the sutures are applied, a little more dissection may be required to expose the buried end of the retracted sphincter-ani muscle. This precaution is important. Tait was in the habit of closing this operation by passing sutures of silkworm gut by means of the Peaslee needle. Although other operators pass these sutures through the cutaneous margin (Fig. 106), the principle which he always observed in suturing was to apply these interrupted silkworm- gut sutures subcutaneously, the object being to draw forward and into approximation the retracted subcutaneous structures. The needle Avas inserted into the tissues beneath the skin, carried under the tissues to the opposite side, and brought out just beneath the cutaneous margin. Several of these sutures were thus passed and then tied. The res^ilt was a gaping margin from which protruded the free ends of the silkworm gut. Superficial sutures I mm^nm^ were next passed be- tween the free ends of the deep tissue su- tures, thus carefully approximating the external margins of the wound. It should have been stated that it was Tait's custom in passing the deep tis- sue sutures, always to make sure that he inserted one of them in such a position as to catch the re- tracted ends of the sphincter-ani mus- cle, which Avere then brought into appo- sition when the su- tures were tied. The sutures were gener- erally removed on the seventh or eighth day, rarely later Fig. 107. — "Tliui'uds See page 305.) Antiseptic Precautions. — It has been the experience of many opera- tors that suiDpuration is quite prone to occur in this operation. This can be readily accounted for by the low vitality of the parts involved — adipose tissue and tendon — by the great amount of handling of the tissues, and by the depths of the cutaneous folds affording safe hiding places to the Staphylococcus pyogenes albus and other micro-organisms. Suppuration can generally be prevented by a very rigid ase|)sis. Un- questionably, the fingers of the surgeon are the great carriers of infec- tion. While experiments show that it is impossible to perfectly steril- ize the fingers^ still, the dangers can be reduced to a minimum by care- ful scrubbing with soap and hot water, and subsequent immersion for at least five minutes in a l-to-1,000 sublimate solution, or in the potassium permanganate and oxalic acid solutions. The use of riiljljer gloves is the most certain way of preventing in- fection from the hands, and they should never be omitted. In a long series of cases done with gloves, not a single supjjurative case has been met with. While the gloves at first seem to be a great obstacle, after a little practice their presence is scarcely noticed. The most thorough disinfection of the jDatient's skin should be employed. After careful shaving, the parts should be covered with a green-soap poultice for some hours, and then thoroughly scrubbed, and a cloth wet in sublimate solution (1 to 1,000) placed over them and left there until the operation begins. Immediately before the opera- tion, an additional scrubbing with alcohol and ether, followed by more sublimate solution, will diminish the chances of suppuration. During the operation all loose i^ieces of fat, torn muscle, or fascia, should be removed, and all blood vessels carefully tied or twisted, so as to prevent the formation of clots as far as possible. It must not be forgotten that the cut end of the ligament sometimes bleeds and may need a fine ligature. The present technique of the operation shows that no improve- ments of importance have been made in the original plan suggested by Alexander. The patient, being properly prepared, is placed upon the table with the feet toward the light. The uterus must first be carefully replaced and a pessary introduced. In most instances it will be advis- able to precede this by a thorough curettage of the uterus. Should there b*; a thorough retroflexion, it may sometimes be necessary to 296 A TEXT-BOOK OF GYNECOLOGY introduce a stem pessary, in order to make the uterus rigid and to pre- vent the fundus from turning over round the pessary. Having thoroughly cleansed the skin at the seat of operation and surrounded the parts with antiseptic towels, wet or dry as the opera- tor may choose, either the spine of the pubis or the external abdominal ring is felt for. One or both can usually be readily distinguished. An incision is then made directly over the ring, a short distance above Poupart's ligament and parallel to it. The length of the incision will vary with the amount of adipose tissue present. In many thin persons, the incision may be less than an inch in length; two inches is the maximum length in any case. The fat and superficial fascia should be carefully incised until the tendon of the external oblique muscle is clearly and distinctly visible. This may be recognised by its white and glistening appearance. Between the fibres of this tendon may be seen the covering of the inguinal canal, which is recognised as a somewhat darker line slightly triangular in shape. The finger tip readily recog- nises the external ring. With the scissors the intercolumnar fascia at the external ring is snipped, and immediately a small mass of fat will extrude itself. This may be picked up between the thumb and finger and slowly and carefully raised; or, should the operator prefer, a strabismus hook may be introduced and the tissues within the canal brought forward. These tissues always contain the cord spread out in fan-shape. By raising them carefully, the whitish fibres of the cord may be recognised. It should then be se^^arated from the surrounding connective tissue and also from the nerve. The nerve should not be cut, but carefully laid aside. Then, with the fingers alone, without the use of any instrument, the cord should be slowly and carefully pulled out. In the majority of instances it comes out readily, increasing in size as the lower por- tions are brought up, until a large, white, fibrinous, structure is brought well in view. In some instances the pubic portion of the cord is exceedingly small and requires the most careful handling; but, if great care and delicacy are used, it may be slowly and gradually brought out until the large and well-developed cord is finally secured. If the cord comes with great difficulty, the intercolumnar fascia may be incised and tbe whole length of the canal laid open, thus exposing the cord at a point where it is usually larger and stronger. Having been once brought out, the cord is allowed to fall back into its place, the pubic end being still connected, and the same procedure is followed upon the opposite side. Most operators prefer to change sides, and to stand upon the side on which they are operating. The length to which the cord should be pulled out varies. In simple retroversions, a moderate amount of shortening is all that is needed. Should the parts be very much relaxed and the uterus en- larged and prolapsed, a greater amount of shortening will be required. No positive rule can be given for this; the judgment of the operator must decide in each case. Both cords beinff loosened and all hemor- DISPLACEMENTS OP THE UTERUS 297 rhage stopped, the pubic end of one cord is cut close to the pubis, and the cord drawn out and held by an assistant, well up to the abdominal wall. A stitch of catgut is passed through one pillar of the ring, and then through the cord and the opposite pillar. The same stitch is then passed through these tissues in reverse order, the two ends being brought out on the same side. This mattress suture serves to keep the cord in place and effectually to close the canal. The cord is then cut off half an inch beyond the last stitch. Should the inguinal canal be still open to any extent, this should be closed by additional catgut .stitches. This procedure having been completed on both sides, the wounds are closed by deep stitches of fine catgut. An antiseptic dressing is applied and held in place by adhesive straps. The bandage devised by Dr. Kelly, and known by his name, has proved very serviceable in still further holding the dressings in place. There are several complications to be taken into account Adhesions in the inguinal canal sometimes effectually prevent the drawing out of the cord. In three cases seen by Mann, the cord was so firmly attached on one side, that it was impossible to draw it out, there having been in each case an inflammatory condition with pus-formation in the neighbourhood of the canal. Upon the opposite side, in each of these cases, the cord was drawn out as usual. It is questionable whether the operation should ever be undertaken under such circum- stances. The shortening of one cord is hardly sufficient to keep the uterus in place, although it may help, and occasionally succeeds per- fectly. We can never predict whether we shall encounter a delicate cord or a strong one, in any given case. In young women who have never borne children, or in whom the uterus is not well developed, the liga- ments are sometimes very small and ill defined. In women who have passed the menopause, and in whom the uterus is atrophied, the atrophic process seems often to include the round ligaments; and in these cases the result of Alexander's operation is not so sure. From these or other causes, the cord is at times so delicate, especially at the pubic end, as to be pulled out with the greatest difficulty. Unless the utmost gentleness is used, it will be broken, and then all clew to its position is lost. By working very slowly and carefully, and opening up the inguinal canal to its full extent, the cord can usually be pulled out, even in the worst cases. Considerable time must be taken, as hurry will surely result in failure. In a few instances the cord will hrealc. If this occurs at the pubic end, and the uterine end of the cord can be kept in view, it may be carefully followed up until it becomes large enough to be firmly seized anrl so be pulled out. It is impossible to pull upon the cord with a homostat or any instrument, for, no matter how carefully it is done, it will crush and cut tbo cord. The cord must always be pulled with the fingers, iiiKJ ilic fiii.iivi's alone. As the gloved fingers are slippery, it 298 A TEXT-BOOK OF GYNECOLOGY is well, until the cord is entirely loosened, to keep its pubic end attached. In pulling on the cord, it must always be remembered that the force should be applied in the direction of the inguinal canal. If the uterine end of the cord breaks after it has been nearly freed, the difficulties of securing it again are very great. The only chance then will be to follow up the inguinal canal and to open into the abdominal cavity through the internal ring. Goldspohn, of Chicago, recommends that the internal ring should be opened in all cases, and he inspects and operates upon the tubes and ovaries in this way. Mann has performed this operation several times, removing diseased ovaries and tubes before shortening the round ligaments. It does not seem to be generally advisable to adopt this procedure, as the median opera- tion, with the internal shortening of the round ligaments, would seem to be safer and easier. By pulling up the horn of the uterus, the broken end of the round ligament may sometimes be found; but the operation may fail because the cord is broken so close to the uterus that there is not sufficient to sew even to the internal ring. The operator is sometimes embarrassed by anatomical abnormi- ties. In a few instances, the cord has been found not to run through the inguinal canal. Doubt may be thrown upon some of these cases, as only the most careful dissection post-mortem would be sufficient to prove that the cord is not there. Failure to find the cord will be less frequent as the operator becomes more experienced. By keeping the anatomic landmarks carefully in view, and by making sure that the ten- dons of the external oblique muscle, with the external ring, are clearly exposed, and that the incision is made between the pillars of the ring and not to one side, very few failures will be encountered. In about 1 per cent of cases the canal of Nuck will be found to be open from the internal ring to the symphysis. In these cases the round ligament is always found embedded in the walls of the canal and can not be sepa- rated, and the shortening of the ligaments is impossible. The fact that there is a persistent canal of ISTuck on one side does not prove that the same condition exists upon the opposite side. Inguinal hernia in the female is comparatively rare, but, when found, often coexists with re- troversion. In these cases, the shortening of the round ligaments and the cure of the hernia can be done together. The round ligament will usually be found upon the hernial sac, and must be carefully searched for before the sac is cut off. The after-treatment is very simple. The patient should be kept in bed for eight or ten days, and the wound left untouched, unless the temperature goes up. At the end of that time the dressings may be removed; when the wound should be found perfectly healed. Upon the tenth day, the patient may be allowed to sit up, and may leave her room as soon after as her strength will permit. The pessary which was introduced at the time of the operation should be worn for two or three months; and, if there is much relaxation of the utero-sacral ligaments, it may be necessary to keep it in for a longer period. DISPLACEMENTS OP THE UTERUS 290 Intra-abdominal Shortening of the Round Ligaments— Mann's Operation. — The operation here to be described is a modilication of the procedure first suggested by Wylie (Fig. 121). It has been de- scribed by Mann in tlie American Gynecological Transactions for 1897. It was first done in June, 1893. The special indications for this operation are a backward displace- ment and such complications with other diseased conditions as to make the opening of the abdomen advisable. It can be done, therefore, Fig. 121.—" The procedure iirst described by WyJie." — Mann. where it is necessary to open the abdomen for reparative work on dis- eased tubes and ovaries, for the breaking-up of adhesions, the removal of one tube and ovary, or the removal of ovarian cyst or pedunculated fibroid. It may also be done when Alexander's operation has been tried and has failed, or is contraindicated for any reason. In any abdominal section for pelvic disease, if the uterus is displaced backward, this or some operation having a similar purpose should be done. Where both tubes and ovaries are removed, or when pregnancy can not possibly occur, some might prefer ventral fixation. This operation does not com- pete with Alexander's operation, as it fulfils entirely different indications. The abdomen being opened, the technique of the operation is as follows: Adhesions are broken up, and any other necessary operative procedure completed. The patient is then placed in the Trendelen- burg position, and the abdominal retractors put in place. A large, flat sponge is spread over the intestines, and the uterus is seized by a small volsella forceps and pulled up to the abdominal wound. The round ligament on one side is made tense by pulling the uterus to the opposite side, and is then seized by two hemostatic forceps, the points of seizure dividing the ligament as nearly as possible into three equal portions. Next, a needle, threaded with silk, is passed through the angle in the round ligament made by pulling upon the hemostat. This passes, therefore, twice through the ligament at points quite near to each other. It is then passed through the wall of the uterus at the point where the round ligament is inserted into the anterior uterine wall. It is well that a considerable quantity of uterine tissue be included in this suture. The usual method of passing the sutures through the anterior wall of the uterus is wrong (Fig. 122). 300 A TEXT-BOOK OF GYNECOLOGY The hemostat being removed, the loop of the ligament is tied to the uterus. A second stitch is passed through the ligament just as it leaves the abdominal wall, and then through the second angle in the round ligament at the site of the other forceps. This ligature is tied Fig. 122. — " The usual method of passing the suture through the anterior wall of the uterus is wrong." — Mann (page 299). and cut as before. In this waj the ligament is doubled on itself, and three thicknesses of round ligament are stretched between the sides of the pelvis and tlie wall of the uterus. The same thing being done upon the opposite side, the wound is closed in the usual manner. Eeed has adojDted Mann's operation as the one of choice in practically all retro-deviations of the uterus. He em- plo3's a forceps, having four flat approxi- mating prongs, the whole being an inch or more wide, with which to seize the round ligament in its middle (Fig. 123). A half turn of the forceps makes the de- sired fold in the round ligament (Fig. 12-i). The folds of the ligament are now fixed at the uterine and parietal ends as already described, interrupted sutures being emploj^ed; the middle zone is next fixed by a continuous suture passed be- tween the prongs of the forceps. The result is a triplicate ligament of desirable shortness and great strength (Fig. 125). The character of the suture material with which the round ligaments are sewed up is of some importance. Silk- worm gut is satisfactory, and has been used in many cases without harm; and, should an abscess occur and the removal of the suture be found neces- sary, it can be more easily found than a suture of any other material, as the sharp cut ends can be appreciated by the sense of touch. Catgut, which is readily absorbed, may produce adhesions, but the adhesions are Fig. 123. — " A forceps with four flat approximating prongs, the whole being an inch or more wide." — Eeed. DISPLACEMENTS OF THE UTERUS 301 not always permanent, and some cases of failure, or, rather, of recur- rence, have been reported. In one case operated on by Mann, in which catgut was used, in the year subsequent to the original operation all traces of the doubling of the ligaments had disap- peared. For this reason an unabsorbable ligature seems preferable. The results as shown by a number of cases which have been reported by different operators have been satisfactory. When pregnancy has oc- curred after this opera- tion, the labour has been entirely normal in each instance. As the uterus is held in its normal posi- tion, and as the round ligaments can stretch and grow as well as they could were they not stitched to- gether, there is no reason why pregnancy and la- bour should be interfered with in any way by this operation. The after-treatment is that which is usual for cases of abdominal sec- tion. For those who prefer the vaginal route, the op- erations of Goffe or Byford for shortening of the round ligaments through the vagina are practical and give good results, though they are confessedly more difficult of performance than where the round liga- ments are shortened through an abdominal incision. For those who are skilled in vaginal work, this operation may be indicated whenever the uterus is displaced, whether there are adhesions and tubal and ovarian disease or not. Unless the adhesions are very dense and the disease of the adnexa extensive, they can all be treated through the vagina, thus widening materially the indications for this operation over that of Alexander, and bringing it in direct competition with the abdominal operation. Gaffe's Ojierfilhiii. — (JofFc, after placing the patient in the dorsal posifion, uIHi the lliiglis well flexed, seizes the cervix through a specu- FiG. 124.—'' A half turn of the forceps now makes the desired fold in the round ligament."— Eeed (page 300). 302 A TEXT-BOOK OF GYNECOLOGY lum, and pulls it strongly away from the pubis. An incision is then made halfway round the uterus, through the vaginal wall. Another incision at right angles to this, in the median line, converts the opening into a T-shaped incision. Through this, the bladder is carefully sepa- rated from the vaginal wall by the finger, and the peritoneum opened. The fundus of the uterus is next pulled down until the round ligaments are brought into view. They are then doubled upon themselves in two places, much as in Mann's opera- tion. It is impossible, however, to get the out- side stitch as near the l^elvic wall as is done when the abdomen is opened. Otherwise, the operation is practically the same. With the uterus pulled down through the vaginal wound, the tubes and ovaries can be inspected and operated on, if de- sired, and adhesions Ijroken. After the liga- ments have been short- ened, the vaginal wound is closed with catgut su- tures and a small open- ing for drainage left, if thought desirable, though usually this is unnecessary. The vagina is then dusted with iodo- form, and the patient placed in bed. Byford's operation differs from the procedure of Goffe in that he draws down the fundus of the bladder and stitches the fundus of the uterus to the post-pubic peritoneum, which is drawn down after the bladder but recedes upward when released, and draws the fundus with it. The fundus is thus sutured to the peritoneum over the blad- der, much in the same way as in abdominal hysteropexy. For the suture of the bladder to the fundus, he uses formalinized catgut, placing two stitches about an inch apart. He draws down the round ligaments and uterine horns into the vagina, suturing the for- FiG. 125. — "The result is a triplicate ligament of desir able shortness and great strength." — Eeed (page 300). DISPLACEMENTS OF THE UTERUS 303 mer as taut as possible to the uterus just above the uterine insertion. As he finishes the suturing of the ligament, he throws the same catgut thread around the neck of the loop thus formed, and ties it securely. This last step he considers an important detail. He pays no attention to the remainder of the loop, which forms adhesions to the bladder and uterus just below the sutures. After all intraperitoneal oozing has ceased, he closes the peritoneum with fine catgut and the vaginal wound in the ordinary way. Byford asserts that the simple shortening of the round ligament is not sufficient, because, if it depends simply on adhesions, these ad- hesions will stretch and give way, and allow a recurrence of the dis- placement. This objection does not hold if a nonabsorbable ligature is used in the shortening of the ligaments. Byford reports a number of cases with generally satisfactory results. The principal complication which is likely to give trouble is narrow- ness of the vagina. This is particularly the case in virgins and in women past the change of life, in whom atrophy has occurred. The narrow vagina makes the operation very much more difficult, and may be a positive contraindication unless the operator is an adept. Exten- sive disease of the tubes or ovaries may also contraindicate this method of operating, and may even, where it has been begun, necessitate its abandonment, and the opening of the abdomen instead. This method has the great advantages of rapid recovery, absence of an unsightly scar, and freedom from danger of ventral hernia. As compared with the abdominal operation, it is more difficult of perform- ance, requires a large experience in vaginal work, and occasionally it is even necessary to open the abdomen to complete it — this, however, only in the presence of formidable complications. As compared with Alexander's operation, it is much more difficult and more dangerous. In simple cases the vaginal operation should always give way by prefer- ence to the Alexander. Vag-inal Fixation. — Under this heading Mann includes all those operations which have for their purpose the fixation of the uterus through the vagina. Either the body or the neck of the uterus can be fixed directly; or it can be fixed indirectly by acting upon the vaginal walls. Fixation of the fundus originated with Eabenau (1886); but at pres- ent there are a number of methods of performing it in use, and no one fixed method seems to be generally adopted. The operation employed hy Miiller is as follows: After curetting in the usual way, the uterus is pushed into a position of anteflexion by means of Orthmann's instru- ment, and drawn strongly downward. (See Macnaughton Jones, Diseases of Women.) The anterior vaginal wall is then cut from the point of insertion into the cervix almost to the meatus urethrge. If a cystocele is present, an oval of mucous membrane upon the anterior vaginal wall is removed. The bladder is then separated from the vagina, ilie forinor Ijcing drawn up and held by a retractor. Great care 304 A TEXT-BOOK OF GYNECOLOGY must be taken to have the bladder thoroughly separated, in order to avoid injur}^ by suture or pressure by the uterus. The fundus is then reached;, and half a dozen strong catgut sutures are next passed trans- versely in the anterior uterine wall, beginning at the wound above. The points of entrance and exit of the stitches are 2 centimetres apart. Then these stitches are carried through the edges of the wound, 1 centi- metre from the margins. The sutures are not tied yet, but the vaginal wound is closed; after which Orthmann's instrument is removed and the sutures tied in the order of insertion. The uterus, being in a posi- tion of anteversion, is held there by a firm tamponade of the vagina with iodoform gauze. In MacJcenrodfs operation, after separation of the bladder from the uterus and the opening of the abdominal cavity,, the anterior flap of the peritoneum is stitched to the front of the uterus, and then to the posterior surface of the bladder, thus closing the vesico-uterine pouch. A. Martin does an intraperitoneal vaginal fixation after colporrhaphy in a somewhat similar way. In this coun- try, Yineberg has practised an operation which involves both the short- ening of the round ligaments and the anterior fixation of the uterus. All of these operations of anterior fixation have the very great dis- advantage that they interfere more or less with pregnancy; and in the earlier cases, where the fundus was fixed to the vagina, very serious results followed. These earlier methods have been almost entirely given up, and seem to have very little place in gynecological practice. Besides the methods described, there are a variety of others, each operator seeming to have a plan of his own. It is not thought advisable to multiply descriptions of slight modifications of technique. Fixation of the cervix has been attempted, the object being to fasten it back in the hollow of the sacrum. It can be readily understood that, if the cervix is held upward and backward in the sacrum, the fundus will be thrown forward. This may be done either by shortening the utero-sacral ligaments, or by causing adhesions between the posterior surface of the cervix and the rectum — in other words, by obliterating Douglas's cul-de-sac. The operation for shortening the utero-sacral ligaments has not been successful, no technique having been developed which could make the operation available. Mann made attempts to do this a number of years ago, putting the patient in the Trendelenburg position. In this way each utero-sacral ligament was folded upon itself and sewed with catgut. In some cases it may be done with com- parative ease, but in the majority of cases it is a very difficult matter,, and the results have not been altogether satisfactory. Freund has proposed to shorten these ligaments by sewing them to the posterior wall of Douglas's pouch. Probably the best operation is that sug- gested by W. E. Pryor. His plan is as follows : Pryor's operation is done by preparing the patient locally and gen- erally as for a capital operation. After the uterus is curetted, the cul- de-sac is opened, the patient being in the dorsal position. If no pus is found, the operation is then continued. The tubes and ovaries. DISPLACEMENTS OP THE UTERUS 305 are treated as circumstances may require. After this, the pelvis is wiped dry and a gauze pad inserted. The patient is placed in the Trendelenburg position and the gauze pad removed. After the uterus has been packed with iodoform gauze, a piece of the gauze suffi- ciently wide to fill the vaginal opening, and about an inch and a half long, is inserted just within the edges of the vaginal wound. Over this enough strips are placed to fill the incision in the vagina. The uterus is then put in place, the gauze plug being carefully retained in position. Holding the uterus in place by the tampons pu^shing against the cervix, pieces of gauze are inserted to the sides of the cervix and in front of it, until the vagina is filled to the margin of the levator-ani muscle. The operator now takes a stout roll of gauze, as thick as his thumb, and about two inches long. This Pryor calls the gauze pessary. One end of this is introduced in front of one side of the cervix, just behind the levator-ani fibres, and the other end is pushed into a similar posi- tion on the other side. This plug lies transversely across the vagina and in front of the cervix. It will prevent the descent of the cervix, even in the face of the most severe vomiting. The uterine packing should be so arranged that it can be removed without disturbing the anchoring plug. (Fig. 36, p. 120, Pelvic Inftammations, Pryor.) A self -retaining catheter is introduced and is left in for two days. The after-treatment is important. In from seven to ten days, the patient is placed in Sims's position and all the dressings are removed and replaced exactly as they were at first. The operation will fail unless the supporting plug is properly inserted. Dressings are con- tinued as long as there is any raw surface in the vaginal vault. The supporting tampon is used for six weeks. The cervix must be kept pressing high and backward until the cul-de-sac opening closes and the posterior cervical scar is healed. Among the advantages claimed for this operation are that it leaves the corpus uteri perfectly in place, pregnancy is uninterrupted, and labour normal. The laceration and diseases of the cervix and peri- neum, according to Pryor, are to be corrected by subsequent operations, and not done at the time of the cul-de-sac operation. This is certainly a disadvantage as compared with Alexander's operation, which may very properly be joined with the various plastic operations on the vagina, cervix, and perineum. This operation may he done in any case of retroversion, and is espe- cially indicated when the utero-sacral ligaments are relaxed, particu- larly in cases of retroversion with prolapse. It may be combined with Alexander's operation in cases of great relaxation. When the back- ward position is accompanied by occluded tubes, by hydrosalpinx, or by cystic ovaries, Pryor thinks this is the preferable operation; but when pus is present in either tube or ovary, he thinks laparotomy preferable. Ventral Fixation. — Under this head it is proposed to consider all tlie operations by wliich the uterus is fastened, either directly or indi- rectly to tlie abdoininal wall. According to Delageniere, this opera- 21 306 A TEXT-BOOK OF GYNECOLOGY tion was first done in 1869, by Koebeiie, avIio, after removing an ovary, .fastened the pedicle into the abdominal wound. Lawson Tait first fixed the body of the uterus to the abdominal wall by passing a ligature through the fundus and through the edges of the wou.nd. These two operations represent the direct and indirect methods which have been developed by later operators. Direct fixation of the fundus to the abdominal wall may be accom- plished in two ways — either by passing ligatures so as to simply ap- proximate the peritoneal surfaces; or the fundus may be sewed to other structures of the abdominal walls. In the first method the suture is passed first through the fascia, subperitoneal fat and peritoneum, and then through the posterior wall of the uterus a little below the fundus. It then passes through the opposite edge of the wound, com- ing out above the fascia. A similar stitch is passed a quarter of an inch nearer the umbilicus and a little lower upon the uterine wall. These stitches, when tied, approximate the posterior surface of the fundus to the abdomen; adhesions then form, and in time the perito- neum pulls down, forming what has been described as a " suspensory ligament." The second method is employed in cases of great enlargement of the uterus, and particularly in cases of prolapse, in which the adhesions formed by the first method are not sufficient to permanently support the uterus. Under these circumstances, it is well to attach the uterus more firmly. It may then be drawn out of the abdominal wound and the peritoneum sewed with a running suture entirely around the fun- dus, going farther down upon the posterior wall than upon the ante- rior. In this way half an inch of the fundus is brought above the peritoneum. It is then sewed firmly with buried catgut stitches to the fascia and the edges of the recti muscles. In this way very firm adhesions are formed and the most obstinate case of prolapse may be relieved. Kelly inserts the sutures through the peritoneum and fascia in such fashion that, when tied, the knots are within the peritoneal cavity (Fig. 126). In Mann's experience this method is satisfactory, but should never be performed in cases where pregnancy may possibly occur. It is especially indicated in women past the menopause, in whom very great relaxation of the vagina and perineum exists. The needle which should be used in this operation should have no cutting edge. The needles known as Emmet's vesico-vaginal-fistula needles are particularly appropriate, having large eyes and a round body with a slight curve. If such needles are used no hemorrhage will occur from the puncture of the uterine tissue. If the uterus is brought up against the line of the abdominal incision, sufiicient adhe- sions will take place. If, however, it is brought up against a portion of peritoneum which has not been cut, then either the uterus or the peritoneal surface against which it is brought should be scarified. The early operators used silk, but to-day nearly all writers recommend the use of catgut. The chromatized or formalinized catgut is prefer- DISPLACEMENTS OF THE UTERUS }or able, as it lasts longer and creates more irritation, and stronger adhesions are consequently formed. By bringing the posterior surface of the uterus in contact with the abdominal wall, intra-abdominal pressure is brought to bear upon the posterior surface in such a way that there is no tendency to a recurrence of the malposition. The indications for this operation, by either method, would seem to be limited to those cases in wliich pregnancy is impossible, and where Fig. 120 (liedrawn from Kelly). — " Kelly inserts the sutures through the peritoneum and fascia in such fashion that when tied the knots are within the peritoneal cavity." — Mann (page 306). the abdomen is opened for some other purpose; also to cases of very severe prolapse with great relaxation, as already mentioned. Where there is a possibility of pregnancy the operation should not be done, as a large number of cases have been reported where pregnancy and labour have been materially interfered with by the binding down of the fundus uteri. Indirect Ventral Fixation. — Dr. A. H. Ferguson (Journal of the American Medical Association, November 18, 1899) describes a method 308 A TEXT-BOOK OF GYNECOLOGY of transplanting the round ligaments and attaching them to the abdomi- nal wall. After the usual preliminary antiseptic precautions, he opens the skin of the abdomen in the median line, the incision being three inches in length and beginning an inch and a half above the sym- phj^sis. The linea alba and the anterior sheath of the recti muscles are exposed, and an incision is made on either side through the anterior sheath of the rectus. The rectus muscle is retracted outward, and an incision is made di- rectly behind it into the peritoneal cavity through the transversalis fascia and the perito- neum. Next, the round liga- ment and the portion of the broad ligament are seized by forceps one inch from the origin of the former at the inter- nal ring. These struc- tures are then tied, ex- ternally to the forceps, and divided (Fig. 127). The distal end of the round ligament is dropped into the peri- toneal cavity, and the I^roximal end is also pulled well out of the wound into it. The round ligament and its accompanying portion of the broad ligament are next sewed with catgut to the margins of the wound in the trans- versalis fascia and peritoneum (Fig. 128). The fibres of the rectus muscle are then replaced, and the opening in the anterior sheath closed with continuous catgut suture, which gras^DS the end of the round ligament. A similar operation is carried out upon the other side of the median line, and the incision closed. Dr. Ferguson claims in this way to get a firm support for the uterus, which is not adherent to the abdominal wall, but is suspended free in the pelvis and capable of motion. He reports twenty-two cases operated l-'iii. 1-J7. — "Next [in Fergusson's operationj, the round ligament and the portion of the broad ligament, are seized by forceps, one inch from the origin of the former . . . tied . . . and divided." — Mann. DISPLACEMENTS OF THE UTERUS 309 on in two and a half years, with ideal results. One of the patients be- came pregnant, and the pregnancy went on to normal termination. The indications for this operation are the same as for intra-abdomi- nal shortening of the round ligaments, for which it may be substituted. In comparing these various operations for the treatment of posterior displacements, it will be seen that each has its special indications, and no operator should become so attached to one method as to employ this to the neglect of the others. Alexander's operation unquestion- ably fulfils the indications in a large majority of simple cases. Where adhesions have occurred, if they are slight, they may be broken up through a vaginal inci- sion, and Alexander's operation done after- ward. In view of the excel- lent results obtained by Alexander's operation, the opening of the abdo- men for ventral fixation alone is scarcely war- ranted in simple cases. Where the abdomen is opened, and the tubes and ovaries left in such a condition that pregnancy may occur, then the in- tra-abdominal shortening of the round ligaments would seem to offer bet- ter chances of perma- nent cure without inter- ference with gestation. If serious disease of the tubes and ovaries ex- ists, then either the ab- domen must be opened or the vaginal operation done, as the operator may elect. For an operator with small experience, the abdominal operation unquestionably offers the fewer obstacles. For those skilled in vaginal work, the vaginal operation causes the woman the least trouble and annoyance from the operation. Where the abdo- men is opened for other cause, and pregnancy is rendered impossible, either by disease, age, or the operation, then ventral fixation would seem Fig. 128. — " The round ligament and its accompanying portion of the broad ligament are next sewed with catgut to the margins of the wound in the transver- salis fascia and peritoneum." — Mann. 310 A TEXT-BOOK OF GYNECOLOGY to be the simplest and easiest of performance, and to give promise of equally good results. Vaginal fixation has found little favour in this country, and, in view of the great difficulties encountered where preg- nancy has followed, should never be done in women liable to become pregnant. The tendency in this country, even among those who have been its advocates, seems to be to substitute some other form of opera- tion for it. Anterior Abdominal . Cuneohysterectomy for Retroflexion of the "Uterus. — In 1895 Eeed applied Thiriar's operation of cuneohysterectomy to the anterior wall of the uterus for the relief of retroflexion. Jonnesco made a similar adaptation of the operation in 1897. The technique does not differ in any essential particular from that described in the treatment of anterior displacements of the uterus, except that the site of operation is the anterior instead of the posterior wall. Reed has done the operation but a very few times because the indications in retro-deviations generally are more effectively met by the operations upon the uterine ligaments, as described under another heading. The operation of anterior cuneohysterectomy is indicated only in those cases of retroflexion presenting marked hypertrophy with induration of the convex wall. When this condition exists, the removal of an ellip- tical segment is necessary to restore the organ to its normal axis. Jonnesco and Reed perform this operation in connection with shortening of the round ligaments. Ante-deviations. — The facts that the uterus occupies normally a position of anteversion and that there are no definite lines by which its normal position may be prescribed and limited, make it relatively diffi- cult to determine when an anterior displacement exists in a pathological degree. This is particularly true of anteversion; while the detection of a point of flexure in the axis of the uterus on its anterior surface is conclusive evidence of the existence of an anteflexion. The symptoms of forward displacements are pain in the sacral region with more or less vesical irritation and tenesmus; dysmenorrhoea and sterility are usually present. The diagnosis is generally made without difficulty by bimanual examination. The fundus is felt to occupy a position anterior to its normal plane, the cervix generally pointing backward. If, with the patient lying upon her back, the finger is passed behind the cervix and the latter is drawn forward to- ward the pubis, the fundus will naturally be drawn upward and back- ward; and if, when the force is removed from the cervix, the uterus returns to the state of extreme anteversion, it may be known, not only that forward displacement exists to a pathological degree, but also that the anterior wall of the uterus is attached to the fundus of the bladder. The existence of a point of flexure on the anterior wall about the cervico-corporeal junction will establish the difference between anteversion and anteflexion. It should be remembered that a small subperitoneal fibroid on the anterior wall may feel like anteflexion — and the difference may not be detected without the use of the sound or an DISPLACEMENTS OF THE UTERUS 311 abdominal section. The sound ought to be employed only under circumstances of exceptional importance. The pathology of ante-deviations, like that of other forms of dis- placement, is not confined to the uterus itself, but embraces a con- sideration of imjDortant changes in its suspensory apparatus. In the organ itself, however, in anteversion there frequently exists a condition of hyperplasia, and, occasionally, of neoplastic growth that makes the organ toi3-heavy, as it were, and acts as a potent cause in producing and maintaining a displacement. In other cases of anteversion paren- chymatous changes are sequent rather than causal. When this devia- tion exists to such a degree as to interfere mechanically with the circu- lation — particularly on the venous side — more or less passive conges- tion of the organ results. This is expressed, not only in the gross enlargement of the uterus, but in the thickening and excessive epithe- liah growth of the endometrium. In anteflexion important structural changes are added to those already enumerated. If the angle of flexure is acute, atrophy of the uterine wall occurs at the point of angulation on the concave side, while hyjDertrojDhy is likely to occur on the con- vex side (Fig. 131). (See Pathology of Eetro-deviations.) Contrac- tion of the utero-sacral ligaments, whether as a cause or as a conse- quence, generally exists in connection with forward displacements. It is probably a causative factor in many cases and one to be taken in account in the treatment. When the uterus is displaced forward in an extreme degree, the fundus of the uterus riding upon the fundus of the bladder, adhesion of the proximal peritoneal surfaces is liable to occur, particularly in the presence of infectious infiammator}^ condi- tions within the pelvis. When this complication exists, there is always more or less inflammatory mischief in the wall of the bladder. Ex- treme ante-deviations imply more or less constant tension on the broad ligaments, which, sooner or later yielding to this influence, become relaxed and cease to exercise their function of holding the uterus in its natural poise. The treatment of forward displacements of the uterus, aside from surgical measures, has been unsatisfactory. Pessaries, while occasion- ally affording temporary relief, have more frequently caused discomfort and damage. Graily Hewitt's cradle pessary at one time had a con- siderable vogue, but it, like its congeners, is now generally abandoned. The judicious use of tampons has been attended with comfort and fol- lowed by substantial improvement. When acute pain exists with for- ward displacements the patient should go to bed, take a laxative, and be given frequently repeated hot douches, with occasional glycerine tampons. A case that can be controlled by a pessary can, in all proba- bility, be relieved with equal efficiency and greater comfort by the measures Just enumerated. When, however, in spite of careful atten- tion to the details given, forward displacements exist to such a de- gree as to interfere with health, recourse should be had to surgical treatment. 312 A TEXT-BOOK OP GYNECOLOGY Forward displacements of the pregnant uterus occur either- by re- laxation of the abdominal wall or by a ventral hernia. Sometimes the entire gravid ntertis occupies a large hernial sac (Fig. 129). A sup- port should be furnished to the protruding mass until delivery lessens its volume and renders it reducible. The case after this period is to be recognised and treated as one of ventral hernia. The surgical treatment of forward displacements has as yet embraced no operation for anteversion of the uterus. Where that condition is due to retrac- tion and shortening of the utero-sacral ligaments pulling the cervix upward and backward, and thus throwing the fundus too far forward, it has been proposed to cut through the posterior vaginal wall and resect the ligaments, thus allowing the cervix to come forward and as- sume a more normal posi- tion. This operation is rarely necessary. It has also been pro- posed to do Alexander's operation in these cases, and to raise the fundus by the round ligaments. As the round liga- ments were never made for this purpose, it is not likely that the opera- tion would be permanently successful. At any rate, these operations have never achieved a position in gynecological surgery, and are rarely even mentioned in literature. A history of the operations Avhich have been devised for the cure of pathologic anteflexion would form a very interesting chapter. From the operations of Simpson, Sims, and Peaslee, down to the present time, very many operations have been devised, all having for their object the straightening of the uterine canal. The earlier operations of Sims were not successful, owing, however, largely to the conditions in which they were done — the want of a proper aseptic technique. The later opera- tions which have been done have been much more successful and satis- factory. The majority of operators, however, are content with the operation of forcible dilatation, usually conjoined with curetting. Dilatation and Curetting". — This was suggested by Dr. Jolm Ball, of Brooklyn, in 1877 {New Yorh Medical Journal, vol. xviii, p. 363). Fig. 129. — " Sometimes the entire gravid uterus occu- pies a large Jiernial sac." — Eeed. DISPLACEMENTS OP THE UTERUS 313 Ellinger did a similar operation, and Goodell modified Ellinger's dilator and followed Ball's method, and was the first to popularize it in this country. Hanks also operated about the same time, using graduated dilators instead of the expanding dilators of the other operators. That dilatation is better than cutting is now generally admitted, and the large number of good results which have followed it has made this one of the most beneficent operations in gynecological surgery. That it cures the fiexion is not asserted by its most ardent supporters; but that the flexion is benefited and the symptoms relieved, is, in the major- ity of cases, generally admitted. This operation is indicated in any uncomplicated case of anteflexion where the flexion seems to be productive of symptoms. There is usu- ally present an endometritis, and this has more to do with the symp- toms than the flexion, and is, in turn, largely the result of the flexion. The operation has in view, not so much the cure of the flexion, as the relief of the complication — that is, the endometritis. TecJmique. — The patient being anaesthetized and placed upon the table, with the hips overhanging the edge and the thighs held in place by suitable legholders or assistants, the vagina is thoroughly scoured with gauze and green soap. The advisability of this procedure has been doubted by some, as it is a well-known fact that the normal vagina is aseptic. While this is generally admitted, it is not true in morbid conditions; and, as we can hardly make a complete bacteriological in- vestigation in every case, it is better to be upon the safe side and thoroughly to wash out and disinfect the vagina. After the scrubbing with the green soap, the vagina should be washed with a solution of bichloride (1 to 3,000). An Edebohls's or Jones's speculum is then introduced, and the cervix seized with the traction forceps and pulled down toward the vulva. After the direction of the cervical canal has been carefully made out by the uterine sound, a small uterine dilator (Hanks's or Palmer's) is introduced, and suificient dilatation effected to admit the introduction of the Ellinger-Goodell dilator. With this the cervix may be forced open, at least up to the inch and a quar- ter mark upon the index. A few minutes should be allowed for this, as the uterus is sometimes very friable, and too rapid dilatation may tear the tissues. When the dilatation is complete, the uterus should be washed out with the bichloride solution, and then thoroughly curetted with the Sims sharp steel curette. After this, it is again washed, and packed with iodoform gauze. Some operators, instead of packing with gauze, prefer to introduce a large stem pessary, half an inch in diameter, and then to pack the upper part of the vagina around the stem with iodoform gauze. If the cavity of the uterus has been packed with gauze, the gauze may be removed on the fourth day, or sooner if it causes too much pain. Tf the glass stem has been introduced, upon the fifth day the stern shoiilrl be withdrawn, the interior of the uterus carefully washed out witli pci-oxidc of hydrogen, and mopped out with a 5-per-cent 314 A TEXT-BOOK OF GYNECOLOGY solution of iclithyol and glycerine. Tlie stem should then be reintro- duced, and a tampon of cotton or iodoform gauze put in, to keep it in place. This procedure should be carried out daily until all the tender- ness upon the interior of the uterus has disappeared. The patient should be kept in bed for four days, though she may be allowed to sit upon the commode for the purpose of emptying the bladder and bowels. After this, she may be up and dressed, and gradu- ally resume her ordinary mode of life. In this way a very large proportion of cases will be relieved, not always of the anteflexion, but of the symptoms to which the anteflexion has given rise. Dudley's Operation. — Dr. E. C. Dudley, of Chicago (Diseases of Women, 1898), recommends an operation for anteflexion which has for its object, not only the curing of the endometritis, but also the com- plete correction of the deformity. Mann has had some experience with this operation, and has been entirely satisfied with the results, although his cases have not been numerous enough to enable him to speak with a great deal of positiveness. Dudley, however, recom- mends the operation, and it certainly accomplishes what he claims for it — namely, the complete rectification of the displacement. Technique. — The operation is done as follows: The patient is placed in Sims's position, and the speculum is introduced under ether. The uterus is then dilated and curetted in the usual manner. The cervix is divided with scissors, backward in the median line, past the utero- vaginal attachment, nearly to the utero-peritoneal fold, in the pouch of Douglas (Fig. 381, Dudley). " The cut surfaces thus incised are then held widely apart by means of two tenacula in the hands of an assistant; the incision is somewhat deepened by means of a scalpel, especially in the uterine wall next to the cervical canal, and a small angle is cut out on either side, as shown by the dotted lines in Fig. 383. The cut surface on. each side is now folded on itself by a single silkworm gut suture, as shown in Fig. 382. This suture is tied and fortified by interrupted sutures on either side. The lines of union thus made are shown in Fig. 383. " These sutures are not introduced in such a manner as to stitch the intracervical to the vaginal margin of the wound, but the cut surface is folded upon itself in a direction at- right angles to this. On either side, that point at the margin of the os externum where the back- ward incision commenced is stitched to the very angle of the incision, so that each cut surface is folded upon itself, not from within outward, but from before backward. Thereby the os externum is carried di- rectly back to the angle of the incision. The cervix now points back- ward in its normal direction toward the hollow of the sacrum, instead of forward toAvard the vaginal outlet (see Fig. 383). " In some cases of extreme anteflexion, there is a disproportionately long anterior lip. This elongation is shown by the dotted line in Fig. 377. It is the result of a relatively greater pressure on the DISPLACEMENTS OF THE UTERUS 315 posterior lip by the posterior vaginal wall; this lip should be caught with the tenaculum and partially removed by the scissors. The incised surface is then closed upon itself with sutures as shown in Fig. 384. The dotted line in Fig. 377 shows in section the line of incision through the protruding lip; the incision should extend to, but not into, the OS externum. This part of the operation is not required unless the anterior lip decidedly protrudes, and is therefore usually omitted. The removal of a portion of the lip in a suitable case is not only not a mutilation, but it even contributes to the straightening of the uterus. " Conjoined examination upon completion of the operation in each of the author's cases has invariably shown the uterus either to have been straightened or the anteflexion to have been reduced to a degree quite within physiological limits. The results have been substantially the same whether the point of flexure was at the os internum or be- low it. " The two posterior lines of sutures have the effect of transplanting the OS externum to the very angle of the posterior incision. The an- terior sutures, if used, have the effect of carrying the cervix back by a distance equal to one half the length of the anterior cut surface, which is doubled upon itself. By these means a permanent change, quite equal to overcoming the flexure, is effected in the direction of the cervix. As the result of the anterior portion of the operation, the uterus in a suitable case is lifted also in a higher plane in the pelvis, where it ceases to be a mechanical irritant to the bladder. This por- tion of the operation may therefore be indicated for descent when complicated with anteflexion." (Dudley, Diseases of Women, p. 581, etc.) This operation is not a substitute for dilatation and curetting, but rather supplementary thereto. An operation called cuneolujsteredomy has been devised for the cure of anteflexion. It is done by abdominal section and consists in removing a cuneiform piece of tissue from the convex side of the uterus at the point of angle. Its object is to straighten the anteflexed uterus by reducing to normal dimensions its elongated posterior wall. When done on the posterior Avail it is called posterior cuneohysterec- tomy, and vice versa. The procedure was devised and practised by Thiriar in 1893. Eeed did it for the first time in 1894. The details of the operation, as he has modified and now practises it, are as fol- lows: The patient is prepared with the usual aseptic and other pre- cautions for abdominal section. An incision about 12 centimetres in length is made in the median line and is carried as low as practicable with safety to the bladder. The patient is now placed in the Trende- lenburg position. All adhesions between the uterus and bladder or between the uterus and other organs are carefully broken up, and rents in the serosa that may be induced thereby are carefully stitched. The uterus is then brought toward the incision by gentle but firm 316 A TEXT-BOOK OF GYNECOLOaY traction and an ellipse of tissue about 1 centimetre wide, and hav- ing a length corresponding to the breath of the organ, is removed from the convex side of the site of flexure (Fig. 130). Care must be taken not to carry this dissection into the cavity of the uterus (Fig. 131), or to wound either the circular artery or the anastomosing branches of the uter- ine arteries. Should the latter accident occur, its result is Fig. 130. — ". . . an ellipse of tissue about one centimetre wide, and having a length corresponding to the breadth of the organ, is removed from the convex side at the site of flexure."— Reed. best counteracted by ligatures en masse passed deeply into the uterine tissue at either end of the yet gaping ellipse. Retraction of the vessels generally prevents their isolation and closure by direct ligature which, when practicable, is al- ways the preferable meth- od. After all hemorrhage, except mere capillary ooz- ing, is controlled, the margins of the ellipse should be carefully ap- proximated and closed by an interrupted suture, or a continuous animal su- ture fortified with two or three interrupted ones of the same material. The uterus is then dropped back, and, after pausing a moment to make sure of complete hemostasis, the abdomen is closed with- out drainage. A further modification of this op- eration, and one which Eeed has practised with satisfaction, consists in stitching a reef of the posterior folds of the p^, 131.— "Care must be taken not to carry this dis- broad ligament to either section into the cavity of the uterus."— Reed. DISPLACEMENTS OP THE UTERUS 317 side of the posterior surface of the uterus (Fig. 132). The utero- sacral ligaments, if found contracted, are nicked and stretched. He has been able by these combined methods to relieve the most dis- tressing and persistent symptoms, vesical, uterine, ovarian, and neuro- tic, due to otherwise intractable anteflex- ion of the womb. Prolapsus Uteri. • — Prolapsus is that anomaly of position of the uterus in which the organ has shifted from its normal site, has descended or fall- en to a lower level, and projects partly or completely outside of the vulva (Fig. 133). According to the degree of the descent we distinguish between partial or total prolapse. There is only a difference in degree between these varieties, their entire etiology Fig. 132. — " A further modification . . . consists in stitch- ing a reef of the posterior folds of the broad ligament to either side of the posterior surface of the uterus." — Eeed. ?a HiiP H WS I'lo. loo. — '■ Trolapsus is that anomaly of poisition in which tlie uterus projects partly or completely outside the vulva." — Herzog. being tJie same, and they do not call for a separate consideration. Par- tial prolapse is frequently spoken of as descensus uteri; the term pro- lapsus is then reserved for the total prolapse. 318 A TEXT-BOOK OF GYNECOLOGY ProlaiDsus uteri is almost invariably an acquired condition^ though there have been reported by Ballantj-ne and Thomson, Heil, Krause, and Eemy and Quisling, a few eases of congenital prolapse. These cases Avere always found in connection with other congenital anoma- lies. A condition simulating partial prolaj^se, which, however, anatom- icall}^, as well as from an etiological point of view, is entirely different from the morbid condition under discussion, is that of primary hyper- ti'ophy of the jjortio vaginalis uteri. This anomaly is always congeni- tal, and it may and does secondarily lead to a true prolapse. There exists still a good deal of controversy as to the etiology and mechanism of prolapsus. A view formerly held almost universally, and still adliered to by some, is that the primary factor in the produc- tion of a prolapse of the uterus is the prolapse of the vagina. The latter again is traced back to a subinvolution during the puerperium. This opinion is contested by Ktistner, who has studied the subject extensively and who very clearly and forcibly elaborates his observa- tions and views in a most excellent treatise (Veit's Handbucli der Gijndlvlogie, Wiesbaden, 189T, vol. i, p. 168). This author holds that it is impossible that a uterus normal in position can be forced out of the pelvis into the vagina. As long as the uterus is in its normal antero-versio-flexio position abdominal pressure acts upon its posterior wall and presses the body upon the bladder. The portio vaginalis under increased abdominal pressure has a tendency to rise, if anything. When, however, the uterus is in a retroverted- retroflexed position its vaginal portion becomes dislocated in the direction of the symphysis pubis and moves at the same time nearer the pelvic outlet. The uterus and its cervix now lie so that their axis has the same direction with, or forms the continuation of, the axis of the vagina. Increased intra-abdominal pressure can now easily force down the uterus into the vagina, this being made still easier since in retro-versio-flexio the vaginal portion of the cervix is nearer the pelvic outlet than under normal conditions. It is quite common that a history of retro-versio-flexio can be obtained in cases of prolapsus. The reason this condition is most frequently found among women in the lower walks of life is easily explained. Women of the better classes, as a rule, when retro-versio-flexio leads to any symptoms, seek medical aid and receive the proper attention. Women who have to work hard for a living often find no time to consult the physician, and, even if they do, they can not submit to the proper treatment and regimen to correct the retro-versio-flexio. If this goes on uncorrected and the woman suffering from it is performing hard physical work, the constant exertions, and the persistent abdom- inal strain in consequence thereof, will, in a large percentage of cases, force down the uterus and produce descensus and prolapsus. There are also some cases, however, in which the causation of the affection may be different. If, after childbirth, the vulva remains gaping for too long a time, there may occur a prolapse of the anterior vaginal DISPLACEMENTS OF THE UTERUS 319 wall, even if the uterus is not in retro-versio-flexio, and this may be followed by prolapse induced by the persistent traction upon the uterus and its ligaments. Prolapse may be preceded and caused by extensive untreated perineal lacerations, the mechanism of causation being the same as just indicated. Another set of conditions which may bring about prolapse is senile changes of the genitalia, accom- panied by atrophy of muscular, and disappearance of adipose, tissue. A factor which may greatly hasten the establishment of an extensive prolapse, if the other conditions are favourable, is great increase in the intra-abdominal pressure in consequence of large pelvic tumours or ascitic accumulations. In prolapse of the uterus there is, of course, present a prolapse of the vagina. The upper part of the latter is either invaginated into the lower part, or the whole of the vagina lies inverted in front of the vulva. Total prolapsus uteri, however, does not always mean total prolapse of the vagina, and vice versa. Combined with the uterine jDrolapse, there is present a displacement of the bladder (cystocele), and of the urethra. Eectocele may be present but is usu- ally absent. The patJiologic changes are various. That such a malposition, such a complete change of conditions as is found in prolapsus uteri, is accompanied by grave and profound anatomical lesions, is self-evident, though of course some of the pathologic changes precede instead of follow descensus. Yery marked are the changes of the lining of the inverted vagina. The epithelia become dry and horny. In some places the epithelial covering is thickened, while in others, particularly in the neighbourhood of the external os of the cervix, it becomes thinned out and is entirely lost, so that ulcerations appear in this neighbourhood. These changes are due to the fact that the inverted vagina is no longer moistened by the cervical secretion but is exposed to the air and subjected to other insults. The ulcerations frequently show sharp margins, or they present clefts caused by traction upon the changed tissues. There is generally noticeable a hypertrophy of the prolapsed parts. It is most marked at the portio vaginalis uteri, but is also well seen in the supravaginal portion. The cervix as a whole is often greatly elongated and thickened in its antero-posterior and lateral diameters (Fig. 134). The uterine body is likewise en- larged, though proportionately to a lesser degree. In women advanced in years, the enlargement of the corpus may be very insignificant or even absent. The enlargement of the uterus is, however, not so much due to a true hypertrophy as to an extensive oedema caused by circulatory disturbances. That this is indeed the case, is proved by the observation that after reposition of the organ, its size is often ma- terially decreased in a very short time. The mucous membrane of the uterus in prolapse is thick and succulent, and there occurs not infre- quently an endometritis glandularis h}qoertrophica. The higher de- grees of prolapse being usually combined with prolapse of the bladder, this organ likewise shows morbid changes, such as catarrhal inflam- 320 A TEXT-BOOK OP GYNECOLOGY mation of the vesical mucous membrane, or inflammation of the muscu- lar coat which may even lead to destructive processes. The vesical inflammation may spread by continuity to the ureters and the pelves of the kidneys. Klistner in a case of prolapsus uteri saw a profound purulent pyelitis which ran a fatal course. Inflamma- tory changes of the internal sexual or- gans, the tubes and ovaries, and the pelvic peritoneum, are quite frequent in prolapse. Klistner, in a series of eighty cases of laparoto- mies, ventrofixa- tions, and plastic operations on the vagina for |)rolapse, carefully examined the internal sexual organs and found that in almost one half of them chron- ic inflammatory pro- cesses could be ob- served in the ova- ries, the pelvic peritoneum, and the fimbriated extremi- ties of the Fallopian tubes. The patho- logic conditions found were oophori- tis corticalis, hy- drops folliculorum ovarii, perimetritis, perisaljDingitis with or without closure of the abdominal end of the tube, and hydrops of the tubes. The same author frequently noticed a mild degree of serous infiltration of the pel- vic peritoneum. In some of his fatal cases of prolapse he saw, in conse- quence of profound septic infection due to streptococci, abscess forma- tion in the subperitoneal connective tissue, particularly in the con- nective tissue between the bladder and uterus. Also purulent infil- tration of the muscular coat of the uterus, abscess of the ovary and Fig. 134 (Martin). — " The cervix as a whole is often greatly elongated and thickened in its antero-posterior and lateral diameters." — Heezog (page 319). DISPLACEMENTS OF THE UTERUS 321 encapsulated or general purulent peritonitis. (See Pathology of Uter- ine Displacements.) The symptoms of prolapsus uteri may be so mild in the earlier stages as easily to escape attention, or, if detected, they are liable to be interpreted as indicating a less important condition than a displace- ment of the uterus. Pain in the loins, sacralgia, increased by walking, prolonged standing or overhead work, and, particularly by straining at defecation, is the first to attract attention. This pain increases as the condition advances until the patient becomes conscious of what she construes to be a foreign body in the vagina. Pressure by the ■descending organ is liable to cause vesical and rectal tenesmus. In a .still further stage of development the cervix presents at the ostium vagina3, or the entire uteriis may protrude externally and occupy a position between the thighs. The diagnosis in the earlier stages is not always easily made. Patients are generally examined in either the recumbent or the semiprone (Sims's) position — in either of which, but particularly in the latter, a uterus in the earlier stages of descent has a, tendency to gravitate into its normal situation. It occasionally hap- pens that the first suggestion of an existing prolapse is derived from the fact that a well-adjusted tampon is being unaccountably extruded from the vagina. This fact will prompt an examination of the patient in the standing posture — provided that this has not already been done, as a part of the earlier examination of the case. The uterus will be found to have descended from its normal plane and to occupy a posi- tion of relative retroversion. It may be found in any degree of de- scent. Complete procidentia may be mistaken by the patient herself for cystocele and hydrocele, bu.t this point is easily cleared up by care- ful examination. A uterine polypus, or even one of vaginal origin, may simulate complete procidentia uteri. The diagnosis is cleared up under these circumstances by careful digital examination, with par- ticular reference to detecting the location and condition of the cervix. Bimanual exploration, by determining the location of the fundus and the size of the uterus, will clear iip any remaining doubts. Inversion has been mistaken for prolapsus of the uterus, but the history of the case, the existence of the hemorrhage, the character of the mucosa, and the existence or nonexistence of the fundus in its normal relations as determined by bimanual examination, will lead to an accurate con- clusion. Treatment. — Conservative, or, more properly speaking, the nonsurgi- cal treatment of these cases, resolves itself into medicinal, hygienic, and mechanical. The m,edicinal treatment consists, for the most part, in the administration of laxatives to overcome the constipation, which, in many cases, is a potent factor in the causation of the trouble. For this purpose saline waters, such as the Hunyadi Janos or the Apenta, should be given persistently in comparatively small doses after, but not be- forf, meals. If given before meals, they will cause catharsis, enerva- tioti of the bowels, and consequent aggravation of the constipation; 22 322 A TEXT-BOOK OP GYNECOLOGY but if given after meals they will mingle with the food, and, after a. couple of days, induce normal dejections not followed by serious conse- quences. Hygienic measures consist in attention to all the secretory functions, and especially avoidance of errors in diet. Massage of the uterus has been recommended, and as a remedy for relieving passive engorgement or chronic hyperplasia it is of value, and should be employed for the relief of prolapse, especially in its incipiency, when- ever dependent upon these conditions. It should not, however, be employed in the presence of acute inflammation of either the uterus or its appendages. Under the head of mecJianical treatment tamponade must be given first place. This should be practised as elsewhere de- scribed in this volume. If tampons saturated with some astringent, agent are carefully adjusted they will give excellent mechanical sup- port and afi^ord the relaxed ligaments an opportunity to regain their strength. Pessaries are employed for the same purpose and a certain percentage of cures is realized from their employment, which, how- ever, is not destitute of danger. The pessary with an intrauterine stem should never be employed; cup-pessaries are for the most part mis- chievous in their results, and, to avoid their damaging influence, must be frequently removed. The martingale ring of hard rubber may keep the uterus within the pelvis, but it does so by distending the vagina, laterally and by resting upon the pelvic floor. The inflated soft-rubber pessary has an even better power of retention, but it is, at best, a dirty and stinking thing, and should be used only when other means of treatment are not available. This instrument is very popular with practitioners because of the facility with which it is placed and the effectiveness with which it keeps the womb from dropping out of the vulvar orifice. The fact, however, is generally lost sight of, that this, pessary never cures prolapsus in the sense of restoring the uterus to its normal position and keeping it there, and but few practitioners take into account the other fact, namely, that by a continuous pressure upon the pelvic floor and by persistent lateral distention of the vagina, this instrument has a tendency really to aggravate pre-existing troubles, notwithstanding the fact that it alfords temporary relief. The soft-rubber pessary favours germ propagation and is, therefore, a. constant menace to the health. The best device among pessaries is Thomas's retroversion pessary already alluded to. If carefully ad- justed, it affords comfort in these cases and its use is sometimes fol- lowed by cure. The surgical treatment of downward displacements of the uterus- has for its object the return of the organ to its natural position and its retention there by the restoration, so far as possible, of its normal anatomic connections. Any treatment, to be effective, must be carried out in full recognition of the fact, that prolapse of the uterus commonly occurs as the result of either serious lacerations of the pelvic floor and the perineum, or as the result of atrophy and relaxation of all the uterine supports. The final result is the same in each case. In a DISPLACEMENTS OF THE UTERUS 323 limited number of cases, the injuries below are not so much the cause of the prolapse as the great relaxation of the uterine ligaments, particu- larly the utero-sacral. No prolapse can take place without relaxation of these ligaments. The first step in a prolapse is always a retroversion; so that relaxa- tion of the round ligaments is a universal accompaniment of this con- dition. If, with the relaxation of the round ligaments, there is also relaxation of the utero-sacral ligaments, then the uterus, following the axis of the pelvis, slowly and gradually makes its way downward under the influence of intra-abdominal pressure, until it finally appears at the vulvar orifice, .and may eventually be forced outside the patient's body. These being the causes of prolapse, all operative procedures must have for their object the restoration of the normal supports of the body. If these can not be restored, then some new support must be sought. With the object of relieving the downward traction on the uterus, operations may be performed on both the anterior and pos- terior vaginal walls. Unquestionably, the best operations for this purpose are those devised by Sims and Emmet. Emmet's Operation upon the Anterior Vaginal Wall (Anterior Col- porrhaphy). — " I first antevert the uterus with my finger, as the patient lies on the back. The neck of the uterus is then kept crowded up into the posterior cul-de-sac by a sponge probang in the hands of an assistant, while the patient is being placed on the left side for the intro- duction of the speculum. I then endeavour to find two points, one about half an inch from the cervix on each side, and a little behind the line of its anterior lip, which can be drawn together in front of the uterus by means of a tenaculum in each hand. When two such points can be thus brought together without undue tension, forming trian- gular-shaped folds, the surfaces are to be freshened. One of the te- nacula must be securely hooked in the tissues, to indicate the point. Then, one hand being disengaged, a surface half an inch square about the point of the other tenaculum is to be denuded with a pair of scissors. Next a similar surface is to be freshened around the point of the first tenaculum, and a strip afterward removed from the vaginal surface, in front of the uterus, about an inch long by half an inch wide." (Emmet's Gynecology, third edition.) A ligature of catgut is then passed beneath each of these freshened surfaces, which, when tied, brings them all together in front of the cervix, with the effect of forming a fold at this point. There are also, upon the anterior vaginal wall, two folds in the shape of an ellipse, extending from the surfaces secured in front of the uterus, nearly to the vaginal outlet. These folds are now to be denuded, turned in, and secured with a continuous catgut suture. The stitches should be placed about a quarter of an inch apart, and should include a libera] amount of tissues. The patient should be confined in a re- cumbent position for two or three weeks after the operation, until the parts are firmly united. 324 ^ TEXT-BOOK OF GYNECOLOGY Following this operation, or at the same sitting if thought advisable, the perineum should be firmly closed by Emmet's method. (See Chap- ter on Eupture of the Perineum.) The cervix uteri, if lacerated or diseased, should be closed by the operation of trachelorrhaphy, or amputated, as the case may be. It is Mann's belief that these operations alone will not generally cure permanently a bad case of prolapse. As the uterus is always retroverted in this condition, if it is left turned back it will remain in the axis of the vagina, and, acting as a wedge, will gradually force its way down and out, and the old conditions will be reproduced. To ob- viate this condition, it will be necessary to restore the round ligaments and the utero-sacral ligaments. In this way the cervix can be kept up in the hollow of the sacrum and the fundus turned forward. If this is done, the uterus will be at nearly right angles to the vagina, and the danger of a return of the prolapse will be done away with. After the operations upon the vaginal outlet the patient may wear a pessary, which takes the place of the utero-sacral ligaments, and this in itself may be enough. If not, then Alexander's operation may be done and the fundus kept forward b}' the tightened round ligaments. All idea of curing a prolapse by doing Alexander's operation must be laid aside, as the round ligaments alone are not strong enough to sus- pend the uterus, but, in a very short time, will give way and allow a relapse. In very bad cases where the uterus is greatly enlarged, and in old women, in whom very great atrophy of the parts has taken place, all these procedures are apt to fail, and we must then resort to ventral fixation, as already suggested. The removal of the uterus for the cure of prolapse, in the opinion of Mann and other representative gynecologists, is wrong. It is not, in his view, the weight of the uterus merely which brings it down, but the relaxation of the supporting structures. After the uterus is re- moved, the vaginal walls will come do-^oi as badly as ever, and Mann has seen one case at least in which hysterectomj^ failed to cure, the previously existing rectocele and cystocele recurring and becoming worse, until a complete hernia of the vagina existed. The cure of this condition is exceedingly difficult, and is harder than before removal of the uterus, as the possibility of ventral fixation is done away with. Inversion of the Uterus. — Inversion of the uterus means a turning inside out of that organ, and consists of the invagination of the fundus into or through the cavity of the womb. This form of displacement is not frequent; Braun and Spaeth report that not a case of complete inversion of the uterus has occurred in 250,000 births in their clinics; while it has been observed but once in 191,000 deliveries in the Eo- tunda Lying-in-Hospital of Dublin. The causes of inversion of the uterus are generally, but not always, connected with parturition. At this time, when the uterus is enlarged and its walls are softened by the ordinary evolutional changes of preg- nancy, but two additional conditions are required to render inversion DISPLACEMENTS OF THE UTERUS 325 probable^ viz.: relaxation of the uterine wall and downward traction upon the fundus. This traction may be exercised by drawing upon the cord in a case of fundal implantation of the placenta; or, given a case of adherent fundal placenta, the involuntary efforts of the uterus to expel the afterbirth, may cause the latter to drag the fundus down- ward into the cavity, or, for that matter, through the open cervix into the vagina. A large pedunculated polypus attached to the fundus of the uterus and finally expelled by that organ may, by persistent trac- tion, induce inversion in the nonpregnant uterus. A case of this kind came under the observation of Eeed. Small sessile fibroids have been found in the wall of the inverted uterus and have been construed as causes of the condition. The mechanism of inversion in these cases has been explained by Treub, who states (British Gynecological Journal) that in them there " is no regular contraction of the uterine wall and that there can not be. The base of a sessile tumour can not contract, because of the implantation of the tumour, which diminishes or alto- gether abolishes the contractility of that part of the wall, and it can not be that only the contractility of that base is diminished; the sur- rounding parts must necessarily be feebler within a greater or smaller circumference. If from the outset the tumour was intramural, the smaller degree of resistance of that part of the uterine wall, coupled with intra-abdominal pressure, may occasionally bring about a slight beginning of inversion. And when this is the case, the conditions are essentially the same for sessile and intramural tumours, and for the partial inversion described by Rokitansky. A circle of uterine tissue is abruptly curved in the place where Eokitansky found the external indentation. I need hardly say that in that incurved circle the uterine muscle must be absolutely paralyzed. And this paralysis again will not be confined to a linear circle, but gradually diminishing will extend over a greater or smaller surface. The contractions of the normal part of the uterine wall will try to expel the part of the wall that acts as a foreign body. These expulsive efforts may slightly increase the inver- sion as far as the paralysis surrounding the circle of inversion permits, thus displacing the circle itself; and paralyzing another part of the uterine wall. Necessarily the extension of the partial paralysis proceeds farther in the uterine wall, too, and by the repeated action of this mus- cular play the inversion may gradually become complete as regards the body of the uterus. As soon as the body is inverted, there is no longer any excitement for uterine contractions, and the inversion of the cervix generally does not take place. And it is the intra-abdominal pressure again that may invert the cervix too." Inversion of the uterus may be complete or incomplete; in the for- mer case the organ is turned completely inside out, the inverted fundus and body of the uterus lying within the vagina (Fig. 135), or protruding from, the vulvar orifice. The condition may also be described as recent or old, acute or chronic, the one type being represented by the recent inversion of the organ with its attendant alarming symptoms; the 326 A TEXT-BOOK OP GYNECOLOGY other, when the condition either complete or incomplete has occurred, involution of the uterus having taken place after the occurrence of the displacement, which remains in a chronic and more or less perma- nent form. The symptoms of inversion of the uterus following parturition con- sist, first, in profuse hemorrhage ensuing upon the delivery of the placenta; or, when the fundus is drawn down by the still adhering placenta the latter T^^^P^'W may be peeled off by external action, and violent hemorrhage ensue. Physical ex- amination should be made at once by the bimanual method. The intra - vaginal finger will detect a globular mass, pre- senting either just without or just with- in the thoroughly re- laxed cervix; while the hand upon the abdominal wall will readily detect the disapjoearance of the fundus from its nor- mal site with the development of a dis- tinct ring at the point of its disap- pearance. In an in- teresting case reported by Cordier wherein an inversion had fol- lowed an operation for the removal of a polypus, the symptoms during the next few months were those of frequent yet slight discharge of blood-stained fluid from the vagina; there were no menstrual pains, nor was there a history of extrusive contractions of the uterus. Digital examination revealed in the vagina a pyriform mass about 3 inches in length by 2.5 in breadth, of a soft and velvety nature, and not painful to the touch. The finger could be carried all round the mass, which disappeared through the os by a constricted neck, and could be swept around the neck of the mass for nearly an inch within the cervical canal. The speculum revealed the openings of the Fallo- pian tubes, on the presenting aspect of the mass. A probe could be easily introduced into the uterine ends of the tubes under vision while the speculum was in position. Such appearances as the foregoing, coupled with the disappearance of the fundus from its normal situa- FiG. 135. — "Inversion of the uterus may be complete . . the . . . fundus and body . . . lying within the vagina.' — Eeed (page 325). DISPLACEMENTS OF THE UTERUS 327 tion, as determined by bimanual exploration, comprise the essential diagnostic criteria in these cases. If the abdominal wall is thick, and the condition of the uterus, particularly in nonparturient or in chronic cases, can not be outlined by the bimanual maniiDulation, the index finger of one hand should be introduced into the rectum while a sound is passed into the bladder; if the sound and the finger meet above the presenting tumour the evidence is conclusive that inversion exists. The prognosis of inversion of the uterus is never favourable, although A. F. Jones, of Omaha, reports a case of spontaneous reduc- tion of an inverted uterus three years after the occurrence of the acci- dent. Crosse studied the histories of nearly 400 cases, with the result that he ascertained the mortality from this condition to be nearly -35 per cent, death occurring either very soon after the accident or within a month. Of 109 fatal cases, the fatal termination in 72 ensued within a few hours, and in the majority within half an hour. Eight died in from one to seven days and six in from one to four weeks. After the first month the danger is slight, but it begins again with the resumption of menstruation, which has a tendency to become hemorrhagic. Crampton's table {American Journal of Obstetrics, October, 1885) re- veals the fact that of 120 recent cases, 87 recovered, 32 died, 1 remained unrelieved. Twelve of the cases, however, were moribund when first visited. In the fatal cases, reposition was usually effected readily enough, but too late to save life. Of 104 chronic inversions, 91 recov- ered, 7 died, and 6 remained unrelieved. The average mortality as shown by Crampton's table is about 20 per cent. Pregnancy may occur, followed by normal delivery, in cases in which the uterus has been inverted and has either reduced itself spontaneously or has been reduced by operation. The pathology of this condition is by no means distinct. '\Ylien the accident occurs in the puerperal state the probably one essential factor in its causation is uterine inertia, which is a functional rather than an organic condition. After the occurrence of pvierperal inver- sion, the womb, if left in position, seems to undergo the ordinary course of involution. Aside from the malposition there seems to be no special pathologic state induced. Treub, of Amsterdam, made a careful microscopic examination of a uterus which he removed for nonparturient inversion, and found the muscular structure normal with absolutely no appearance of atrophy. There existed, however, a very redematous hypertrophy of the exposed mucous membrane. The treatment of inversion of the uterus differs materially in acute and in chronic cases. In acute cases — i. e., those of recent occurrence — the first indications are to secure hemostasis and to effect reduction. The hand should be immediately inserted into the vagina and upward pressure should be exercised by the fingers directly against the centre of the protruding mass, while counter pressure should be exercised from above by a hand placed against what may now be designated as the 328 A TEXT-BOOK OP GYNECOLOGY cervical ring. It is better to conduct the intravaginal manipulations under a current of water heated to 110'' F., or, preferably, water and vinegar, half and half, brought to the same temperature. Vinegar is an excellent hemostatic with distinct antiseptic properties. If the fountain syringe or other reservoir is hung very high, the hydrostatic pressure thereby secured becomes an additional force available in the work of reduction. If these measures do not at once control the hemorrhage, and if its continuance for any length of time is a menace to the patient's life, an elastic band should be placed around the neck of the protruding mass and should be left iii situ for several hours. It should not be adjusted so tightly as to induce strangulation, nor should it be left on so long as to produce destruction of the tissue. When it is unwound the hemorrhage will generally be found to have ceased, in wdiich case manipulations looking to the reduction of the organ should be resumed. Mechanical repositors, consisting of a staff with a bulbous extremity, may be made from wood or other ma- terial and used with persistent pressure. Lawson Tait utilized con- stant elastic pressure, which he applied to a repositor by means of an elastic perineal belt fastened before and behind to an abdominal girdle. There are some dangers attached to this method of treatment. If the intrauterine extremity of the repositor is not very blunt, or else bulb- ous or cup-shaped, an apparently slight elastic pressure may be suffi- cient to force it through the soft uterine tissues. Then, too, if the repositor with a large bulb, or a cuplike intrauterine end, succeeds in accomplishing its purpose, the instrument itself may become incar- cerated by contraction of the cervix. AVhile this complication is by no means insurmountable, it has proved embarrassing. If the extem- porized repositor is made of wood or other porous material, it may speedily become septic and a consequent source of extreme danger. To avoid this accident, it should, if conveniently possible, be given two or three coats of shellac before being used. The treatment of clironic inversion of the uterus has been a source of great perplexity since the days of Hippocrates. This master genius de- scribed with great fidelity the condition of inversion, which he treated by placing the woman on her back, upon a couch, elevating her feet, extending her legs, and applying compresses and sponges against the tumour, holding them in place by means of a perineal bandage. This was kept up for seven days. If it failed, the woman's womb was anointed, she was fastened by her heels to a ladder with her head hang- ing down, and was violently shaken with the object of thus reducing the displaced organ. Strange as it may seem, Castex, as late as 1859 {Gazette hebdomadaire de nicdecine et de cliirurgie), reported the success- ful adoption of this Hippocratic practice by a Moorish midwife at Tangier. The condition and its treatment through the succeeding centuries commanded the attention of Rhazas, Avicenna, Aretseus, and Themison, among the ancients. Various modern methods have been devised to effect the reduction DISPLACEMENTS OP THE UTERUS 329 of chronic inversion of the uterus. White, of Buffalo, as long ago as 1858, published a plan of reduction by continued pressure, which he applied by adjusting the soft rubber cup-shaped end of a repo.sitor against the presenting fundus of the uterus; to the other end of this repositor a spring capable of maintaining ten pounds pressure was adjusted, and so arranged as to lie against the breast of the operator. Pressure was thus exerted, while counter-pressure was made by the hands against the cervical ring, the pressure being exercised through the abdominal wall. This method was modified by Tyler Smith, Ave- ling. Wing, Eobert Barnes, Lawson Tait, and others, but with no essential deviation in principle. Carl Braun, in 1851, introduced a method of reduction by vaginal tamponade by means of a caoutchouc bag which he called a colpeuryn- ter. When this bag is properly adjusted to the uterus, the latter is pressed upward in such a way as to place the vaginal attachments upon the stretch, causing them to draw open the cervical cavity by lateral tension, thus acting not only as a dilator but as a repositor. The same principle is applied to-day by many practitioners. Neugebauer utilizes an intravaginal elastic bag which is gradually distended with water from a high plane. The hydrostatic pressure thus induced is found to be effective, a case in which the inversion had existed for two years having been thus reduced in nineteen days. The patient suffered no pain and learned to fill and empty the bag herself when it was necessary to relieve the pressure upon the urethra. When conservative means at reduction fail, recourse must be had to surgical intervention. T. Gaillard Thomas advised an operation of forcible dilatation of the inverted uterine canal. This was practised by first making an abdominal section, stretching the uterine tissues by means of a strong uterine dilator, and then reducing the uterus by conjoined manipulation. The mortality following this operation was large and it has been practically abandoned. The principle involved in Gaillard Thomas's operation, viz., the forcible dilatation of the inverted uterine canal, has been so modified as to avoid the necessity of the preliminary abdominal section. This modification consists in drawing down the uterus carefully enveloped about its neck with some sterilized gauze. An incision is then made through either the anterior or the posterior uterine wall, and through this incision a dilator is introduced. When the dilatation has been carried to a suflicient de- gree, as determined by the introduction of the finger through the operation wound and through the now dilated cervical canal, the incision is sewn up with sterilized catgut and the fundus is forced back into position. Kehrer (Centralhlatt fur Gyndhologie) draws the in- verted uterus down to the entrance of the vagina and makes an incision on its anterior surface through the whole length of the cervix from the OS externum to a little beyond the middle of the corpus, and ex- tending directly tbi'ough into the peritoneal cavity. The wound is then stitched from l,lie fundus to the os internum, after which the 330 A TEXT-BOOK OF GYNECOLOGY inversion is reduced, when, finally, the lower part of the wound is sewn up as far as the os externum. Hirst operates by dividing the posterior cervical wall as far up as may be necessary to gain space through which to effect the reduc- tion, which he has been able to do without making the extensive inci- sion of Kehrer. After the uterus has been restored by Hirst's method, the only remaining step consists in applying a few interrupted sutures to the incised posterior lip. This operation impresses one as being at once simple and effective. Vaginal hysterectomy as a remedy for chronic and irreducible inversion of the uterus is not a modern conception. Themison sug- gested it B. c. 50, but it was not adopted in practice until Soranus, of Ephesus, amputated an inverted uterus about the end of the second century of our era. The suggestion has been recognised as one of practicability from that day until the present. In its adoption the general principles of technique should be observed that are outlined in the chapter on vaginal hysterectomy. In view of the fact that the inverted uterus, when once restored, is capable of exercising the functions of reproduction, vaginal hyster- ectomy should not be performed in child-bearing women. CHAPTEE XXV INJURIES OF, AND FOREIGN BODIES IN, THE UTERUS Injuries: (a) parturient; rupture, laceration of the cervix — Trachelorrhaphy (Em- met) — Amputation of the cervix — (b) nonparturient ; wounds from external causes — Foreign bodies. Injuries of the uterus divide themselves naturally into (a) par- turient, and (b) nonparturient. Rupture of the uterus is an accident of parturition. It may be complete or incomplete. In the latter, the injury is restricted to the muscularis while the peritoneum remains intact. This was regarded by Lusk as more likely to occur in lateral tears at the site of the folds of the broad ligament — though, owing to the relatively loose attach- ment of the peritoneum at the lower segment, incomplete ruptures are not necessarily confined to those points. In the complete form the tear extends through the muscularis and the peritoneum, making, usually, a communicating wound with the abdominal cavity, although lacerations have occurred in that zone of the uterus which lies in normal attachment to the bladder. The causes of rupture of the uterus may be summarized by saying that they may consist of any condition that interferes with the descent of the child, that favours the ascent of the body and fundus, or dimin- ishes the normal powers of resistance of the uterine walls. A mon- strosity, a hydrocephalic head, neglected shoulder presentation, are examples of causes that may exist in the foetus. Fibroid tumours, dis- tortion of the pelvis, and malignant disease of the cervix, are among the maternal causes. Some writers have placed emphasis upon fatty degeneration of the uterine parenchyma as a demonstrated cause of this condition. The mechanism by which u.terine ruptures are caused was first satisfactorily explained by Bandl. He explained that in normal labour the contractions of the uterus resulted in a thickening of the fundus and body, while the lower segment was stretched and thinned by the downward pressure exercised by the presenting part of the fcetus. This process was strictly physiologic, so long as no obstacle existed to interfere with the descent of the child. The natural result of this dilatation was the practical conversion of the uterus and vagina into a continuous canal. When labour was advanced, the lower circum- ference of the body of the uterus was ordinarily distinguished from 331 332 A TEXT-BOOK OF GYNECOLOGY the stretched lower segment by the ridge induced by the contractions^ and now known as the ring of Bandh This ring was ordinarily found in the neighbourhood of the pelvic brini^ but its development was proportionate to the difficulty of the labour. In the presence of some obstruction to the normal descent of the child, the retentive force exercised by the suspensory ligaments of the uterus resulted in the upward retraction of the fundus and body of that organ. This up- ward migration of the superior zone of the uterus resulted in a cor- responding upward migration of the contraction ring, or the ring of Bandl. The ascent of this ring deprived the lower segment of the uterus of those accessions to its volume and resistant force, which, under normal circumstances, would be derived from the natural dilata- tion of the ring of Bandl. As a consequence, the lower, or cervical, structures became stretched and thin, often to a degree that they could no longer maintain their integrity against the exi^ulsive and divulsive force from within. In this way, according to Bandl's explanation, the majority of all ruptures of the uterus begin in the lower segment, a philosophic conclusion which is amply confirmed by clinical observa- tion. The view has been urged that, while ruptures of the uterus, for the reasons already given, generally begin in the lower segment and extend upward, their further extension toward the fundus is arrested by the action of the now migrated ring of Bandl, which, in certain cases, may be felt through the abdominal walls above the pubis, or, even as high as the umbilicus. Many of the ruptures reported, indi- cate that a tear probably started in the lower segment of the uterus, and extending upward part way to the fundus, had been deflected to one side or the other. This was manifested in two cases by Eeed. {New York Medical Journal, November 9, 1889.) The symptoms of rupture of the uterus, when partial, may consist of only an evanescent and not severe shock, a temporary interruption of the pains, and a persistence of hemorrhage after delivery. When the rupture is complete, however, the phenomena induced by the accident are striking and immistakable. There is profound shock; the uterine contractions and pain cease instantly; the presenting part of the child recedes; the fundus of the uterus tilts to one side, or entirely disappears in the presence of a new, strange, and indefinite tumefaction within the abdomen; a bloody discharge makes its appear- ance; and frequently there is prolapse of the funis. A careful exam- ination at this time will indicate, not only a recession of the presenting part of the child, but an apparent atony of the cervical structures. If the child has escaped into the abdominal cavity, the hand is intro- duced without difficulty into the uterus, and may, in certain cases, be carried through the rent in the uterus into the peritoneal cavity. The diagnosis, according to Ludwig, is not always easy, even when the fore- going symptoms are taken into account. He has found the best diag- nostic sign to be, (a) in lateral rupture, the interruption of the natural contour of the uterine quadrant, when either a projection or a nodule INJURIES AND FOREIGN BODIES OP THE UTERUS 333 is formed; (&) suddenly acquired abnormal mobility of the uterus; and (c), a sign upon which he places great emphasis, viz., emphysematous crackling at the seat of rupture. If the head presents and can be pushed back, the bimanual examination under deep narcosis makes the diagnosis certain. The treatment of rupture of the uterus is to be directed to the saving of the life of both the mother and child, when possible. If the child is yet within the uterine cavity, the vertex presenting, forceps should be applied without delay; if breech or shoulder is presenting and the child is known to be alive, version may be practised. If the child is still within the uterine cavity but is known to be dead, it may be delivered by craniotomy, morcellement, or by any other means that will most speedily empty the uterine cavity. After delivery the uterine cavity should be carefully explored, and, if the rupture is found to communicate with the peritoneal cavity, an abdominal section should be done at once. If rupture has been complete and has been followed by the escape of the child into the ]3eritoneal cavity, the child should be delivered by abdominal section. The same course is to be followed when the child has been delivered per vias naturales, and the placenta has escaped into the abdominal cavity — indeed it may be adopted as a safe rule that the abdominal cavity should be opened whenever rupture of the uterus can be demonstrated to be complete, no matter what may or may not have passed through the rent. This conclusion is based upon the fact that although neither the child nor the placenta may have escaped into the abdominal cavity, complete rupture could not occur without the escape into the peritoneal cavity of either blood, amniotic fluid, or other products of gestation, liable to be either the bearers or the sources of infection. The abdomen should in such cases be opened and thoroughly washed out with normal salt solution. If hemorrhage is in progress, it should be controlled either by the application of forceps to the broad ligaments, far enough down to control, not only the ovarian, but the uterine arteries; or by an elastic ligature temporarily applied below the site of rupture. The treatment of the uterus at this point is one of extreme importance. The rent may be closed, which is best done by paring the edges, and approximating and closing them by the seroserous suture, adopted by Czerny and Lembert, in Csesarean section (see Csesarean Section); or the uterus may be removed, converting the procedure essentially into a Porro operation. Unless there is extensive destruction of the tissues of the uterus, with obvious infection, its removal is not justifiable. Women who have sustained rupture of the uterus and who have been successfully operated upon by closure of the tear, have subsequently borne children. Deutsch {C entralhlatt fiir Gyndhologie, November 14, 1889) reported a case of symmetrically contracted pelvis in which rupture of the uterus had been treated by abdominal section four years previously. The patient went to term, when examination revealed the uterus adherent to the abdominal wall, causing a marked projection 334 ^ TEXT-BOOK OF GYNECOLOGY of the abdomen. The foetus being found to be living, the patient was narcotized, the os was dilated, and a living child was delivered by po- dalic version. If carcinoma or fibroids are either the underlying cause or the associated condition of a rupture of the uterus, no hesitancy about its ablation need be entertained. The operation should be done as soon after the condition is detected as necessary preparations can be made. The possibility of hemorrhage and the still greater pos- sibility of infection make it imperative that intervention should be practised as speedily as possible. Patients may, however, live for a considerable time after the occurrence of this accident, even without treatment. Thus St. Braunwas, of Cracow, reports a case in which he had extracted the foetus by abdominal section six weeks after it had escaped through a rupture of the uterus into the peritoneal cavity. The foetus was bathed in pus, which filled the cavity of the abdomen. The patient, of course, died from chronic sepsis. In cases in which abdominal section is practised, the operation proper should be both preceded and followed by free administration of normal salt solution, either by intravenous injection or by hypodermoclysis. Lacerations of the cervix occur chiefly as accidents of childbirth — although latterly they are encountered in occasional instances as re- sults of forcible dilatation of the cervix. (See Dilatation of the Cer- vix.) When this operation is performed with too much rapidity and by one of the powerful instruments now in use, the divulsion may result, not merely in the separation of submucous fibres, but even in a complete severance of continuity of the cervical tissue. It may be said that laceration of the cervix, when occurring as the result of for- cible dilatation or of parturition, is always caused by divulsion carried to a point beyond the resistant power of the cervical structures. Lac- erations of the cervix may be either superficial or deep, extending as far up as the cervico-corporeal Junction, and are, in reality, but examples of rupture of the uterus, the damage occurring in the lower segment of that organ and involving the cervical margin. More than one rup- ture of this kind may occur at once, occasioning what is spoken of as multiple or stellate laceration of the cervix. When lacerations occur chiefly within the cervical canal, but do not extend entirely through to the lateral vaginal surfaces of the cervix, they may result in a permanent enlargement of that canal. The attention of the profes- sion was first called to the pathologic character of these injuries by Emmet, who devised the operation for their repair. (See Trache- lorrhaphy.) The pathology of lacerations of the cervix relates chiefly to ante- cedent and subsequent changes. The antecedent changes consist of those modifications of the cervical structure — e. g., fatty degeneration and oedema — occurring during the course of pregnancy, which result in a loss of the normal elasticity of the tissues. The subsequent changes relate to those interferences with involution, and those modifi- cations of local nutrition, which are caused by the tear, and the con- INJURIES AND FOREIGN BODIES OF THE UTERUS 335 sequent interference with the circulation. After the receipt of the injury, laceration of the cervix rarely if ever heals spontaneously. Eepair occurs by process of cicatrization; the tissue thus formed subse- quently contracts; and the underlying cervical structures are distorted. When the laceration is bilateral the resulting contraction of the cica- tricial tissue causes a retraction outward of the cervical lips, with con- sequent e version of the mucous membrane. The mucous membrane itself, exposed on the everted surfaces of the cervix, presently under- goes glandular hypertrophy, giving to the unpractised eye the appear- ance of ulceration, and abounding in granulations. There is no doubt that many of the so-called " ulcerations of the womb," treated in the years gone by with repeated applications of lunar caustic, were, in reality, but eversions of the endocervix in a state of glandular hyper- trophy. The enlarged follicles of the cervical mucosa manifest an augmentation of function corresponding with their abnormal develop- ment; and, as a consequence, the cervix is always covered in such cases with a clear viscid mucus, sometimes tinged with blood. Changes in the parenchyma of the cervix are equally marked and may present two extremes, namely, atrophy or hyperplasia. When the laceration is comparatively superficial, the resulting inflammation goes through all the consecutive stages from preliminary engorgement to final atrophy; but when the laceration is deep and the consequent cervical eversion is pronounced, tliere is so much mechanical interference with the circulation, particularly upon the venous side, that passive engorgement ensues, resulting finally in an actual increase of the tissue elements. This state of hypertrophy is sometimes associated with oedematous in- filtration; but, as a rule, there occurs an organization of the adventi- tious tissue elements with consequent enlargement and induration of the cervix. These changes may be more pronounced in some parts of the cervix than in others, the difference being determined by the location, depth, and consequent infiuence, of the laceration. The body and fundus of the uterus, being largely supplied with blood by the ovarian artery, and being drained by the ovarian veins, are not subject to the infiuences arising in the injury of the cervix. It is noticeable, however, notwithstanding the fact that the upper zones of the uterus possess a practically independent circulation, that they undergo the post-parturient involutional changes tardily in the presence of deep injuries of the cervix. Glandular hypertrophies are, consequently, not uncommon in these cases in the corporeal endometrium. (See Endometritis.) The inflammations producing this increase in tissue, both glandular and parenchymatous, are manifestly dependent in a large degree upon mechanical disturbances of the pelvic circulation; but, from the facts that lacerations of the cervix never heal without at least superficial bacterial invasion, and that infection once established at the seat of laceration readily extends upward, these inflammations must be recognised as infectious quite as much as traumatic. Symptoms of laceration of the cervix at the time of its occurrence 336 A TEXT-BOOK OF GYNECOLOGY may be absolutely nil. The absence of all symptoms indicating lacera- tion of the cervix accounts for the fact that the majority of these acci- dents are never discovered until long after their occurrence, when the patient presents herself for treatment for vague and indefinite pelvic symptoms. In occasional instances, however, the laceration is so deep, ■extending up to and involving the circular artery, that hemorrhage results. This symptom is often overlooked for a time under the im- pression that the flow of blood is nothing more or less than that which occurs in normal cases following delivery. When, however, this hemor- rhage persists for a considerable time, imparting an arterial tinge to the otherwise dull-coloured lochia, it becomes the occasion for a local examination. Digital exploration at this time, particularly if done by an inexperienced operator, is liable to be negative, if not misleading, in its results. The cervix during the first few days following delivery is enlarged, dilated, oedematous, and flabby; its normal contour can not be detected, while superficial abrasions, or even deep lacerations, can not be distinguished by the touch. Under these circumstances the patient should be placed in the Sims position, the perineum should be retracted, and the cervix should be drawn down and carefully inspected, when the bleeding point, if within the area of a laceration, can be detected and controlled. In the later stages of a laceration — i. e., sev- eral weeks or months after delivery — there is vastly less difficulty in detecting the actual conditions. The patient may or may not com- plain of 23ain. Cicatricial dej)osits, particularly in the angle of lacera- tion, and especially in cases of long standing, may impinge upon ter- minal nerve filaments and occasion severe distress, and that not only in the uterus, for through its intimate nerve connections with both the sympathetic and cerebro-spinal systems, this relatively slight local injury may cause a widespread perturbation of nerve function. It would seem in certain cases, as if the cervix under these circumstances were a sort of central telegraphic office, with radiating lines over which morbific impulses are telegraphed to the remotest parts of the system. Erratic behaviour of the apparatus of accommodation, eccentric dis- turbances of hearing, evanescent or persistent turgescences of the turbi- nates, congestions of the Schneiderian membrane, asthmatic disturb- ances, localized variations of cutaneous sensibility, and that congeries of nerve perturbations designated as hysteria, have been known to fol- low in the wake of this accident and to have been cured by repair of the cervix. These so-called reflex symptoms, however, never occur with that degree of constancy necessary for them to be accepted as indications of an existing laceration of the cervix. It may be said in short that there are no symptoms of a subjective character that are pathognomonic of this condition. Local examination alone detects the condition, which has existed, possibly, for years, without being suspected, either by the patient or her medical adviser. Introduction of the finger into the vagina will reveal the cervix with an irregular contour; it may be multilobular, each lobule being divided by a distinct INJURIES AND FOREIGN BODIES OP THE UTERUS 337 iissure (stellate laceration), or it may be divided into an anterior and a posterior lip (bilateral laceration), or it may be fissured upon only one side (single laceration). If examined by the speculum, these appear- ances may be much modified; as, for instance, if a bivalve speculum is employed, its dilatation will result in stretching farther apart the antero-posterior lip of the cervix in a bilateral laceration; indeed, in cases of long standing in which the eversion has become pro- nounced, the retracted lij)s may have been drawn up to the utero- vaginal junction, and, when distended by means of a bivalve speculum, the marginal contour of the cervix may entirely disappear. The pic- ture presented in the speculum will be that of a double, elliptical, area of apparent erosion. This will be nothing more or less, in practically every case, than the hypertrophic endocervium. If, now, this patient is placed in the Sims posture, the perineum retracted, and the retractor intrusted to an assistant, the examiner may, by means of a volsella placed in the apex of each lip, draw the severed portions of the cervix into api^roximation. He will thus be enabled to determine the depth and other exact characters of the laceration. The complications of laceration of the cervix are worthy of con- sideration. They naturally coexist with atrophies, hypertrophies, or hyperplasias of both the parenchyma and endometrium. As already indicated when considering the pathology of this lesion, bacterial in- fection of the laceration takes place at the time of its occurrence; pro- gressive invasion, either of the contiguous mucous surfaces or of the opened lymph spaces, ensues; the result being either infection and enlargement of the pelvic lymphatic glands, with possible resulting suppuration, or infection with purulent accumulation in the Fallopian tubes, involving the ovaries in the general pathologic processes. These complications are frequently encountered and are directly traceable to the original injury for their causation. It not infrequently happens that laceration is not detected until an examination is demanded for symptoms of carcinoma. This disease, indeed, exists as a frequent complication of laceration, the carcinomatous process in many in- stances having its origin in the cicatricial covering of a cervical tear. Fibroids and other neoplasms may coexist with laceration of the cervix. The treatment of laceration of the cervix consists essentially in restoring that structure, so far as possible, to its normal state. The steps by which this may be accomplished must vary according to the pathologic conditions present in the case; thus, if the case is one simply of laceration without marked tissue changes, the treatment will consist in revivifying the margins of the wound and approximating them by sutures; if, however, there is extensive liypertrophy, it may be necessary to remove, at least, a part of the enlarged segment of the uterus. At the same time, associated pathologic states in the endometrium must be appropriately treated. 338 A TEXT-BOOK OP GYNECOLOGY Instruiinents for Catheter, glass 1 Curette, dull 1 Sharp (Sims's modified) 1 Martin's 1 Recamier's 1 Dilators, difEerent sizes 3 Hegar's, three sizes. Forceps, hemostatic, two of each size. 6 Long dressing 1 Rat-tooth dressing 2 Bullet 2 Needles, assorted sizes 8 Trachelorrhaphy Needle holders 2 Nozzles, glass or Edebohls's hard rubber 1 Retractor, small 1 Intermediate 2 Scalpels 2 Scissors, straight 1 Shot compressor and shot. Sound, uterine 1 Speculum, Sims's small 1 Simon's, with handles and four blades 1 Tenaculum, straight 1 Tenacula, curved 2 Trachelorrhaphy, or the operation for repair of the lacerated cervix, is conveniently clone as follows: The patient is placed in the dorsal l^osition, her buttocks at the edge of the operating table, her knees well drawn up, her flexed legs being intrusted either to an assistant or to the efficient mechanical attachments of the modern operating table. A Jones's perineal retractor with a short blade is now inserted and the pos- terior lip of the cervix is seized with a self-locking volsella and is drawn down. Newman has devised an excellent reverse- acting, self -locking volsella (Fig. 136) which on being inserted into the cervical canal and expanded, becomes fixed in the uterine tissues. The instrument is an ex- ceedingly convenient one, as its shaft lies along the mucous track of the cervical canal and becomes a convenient guide, both in denuding the surfaces and in pass- ing the sutures. The downward traction on the uterus must be judiciously regu- lated, force beyond a few pounds never being exercised. Whenever distinct and sudden resistance is experienced in effect- ing the temporary prolapse of the uterus, it is to be construed as an evidence of adhesions, and is a danger signal admon- ishing the operator against more forcible traction. When the uterus is thus drawn down, the endometrium, if the seat of T. .„^ ,^-r 1 , . , glandular hypertrophy, should be vigor- FiG. 136. — "Newman has devised ° ^^ i iiii an excellent reverse-acting, self- 0"Llsly Curetted, the mUCUS, blood, and locking volsella."— Reed. debris, being carefully washed away with a INJURIES AND FOREIGN BODIES OF THE UTERUS 339 jet of bichloride water, after which the surface is dried and painted with pure carbolic acid. The next step consists in denuding the sur- faces to be approximated. Their respective areas should be defi- nitely determined in advance by making a preliminary approximation. The denudation may be accomplished either by a knife or by scissors, prefer- ably the former. A very good knife for the purpose is that devised by ISTew- man (Fig. 137) and its sharp point is so arranged that it can be easily passed through the cervical tissue in the upper angle of the laceration. It is a good rule to begin the denudation by first outlining with the edge of a bistoury the tissues to be removed. These may then be cut away, leaving two equal, denuded, approximating surfaces. Great care should be taken to remove the deposit of cicatricial tissue from the upper angle of the laceration. In the case of a bilateral laceration, all the surfaces to be approximated must be denuded before the work of sutur- ing is begun. The sutures may be in- serted by means of a short, heavy, de- tached needle, which is employed by means of a needle holder; or, they may that devised by be inserted by means of an obliquely Newman."— Keed. curved needle such as that used by Reed (Fig. 138). The sutures themselves should be of nonabsorbable material. Emmet does this operation with a silver wire, and annealed iron wire is employed by some operators. As a rule, however, the silkworm gut is the material of preference. Which- ever material is employed, careful antiseptic precau- tions should be taken. Catgut has been used with suc- cess since the process of preparing it with formalin and boiling it has been perfected; it generally lasts fourteen days, which is long enough, while the facility with which the external and unabsorbed remnants are removed is a point in its favour. The suture should be passed beneath and on a level with each surface to be approxim.ated, as illustrated (Fig. 139). Two, three, or even four, sutures may be required upon either side, the number being governed by the depth of the laceration. After all of them have been passed the volsella may be removed, the remaining traction on the uterus being exercised by means of the ends Fig. 137.—" A very good knife ... is Fig. 138. An obliquely curved needle used by Eeed." — Eeed. 340 A TEXT-BOOK OP GYNECOLOGY of the sutures on one side being gathered together in a forceps. The surface of the wound should be irrigated and removed by means of sterilized water. If there is no pulsating hemorrhage, no further atten- tion need be given to hemostasis which will be effected by the approxi- mation of the surfaces and the pressure of the sutures. The sutures are tied, beginning upon one side at the upper angle, care being taken that, as they are tightened, the underlying margins of the tissues are brought into accurate coaptation. Care should be taken to avoid tying the sutures too tightly, as tissue ne- crosis may thereby be in- duced and the success of the operation be com- promised in consequence. After being twisted, if silver wire is used, or tied, if other material is employed, the distal ends should be cut off about an inch from the knot, and so arranged as to avoid causing mechanical irri- tation of the parts. The sutures, if of nonabsorb- able material, should be left in situ for about ten days, antiseptic vaginal irrigation being practised twice daily during the entire time. To remove the sutures, the patient should be placed in the Sims position and each suture seized with long-fixation forceps and subjected to gentle traction. The loop of the suture will thereby be drawn up so that the point of a scissors blade may be easily in- sinuated beneath it. It is important that the stitches should be re- moved under inspection, for, if the effort is made to remove them by the sense of touch alone, there is a likelihood of cutting both ends of the loop near the knot, leaving the loop itself buried in the tissues. It is true that this is not a matter of any serious moment, but it may occasion annoying local infection; and the escape of a loop of suture material at some subsequent time is always construed by the patient as a more or less serious reflection upon the surgeon. Amputation of the cervix, in whole or in part, is demanded for hypertrophic and hyperplastic conditions that are sometimes associated Fig. 139. — " The suture should be passed beneath and on a level with each surface to be approximated." — Eeed (page 339). INJURIES AND FOREIGN BODIES OF THE UTERUS 341 with and result from lacerations. Emmet {Transactions of the American Gynecological Society, 1897) believes that these conditions should be subjected to preliminary local treatment, consisting of douches, elimi- native tamponade, alterative topical applications, or even local deple- tion by puncture. Treatment of this kind may, in some cases, so far reduce hypertrophy that amputation or excision is unnecessary. When, however, the desired reduction in the volume and consistence of the tissues is not realized by such conservative treatment, Emmet's opera- tion of amputation may be adopted. He first draws the uterus down by gentle and steady traction to the vaginal outlet, always taking care to avoid a Jerking movement which would be liable to rupture some blood vessel, especially if there has been a pre-existing intrapelvic in- flammation. The cervix is steadily held by an assistant just within the vaginal outlet, for at this point the arteries will be placed suffi- ciently on the stretch to lessen their calibre, and thus to render the operation to a great extent bloodless. Care is taken to accurately deter- mine the line of vaginal junction, since the bladder will be entered in front and the peritoneal cavity behind, if an attempt is made to remove what seems to be the cervix over which a mass of thickened vaginal tis- sue has been crowded. In those cases in which atrophy takes place as already described in this chapter, the field of operation can not be a large one at the beginning. An incision is now made round the cervix near the vaginal juncture; the subsequent dissection should be made by cutting always toward the centre as a precaution against entering the bladder and the peritoneal cavity, and with the object of removing a cone-shaped piece of tissue. As the operation advances, the excava- tion must continually be drawn up to the vaginal level so that the operator may have the parts under observation and the bleeding under control. As each blood vessel is divided, the neighbouring tissues should immediately be seized by an assistant and held as a fresh point for traction, when the vessels will promptly retract and cease to bleed. The cervix is to be removed segment by segment until underlying healthy tissue is reached. The most efficient instrument for this purpose is the pointed scissors which Emmet devised nearly thirty years ago for clearing out the angles in the operation for laceration of the cervix. After having removed the tissues in the manner just de- scribed, nonabsorbable sutures are inserted; Emmet employs the silver wire. The sutures are inserted antero-posteriorly. Those to either side of the cervical canal are inserted (Fig. 140) through the posterior lip, into the excavation, into the tissued at the fundus of the excava- tion, out again, and then through the anterior lip of the wound. The sutures that are passed coincidently with the cervical canal are intro- duced through the posterior lip of the wound, out again, in again through the posterior lip of the cervical canal, and out through the cervical canal. Another suture is passed similarly to the last, through the lip formed by the anterior wall of the cervical canal, out again and through the anterior lip of the cervix. As many antero-postei'ior 342 A TEXT-BOOK OF GYNECOLOGY sutures are passed transversely to the cervical canal as may be required. " If/^ says Emmet, " we follow the course of either of these sutures it • will be apparent that when the front suture, for instance, is twisted, the free vaginal surface must be drawn over the stump, and as the edge of the uterine canal is a fixed point, the former will be secured at that point, and a similar effect will be produced posterior to the cervical canal when the posterior suture has been twisted in the same manner. The result of thus securing these sutures will be that the edge of the divided mucous membrane on the vaginal surface, front and back, will be rolled over in contact with the edges of the uterine canal, and when primary union has taken place the natural calibre of the passage must be preserved. But before securing these, or any of the sutures, as many as may be deemed necessary should be first introduced on each side of the cervi- cal canal. Here the loose vaginal edge is first caught up, and then the needle is made to include a sufficient portion of the uterine stump on a line with and lateral to the uterine canal, and in turn it should take up the vaginal tissue behind. The only difficulty is in catching up enough of the uterine tissue in the centre of the stump to hold it firmly in contact with the flaps after the sutures have been secured. But this difficulty can be overcome by using a properly-shaped needle with the pointed end slightly bent on itself. The passage of the needle is greatly facilitated by snipping with pointed scissors a sulcus in the tissues at a sufficient depth in front of the advancing needle, and from the bottom of this cut its point should be brought out to pass over to secure the vaginal edge. " After all the silver sutures have been twisted it will be made evident, by the introduction of a uterine sound for half an inch, that the canal has been left fully open, and it will be seen at the same time Fig. 140. — " Those to either side of the cervical canal are inserted through the posterior lip, into the exca- vation, into the tissues at the fundus of the excava- tion, out again, and then through the anterior lip of the wound." — Eeed (page 341). INJURIES AND FOREIGN BODIES OF THE UTERUS 343 that the vaginal tissues have been drawn over the stump and firmly secured to its surface. " At the completion of the operation it is necessary that the uterus .should be carefully replaced with the finger to its natural position, and it must be done without displacing the ends of the sutures, which have been carefully bent down on to the vaginal surface. As soon as the uterus is replaced in its normal position the lateral traction then exerted in the vagina will keep the vaginal covering in close relation with the stump. " No surgical operation with which I am familiar yields a more uniform and satisfactory result than this one, when performed under the following conditions: The proper use of silver sutures, keeping the patient in bed for three weeks after the operation including the menstrual period when possible, and not removing the sutures before the nineteenth or twentieth day, when the parts will have become firmly united and the uterus greatly reduced in size." Vesico-uterine Fistulse. — These fistula are of two kinds. In one form the cervix is partially destroyed, and in the other form the fistu- lous opening occurs into the cervical canal and is so concealed that the cervix must be split during any operation for its obliteration. These fistulas can only take place in the cervix. It is imjjortant that a diagnosis should be made in these cases dis- tinguishing between a vesico-uterine fistula and a uretero-uterine fistula. In each case the urine is discharged from the os uteri. Sometimes a probe can be passed through the fistulous opening from the bladder into the cervical canal or vice versa. Clear fluids injected into the bladder will come out of the os uteri. If continued pressvire is kept Tip in the cervical canal no acute nephydrosis will occur if the iistula is vesico-uterine and not uretero-uterine. The electric cysto- scope should be of great assistance. With it one should be able to make out any perforation of the bladder wall, and thus to distinguish between vesical and ureteral fistulse. (See Examination of the Bladder.) Prognosis.— -These fistulge oftentimes heal very kindly owing to the fact that the thick wall of the uterus, during the process of heal- ing, is likely to close the opening. Treatment. — The treatment is the same as that for vesico-vaginal fistula, namely, closure by suture. Each of these cases must be judged upon its own merits and the operator must think out for himself his exact method of procedure. If the main principles, previously stated, are adhered to, he will, in all probability, meet with success. If the fistula is situated close to the cervix the anterior lip may be made use of to close tbe opening. If a great deal of the anterior lip has been destroyed it will then be necessary to use the posterior lip, and if this is done the menstrual fluid will be discharged into the bladder and out through the urethra. It is unfortunate to have this happen and if possible it should be avoided. 344 A TEXT-BOOK OF GYNECOLOGY Fig. 141. -" The bladder, thus separated, should be drawn down with a forceps or volsella." — Keed. Reed's Operation for Vesico-uterine Fistula, — The condition is best controlled by a free incision, dividing the uterus from the blad- der, just as is practised in the preliminary step of vaginal hysterec- tomy. The bladder, thus separated,, should be drawn down with a forceps or volsella (Fig. 141); the fistula will then be brought into clear view and can be closed by a double line of continuous catgut sutures. If the fistula opens di- rectly into the ute- rus (Fig. 142), the latter should be curetted and packed and a single suture should be placed across the orifice of the fistula as it presents at the denuded anterior uterine surface. If the fistula traverses the uterus longi- tudinally and opens at the cervical margin (Fig. 143), a curved director should be inserted and the uterine tissues split up to the point of en- trance of the fistula. If the tract has become cicatricial it should be carefully dissected out, and the place that it for- merly occupied should be closed by repeated inter- rupted sutures. In split- ting up the uterine tis- sues, the circular artery is more than likely to be divided. The hemor- rhage may be somewhat difficult to control. This, however, is best done by passing a deep suture e7i masse to either side of the incision, so situated as severed ends of the artery within its grasp. Both the bladder and the uterus having been thus repaired, the parts should be brought into apposition and closed by interrupted sutures. The vagina should be packed with antiseptic gauze and the 142. — " The tistula opens directly into the uterus." — Eeed. to embrace the INJURIES AND FOREIGN BODIES OP THE UTERUS 345 usual precautions observed during convalescence. The most notable of these precautions is the introduction and retention of a sigmoid cathe- ter during several days after the operation. The evacuation of the bladder, either by catheter oi' spontaneously, at intervals of not more than three hours during the succeeding week should be rigorously practised. Wounds of the uterus from external causes are of occasional oc- currence. The injudicious use of the uterine sound sometimes re- sults in perforation of the walls of that organ. Cases of this kind have been recorded by Law- son Tait and others. If the instrument is aseptic the accident is rarely followed by serious con- sequences; if, however, infection ensues, death may follow. The intro- duction into the uterus of catheters, sounds, and bougies for the purpose of inducing criminal abortion, generally re- sults in more or less in- jury to the endometri- um, if not to the deeper structures of the wound. Injuries of this kind, when inflicted by unclean instruments, result in those deaths from constitutional sepsis which occur so frequently in the annals of crime. There is probably nothing more dangerous to a woman than an effort, particularly on her own part, to induce abortion by intrauterine instru- mentation. In many cases of perforation of the uterine wall by the sound, at the hands of experienced operators, the diseased condition of the uterus itself is responsible for the accident. The walls of the uterus are very nonresistant in all inflammatory conditions, but par- ticularly so in the presence of puerperal infection. In ordinary cases of subinvolution, the uterine tissue is very friable. When the walls of the uterus are soft and a>dematous as the result of a flexion at an acute angle, the muscularis is easily penetrated; and the same is triie when the organ is the seat of malignant disease, such, for example, as sarcoma, syncytioma malignum, and adenoma malignum. Under these circumstances the uterus is sometimes perforated by means of a curette, many of these instruments being so constructed that they ofi'er no safe- guard against the accident. Gau, of Cincinnati, has devised an ex- cellent curette with a safety point and edge calculated to prevent acci- dents of this character (Fig. 144). The diagnosis of uterine perforation is not difficult. Perforation may be suspected whenever the sound or Fig. 143. — " The fistula traverses the uterus longitudi- nally and opens at the cervical margin." — Eeed (page 344). 346 A TEXT-BOOK OP aYNECOLOGY curette j)enetrates farther than the previously ascertained limits of the uterus. The treatment consists in quietude and vigilance. In a septic case it may be prudent to await the development of menacing symptoms, which, as soon as they occur, should prompt the surgeon to extirpate the uterus. Intrauterine injections are to be carefully avoided, even when administered by means of a recurrent syringe, for the reason that any force, however slight, may be sufficient to carry infectious material from the uterus into the peritoneal cavity. In some cases the injury inflicted, particularly by the curette, may cause an opening which may result in the protrusion either of omentum or of a loop of intestine. In the presence of this complication the protruding struc- ture should be replaced and the uterine cavity packed pending the completion of preparations for hysterectomy, which should be done as promptly as j)ossible. In cases in which injury has occurred to the intestines, as rarely happens from either the sound or the curette, an abdominal section should be done at once. Gunshot wounds of the uterus, particu- larly when pregnant, are recorded. Ben- brook {Medical Times) relates an interest- ing case of this sort, in which a 44-calibre pistol ball passed in just below the crest of the ilium going downward and back- ward, and a second one entered the ab- dominal cavity from a point between the eighth and ninth ribs. Three days later, the woman was taken with hemorrhage from the uterus associated with labour pains, and resulting in the expulsion of a quantity of blood clot together with a bul- let, which had passed into the cavity of the uterus through the fundus. Another case by Eobinson {Lancet) revealed the fact that a ball had en- tered the abdomen a little to the right and below the umbilicus; an hour later labour set in, resulting in the instrumental delivery of a dead child near full term, with a gunshot wound in its right shoulder. The ball was found in the debris. The mother made an uninterrupted recovery. Metert records {Medical Review) an interesting case of a self-inflicted gunshot wound in the abdomen of a pregnant woman, the ball passing through the uterus and the arm of the child, an abdominal section being followed by the recovery of the mother. G-unshot wounds gen- erally occur either at the fundus or the anterior wall of the uterus. Their infliction is followed by pronounced shock and collapse, pain in the abdominal region, at first located at the site of injury, but presently becoming diffuse, while symptoms of peritonitis of the dif- fuse form shortly manifest themselves. In the course of a few hours pains with rhythmic contractions of the uterus occur, whether in the Pig. 144. — " Gau has devised an excellent curette with a safety point and edge." — Keed. INJURIES AND FOREIGN BODIES OP THE UTERUS 34Y impregnated or the nonimpregnated uterus. In either instance the organ is more or less distended; in the first by the products of con- ception, and in the latter by clots. The gravid uterus in many cases throws off its contents, a fact which does not in the least diminish the necessity for prompt intervention. As to treatment, it may be laid down as a rule that every case of perforating wound of the abdomen of a jDregnant woman would be subjected to an exploratory abdominal section without reference to symptoms. The probability of perforation of the uterus and of the consequent escape of amniotic fluid and blood into the peritoneal cavity, makes it imperative that intervention should be both prompt and thorough. The fact, also, that in these eases the womb and its contents act as a sort of shield to the intestines, saving them from injury, increases the prospects of the mother and forms an additional reason for speedy intervention. The character and extent of the operation must be determined by the conditions revealed by the exploratory incision. If there has been extensive destruction of uterine tissue, offering no reasonable prospect of recov- ery, with the uterus m situ, hysterectomy should be done. This rule applies whether the uterus has been emptied or not. All debris should be washed from the abdominal cavity by copious irrigation with normal salt solution, and intravenous injection or hypodermoclysis should be practised in the presence of the generally pronounced shock, or when- ever there has been a free loss of blood. If the gravid uterus has thrown off its contents, the necessity for abdominal section is all the more imperative, for the very contractions of the uterus which result in the expulsion of the embryo, result also in the extrusion of the liquid contents of the uterus into the peritoneal cavity. Cattle-horn wounds of the uterus are of occasional occurrence in the cattle-raising districts of the world. A number of these cases have been reported describing accidents with revolting details but attended with a singularly slight mortality. These injuries considered as ab- dominal wounds may or may not involve the uterus; the latter class need not be considered in this connection. Of the former it may be said that they divide themselves natu^rally into those wounds which involve the uterine wall alone, and those which involve both the uterus and the child. The prospect of the child living under these circum- stances depends, naturally enough, upon the stage of pregnancy and the degree of injury sustained by the child. Occasionally the rent in the uterine wall is so great that the foetus and secundines escape into the abdominal cavity; and, even under these circumstances, a viable child has been known to survive. Harris {American Journal of Obstetrics, 1887) collected the histories' of nine cases of this char- acter, with a mortality of four women and four children. In an injury of this character the diagnosis declares itself. Whether a hysterectomy should be done in these cases, or whether the wound in the uterus should be treated just as in an elective Cgesarean section, must be determined at the time by the conditions presented. As a rule the uterus contracts 348 A TEXT-BOOK OF GYNECOLOGY vigorously after the receipt of the injury and particularly after being emptied. In certain of the recorded cases occurring before the modern surgical epoch, closure of the uterine wound was effected by suture, and even in cases of recovery the treatment was destitute of those features which we should to-day designate as antiseptic. In some of the recorded cases subsequent pregnancies with successful deliveries have occurred. These facts should prompt the operator to be cautious before sacrificing a womb by ablation, even though it may be the seat of extensive injury. In those cases in which exploratory incision reveals the fact that the perforating wound of the uterus is small, delivery may be effected by the Cesarean section. (See Caesarean Section.) In such cases it is important that the gunshot wound be carefully closed on the peri- toneal surface of the uterus. Foreign bodies in the uterus are occasionally encountered in prac- tice. They ma}^ consist of pledgets of cotton or of gauze left by acci- dent in the uterine cavity in the course of treatment, the broken end of a uterine electrode, or the stem of an intrauterine pessary. Schauta {C entralblatt fur Gyndl-ologie) reported a case in which a hard-rubber pessary, 2.5 inches in long diameter, inserted into the vagina, had escaped into the uterine cavity from which it was delivered with ex- treme difficulty by morcellement. ISTeugebauer, in his collected series of 297 cases of pessaries neglected and incarcerated in the vagina or escaped into adjacent parts, notes six in which a vaginal pessary slipped into the uterus. Bodies usually found in the uterine cavity are hairpins or broken-off ends of instruments employed for the most part by patients themselves in an effort to produce abortion. Fig. 145.- -" W. E. Ashton reports an interesting case in which ... a false passage was made from the internal os through the anterior uterine wall." — Eeed. W. E. Ashton reports (Medical Bulletin) an interesting case (Fig. 145) in which, as the result of an attempt to forcibly insert a tupelo tent, a false passage was made from the internal os through the an- terior uterine wall to a point above the utero-vesical fold where the tip of the tent protruded into the peritoneal cavity. Laminaria and INJURIES AND FOREIGN BODIES OP THE UTERUS 349 other tents introduced into the cervical canal have escaped into the uterine cavity proper. Mittermaier reports a case in which a loosely tied silk ligature had become the nucleus of an infection and of a foreign body following an operation for fibroid, and another case in which the glass catheter used for irrigating the uterine cavity had broken tw situ, the fragments having become so thoroughly embedded that all attempts to remove them had proved futile. The diagnosis of some of these cases in the absence of a definite history can be made only by forcible dilatation of the cervix, and either instrumental or digital exploration of the uterine cavity. The treatment consists in dilating the cervix and, if possible, removing the foreign body. This is sometimes a matter of extreme difficulty. Thus Schauta, in his efforts to remove the long incarcerated pessary from the uterine cavity, perforated the latter repeatedly with a Pacquelin cautery for the pur- pose of getting some means of grasping the ovoid body. The removal of smaller foreign bodies can generally be effected by means of the curette, the Emmet curette forceps, or the Lawson Tait colpocystotomy forceps. In some cases, however, this will prove unavailing; thus, Mit- termaier found it impossible by such means to remove the fragments of broken glass from the cavity of the uterus, to accomplish which he had to divide the uterus from the bladder, draw the fundus down into the vagina, and make an incision into the uterine cavity. Having removed the glass, he stitched up the incision, and returned the womb to its nor- mal position. It is important to bear in mind in cases in which such an operation is necessary that the operation shoiild be made anteriorly, rather than posteriorly, to the cervix. When a foreign body results in injury and consequent infection, hysterectomy may be done, as Ashton did successfully in the case to which reference has just been made. CHAPTEE XXA^I INFECTIONS OF THE UTERUS The uterus — The endometrium — The myometrium — Bacteria of the uterus — Infec- tions : (a) Mixed, (6) specific — Endometritis and metritis — Pathology — Causes — Symptoms — Diagnosis — Treatment: (a) Topical, Reed's method ; (&) curettage. The uterus being a frequent seat of infections, a proper compre- hension of them must presuppose a knowledge of (a) the endometrium, (&) the myometrium, (c) the bacteria of the uterus, and (d) the recog- nised infections in their clinical, pathological, and therapeutical aspects. Tlie endometrium consists of a stroma of fibro-connective and mus- cular tissues in Avhich are embedded glands covered by a single layer of columnar ciliated epithelium. It contains lymphatics and nerves, and the mucous glands are large and numerous. The endometrium is not supplied with separate blood vessels, but receives its nutrition from the superficial capillaries of the uterus. The ciliated columnar epithe- lium lines the entire uterus, also the uterine glands, and is continued through the Fallopian tubes. As the endometrium approaches the external os it loses its cilia and becomes blended with the pavement epithelium upon the vaginal portion of the cervix. The glands are tubular and narrow, dip down to the muscularis, and constitute a large portion of the volume of the endometrium. These glands are active and maintain a free secretion upon the surface of the membrane, with a plug of thick mucus in the cervical canal. Lymph spaces and vessels are abundant throughout the uterus, lying in the interglandular spaces around the bundles of muscular fibres and in the serosa, and con- verging into large channels which pass outward in the broad ligaments. The cervical endometrium has a peculiar arbor vitse arrangement, is more dense than the corporeal, and is attached to the muscularis by looser tissue; it does not participate in menstruation. The normal secretion of the endometrium is alkaline in reaction; the corporeal mucus is clear and watery, the cervical, viscid. One important func- tion of the cervix is to close as by a sjDhincter the uterine cavity; the great function of the corporeal endometrium is to form the decidua and nourish the embryo. A knowledge of this function of the cervix should of itself forbid the much-abused operation of forcible cervical dilatation in virgins. The gland crypts of the cervix readily become a culture bed for germs, which may long remain therein in an attenu- 350 INFECTIONS OF THE UTERUS 351 ated form, and under favourable conditions develop new cultures and activity. The endometrium, says McMurtry, is one of the most variable tis- sues of the body. It is subject to alterations that are physiologic, so that it is most difficult to establish a normal appearance that is typical. This fact often leads to a mistaken diagnosis of endometritis. The endometrium is suffused with blood during menstruation, under- goes marked disintegration at that time, and is afterward regenerated. During adolescence there is an increase in glandular tissue; during pregnancy this is even more marked, and atrophy supervenes after the menopause. The blood supply of the uterus is altered by physio- logic and pathologic conditions extraneous to that organ, such as nerv- ous states and wasting disease. These observations are of the utmost importance in the practical diagnosis and treatment of uterine dis- eases, and will convince the' painstaking observer that the common diagnosis of endometritis, followed by aggressive instrumentation and chemical antisepsis, is a grave error both in diagnosis and treatment. The secretion of the uterine cavity is alkaline; that of the vagina acid. Under normal conditions, the acid secretion of the vagina is a protection from pathogenic organisms and the endometrium is always sterile. Pathogenic cocci and other germs which might enter from adjacent cutaneous surfaces perish in the acid vaginal secretions, which are unsuited for their growth. The reaction of the vagina, however, may be altered by the presence of inflammatory products, so that in- fection may occur through this route. The epithelium on the crests of the endometrial folds is usually described as having cilia, which Wyder insists have a motion from the os internum toward the fundus. Hofmeier {C entralhlatt fur Gynakologie) criticises this view. Not only were his own studies conducted upon fresh uteri removed from mammals, in which the conditions ought to be the same as in the human female, but he also examined organs removed at the operating table and at once immersed in warm saline solution. In several of these latter he demonstrated conclusively, by removing strips of endometrium and placing them under the microscope, that minute particles of charcoal were invariably carried by the ciliary movement from the fundus toward the os internum. This observation of Hofmeier's seems at least to be in harmony with an intelligent design of Nature by which obstacles are interposed to the easy invasion of the upper reaches of the genital tract. The endometrium, responsive to the increased nutrition which comes from the premenstrual afflux of the blood to the pelvis, under- goes a sort of periodical hypertrophy, preceding each onset of the monthly flow. (See Normal Menstruation.) The exuberant epithe- lium undergoes a sort of desquamation. Von Kohlden (Centralblatt fur GynaJcologie), who has studied the endometrium during and after menstruation, states that immediately after menstruation large gaps are seen in llio snpefficifil layer of the epithelium, and that during men- 352 A TEXT-BOOK OF GYNECOLOGY striiation the entire epithelial layer is east off, and that there is infiltra- tion and hemorrhage into the mucosa. This infiltration may extend through two thirds of the thickness of the latter. The blood clots which are found within the uterus contain desquamated epithelium and glands. No true solution of continuity of the endometrium can be established. Von Ivohlden has never been able to find the giant cells described by Leopold, or evidence of dilatation and tortuosity of the glands. The reproduction of epithelium begins de novo within the glands, not from islands of cells which were not cast off; there is also a new formation of blood vessels. Lohlein (Ibid.) prefers this expression to either " membranous dysmenorrhoea " or " exfoliative endome- tritis," since dysmenorrhoea is a prominent symptom in only one half of the cases, and most observations show that there is no real inflamma- tory trouble. He believes that the membrane bears more of a resem- blance to a product of conception than to that of inflammation. The myometrium, or the muscularis of the uterus, consists of bands of decussating fibres arranged in different directions and in more or less definite concentric layers. Within the meshes of this fibrillation are to be found numerous nutrient vessels, branches of the uterine and ovarian arteries, with their accompanying veins. There are also freely interspersed within the muscularis numerous lymphatic vessels, which in the nongravid uterus are minute and generally closed, but which during pregnancy and immediately after parturition are greatly en- larged, their orifices communicating directly with the placental site. There are also numerous nerve filaments, derived, for the most part, from the sacral sympathetics. The Bacteria of the Uterus. — From just within the os externum upward, says Professor Sinclair, the female genital tract in health is free from bacteria. Confusion has arisen from methods of obtaining material for micro- scopic examination and cultivation experiments. Many observers have not succeeded in getting rid of the drop of mucus at the external os which should be considered as vaginal, and so have obtained results vitiated by the presence of vaginal bacteria in the material examined. Another trifling question which has received too much attention is the limit of the vagina in case of laceration of the cervix. The dis- cussion is mere logomachy. The part of the cervical canal which, by reason of laceration, is exposed to the vagina, must count as vagina from the point of view of bacteriological research. The part is well worthy of examination and comparison with the vagina and cervix proper, because of the change in the reaction of the secretion, which is alkaline within the lacerated portion; the difference in anatomic structure of the part which is cervical, and the inability of its lacerated muscle to completely contract, thus leaves the fissure in a state of stagnation. The external os uteri, then, thus defined, is the boundary line be- tween the vagina which in health swarms with all sorts of bacteria, and INFECTIONS OP THE UTERUS 353 the canal of the cervix and body of the uterus which in health is abso- lutely free from germs. Upon this point at least there is almost abso- lute unanimity among the bacteriologists. Winter, who differed so egregiously from the majority with regard to vaginal bacteria, found, on examination of the healthy uterus with apparently healthy secretion, no bacteria in the cervix. When the cervical secretion was purulent he found bacteria in the cervical canal. The material on which he worked consisted of uteri obtained by ex- tirpation. He reached the following conclusions: (1) The healthy uterine cavity contains no micro-organisms; (2) the vicinity of the OS internum in half the cases contains no bacteria; (3) the cervical secretion of every healthy woman contains numerous bacteria, and in pregnancy the bacteria, especially the bacilli, increase to a large extent. These statements coincide with those of many other German bacteriolo- gists, including Lomer and Bumm. Goenner, who made numerous observations, found bacteria in the cervix of pregnant women, but he failed to cultivate any. From this experience he draws conclusions against the theory of self-infection. Solowieff examined women suffering from gonorrhoea or from tuberculous disease. He found micro-organisms in the cervix in 39 out of 45 women examined. In 7 cases he found streptococci and staphylococci. He concluded that bacteria are frequently found in chronic endometritis. Acute puerperal endometritis depends upon the presence of pyogenic bacteria. He reached the conclusion that the possibility of self-infection from the genital canal must be ad- mitted. Brandt (Zur Bacteriologie der Cavitas Corporis Uteri bei den Endo- metritiden) found, in 22 out of 25 cases, bacteria in the cavity of the uterus, and in 31 per cent of cases of endometritis, he found patho- genic organisms. Similar results of examinations have been published by many others. Menge published the results of some work in 1893. He always found the cervical canal free from germs except in cases of gonorrhoea. In these the gonococcus was always found in the cervical canal, and in many cases he obtained the bacterium in pure cultivation. In preg- nant women infected with gonorrhoea he always found the gonococcus and made pure cultivations from it. The secretion of the cervical canal was always alkaline. Stroganoff made observations on women during menstruation. After complete cleansing of the os externum he always found the canal free from bacteria. In elderly women, Stroganoff found the cervical canal free from bacteria in 50 per cent. When the uterus was prolapsed, bacteria were always found in small quantities in the cervical canal. In pregnant women under ordinary conditions he always found the canal free from bacteria. StroganofF therefore concluded: (1) in normal circumstances the cervix contains no bacteria; (2) the normal cervical secretion possesses a bactericidal quality; (3) in the genital 24 354 A TEXT-BOOK OF GYNECOLOGY canal the os externum forms the dividing line between the germ-con- taining and the germ-free portions. Bmmn maintained in 1895, that in chronic endometritis of the body and cervix, in hyperplastic conditions resulting from inflamma- tion, as well as in the catarrhal form, no micro-organisms can as a rule be demonstrated to exist. The continuance of the disease of the mucosa does not depend upon the presence of micro-organisms. In a small number of cases there may be found in the secretion, but not in the tissues, of the diseased mucosa, a small number of bacteria includ- ing pyogenic cocci. These must usually be considered accidental ac- companiments of the endometritis. Wertheim says that gonorrhoeal infection of the uterus always causes a purulent catarrhal endometritis, which, when it runs a chronic course, leads to hyperplastic-hypertrophic changes in the glands. The inflammation also extends frequently to the myometrium, and it is less marked in the cervix than in the cavum uteri. In about half the cases, the gonococcus was demonstrated in the secretion, and pure cultivations were obtained. No other bacteria were ever found when the gonococcus was present. Wertheim concludes that the external os presents no barrier whatever to invasion by the gono- coccus. Gottschalk and Immerwahr examined 60 cases and found bacteria, including Staplit/lococcus pyogenes, in the uterine canal in 65 per cent. The}^ concluded that there was a secondary invasion of the endometrium by the staphylococcus in connection with a gonorrhoeal infection which had run its course or become chronic. Menge made his investigations on 50 pregnant women. Of these, 3-i appeared to be without any disease whatever; in 16 there was something suspicious about the discharge. He found the gonococcus in 4 cases. In only 3 others were cultivations obtained, and these were white saprophytic masses which softened gelatine very slowly. He attributes their presence to filth from the vagina. Microscopic examination did not reveal the presence of cocci. Bacteria were seen with the microscope, but could not be cultivated. No bacteria which we know, that is to say, which can be cultivated by methods usually employed for aerobic and anaerobic germs in acid or alkaline media, or suitable for the gonococcus, could be discovered. The conclusion which Menge reaches is, consequently, that with the exception of the gonococcus no bacteria are found as a rule in the cervix of pregnant women. The material which ]\Ienge employed for his further work con- sisted of the extirpated uterus in 50 cases suited for operation. He was thus able to eliminate the errors arising from the necessity of obtaining secretion through the os uteri. The diseased conditions which called for operation had, however, led in many cases to the in- vasion of the cervix by bacteria which had only a modified interest for the gynecologist. INFECTIONS OP THE UTERUS 355 In 20 cases Menge found nothing to suggest pathologic clianges in the endometrium. In 30 cases there existed some turbid slimy discharge or other changes suggestive of gonorrhoeal infection. Of the 20 normal cases the cultivation material remained abso- lutely sterile in 16. In the remaining 4 cases only colonies of saprophytes were discovered. Vaginal bacteria were also found by other methods of cultivation, including an anaerobic streptococcus. In a large proportion of the suspicious cases the gonococcus was found. All the rest were considered to be vaginal bacteria. It was found in the course of examination of another series of uteri extirpated for various reasons, that the tubercle bacilkis existed in the canal of the body and cervix when tuberculous disease affected the uterus or tubes. When necrotic tissue was present, as in cancer of the vaginal portion of the uterus, innumerable saprophytic bacteria were found to flourish. Among the causes of the immunity from bacterial invasion of the cervical canal Professor Sinclair suggests: 1. The difference in the reaction of the secretion, which keeps away from the cervix the facultative aerobes and pathogenic organisms which sometimes gain a footing in the vagina. 2. The sudden change in the calibre of the canal. 3. Increase of the muscular power of the walls of the canal. 4. The downward stream of the secretion, which may add another mechanical influence. 5. Some germicidal quality in the secretion — that is, in the leuco- cytes and in the fluid. 6. The presence of the gonococcus when it has obtained access to the cervix. In reference to this last jooint there can be no doubt that the os externum and all the influences at work in the cervix present no obstacle to the advance of the gonococcus, and there is reason to believe that the presence of the gonococcus has some deterrent influence on the development of other bacteria. From what has now been said about the cervical canal, and a fortiori about the canal of the uterus as a whole, certain practical conclusions may be indicated without unpardonable irrelevancy. It must be obvi- ous that the cervical canal of the pregnant or parturient woman does not require disinfecting, and that any proceedings with that object are, to say the least, unnecessary. When the cervical canal is found to be the source of gonorrhoeal dis- charge in the woman in labour, disinfection is not possible. From the bacteriological standpoint, attempts to disinfect the cervix before or during labour are inadvisable. In women suffering from fibromyoma of the uterus, it used to be the custom fluring operation to dissect out or destroy by cautery the mucosa of tlie cervix, for fear of the stump in the intraperitoneal 356 ^ ^ TEXT-BOOK OF GYNECOLOGY operation becoming infected. The fear of infection at this point was also used as an arg'unient in favour of pan-hysterectomy. It is obvi- ous from the teaching of bacteriology that all these operative details are unnecessary, and the argument as to pan-hysterectomy is all on the other side. Some interesting reflections arise in connection with this subject, in relation to the vicissitudes in the history of lamina da tents. In Sinclair's opinion, tents are still the unrivalled means of dilating the nonpregnant uterus. The tents can be disinfected, the houchon muqueux can be removed from the os externum, and then the canal is germ-free. Whence arise the exceptional cases of acute bacterial infection following the use of tents? Probably from some occult arrested condition of the gonococcus or from the life energies of bac- teria not yet discovered. We are now in a position to appreciate the dictum: The asepsis- of the healthy genital canal in a pregnant woman begins at the introitus vagince, and the germ-free portion begins at the os externum. In the non- pregnant woman the cervical canal is also germ-free. It is hardly necessary to consider the cavity of the uterus as a dis- tinct part of the genital tract — a conclusion in which Professor Sin- clair is in accord with other advanced investigators. The result of such consideration is to emphasize the fact of immunity from organ- isms. All the work of bacteriologists who have obtained material by the curette or spoon, as applied to the cavity, may be set aside as- vitiated by the mixing of material from the vagina. The most trust- worthy results have been obtained by examination of the uterus im- mediately after extirpation. Wertheim, whose work was pursued chiefly with the object of investigating the pathology of the sexual organs resulting from gonorrhoeal infection, concluded that the cavity of the uterus contained either the gonococcus or no bacteria of any kind. Menge worked on the vast material of 118 uteri obtained by ex- tirpation, and the uterine canal in every case was immediately ex- amined for bacteria both by microscopic examination and by cul- tivation experiment. He devoted a good deal of time and trouble to the investigation of pyometra, which is almost always a result of bacterial invasion from malignant disease of the cervix, a work of supererogation as far as our subject is concerned. He might as well have given us the results of researches on the bacteria which infest the cancerous area itself and produce the foul smell of the discharge and other phenomena. On the ground of bacteriological researches Menge concluded that, neither in the secretion, nor in the tissues of the mucosa of the normal cavity of the body of the uterus, did bacteria exist which could be culti- vated in our usual media; and that, neither in the secretion, nor in the tissues of the mucosa of such uteri as showed in the corporeal mucosa, the usual anatomic changes marking the individual forms of chronic endometritis with small-cell infiltration, did bacteria exist which could INFECTIONS OF THE UTERUS 357 be cultivated according to any of our known methods. An exception must always be made as to the gonococcus and the tubercle bacillus. With regard to the tubercle bacillus it is a curious fact, to which Professor Sinclair calls attention, that though tuberculous disease exists either primarily or, more frequently, secondarily, in the cavity of the body, it seldom extends downward beyond the os internum, while in most cases of malignant disease of the cervix, the process comparatively seldom extends upward beyond the os internum. Individual cases of chronic endometritis stand probably in some causal relationship with the bacterial producers of puerperal infection and intoxication. The chronic endometritis of the nonpregnant woman is, however, not perpetuated by these micro-organisms. The cavity of the body of the uterus can be invaded by bacteria, or can for a considerable time harbour bacteria when it is injured, and bacteria are conveyed to it by direct inoculation, or when the defensive power of the cervix is inhibited by dilatation and the unfold- ing of its rug^e, either by new growths or by products of conception. Infections of the uterus may be appropriately classified as (a) mixed, and (b) specific. The mixed infections are those in which patho- genic bacteria of various classes are carried into the uterus and estab- lish inflammatory changes in the endometrium, or possibly subse- quently in the myometrium, or even in the perimetric structures. As will be seen when the pathology of these infections is considered, they are but rarely limited, at least in their sequent changes, to the lining membrane of the uterus; but through the utricular glands or the open lymph spaces the infection extends into the underlying muscular struc- ture; or, in the absence of absolute invasion by morbific micro-organ- isms, the secondary inflammatory phenomena, in view of the non- existence of a submucous connective tissue within the uterus, are manifested directly in the myometrium. Specific infections probably never exist as such if the term is construed to mean an infection due exclusively to a particular micro-organism; there are, however, cases in which a special bacterial organism — e. g., the Streptococcus pyogenes, the gonococcus, the Bacillus tuberculosis — exercise a predominating influence in producing pathologic changes, some of which are charac- teristic of the respective specific infection. It is probably not a demon- strable fact that any well-developed infection, however closely it may approximate the specific standard, ever exists except as a mixed infec- tion; yet, as in the cases of puerperal fever, gonorrhoea, tuberculosis, and especially in parasitic invasions — e. g., the echinococcus — the organism which exercises the controlling influence is so distinct, its characteris- tics are so well understood, its clinical manifestations are so definite, that the fondition should be discussed as one of specific infection. Endometritis not depending upon specific micro-organisms for its causation, is the first and most frequent manifestation of ordinary mixed infections of the uterus. This terra, etymologically, means an inflammation of the lining membrane of the uterus. There is serious 358 ' A TEXT-BOOK OF GYNECOLOGY question whether this condition ever exists as a distinct clinical and pathologic entity — although Welch has stated that he has seen cases of genuine inflammation which can be called nothing hut endometritis (American Obstetrical and Gynecological Journal). The connection between the endometrium and the myometrimn being intimate, there being no intervening cellular structure and a common circulatory and lymphatic arrangement, it follows that inflammatory processes origi- nating in the endometrium are exceedingly prone to penetrate the muscularis. In those cases in which the inflammatory process is limited to the endometrium, such limitation probably exists simply in con- sequence of either the relatively slight virulence of the infectious elements, or the relatively short duration of the disease, or, a third possibility, because resolution has taken place in the deejjer struc- tures. As a matter of fact, inflammatory exudations are generally observed in at least the superficial strige of the muscularis in practically all demonstrated cases of endometritis; and it is also true that in many cases of infections which must of necessity commence in the endometrium, the most essential pathologic changes are manifested in the parenchyma. It is to be concluded, therefore, that, patholog- ically speaking, infection of the endometrium implies an inflammatory disturbance, not alone of the mucosa, but also of the muscularis, and should, therefore, be designated as metritis. Backer denies that inflammation of the uterine mucous membrane exists as a separate condition. He believes it to be always associated with inflammation of the body of the uterus, and classifies it accord- ing to the French plan among the metriticles. He divides metritis into the following groups: I. Uncomplicated infectious form: {a) catarrhal metritis; (&) gonor- rhoeal metritis. II. Complicated forms: (a) metritis post abortium; (&) metritis ex- foliativus; (c) metritis atrophicans. The diagnosis between the forms of Group II is easy, but the catarrhal is hard to distinguish from the gonorrhoeal metritis. The pres- ence of gonococei is pathognomonic; in their absence the clinical his- tory must furnish the decisive details. The ordinary " catarrhal " metritis, such as results from excessive venery, onanism, and displace- ments of the uterus, is not an inflammation but simply a hyperasmia which disappears when the cause is removed. The position assumed by Backer is that entertained by Pozzi and numerous other modern writers and pathologists; and it is the view upon which the discussion of infection will be based in this work. The terms endometritis and metritis will both be employed; the former, in particular, because it designates inflammation of the lining mem- brane of the uterus, to whatever extent the myometrium also may be involved. It is convenient for the purpose of designating inflammatory processes of the uterus since the most important phenomena of them are manifested upon its internal surface. INFECTIONS OF THE UTERUS 559 The ground upon which endometritis should he considered as a mixed infection is firmly estahlished. Brandt found pathogenic organisms in 31 per cent of his cases of endometritis. Other ob- servers have found them in larger proportions of cases. The fact that Brandt's cases embraced both acute and chronic endometritis favours the doctrine of a bacterial causation in a much larger per- centage of the acute cases than was demonstrable; for, as is well known, bacteria within the uterus are relatively self-limiting, while the pathologic changes which they induce may continue. It follows from this, that in many cases of so-called chronic endometritis in which no bacteria can be demonstrated, the organisms have disap- peared by process of self-limitation. The pathologic changes that are induced by an acute mixed infec- tion are simply those characteristic of an acute inflammation in the mucous membrane. There is an immediate turgescence of the sub- FiG. 146. — " The stage of inflammatory exudation is speedily reached." — Reed. epithelial cay)il]aries, with a consequent overstimulation of glandular activity. The influence of the micro-organisms or of their toxines is such as to destroy, in some cases, the superficial epithelium in the more exposed area, while the germs themselves penetrate deeply into the mucous folds and the utricular follicles. The stage of inflamma- tory exudation is speedily reached (Fig. 14G), and differs fi'oni the same 360 ' A TEXT-BOOK OF GYNECOLOGY stage of inflammation in other tissues in the fact that there is no nnderlj'ing submucous connective tissue to become the receptacle of the transuded liquor sanguinis and the migrated cellular elements of hematogenous origin. The exudation on the other hand takes place^ at least, to an important degree, directly among the fibrillae of the myometrium. In exceptional cases, however, the exudation takes place more distinctly between the mucous membrane and the mus- cularis, with the result that the former is sometimes separated, in part at least, from the latter. It is this condition that occasions severe dysmenorrhcea. Winter asserts that it is the origin of some cases of dysmenorrhoea of the membranous variety. The sero-albuminous de- posit gives to stained sections an appearance more transparent than is observed in the normal mucous membrane. The changes incident to resolution now manifest themselves in the disappearance of the liquid elements of the exudate, and in the migration of the leucocytes toward the surface or into the minute lymphatics, until presently both the cel- lular and the noncellular elements of the exudation have disappeared. In many cases, however, in consequence of the peculiar structure of the endometrium, there exist within the deep follicles bacterial elements, which, modified in their virulence, perpetuate in a lesser degree the original inflammatory changes. The persistence of this irritation is sufficient, not only to prevent the resorption of the exuded elements, but to effect their continued deposition and organization. The result is a distinct hyperplasia, characterized by an increased thickness of the mucous membrane. A section of the mucosa reveals that it is of increased depth, while its cellular elements are not only relatively but absolutely increased in number. The leucocytes are found in some cases in large interstitial deposits, while the blood vessels them- selves show but slight thickening of their walls. As a result of these interstitial deposits increased pressure is exercised upon the glands which now seem smaller and relatively fewer in number. In this stage, bacterial elements have generally disappeared from the secretion, the withdrawal of their influence resulting in the more or less speedy super- vention of the next stage of the process; this is characterized by an absorption, to a certain degree, of the remaining free elements of exudation, but without any material diminution in the number or size of the hyperplastic products. These, on the contrary, con- tinue to exercise pressure upon the already compressed glands which now undergo atrophy; or, as may happen, an efferent duct may be- come occluded and the underlying follicle thus become converted into a retention cyst. Some of the glands, instead of being at right angles to the mucous surface, as under normal conditions, become oblique, and the stroma is characterized by increased density, and, on section, shows cells that have become elongated and arranged in bun- dles and fasciculi. The changes that are now presented are very much like those observable in the senile uterus. In these cases there is generally diffuse sclerosis of the muscularis. INFECTIONS OF THE UTERUS 361 The most ordinary, and more or less persistent, change following an acute infection of the uterus is that of glandular hyperlrophic endo- metritis. In this form the cellular changes are restricted chiefly to the epithelium, the cells of which undergo, not only hypertrophic, but hyperplastic changes. The result is essentially one of increased glandular development, with corresponding increase of functional capa- city. The glands seem to be increased in size and number and to be studded more closely together than in normal conditions. The exuberance of epithelial cell growth results in an apparent thickening of the endometrium, which now appears to be arranged in slight folds, on the apices of which, more distinctly than elsewhere, the cell de- velopment seems to be luxuriant. On section, the mucous glands, instead of being straight tubules projecting downward into the stroma, are found to be tortuous, or, in other cases to show simple devia- tion in axis. On cross section their calibres are found to be widened, their lumen being largely occupied by the exuberant cell growth. In this class of cases the lumen of the mucous gland often becomes so distended with newly formed epithelial elements that the latter project from the ostium and appear upon the surface with a sort of granu- lation. In the more distinctly hyperplastic varieties, there seems to be not only an increase in the number of the tissue elements, but a multiplication of the glands themselves. These glands increase in size and number, and sometimes show a marked increase in the interglandu- lar stroma. The exuberant cell growth in these cases results in a thickening of the mucous membrane, the surface of which presents a fungous appearance. It is for this reason that the condition is some- times called fungous endometritis. As the epithelial cells develop from the matrix there is demonstrable a certain proliferation of the sanguiniferous capillaries to give them support. The cell growth is, however, so active that it gets beyond the influence of the nutrient supply and undergoes fatty degeneration. When this occurs, the ter- minal filaments of the newly proliferated vessels are exposed, and hemorrhage results. It is sometimes important to distinguish areas of glandular hyper- trophy occurring upon a limited area of everted cervical membrane, from syphilitic infection. In the first place the primary syphilitic sore of the portio vaginalis is rare, and when it occurs it is manifested by a distinct erosion, ulcerative, with sharply defined borders. It is in nearly every case associated with induration of (1) the intra- pelvic l}Tnphatics, and later (2) those in the inguinal regions. Chan- croids are liable to be overlooked, as they are generally painless and, aside from an ofi'ensive discharge, produce no symptoms. The causes of endometritis may be summarized in the general word infection. There are, however, numerous conditions which seem to contribute to this infection. As has been shown by Sinclair, the uterine cavity from the os externum to the fundus is normally free from bacteria. A^Tien infection occurs above the external os i1 must be as 362 A TEXT-BOOK OF GYNECOLOGY the result of the carriage thither of the infectious element. The use of instruments to produce abortion^ and the employment of the uterine sound for more legitimate purposes, may be held responsible for a large number of cases. The use of an unclean speculum is a reasonable explanation of the infection of the upper portion of the vagina, whence the infection may extend by progressive invasion of the mucous sur- faces to the endometrium. Pessaries, for the most part unclean and stinking things, are to be looked upon with more than suspicion. The use of an unclean syringe nozzle is dangerous. There are certain phys- ical conditions of the uterus that are undoubtedly predisposing causes of infection. Laceration of the cervix, b}^ exposing a portion of the endocervium to the infectious elements that abound in the vagina, may pave the way for a more general involvement. Schultze has called attention to the influence of a chronic dilatation of the cervix in favour- ing the introduction of morbific agencies into the uterine cavity. Pro- lapsus of the uterus, when complete, is generally associated with more or less infection of the endometrium. Uterine displacements in gen- eral may be looked upon as contributory influences in producing the pathologic states which are found in patients with associated demon- strable infection. Neoplasms of the uterus, particularly when they have become the seat of retrogressive changes, are a source of infection. Abel and Lan- don, after making numerous careful microscopic studies, arrived at the conclusion that in cases of cancer of the cervix the corporeal endo- metrium undergoes marked changes — especially of an inflammatory character. Acute infectious diseases have been looked upon as causes of endo- metritis. Massin of St. Petersburg {Arcliiv fiir Gyndl-ologie) made an efl^ort to settle this question by conducting a series of experiments upon eighteen cases. Of these, twelve were cases of relapsing fever, two of pneumonia, two of enteric fever, one of dysentery, and one case of acute general peritonitis of unkno-ooi causation. The uterus, with the adnexa, was removed at the autopsy and placed in Miiller's fluid, and allowed to remain therein from a month to six weeks. Sections were made from different portions of the uterine walls, including the os internum and cervix. They were first kept in alcohol (70 per cent), then placed in absolute alcohol for one week, and then in photoxylin solution. The sections were stained with borocarmine, picrocarmine, eosin, and methylene blue. From an examination of these specimens the follow- ing conclusions were arrived at: " The mucosa is afl^ected in all of these acute infectious diseases, as are the glands, the vessels, and the uterine muscular fibres. Firstly, they are all markedly injected. The injec- tion may be marked in one portion of the mucous membrane, or, as was usually the case, may afi^ect the entire mucous membrane. The in- creased size of the vessels was especially noted in the small veins and capillaries. The arteries were empty, and in only a few cases did they contain formed blood elements. In many cases the dilatation was so INFECTIONS OF THE UTERUS 363 great as to cause a rupture of the vessels, and consequently hemorrhages into the mucous membrane and between the muscular layers. These ecchymoses occurred in cases irrespective of the age of the patients. The most marked cases of dilatation and rupture were those in which the disease had been continuous, as in the cases of pneumonia and enteric fever, whereas in the cases of relapsing fever hemorrhages were only found in half of the cases. Next, in reference to the glands. The epithelium lining these was always swollen and cloudy, having rounded edges; the cells were coloured with difficulty. The epithelial cells secreted more mucus than normally. In some cases the glands were markedly enlarged. In many cases the epithelium was detached from the glandular tissue and lay in irregular masses in the glandular cavi- ties. The membrana propria of the glands and the surrounding layer of spindle-shaped cells were well marked in nearly all of the cases. We frequently observed new-formed granular elements, which were arranged around the glands in the form of a belt. The muscular layer of the uterus did not seem to be much affected by the disease. As stated above, the vessels in the muscular layer were injected. The changes which we observed represent a parenchymatous and interstitial inflammation of the mucous membrane and an interstitial inflammation of the muscular layer. Furthermore, in all of the cases a condition was observed which can be termed a hemorrhagic endometritis. AVe naturally conclude, after having made these experiments, that the endometritis undergoes three processes: 1. Increased amount of blood to the uterus, venous stasis, and inflammation of the vessels; 2. Granu- lar inflammation; 3. Diffuse spreading of this inflammation. In our experiments we were unable to ascertain whether micro-organisms were present or not. We must, therefore, consider acute infectious diseases as important factors in the causation of uterine diseases, so that when we consider the etiology of acute and chronic endometritis we must always think of the possibility of the affection being the result of an acute infectious disease." The symptoms of endometritis vary somewhat according to the pathologic changes upon which they depend. In the simple infec- tions of the endometrium involving only the superficial epithelium and the mucous follicles, there occurs a discharge ordinarily designated as uterine leucorrhoea. This discharge is generally clear and viscid and is occasionally stained with blood. It is sometimes of a distinctly muco-purulent character. Schultze, recognising the fact that purulent elements may be so slight in the uterine discharge as to escape detec- tion, advises the use of a glycerine tampon for diagnostic purposes. The tampon should be removed by the surgeon, who should carefully inspect it and thereby ascertain with accuracy the presence or absence of puru- lent elements. In cases of long standing, frequent hemorrhages, oc- curring either in connection with menstruation or during the inter- menstrual period, are to be construed as evidences of fungous degen- eration of the endometrium. There may or may not be dysmenorrhoea. 364 A TEXT-BOOK OF GYNECOLOGY and the uterus may or may not be enlarged. The cervix in the major- ity of cases is, however, the seat of more or less engorgement or infiltra- tion, or may even be oedematous. In some cases the uterus may be painful, a condition which Sneguireff of Moscow designates as endome- tritis dolorosa. Sensibility of this character is generally more marked at the fundus. The diagnosis depends not only upon the symptomatology, but especially upon the demonstration by microscopic and bacteriological examination of bacterial elements in the uterine secretion. If the endometrium is everted at the cervix and presents a granular appear- ance the case is one of glandular hypertro]3hy. If hemorrhages are present there exists a strong suspicion of endometritis fungosa. It should be remembered, however, that hemorrhage is a conspicious symptom of various malignant processes, not only of the cervix but of the corpus uteri. (See Symptoms of Malignant Neoplasms of the Uterus). In view of these facts and under these circumstances it is imi^erative that the uterine cavity be explored. The cervix should be dilated. This is done preferably by some of the mechanical dilators, such as Palmer's convenient device; or, as preferred by Sinclair, a carefully sterilized laminaria tent may be then employed. The chief objection to the latter is the time and discomfort involved in its use. Dilatation should be carried to a degree that will admit of the easy introduction of a curette or of a curette forceps. Either one or the other of these instruments should then be inserted and by gentle scraping some of the intrauterine tissue should be removed. This should be carefully preserved and examined microscopically. Gessner {Zeitschrift fiir GehurtsMUfe u. Gtjnakologie) in a careful discussion of the techniqiTC of exploratory curettage states that anaesthesia is useful although not indispensable. The dilatation is to be carried to a degree that will admit of the introduction not only of the curette, but subse- quently of an irrigation catheter. A sharp curette is to be employed and the whole interior of the uterus must be carefully scraped and every fragment so removed must be examined under the microscope. Unless this precaution is taken, evidences of malignancy which may be derived from a very limited area may escape detection. Sanger recommends that the uterine canal be dilated by means of laminaria tents until not only a curette, but also the finger, can be introduced into the uterine cavity. He states that in those affections of the corpus in which malig- nancy is always to be suspected, the use of the curette is superior to simple palpation, but palpation with curettage and microscopic exam- inations of any dehris that may be removed will give more information than the two latter only. While Sanger insists upon this technique in cases of abortion and of myomata of the corpus uteri, he recognises in digitation a valuable diagnostic expedient in certain enlargements of the uterus associated with involvement of the endometrium. Gessner, in speaking of the diagnostic value of exploratory curettage, states that in the FrauenMinik of the University of Berlin, a diagnosis of INFECTIONS OF THE UTERUS 365 malignant disease of the corpus uteri had been made and the organ had been extirpated in fifty-eight cases during a few years. In eleven, carcinoma could be distinctly felt through the dilated cervix; in three others in which the finger could reach the new growth the disease was found to be sarcoma. In forty-one cases, however, the diagnosis was made, not by digitation, but by exploratory curettage. He looks upon the latter as the more valuable expedient. When the scrapings are examined the diagnosis will be established by their resemblance to the histopathologic appearances already described. The treatment of endometritis must depend somewhat upon the particular pathologic condition that may be presented at the time. In the simple catarrhal forms, in which the most annoying symptom is a persistent leucorrhcea, reliance is often placed upon topical remedies. As has been shown in the discussion of the pathology of this condition, there exist such organic changes that any results that may follow the use of local medication must be at best slow and uncertain. It may be stated as a rule that intrauterine medication for catarrhal conditions is unsatisfactory. There are patients, however, who prefer to be treated locally for a long time rather than to submit for a few days to anything suggestive of surgical intervention. In these cases treatment should consist in the use of bactericidal agents. These should be so applied that the entire mucous surface should be subjected to their influence; for, if a portion of the mucous surface remains untreated, and consequently infected, it becomes the focus for the reinfection of the entire structure. Another principle of equal importance is, that an intrauterine application of a bactericidal character should be repeated or maintained for several days, so that, not only the bacteria themselves, but their spores also will be destroyed. There is probably nothing in the whole range of gynecological therapeutics that is so futile, not to say farcical, as the repeated applications to the cervical membrane of various medicaments of undetermined antiseptic value, and many of them of unknown ingredients. As a rule these applica- tions are made to a canal bathed with tenacious mucus, which of itself constitutes an efficient protective for the underlying micro-organisms. Topical treatment, to be effective, must be brought into direct contact with the micro-organisms. These, as already described, are hidden away within the epithelial folds or deep down in the mucous follicles. The tissues themselves, both epithelial and subepithelial, are more or less hypertrophied; an agent, therefore, which will be effective must modify this histologic state. Most practitioners have, therefore, aban- doned the use of nonescharotic agents. Those that are employed, however, are not viciously destructive of the tissues like nitric acid or sulphuric acid, or pure formalin. Reed's method of treating these cases is as follows: The cervical canal is dilated, if necessary, to a very slight degree by means of a Nott or other small dilator. The posterior lip of the cervix is seized with a vol sell a or the serrated cervix forceps of Dumont-Lelois and held by slight downward traction. The uterine 365 A TEXT-BOOK OF GYNECOLOGY cavity is then packed with a very slender ribbon of dry sterilized gauze; this is immediately withdrawn, bringing with it all the mucus from the endometrial surface. If a first packing is not satisfactory for this purpose, a second may be utilized. After the mucous surfaces have thus been carefully cleansed, the uterine cavity is again packed with a slender ribbon of gauze saturated with 98-per-cent carbolic acid. This is left in situ. In applying the carbolic acid it is important to avoid bringing it in contact with the integument of the mucous mem- brane of the vagina; but if this accident should happen, the place should be immediately touched Avith pure alcohol, which will neutralize the carbolic acid. A tampon of glycerine or of boroglyceride is applied and the patient is permitted to go home, returning in forty-eight hours for a repetition of the treatment. Three or four applications of this kind, made at lengthening intervals during ten days, are generally sufficient to cure an ordinary case of catarrhal endometritis. The treatment, contrary to usual theoretic preconceptions, is not particu- larly painful and never requires an angesthetic. The destruction of epithelium from these repeated applications is not sufficient to inter- fere with its speedy reproduction. Cases have been reported in which cures have been effected by the introduction into the uterine cavity of a piece of lunar caustic, which was permitted to dissolve in situ. The uterine cavity has been packed with boric acid and with iodoform, both of which have some bactericidal properties. Canquoin has re- ported successes from the intrauterine application of a paste the essential ingredient of which is the chloride of zinc. It is prepared in the form of a pencil and is introduced into the uterus; Pichevin, Emmet, Schroder, Martin, Munde, Jacobs, and others, have reported adversely on its use, and it seems to have been discontinued. As an escharotic agent, the chloride of zinc is vastly more destructive than even the silver nitrate, the use of which has been very generally abandoned. Sneguireff recommended the action of steam upon the inner surface of the uterus as a means of arresting intrauterine hemorrhage, and it has been quite extensively employed, especially in Eussia. Its applica- tion requires a steam generator with a safety valve and with a central opening for the insertion of a thermometer, the generator being con- nected by rubber tubing with a metal catheter of necessary length for intrauterine application. The temperature should be kept between 100° and 110° C. (212° F. to 230° F.). A Fritsch uterine irrigator may be used for the application of the steam. The patient is placed in the lithotomy position, and a short cylindrical speculum of some noncon- ducting material, such as celluloid or hard rubber, or preferably wood, is inserted. A catheter is then inserted and the steam is turned on. The instrument should be encircled with gauze, or provided with a nonconducting handle, to avoid burning the hands of the operator. The patient should remain in bed for a few days. There is generally considerable reaction with pronounced perimetric irritation. It has INFECTIONS OF THE UTERUS 3O7 been recommended by Pincus for senile endometritis with profuse hemorrhage or leucorrhcea; where irregular hemorrhages are associ- ated with subinvolution of the uterus; for diffuse myomata; for hyperplastic or catarrhal endometritis; and for gonorrhoeal and strep- tococcous infections of the uterus. It must not be used in the presence of diseased adnexa or in cases of stricture of the cervical canal, while it is not advised in polypoid myomata. This method is spoken of as vaporization, but it is really a cauterization with extensive destruction of tissue. It is possible that the principle may survive, although the present technique seems to be defective. The use of superheated steam destroys tissue to a depth that is dangerous. Baruch reports a case of atrophy of the uterus with occlusion of the cervical canal and apparently of the whole uterine cavity, following vaporization in a woman only twenty-seven years old. This condition amounting to the practical destruction of the uterus was induced by a single intrauterine application of steam for the purpose of checking puerperal hemorrhage, an object which was speedily accomplished. Von Guerard {Central- blatt filr Gynak-ologie) reports the case of a woman who had persistent hemorrhages following delivery, with evidences of subinvolution of the uterus and fungous degeneration of the endometrium. Atmocau- sis, as this method of vaporization is called, was employed. There was a cessation of the menses following the operation, but at the menstrual periods unendurable pains were felt, becoming intensified as time went on. The uterine cavity was so obliterated by the steam jet that the sound entered it for about 2 centimetres only. Von Guerard was forced to relieve the patient by a total hysterectomy, from which she recovered. In commenting upon the case, he insists that atmocausis was absolutely contraindicated before the menopause. Schick, of Prague {CentraTblatt filr Gynakologie), recognising the valuable prop- erty of heat for antiseptic and hemostatic purposes and as an escharotic agent, has endeavoured to secure its desired effect by the use, not of superheated steam, but of boiling water. He kept up the irrigation for half a minute, only the vagina and vulva being protected by con- stant irrigation of ice-cold water. Of the four cases in which he tried it three were successful. While this treatment may be of great value, its employment is certainly associated with great danger, and it is mentioned in this connection only with the hope that the valuable principle which it embodies may find safe exemplification in more re- fined methods. It may be stated, as a rule to which there are no exceptions, that in all cases of infection of the uterus in which the condition has assumed the chronic form with associated histologic changes, the topical application of any medicament, escharotic or otherwise, is less satisfactory than curettage followed by appropriate antiseptic treat- ment. 368 A TEXT-BOOK OF GYNECOLOGY CUBETTAGE OF THE ITtERUS Instruments for Dilatation of the Catheters, glass (Fig. 147) 1 Catheter, irrigating two-way, small. . . 1 Curette, sharp (Sims's modified) 1 3Iartin"s blunt, double 1 Martin's sharp (Fig. 148) 1 Dilators, Palmer's medium. Hegar's, 4 sizes (Fig. 149). Goodell-Ellinger. Forceps, Bozeman's long dressing (Fig. 150) 1 Kat-tooth 1 Cervix and Curetting of the Uterus I Forceps, bullet 2 I Serrated cervix forceps of Dumont- ' Leloir (Fig. 151) 1 Nozzle, Edebohls's 1 Packer, vaginal 1 Sound, uterine 1 Speculum, Jones's (Fig. 152) 1 Sims's small 1 Simon's, with handles and four blades (Fig. 153) 1 Tenacula (Fig. 154). In those varieties of intrauterine infection resulting in the develop- ment of fungous granulations with associated hemorrhage, intra- uterine medication of whatever sort is futile. The only available remedy consists in the removal of the adventitious tissue. Patients who are the victims of hemorrhage, and are consequently gi-eatly reduced in strength, are generally less persistent in urging objection to the slight surgical pro- cedure of curettage. This, with associated antiseptic meas- ures, is distinctly the most valuable means of treating infec- tions either acute or chronic, either mixed or specific, of the endometrium; while if not followed by antiseptic measures it is a worthless and dangerous expedient. The uterine curette, according to Pozzi, was invented by Eecamier, after which it fell into discredit. J. Marion Sims did much to re-establish the instru- ment in favour, while Thomas Eoux and the elder ^lartin have been instrumental in defining its uses and limitations. The curettes, as now found, vary in size and form; some of them are dull wire loops, \bent at various angles; others are spoon-shaped, some with dull and some with sharp edges; some are steel loops with sharp edges, while others, like that recently invented by Gau (Fig. 144), are pro- vided with a safet)^ end, and yet can be used as either a sharp or a dull instrument. All of them are found illustrated in the instrument makers' cata- logues. The object of the curette is to remove ad- ventitious tissue from the uterine cavity or cervix. The method of its employment does not differ from that already described in connection with exploratory curettage as a means of diagnosis in endometritis (ante). As a matter of fact, curettage, whether undertaken for diagnos- tic or other purposes, should always be conducted with the same ante- cedent and sequent precautions. The same rigorous antisepsis should precede the operation, the interior of the uterus should be treated in Fig. 147. Glass catheter. EOBB. Fig. 148. Martin's sharp curette. — Kobe. INFECTIONS OF THE UTERUS 369 precisely the same way, and the operation itself should be just as ex- tensive when undertaken for diagnostic as for other purposes. It may be accepted as an axiom of practice that the existence of any condi- tion demanding the use of a curette can be determined by macro- scopic appearances; while the more refined diagnosis may be based upon subsequent examination of the scrapings. The first contraindication of curettage is nonexperience in uterine surgery on the part of the operator. There is probably no manipula- FiG. 149. — Hegar's dilator.— Kobe. tion in surgery for the proper practice of which more dexterity, more deftness, or more of that judgment which depends on the tactus eru- ditus, is demanded than curettage. Among other contraindications, summarized by Currier {International Journal of Surgery), are igno- rance on the part of the operator of the exact limits and outline of the uterine cavity; the presence of the menstrual flow; extreme dis- placements of the uterus; and acute infectious diseases of the uterine appendages. Polk {New York Journal of Gynecology and Obstetrics) takes the ground that curettage is an eligible operation in cases of chronic metritis associated with salpingitis, asserting that, when prop- FiG. 150. — Bozeman's long dressing forceps. — Eobb. erly done, it affords much-needed depletion to the uterus and is not followed by peritonitis or acute salpingitis; and in support of his statement presents a tabulated list of forty cases giving the maximum diurnal temperature for eleven days following the operation. It is certainly a gratifying exhibit showing but trifling and evanescent reaction, and that only in a few cases. But gratifying as these facts are, they can not be accepted as demonstrating the safety of curettage in the presence of inflammatory conditions, whether acute or chronic, in which pus, although in undetectable quantities, is liable to exist 25 370 A TEXT-BOOK OP GYNECOLOGY in the uterine appendages. The necessary traction and vigorous manipulation essential to a thorough curettage is liable to produce cleavages in adhesions and consequently to liberate previously con- fined pus. Objection has been urged against the use of the sharp curette upon the ground that it destroys the epithelium which is replaced by cica- tricial tissue. This objection is not tenable unless the operation amounts to a practical endometrectomy involving the complete re- moval of the basis membrane of the endometri- um. As has been shown by Von Kohlden and others, there occurs physiologically in con- nection with the menstruation a periodical loss of epithelium. This physiologic function may be carried to the jjatho- logical degree involving the shedding of the en- tire membrane. (See Membranous Dysmenor- rhcea). When this oc- curs, however, the membrane is again speedily reproduced. Bossi has studied the repro- duction of the mucous mem- brane of the uterus, following its apparent complete destruc- tion by Canquoin's paste of the chloride of zinc. From his ob- servations and a more or less thorough investigation of the question, he has arrived at the following conclusions (Nou- velles archives d'obsUtrique et de gynecologie, December, 1891): 1. The mucous membrane of the uterine body in the bitch, abraded by free cuts of the bis- toury extending through its whole thickness, is reproduced in its integrity, that is to say, with a formation of true glands. 2. Re- production takes place slowly, and sometimes, by reason of conditions not well determined, is subject to considerable retardation. 3. The covering epithelium, which primarily extends over the wounded sur- face, derives its small glands from the borders of the cut. 4. The newly formed glandules derive from the proliferation of cells a new covering epithelium when it has acquired the cylindrical form. As a final word on curettage in the treatment of endometritis, let Fig. 151. — Serrated cervix for ceps of Dumont-Leloir. Fig. 152, Jones's speculum. INFECTIONS OP THE UTERUS 571 it be said that the mere scraping away of inflammatory products is curative to that extent and to that extent alone; that if the treat- ment stops at that point it will be worthless; that curettage is not necessary in the many cases, even to remove these inflammatory prod- ucts; that its value consists in removing those tissue elements which serve as hiding places for the morbific micro-organisms; and, finally, that the essential element of the treatment consists in the thorough O Fig. 153. — Simon's speculum. — Eobb. Fig. 154. — Tenacula. — Robb. application of antiseptic agencies to the denuded endometrial surface. Curettage is, therefore, but a part, although a very important part, of a plan of treatment which has for its object, not alone the re- moval of pathologic products, but the destruction of the causative bacteria and their spores. CHAPTEE XXYII INFECTIONS OF THE UTERUS (Continued) Specific: Gonocoecous infection (gonorrhoea) — Streptococcous infection (puerperal fever) — Tuberculous infection (tuberculosis): of the cervix: of the corpus — Syphilitic infection (syphilis) — Ecliinococcous infection (hydatids). Gonococcous infection of the uterus is simply an upward extension of gonorrhoea from the vagina. This rarely occurs spontaneously, be- cause of the resistance offered, first, by the mechanical arrangement of the vagina, and next, by its secretions and its normal bacteria, notably, the acid-secreting bacillus of Doderlein. (See Gonorrhoea of the External Genitalia.) Extension to the uterus in the majority of cases is the result of mechanical intervention in some form. As pointed out by Eosenwasser, it often results from meddlesome treat- ment of the disease when limited to the vulva. Some physicians pro- ceed upon the mistaken theory that the vagina is the primary seat of infection of gonorrhcea in woman, and begin at once to treat that canal with mistaken vigour. The ordinary result of such inter- ference is to establish the very condition which it is desired to overcome. It must be admitted, however, that in the majority of cases, the patient herself, rather than her physician, is responsible for the extension of the infection. The practically universal use of the vaginal douche results in these cases in mischievous complications. Schultze investigated two hundred cases with the result that he disj)roved the accuracy of Broese's opinion that the uterus is infected in every case of gonorrhoea in women. Schultze further concluded that gonorrhoea is infectious only until the gonococci have disappeared from the secretion, whether the latter is vitreous or purulent; he found that when the cervical secretion contains no gonococci there are none in the secretion from the cavity of the uterus. The secretion was purulent in a trifle over 50 per cent of the cases, while in the rest it was vitreous and merely turbid, the latter conditions not excluding the existence of gonococci. The gradual upper extension of the in- fection was indicated by the fact that even when the cervix was involved, the uterus showed contamination in only 38 per cent of the cases. The adnexa suffered in 38 per cent of those with cervical gonorrhcea, and in 45 -pev cent when the uterus also was infected. Yan Schaick (Neiv YorJc Medical Journal) made a study of gonorrhoea INFECTIONS OF THE UTERUS 373 in married women and found gonococci existing as at least complicating causes of leucorrhoea which apparently depended upon cervical lacera- tions. The symptoms of gonococcous infection of the uterus do not differ materially from those which have been described in connection with the recognised mixed infections. (See Endometritis.) The diagnosis, however, depends upon the demonstrated existence of the gonococcus; with the gonococc^is present there is gonorrhoea; without it there is no gonorrhosa. Neisser observes that many cases of undoubted gon- orrhoea would escape recognition if clinical evidences, alone, were re- lied upon. The gonococcus is not always easily found. Van Schaick, in a careful examination of sixty-five women, found gonococci seven- teen times, or in 36 per cent of the cases. Nineteen women were examined twice, and in three, gonococci were found at the second examination. Thirty-two were examined three times, and in three of these the third examination revealed the presence of the micro- organisms. It is of imjoortance in this connection to note the con- clusion of Broese and Schiller (Berliner Minisclie Wochenschrift) that the intercellular arrangement of gonococci is not to be recognised as pathognomonic of acute gonorrhoea, since they have repeatedly found them outside the cells. The diagnosis of chronic gonorrhoea, these observers contend, may be based upon the characteristic shape and size of the gonococci, and upon their reaction to the Pick-Jacobson method of staining. The history of a previous acute attack of vulvar and urethral gonorrhoea, particularly if treated with douches and tampons, is a clinical factor of conclusive diagnostic importance. In the puer- peral state, gonococcous infection of the uterus is manifested by an increase in the volume of the lochial discharge, which becomes puru- lent but not necessarily offensive. The purulent character of the lochia is observed as early as the fourth day after delivery. Kronig has observed a temperature of 104° F., or more, resulting from these germs in the uterus. The occurrence of ophthalmia neonatorum in the child is a confirmatory evidence of gonorrhoeal infection. The final diagnosis, however, depends upon the demonstration of the char- acteristic micro-organisms in the lochia. The 'pathology of gonorrhoeal infection of the uterus has but few points at variance from that of the other infections. It would seem that the micro-organism reaches the cervical mucosa in a condition of reduced virulence, but sufficiently potent to cause the usual in- flammatory phenomena. Its behaviour in the endometrium does not differ materially from that in other mucous membranes. In the acute form the micro-organisms may or may not penetrate the cells, and, as has been already stated, their extracellular existence is not in- consistent with, true gonorrhoeal infection. If the infection is received during the course of pregnancy it is liable to cause miscarriage, with a probable upward extension of the disease to the Fallopian tubes, as has been demonstrated by Wertheim. Madleur (Centralhlatt fiir Gynd- 374 A TEXT-BOOK OF GYNECOLOGY hologie) has shown that in the j)i-^erperal state gonococci may pene- trate the miiscularis and cause parenchymatous suppuration; and that from this point the infection may reach the system through the lymph channels and cause arthritis, endocarditis, etc. In these eases, how- ever, the infection is probably associated with, if not dominated by, Streptococcus pyogenes. Leleneff (Wiener Minisclie Woche^ischrift) has confirmed the observations of Madleur, as he has demonstrated the gonococci between the bundles of muscular fibres. He states, in addi- tion, that the destructive action of the gonococci upon cellular proto- plasm causes the latter to degenerate and liquet}', leaving only a feebly staining vacuolated nucleus. In view of the fact that these changes have been observed alike in those cells which contain the gonococci and those which do not, it is assumed that the destructive action must be due to some toxines produced b}^ the gonococci. The widely credited power of gonococci to penetrate the leucocytes is con- firmed, while it is also demonstrated, contrary to previous opinions, that they invade squamous as well as columnar epithelium, and that it is by virtue of this fact that they find their way into the deep struc- tures of the uterus. The treatment of the acute stage should be conducted with refer- ence to avoiding unnecessary diffusion of the infection. As has been shown by observations already alluded to, infection may exist in the cervical canal without its extension to the corpus uteri. This fact is to be held in mind in the adoption of treatment. The cervical canal should be thoroughly cleansed and treated with protargol, a proteid compound of silver. Neisser looks upon this agent as an effi- cient antigonorrhoeal remedy, which, if employed at an early period, exerts a prompt and favourable influence upon the course of the disease. In most cases it arrests all acute manifestations, causing rapid disappearance of the secretion and the gonococci, and prevent- ing the extension of the disease. Salochin has used this remedy in a 5-per-cent solution applied through a speculum to the cervical canal. The vagina was treated with a 2-per-cent solution, and a tampon moistened with it was left in position. The solution made by Colombeni is as follows: Ten grammes of protargol are placed in a small mortar to which are added 5 cubic centimetres of neutral glycerine, the two being stirred together with a glass rod till a thor- oughly homogeneous moist paste is produced. This is next diluted with 95 cubic centimetres of cold sterilized water, and shaken up till a perfect solution is produced; this solution is kept in a col- oured bottle in a dark place. As required, a 0.25-per-cent solution is made by mixing 2.5 cubic centimetres of the standardized solution with 97.5 cubic centimetres of sterilized water; a 0.50-per-cent solution by mixing 5 cubic centimetres with 95 cubic centimetres of water; a 1-per-cent by mixing 10 cubic centimetres, and a 2-per-cent by mix- ing 20 cubic centimetres of the standardized solution with 90 and 80 cubic centimetres, respectively, of sterilized water. A very good way INFECTIONS OF THE UTERUS 375 to use the Colombeni solution is to saturate a ribbon of sterilized gauze with it and insinuate it into the uterus. The uterine packing at this time, whether of protargol, pure carbolic acid, or pure lysol, exercises a profound bactericidal influence, and does not carry the infection upward into the uterus, for the reason that any micro-organism that may come in contact with the saturated gauze will be destroyed. The gauze should be removed after forty-eight hours, and should be re- placed after an interval of another forty-eight hours. In cases of chronic gonorrhoeal infection of the uterus, the cocci have found hiding places in deep folds of the endometrium, whence the disease has been looked upon by some observers as self -limiting, while others with equal emphasis insist that it is more or less constantly revived. It is a matter of clinical observation that in these cases there occur periods of quiescence, followed by exacerbations that are not induced by fresh infections. Jadassohn (Correspoiidenz-hlatt filr Schtveizer Aerzte) asserts that chronic gonorrhoea in certain cases may become acute through super- infection with their own cocci. He reaches this conclusion notwith- standing the observation of Wertheim, that a mucous membrane affected with chronic gonorrhoea did not react to cultures taken directly from it, although it reacted to cultures taken from another patient. The mucous membrane does not become so used to the presence of the cocci that the latter can live as saprophytes on it after the tissue has become normal. On the contrary, the inflammation re- mains for a time after the infectious elements have disappeared. He concludes, also, that chronic gonorrhoea may become acute, not only through the increase of its own gonococci, but by reinoculation from another person. While there are instances in which the membrane does not react to inoculation with gonococci from any source what- ever, they are to be looked upon as exceptional, and the generally entertained theory, that the mucous membrane that has been the seat of a chronic gonorrhoea thereby acquires immunity, is to be abandoned. It is not proper, therefore, to look upon chronic gonorrhoea of the uterus as a self-limiting disease, but rather as one that is capable of indefinite perpetuation. Treatment should, therefore, be directed to the eradication of the infection, which, if left to itself, will, in at least 50 per cent of the cases, extend upward into the Fallopian tube. If this has not already taken place, and if there is no acute infection in the adnexa or other perimetric structure, curettage should be practised. (See Curettage.) The treatment should in no wise differ from that already prescribed for chronic infectious endometritis, with the exception that it is better to select some distinctly antigonorrhoeal remedy, such as protargol, carbolic acid, or lysol, with which to pack the uterus after its cavity has been scraped. This is not a dangerous procedure when done skilfully and under proper antiseptic precautions, all alarmist declarations to the contrary notwithstanding. 376 ^ ^ TEXT-BOOK OF GYNECOLOGY Streptococcous Infection. — Puerperal fever is the ordinary clinical manifestation of uterine infection by the Streptococcus pyogenes — other- wise known as the micrococcus of erysipelas. Streptococcus erysipelatos. Streptococcus tongus, etc. (See Streptococcus Pyogenes.) As elsewhere stated, Oliver Wendell Holmes Avas the first to direct attention to the relationship of cause and effect between erysipelas and puerperal fever, an observation which was confirmed by Stille, who reported ninety-five cases of puerperal fever occurring in rapid succession in the practice of a single physician in Philadelphia, in which fifteen of the children died from erysipelas. Fehleisen was the first to demonstrate that the Streptococcus pyogenes was the essential micro-organism of erysipelas. That this same micro-organism is the materies morbi by which the parturient woman is infected with re- sulting puerperal fever is supported by cumulative evidence. Clivio and Monti demonstrated its presence in five cases of puerperal peri- tonitis; Widal found it in sixteen; Czerniewski found it in the lochia of thirty-five out of eighty-one women with puerperal fever. Bumm was able to find the streptococci alone in five cases (three of these end- ing fatally). In twelve cases, besides the streptococci, there were ob- served upon the plate cultures staphylococci and other germs. In eight cases the number of germs of decomposition were very great (mixed form of septic and putrid endometritis). Two of these cases terminated fatally, the streptococci entering the venous thrombi at the placental site and a pyamiia resulting. Occasionally we may find pyogenic staphylococci, especially the aureus, besides the streptococci. Bumm only observed staphylococci alone in two cases. The cases were mild ones, and this coincides with the observations of Fehling. The pathology of infection by the Streptococcus pyogenes is typically manifested in the uterus. This micro-organism, introduced into the vagina by the finger of the accoucheur or upon instruments em- ployed in delivery, finds in the fluid contents of the uterus a congenial culture medium in which it propagates with great rapidity. The placental site serves as an enormous infection atrium, the wide, dis- tended lymphatics and the open blood vessels alike serving as portals for the reception of the poison, which is speedily transported thence to the general system. In the uterine structure, however, is mani- fested the characteristic action of the streptococci. As soon as they invade the vessels of the uterus they produce changes Avhich break down the endothelium and result in the development of a thrombus. After a while, the thrombus in turn breaks down, and the emboli thus formed spread the organisms in various directions. Many of them lodge in the immediately adjacent vessels of the myometrium, while others, gaining access to the systemic circulations, sanguiferous and lymphatic, are conveyed to distant organs and structures, where they become foci of secondary suppuration. In the uterus itself, however, there are speedily established, either primarily or secondarily, similar INFECTIONS OF THE UTERUS 377 foci of suppuration, by which the organ may become converted into what may be described as an aggregation of small abscesses. The individual accumulations of pus may vary from a few drops to a drachm or even more. Occasionally two or more of these centres of suppuration may coalesce, forming a larger abscess cavity. It should be borne in mind that these suppurative changes occur in the myo- metrium, and that the condition is essentially one of interstitial sup- purative metritis. The invasion of the lymph spaces by the strepto- coccus results very speedily in the development of an acute septic lymphangeitis, involving the lymphatics, first, of the pelvis, and, sub- sequently, of the remoter parts of the system. The lymphatic glands may, themselves, become foci of suppuration. It should be remem- bered, however, that the streptococci do not produce suppuration so promptly as do the staphylococci, and that, consequently, in the cases under consideration, pus does not appear in the uterine structures at once. In the earlier stages of the infection there occurs simply a diffuse infiltration of the tissues, which, if incised, will set free a clear yellowish fluid in which are a few pus cells. As the streptococci develop, however, they manifest their characteristic effect of pro- ducing a coagulation necrosis, which becomes the focus of suppura- tion. In the course of a few days, a parturient uterus which is the seat of this infection may vary in length from 15 to 18 centi- metres, and in fundal width from 12 to 15 centunetres. The uter- ine wall at the fundus is about 3 centimetres in thickness. When cut open, the interior of the uterus above the cervical canal is covered with a dark tenacious mucus, which is very offensive. The placental site is distinct, and may contain fragments of firmly attached placenta. The incised myometrium, as in Cartledge's cases {Trans- actions of the Southern Surgical and Gynecological Society), reveal numerous small discrete abscesses varying in size from a millet seed to a large pea. This description of the general macroscopical appear- ance is based upon examination of the uterus removed by vaginal hysterectomy during the course of the disease, and does not, therefore, depend upon post-mortem changes for any of the peculiarities recorded. Bumm (Archiv filr Gynakologie) has made careful studies of the endometrium, when the seat of puerperal infection, and agrees with Vidal that this structure is the avenue of ingress for the pathogenic micro-organisms that cause the disease. From the endometrium they enter the system in two ways, viz. : first, through venous thrombi, which carries them directly into the circulation, and, secondly, through the lyniph channels where they may either lodge in the lymphatic glands themselves or develop foci of suppuration in connective tissue. Kehrer classifies puerperal enclometritis into putrid and septic. In putrid endometritis, he asserts that saprophytic micro-organisms cause a change in the decidua, in which septic germs do not develop. This change, he contends, affects only the uppermost layer of the decidua, which is exfoliated as the new mucous membrane forms beneath it. 378 A TEXT-BOOK OF GYNBCOLOGY These changes, he considers, are manifested by fever and other symp- toms of intoxication due to decomposition. Ivehrer, however, admits that saprophytic infection is exceedingly rare, and that in the majority of cases of endometritis following abortions and labours, bacteriologi- cal examination reveals the presence of septic micro-organisms, espe- cially streptococci, and sometimes pyogenic staphylococci, so that, as already contended in this chapter, the cases are in reality examples of mixed infection. In the histological examination of a case of so- called putrid endometritis in which, notwithstanding the presence of streptococci, a predominating influence seemed to be exercised by the saprophytes, the following histologic conditions were observed: the superficial layer of the decidua was filled with micro-organisms, among which were all forms of rods, long threads, and cocci of all sizes. Fungi were found growing in colonies entirely covering the base of the decidua. The tissues were found in a state of necrosis, glassy and cloudy, at a point 0.1 millimetre beyond the area occupied by the fungi. The granules could not be stained. Beyond the zone of infection a zone of cellular infiltration had formed. Numerous small round cells were observed which looked like colourless blood corpuscles and formed a layer 0.3 to 0.5 millimetre thick; they were lying close together. The zone of cellular infiltration occupied a position between the super- ficial area of infection and the muscularis. The fibres of the myome- trium, however, were found occasionally to be separated in places by an accumulation of cells, but this condition did not penetrate deeply into the muscularis. The round-celled infiltration, according to Bumm, must be looked upon as an effort on the part of ISTature to set up a granular wall to act as a barrier against the entrance of the germs, and thus to separate the dead from the healthy tissue. The fact, how- ever, that neither Bumm nor Ivehrer have succeeded in demonstrating the existence of this so-called putrid endometritis, independently of the existence of streptococci in large, if not in preponderating num- bers, indicates that the efi^ort to establish a variety of infection depend- ing upon the existence and the action of the saprophytes is not war- ranted by the facts. This becomes the more apparent when considera- tion is given to the histological appearances of what Ivehrer and Bumm designate as septic endometritis. The mucous membrane in these cases is necrotic and reveals the remains of the spongy layer, thor- oughly covered with streptococci yielding pure cultures. The cocci occur in thin layers, while in other places they appear as large colonies occupying considerable areas. There is a reaction zone, less pro- nounced but none the less persisting, just as defined as in the putrid variety. The protection, however, thus afforded, seems to be less com- plete, as there are fewer round cells, and the necrotic zone disappears into the neighbouring tissues without showing any sharply defined boundary. In these situations the streptococci grow and penetrate deeply into and through the strise of the myometrium. The muscular tissue itself reveals an opacity in the presence of large accumulations INFECTIONS OF THE UTERUS 379 of cocci. Where these accumulations occur, they are surrounded by small collections of round cells; in some places the lymph spaces are filled with cocci, while, at the placental site, the venous spaces are closed and contain neither thrombi nor cocci. A few venous branches near the surface, however, contain blood clots which inclose a few of the cocci. An extension of the infection from the surface into the lymph spaces is demonstrable in numerous sections. Some of the finer lymph spaces show a delicate fungus border on their walls, while others are empty or filled with granular material. When the infection occurs within the lymph channel, it does not seem to provoke reaction in the surrounding structures. In other locations, the lymph spaces are filled with fungi, while the cocci are observed in the surrounding tissues. In still other places, the lymph channels are filled with cocci, whence the fungi spread beyond the necrotic muscular layer, pro- voking a reactionary accumulation of cells in the adjacent tissues. The inflammation, thus centring about difi^erent foci, may result in the liquefaction of the entire infected mass, changing it into an abscess cavity. Bumm raises the important question: How can we explain the fact that the affection sometimes remains local, while in other cases it invades the lymph channels or the veins? His answer is that the bacteria must explain this. They are beyond question the agents which produce this form of disease. The danger exists, not in their number, but in their virulence. In making this statement he simply emphasizes the observations of Vidal and Chantemesse. In the local septic infection, and in the thrombotic forms, the germs are only mildly virulent and are made harmless by the speedy reaction that occurs in the organism. On the other hand, the extremely virulent germs penetrate the walls of the uterus and there is no local reaction. The germs occurring in the lymphatic form he would place midway in virulence between the extremely virulent, or, as he expresses it, the internal, puerperal, erysipelatous form, and the mild, local or throm- botic forms. In view of these facts and of the practical identity in character, if not in degree, of the pathologic changes, and in view of the demonstrated common etiology, all of which is at least inferentially admitted by Bumm, there can hardly be said to exist any substantial reason for discriminating between the different varieties of infection as they are manifested in puerperal fever. On the other hand, the evidence seems to be cumulative that this infection should be recog- nised as depending for its essential characteristics upon the Strepto- coccus pyogenes, and that occasional modifications due to the presence, in varying proportion, of saprophytes and other micro-organisms, should be recognised as incidental rather than essential variations. It is important to remember that infection which may invade the lymph channels, may travel through those highways to the peritoneal surface, occasioning thereby a true infection of the peritoneum. It has been stated that in parenchymatous suppuration of the uterus the infection may penetrate directly through the tissues to the peritoneal 380 ^ TEXT-BOOK OF GYNECOLOGY surface; but, be this as it may, the fact remains, that streptococcous infection of the interior of the uterus is speedily followed in many cases by involvement of the peritoneum. When infection of the peri- toneum takes place, the serous secretion, which is copiously thrown out, becomes a culture medium for the rapid reproduction of the strepto- cocci, which are rapidly absorbed thence by the numerous stomata of the peritoneum. Puerperal peritonitis is, therefore, always associated with profound systemic intoxication. Another avenue by which the infection may reach the peritoneum is that of the Fallopian tube, which is frequently invaded by the progressive contamination of con- tiguous mucous surfaces. As a rule, however, the moment that septic inflammation is established within the Fallopian tube, the distal, or fimbriated, extremity becomes sealed, thus converting the tube into a sort of retention cyst. Leakages may occur, however, particularly when the tubal distention has resulted in rupture. The symptoms of streptococcous infection of the uterus begin with a chill, which may or may not be preceded by fever. The temperature reaction, however, which follows the initial chill is generally severe. The lochia which, up to this time may have been normal in quan- tity, colour, odour, and consistence, are temporarily checked, become darker in colour, more viscid, and have an offensive odour. The ther- mic range now becomes characteristically irregular. Another chill, which may be either slight or severe, is followed by a profuse perspira- tion, generally of a clammy character, succeeded by marked exhaus- tion. The chills now become irregular, recurring either daily, or sometimes skipping a day; in which case two or three chills may occur in the course of 12 or 24 hours, being then followed by an- other interval of immunity. The chills are, however, more prone to occur during the evening or the night than in the morning or after- noon. The fever curve may show an evening exacerbation followed by a morning remission, as in certain forms of malarial toxaemia, but, as a rule, the vacillation is of a very lawless kind. As a rule, the first febrile manifestation amounts to three or four degrees; after this, there is a slight remission involving a drop of one or two degrees; then a slight rise and a slight fall. The rise rarely reaches the original eleva- tion and the fall never approximates the normal line. In the course of eight or nine days, however, it will be discovered that the vacillations are a little more pronounced — i. e., the elevations are a little higher and the depressions a little lower than formerly, while the vacillations occur with greater frequency than before. There seems to be a con- stant tendency for the highest and lowest points to get farther and farther apart. There are, of course, individual exceptions to the rule Just given. In the presence of a particularly virulent infection the initial chill may be very profound, the elevation of temperature may be high and may so continue during the course of the disease, showing but very slight remissions. The cardiac centres are early influenced by the infection, the pulse rising to 120, or higher, and being generally INFECTIONS OP THE UTERUS 381 soft and compressible. The respiration is rajnd, the tongue speedily becomes coated, generally with a white fur, though ordinarily moist. There is not, as a rule, marked disturbance of digestion, particularly to the degree which occurs in septicaemia. As the disease advances, however, the patient becomes emaciated and anxious, and delirium may supervene, although in some cases the intelligence remains intact until a short time before death. The diagnosis of streptococcous infection of the uterus is made, first, by a careful estimation of the preceding symptoms; and, subse- quently, by detection of the streptococcus. A curette or a curette forceps may be passed into the uterus, when some of the debris of degeneration can be removed. Microscopic and bacterial examination of the scrapings will reveal the presence of the Streptococcus pyogenes but in association, perhaps, with other micro-organisms. It will, how- ever, be found in such preponderating numbers that the essential character of the infection can not be mistaken. A drop of blood taken from the tip of the finger or from the ear will reveal the presence of the streptococcus and blood plaques in the presence of a pronounced leucocytosis. The red corpuscles are diminished in number, many of them presenting a shrunken appearance. The treatment of streptococcous infection of the uterus must have a threefold object, namely, (1) to arrest the infection, if possible, at its point of entrance; (2) to eliminate the poison from the system after the invasion has passed beyond the point of entrance; and, (3) to support the patient during the course of the pyasmic sequelas of the infection. A moment's consideration of the pathology of this infection renders it unnecessary to emphasize the importance of prompt intervention to arrest the infection. The first signs of temperature disturbance, whether an initial chill followed by fever, or an initial pyrexia with- out a chill, associated with a change in the quantity, colour, and odour, of the lochia, should be the signa,! for a careful exploration of the uterus. If, from examination, the fact is determined that the symptoms are of intrauterine origin, there should be no hesitancy in practising thorough curettement under the most rigorous antiseptic precautions. With reference to the use of the curette under these circumstances much unnecessary dispute has arisen. Those who ques- tion the expediency of its employment apparently fail to take into account, either the character of the infection, or the primary patho- logic changes which it induces. The formation of thrombi in the orifices of the veins in the placental site is, of itself, sufficient to materially diminish the outflow of fluid from that source; while the inflammatory exudation arrests the free escape of serous elements from the intervenous areas. At this juncture. Nature is found in the act of rallying her resources to repel the invader, and there may be said to be a temporary check in the course of the infection. This is pre- cisely the time when treatment, to be of the most value, should be 382 A TEXT-BOOK OF GYNECOLOGY applied with the most thoroughness. The patient should be anaesthe- tized; placed upon the table in the recumbent position; a Jones's, or other perineal retractor should be used; the vagina should be thor- oughly irrigated; and the uterus should be washed out by means of a recurrent catheter. A sharp curette with a blunt, protecting edge, like that of Gi-au's, should be inserted, and the uterine wall should be thor- oughly scraped. If free bleeding is induced, so much the better, as the hemorrhagic current has the mechanical value of washing away remain- ing elements of infection. Great care should be taken to avoid pene- tration of the soft uterine wall. After the interior of the uterus has been thoroughly curetted, the cavity should be washed out by a 1-to- 2,000 solution of the mercuric bichloride, a recurrent uterine irrigator being employed for the purpose. The uterine cavity should then be packed with a long ribbon of iodoform gauze saturated with sterilized glycerine. Glycerine, by virtue of its hygroscopic qualities, favours an outward current of transudation, and thus, if it does not promote elimination of any remaining infection, it, at least, offers some barrier to the further invasion of the tissues. The patient should be placed in the recumbent posture at the expiration of twenty-four hours, when the uterine packing should be removed and carefully reapplied after the uterine cavity has been again irrigated by the sublimate solution. There is no occasion to repeat the curettement provided that it has been well done, and the patient will not, therefore, require an anass- thetic. The dressing should be changed at similar intervals during three or four days, when, if the temperature range becomes normal, the treatment may be discontinued. Some excellent practitioners employ constant irrigation of the uterine cavity, instead of packing with iodoform or other antiseptic agents, and very good results have been reported from this course of treatment. For its accomplishment a reflux uterine irrigator, such as that devised by Gaither, should be used. This is an excellent instrument, and secures the reflux current by effecting the dilatation of the cervix to any desired degree. It is more valuable than the ordinary tubular instruments, which are prone to become choked by clots or other debris. The object of curettage is only half realized when the infected debris has been scraped away; it is equally imperative to asepticize, so far as possible, the remaining endometrium. To accomplish this, the uterus may be packed as indicated in the preceding paragraph. Some excellent practitioners employ constant drainage with the best results. Ill (Transactions of the American Association of Obstetricians and Gynecologists) packs the uterus with iodoform gauze, which is kept saturated with an antiseptic medicament applied through a hollow curved tube (Fig. 155). This ingenious arrangement secures both an influx and an efflux of fluid, and is deserving of consideration. If, however, in spite of these precautions the temperature con- tinues to vacillate and to show a characteristic pygemic range, and particularly if the pulse goes to 130, with a tendency to increase INFECTIONS OP THE UTERUS 5 S3 in frequency and to diminish in force and volume, the evidence is to be construed as meaning that the infection has invaded the lymph channels, and that the myometrium has become the seat of diffuse in- fection, if not of multiple suppurations. It is manifest that, under these circumstances, the disease has passed beyond the control of such a conservative measure as curettement. The condition indicated by this persistence of symptoms is one which, if left alone, is calculated constantly and progressively to re-enforce the systemic infection, and Fig. 155. — " 111 packs the uterus with iodoform gauze, which is kept saturated with an anti- septic medicament applied through a hollow curved tube." — Eeed (page 382). thereby to keep alive a pyasmic state which must result in death. An intelligent comprehension of the symptoms and of the underlying pathologic conditions can not result in any other conviction than that the line of treatment must be complete removal of the uterus. Success- ful cases of this character have been reported by Vineberg, Cartledge, and others. The operation may be done either through the vagina or by abdominal section. The latter route is generally preferable, for the reason that the uterus may be too large to be easily de- livered through the vagina, while in its septic state, its morcclla- 384 A TEXT-BOOK OF GYNECOLOGY tion would be a dangerous expedient. Extraordinary antiseptic pre- cautions shoiild be taken in making an abdominal section under these circumstances. The patient should be prepared by a thorough vaginal and intrauterine irrigation^ and the uterus should be packed with dry iodoform gauze. It may not be amiss to close the os externum by passing a single suture through the anterior and posterior lips of the cervix. By this means the field of operation will be fairly well pro- tected from contamination. These preliminary steps should be taken by the assistant, or, if by the operator himself, he should employ rubber gloves for the purpose. As soon as the intravaginal manipu- lations are concluded the rubber gloves employed at that time should be taken off, and should be replaced by another pair carefully steril- ized. In this way, alone, can the operator feel sure of giving reason- able protection to his patient. The operation should be that of pan- hysterectomy, involving, as the name implies, the removal of the entire uterus with its appendages. The technique of the operation does not differ in any particular from that described in the chapter on panhysterectomy. It is well, as a matter of routine, to practice hypodermoclysis both before and after the operation, three or four pints of water being administered in this way. Supporting treatment should be adopted from the start, care being taken to preserve the digestive functions, which, happily, are not, as a rule, seriously compromised in these cases. Stress has been laid upon alcohol as an article of diet, and the testimony seems to support the claims for its consideration. Whisky may be given in the form of milk punch every few hours. AYines are not, as a rule, so Avell borne, and beer is more prone to disturb the gastric and other functions. Mild acidulous drinks are usually demanded, to con- trol the generally persistent thirst. The bowels should be kept relaxed, but active purgation should be avoided. The old theory of treating these cases with cathartics to favour the elimination of the poison, is, in the light of the now well-understood pathology, a fallacious doctrine. The suggestion has been made that in view of the probable up- ward extension of the infection in puerperal fever, and of the con- sequent involvement of the Fallopian tubes, a sound should be passed through the uterine cavity and the orifice of the tube for the pur- pose of drainage; some, indeed, have gone so far as to suggest the expediency of irrigating the Fallopian tubes. (See Infections of the Fallopian Tubes.) A method of this kind is unsurgical in the extreme, for the reasons, first, that no surgeon, however deft he may be, can be sure of the distention of the tube; and, next, that he can not dis- tinguish the orifice of the tube within the uterine cavity in the post- parturient condition. The most that he will be likely to accomplish by the procedure is to establish a fresh infection atrium within the uterus. Tuberculosis of the Uterus. — A description of tuberculosis of the uterus must be divided into two parts, since it is a well-established fact, INFECTIONS OF THE UTERUS 385 according to Whitacre, that tuberculosis of the body of the uterus and tuberculosis of the cervix are quite independent of each other. A lesion beginning in one portion rarely passes beyond the anatomic dividing line (the internal os), and the pathologic changes which the tubercle bacillus causes are markedly different in the two regions. Tuberculosis of the Cervix Uteri. — Tuberculosis of the cervix is a ■condition which was declared by Kokitansky and Lebert not to exist, and Spaeth in 1885 collected only six cases. Since 1886, however, when Hegar demonstrated the clinical importance of genital tuber- culosis, and since the introduction of routine methods of bacterial and microscopic examination of cervical secretions and curettings, the num- ber of cases has multiplied rapidly, and tuberculosis of the cervix is looked upon at the present day as a condition that must enter into the ■diagnosis of every lesion of the cervix. The disease is usually secondary to tuberculosis of the Fallopian tubes, peritoneum, or vagina, yet it may be the sole seat of tuberculosis in the genital tract of phthisical women, or, as in the cases of Fried- lander and Pean, it may represent the only seat of tuberculosis in the entire body. The relative infrequency of cervical tuberculosis has been explained by the resisting power of the squamous epithelium on the portio vaginalis, and by a natural antibacterial action of the cervi- cal canal, as has been demonstrated experimentally by Menge. Pre- disposing causes of infection are undoubtedly to be found in irritating discharges, lacerations, and erosions. It is difficult to explain the immunity of the uterus to a simultaneous infection when the lesion is clearly secondary to a tuberculosis of the Fallopian tubes or perito- neum. The monthly exfoliation of the corporeal endometrium prob- ably plays a definite role (Sippel, Vassmer, Schottlander). The infec- tion of the cervix may take place by an extension from either the higher or the lower parts of the genital tract, by way of the blood stream, or by direct inoculation from without. Morbid Anatomy. — In describing the lesions of tuberculosis of the •cervix Whitacre recognises: 1. A miliary form. 2. A diffuse tuberculous infiltration with ulceration. 3. A papillary form. Sehlitt describes a fourth form in which the lesion consists of an .apparently simple bacillary catarrh, which is limited to the epithelium and forms a caseous layer over its surface. Daurios has suggested a fistulous form, but the occurrence of fistula? must be considered acci- dental. The miliary form may be looked upon as the first stage of the diffuse tuberculous form, and may be described as a catarrhal inflam- mation of the cervical mucosa with the presence beneath the epithelial surface, of miliary tubercles too small to be seen by the naked eye. The folds of the arbor vita; become enlarged and produce pronounced villosi- iies and secondary viilosities with deep fissures between the folds. The 26 386 A TEXT-BOOK OF GYNECOLOGY epithelium over the surface remains intact, and small masses of round cells containing giant cells, and a few tubercle bacilli, are found in the stroma which is at the same time the seat of a small round-celled infiltration. The glands are not at first involved. Below the mucous membrane, miliary tubercles of larger size are found, and even when we have to do with a tuberculous eruption which is slight, superficial, of recent date, and has caused no destruction of tissue, we must expect to find the muscular layers infiltrated by miliary tubercles which are formed along the course of the blood vessels. The condition may con- tinue as a miliary tuberculosis, the most frequent form of cervical in- volvement, or the miliary tubercles may increase in size and number, become caseous, and run together to form the lesions of the second or diffuse form, where the mucous membrane is converted in part, or in its entirety, into an ulcerating caseous mass. When this occurs, the glandular elements show every degree of destruction, the tissues show infiltration and thickening, and the cervical canal becomes a worm- eaten cavity containing caseous material (Matthews). The interior of such a cavity is lined by tuberculous granulations which bleed easily and exude a heavy discharge, and the muscular tissues are infiltrated by discrete miliary tubercles. There is a marked tendency to fibrous infiltration, as was first pointed out by Williams. The papillary form of cervical tuberculosis, as reported by Frankel, Cornil-Pean, Franque, and Vitrac, possesses a special interest from a clinical point of view because of its naked- eye resemblance to carcinoma (Fig. 156). It is characterized by a papillary growth of the arbor vitse which pushes back the pave- ment epithelium of the portio vaginalis and attains a consid- erable tumour forma- tion. These tumours show slight tendency to break down and present the typical microscopic picture of tuberculosis. Their naked-eye appearance is not typically tuberculous. Sijmpioms and Diagnosis. — In determining the s5anptoms of tuber- culosis of the cervix it is difficult to separate them from the symptoms of the primary disease, which is often of much greater importance than the lesion in the cervix. A primary cervical lesion gives no pain, and there is usually present a muco-purulent leucorrhoea which may be occasionally tinged with blood. A phj^sical examination of the cervix will reveal one of the conditions previously described. The diagnosis of tuberculosis from simple cervical endometritis on Fig. 156 papillary form of cervical tuberculosis."- Whitacre. INFECTIONS OF THE UTERUS 387 the one hand and carcinoma on the other forms an important feature in the description of tuberculosis of the cervix. The condition will be distinguished from simple cervical catarrh by the amount of destruction taking place in the tuberculous ulceration, by the presence of caseous material in the discharge, and by the demon- stration of the tubercle bacillus in the cervical secretions. Some con- fusion with chancroid has arisen in cases reported by Spaeth and Zwei- fel. In the ulcerative and papillary form of the disease, the possibility of confusion with the much more common condition of carcinoma vaust be constantly borne in mind. Many cases of tuberculous cervicitis have been operated on for carcinoma and their true nature only re- vealed on microscopic examination (Cornil, Frankel, Kaufmann, Gog- lio, Vitrac, Emanuel); and it is probable that many such mistakes pass unrecognised when the material is not submitted to microscopic ex- amination. The following table has been arranged by Whitacre to aid the diagnosis between the two conditions: Size . . . Aspect Colour Touch . Spontaneous pain Sensitiveness. . . . Bleeding Discharge Progress Pathologic histology. Bacteria . Tuberculosis. Small. Papillary form : A muriform mass with small vegetations in the vicinity. Ulcerative form : Surface covered by caseous material and mucus. Border a seed bed of granulations. Papillary : Rose- red, deeper col- our than surrounding. Ul- cerative: Bottom yellow or red. Papillary : Surface knobbed, smooth, polished, elastic, no induration, limits not clear. Ulcerative : Depression with- out diffuse induration. Bor- der granular. Little or none Present May be slight in both papillary and ulcerative form. Papillary : Mucous. Ulcera- tive : Often purulent. Papillary: Extremely slow. Ul- cerative : Slow, yet may pro- duce extensive ulceration and fistulas. Both show typical miliary tuber- cles and tubercle tissue. Tubercle bacilli found in smear preparations, or by inoculat- ing guinea pig. Epithelioma. No regularity. Usually fungous. The cavity form lacks gran- ulations in the edges. Never solely intersti- tial. Grayish. Surface roughened, con- sistence very hard. If large and fungous, the base is very hard. Characteristic. Absent. Frequent and abundant. Foetid and abundant. Progressive and accom- panied by constitu- tional symptoms. Typical epithelioma with pearls and columns of cells. None. The treatment of tuberculous disease of the cervix should be radical when tbo disease is primary and whenever it will prolong the life or contribute to the comfort of the patient, but there are naturally many cases associated with advanced tuberculosis of the lungs, intestines. 388 A TEXT-BOOK OP GYNECOLOGY or tubes, in which no operative measures would be justifiable. Any operation undertaken for the cure of the condition must be extensive, since Cornil and others have shown that, even in recently developed and apparently superficial tuberculosis, there is already an extension of miliary tubercles along the blood vessels into the deepest muscle layers. If the uterus can be demonstrated to be free a high amputa- tion of the cervix should be done, yet many authors insist upon hys- terectomy as the rational treatment because of the almost uniform involvement of the tubes, the difS.culty of getting beyond the tuber- culous process, and the fact that there is no certain method of deter- mining the presence of a tuberculous endosalpingitis. (For technique see Panhysterectomy and Vaginal Hysterectomy.) Aron and Tillaud warn against forcible, mechanical handling of the cervix, since we may thereby set up a general tuberculosis. Palliative measures will consist in the thorough curetting and cauterizing of ulcers, the excision of fistulae, the treatment by iodoform, and cleansing douches. Corporeal Tuberculosis of the Uterus (Tuberculous Endometritis). — Tuberculosis of the body of the uterus, or tuberculous endometritis, must be described, as has already been stated, as a lesion distinct from tuberculous cervicitis, and its frequency, compared with that of the latter condition, will make it a much more important lesion. Tubercu- losis of the uterus occurs in two thirds of all cases of general tubercu- losis; it occurs in connection with tuberculous disease of other genital organs, or the process may be primary in the endometrium. From the point of frequency, the corporeal endometrium stands second among the female genital organs. This type, like all other forms of genital tuberculosis, has been studied more especially since Hegar called atten- tion to its clinical importance, yet the frequency of the uterine disease has only been fully appreciated in the last few years since routine histological and bacteriological examinations of all curettings have been made. Its real frequency is certainly well shown by a series of six cases which were observed by Vassmer in the very short period of ten months. The uterus certainly may be infected by the tubercle bacillus either from above or from below, and its frequent association with tubal dis- ease would indicate that a descending infection is the more common. Coitus certainly must be considered to be a source of infection when we remember the frequency of tuberculous disease of the male genito- urinary tract, and particularly since the demonstration by Jani of tubercle bacilh in .the semen and in the apparently healthy prostate and testicles of men suffering from phthisis. Numerous cases are reported where Avomen suffering from genital tuberculosis have lived with tuberculous men. Jani has injected the apparently healthy tes- ticle of tuberculous men into the peritoneal cavity of guinea pigs and has produced a typical tuberculous peritonitis. It has been asserted that a tuberculous process arising from coitus is primarily a tubal tuberculosis, and that the uterus is secondarily infected. Instruments INFECTIONS OF THE UTERUS 389 or the examining finger may carry infection, or the transfer may he by direct self-infection from a tuherculosis of the vulva, vagina, or from tuberculous stools. The relative immunity of the vulva, vagina, and cervix, has been explained by their protecting flat epithelium, and in the uterine cavity we find again a decided protection in the monthly exfoliation of the mucous membrane. The puerperal state certainly predisposes to infection, as is shown by the authentic cases of Frorieps, Kokitansky, Heimbs, Brues, Geil, Schiill, and by the demonstration of tubercle bacilli by Hiinermann in a septic thrombus after abortion. Schmorl, Eockel, Thorn, and others, have reported cases of pregnancy that began and went to full term in spite of a caseous endometritis. The age of the patient seems to make little difference, yet Kauf- mann holds that the female organs show a predisposition to tuberculo- sis with the decline of their activity. Mo7-hid Anatomy. — Pathologically, tuberculosis of the uterus is divided by most authors into — 1. A miliary form without ulceration. 2. A chronic diffuse or caseous endometritis. 3. A chronic fibroid type. The second is the clinical type with which we are familiar; the first is the very earliest stage of the chronic diffuse form or a part of a gen- eral eruption of tubercles and gives no symptoms; while the third has been very rarely recognised. The study of these lesions will be much simplified by considering them to be different stages of the same condition, and by stating that conditions of number and virulence of the bacteria, mixed infection, and the activity of the reparative process, will determine the miliary, caseous, pyometric, or fibroid form. The miliary form begins by a deposit of minute tubercles in the interglandular substance of the mucous membrane of the fundus of the uterus near the entrance of the Fallopian tubes (Kelly, CuUen, Williams, Walther, Vassmer). The epithelial surface remains intact, as does also the glandular element, and the presence of a few tubercles made up of epithelial cells alone, or of .single giant cells containing tubercle bacilli, may be the only evidence of tuberculosis in the entire mucosa. Later, the epithelioid nodules are surrounded by small round cells, and still later giant cells appear in their centre and only remnants of the glands remain (Fig. 157). In more advanced cases, the miliary tubercles are more numerous, and the glandular tissue is so much affected that Cornil and Franque have characterized it as a chronic tuberculous endometritis with the principal participation of the glands, which be- come enlarged and show indistinct markings. Coincident with the glandular hypertrophy there is a strong infiltration of the interglandu- lar tissue (Abel). Polyp formation, however, which is so frequent in other types of endometritis, and which forms a distinct class in tubercu- lous cervicitis, does not occur, and nodules larger than a pea are never seen. Madlener and Zahn have reported cases in which large polypi 390 A TEXT-BOOK OF GYNECOLOGY '-^i^^^h^' were found to contain miliary tubercles and tubercle bacilli, but they are considered to be a secondary infection of a pre-existing polyp. The miliary tubercles finally run together, caseate, and break down to form irregular undermined ulcers, which, by their confluence, con- vert the endometrium into a caseous mass involving, first, the superficial layers, then, the entire thickness of the mucous membrane. Below this is a zone of typical tu- berculous tissue consist- ing of epithelioid cells, tubercles, giant cells, and a varying amount of gland remnants. It is important to remember that the caseous mass simply replaces the mu- cosa (Pozzi). The mus- cle tissue shows distinct miliary and submiliary tubercles which are formed along the course of the infiltrated blood vessels (Hofbauer). The muscle tissue is usually distinctly hypertrophied and finally becomes extensively infiltrated and destroyed. A mixed infection by the pyogenic cocci, when associated with mechan- ical obstruction of the internal os, will lead to pyometra — a very com- mon condition. The chronic fbroid type of tuberculous endometritis was first de- scribed by Williams as a miliary tuberculosis characterized by an ex- cessive development of fibrous tissue within and around the miliary tubercles. Thus far, it has been recognised on the autopsy table alone. The symptoms of the disease are not characteristic and are prac- tically those of an ordinary endometritis with thickening of the uterine wall. Pain, temperature, and a general tuberculous appearance are absent. There may be a noncharacteristic, mucopurulent, even case- ous, discharge, but Vassmer has found no discharge in a series of six cases. Amenorrhcea was present in the majority of reported cases, excessive bleeding very seldom; but menstrual disturbance is prob- ably not important. Suspicious points in the history will be the chronicity, the presence of a general tuberculosis, and tuberculosis in the husband. Diagnosis. — As has just been stated, the symptoms of tuberculous endometritis are not sufiiciently characteristic to distinguish it from Fib. 157. — " Giant cells {h) appear . . . and only i-emnants of the glands (a) remain." — Whitacke (page 389). INFECTIONS OP THE UTERUS 391 simple endometritis or carcinoma, and experience has shown that the diagnosis can only be made by detecting the tubercle bacillus in the histologic structure of tubercle tissue in scrapings from such a uterus. The tubercle bacillus has been found with varying frequency both in the secretions from the uterus and in uterine curettings (Walther, Veit, Peraire). In the beginning stages of the disease, their scarcity renders a diagnosis by this means extremely difficult, but in the more ad- vanced forms the bacilli are numerous. When not found by micro- scopic examination in curettings, their presence may be demonstrated by injecting the curettings into the peritoneal cavity of the guinea pig. A typical peritoneal tuberculosis will develop in from twelve days to four weeks if the bacilli are present, even in small numbers. The histological diagnosis is made difficult by the fact that the tubercles are not always typical, that a simple infiltration of the stroma looks much like tubercle tissue, and that giant cells are sometimes found in an interstitial endometritis. The presence of the epithelioid cells of tuberculosis in the stroma of the mucous membrane, together with the occasional distortion of the glands, may lead to a confusion with carcinoma. Treatment. — The question of the appropriate operative treatment for tuberculous endometritis is as yet sub judice. Certain ojDerators would insist upon hysterectomy as soon as the diagnosis is made (Schauta, Pozzi, Fehling); while others would recommend simple curetting and subsequent cauterization with pure carbolic, and treat- ment by iodoform. Sippel, Walther, Meyer and Halbertsma report cases of complete cure after curetting, the latter after five years. Sip- pel has shown the healing influence of continued menstruation on dis- ease processes in the mucosa — a fact which must not be disregarded. It must be remembered, however, that tuberculosis of the uterus is generally secondary to tubal tuberculosis, and in the presence of advanced disease demanding removal of these organs there could be slight reason for preserving the uterus. The association of a unilateral tubal tuberculosis will call for a laparotomy for the removal of the tube, and a thorough curettement of the uterus. It must be remem- bered in removing tuberculous appendages, that a tuberculous endome- tritis probably already exists, and that the uterus should be curetted if left behind. Kelly has found a tuberculous involvement in such cases when it was entirely unsuspected. It is well to remember that these cases should not be considered malignant, and that conservative measures are indicated in selected cases. Syphilis of the uterus was formerly supposed to be of relatively frequent occurrence. This was due to the fact that, before the days of Emmet, the granular surface of a cervical ectropion was frequently mistaken for a true ulcer — -often syphilitic in character. Since lacera- tion of the cervix has become a recognised condition, it is discovered that what was formerly looked upon as ulceration, is, as already stated, nothing more or less than the everted mucous membrane, 392 ^ TEXT-BOOK OF GYNECOLOGY studded with hypertrophied follicles. Syphilis may occur as either a primary or a secondary affection of the uterus. Chancre of the cervix was recognised in 1838 by Ricord, who found it in 13 out of 199 cases, or, practically in 6 per cent of women presenting themselves at his clinic with primary syphilitic sores. Schwartz found it in 93 out of 686 collated cases. Chancre of the cervix is of about the same frequency of occurrence as primary chancre of the vagina. This statement is based upon tables compiled by Gliick {Wiener medicinische Presse, 1881), by which it appears that primary infection of the vagina occurs in from 0.87 per cent to -|- 6 per cent of all cases of primary syphilis in women. Chancre of the cervix is generally single, although it may be multiple. It may coexist with chancre in some other part of the genitalia. Fournier {Annales de gynecologie, 1876) reported a case in which three chancres of the cervix coexisted with one involving the fourchette. Whitehead {Abortion and Sterility) reported a case of syphilitic ulcer of the cer- vix, associated with constitutional symptoms, while a similar case was recorded as long ago as 1859 {British Medical Journal) by Parker. . Herman {Obstetrical Transactions, London, 1885) recorded a case of large chancre of the cervix, associated with distinct secondary symp- toms. Mackenzie {British Medical Journal, 1854) called attention to the fact that important pathologic changes in the uterus occur as the secondary results of syphilis. Parker confirmed this view. The symptoms of jDrimary infection of the uterus consist of an ichorous discharge, associated with more or less general pelvic discom- fort. This circumstance generally leads to an examination when an ulcer not self-inoculable and presenting the characteristic physical features of a chancre, is revealed. These ulcers may vary in size from a minute disk to the size of a shilling. In Herman's case the ulcer was of the latter size and presented the appearance of a grayish- yellow slough, surrounded by an inflamed areola. The edges were sharp, discrete, and indurated. If of long standing, it may be asso- ciated with syphilides of the vaginal mucosa and the pudendal integu- ment. In chancre of the cervix the inguinal lymphatics are not involved, unless the condition coexists with a primary sore of the external genitalia. Intrapelvic lymphangeitis and lymphadenitis are, however, frequent concomitants. The lymphatic vessels can be felt like tender and tense cords above either fornix of the vagina; while the enlarged glands may be felt as distinct nodules in the superimposed cellular structure. Infection of the intrapelvic lymphatics may result in sup- puration of the glands — a condition which may, with propriety, be designated as an internal bubo. Secondary syphilis of the uterus is generally associated with a puru- lent discharge and with enlargement and tenderness of the portio vaginalis. Patches of redness, sometimes of a very dark colour, are frequently noticed on the cervix. In the centre of certain of these INFECTIONS OP THE UTERUS 393 reddened areas, ulcerative tendencies are occasionally manifested. Care- ful examination will generally reveal slight deposits of cicatricial tissue on the cervix. Ulcers varying in size and appearance are occasionally found. Endometritis is a common accompaniment of these changes. It is to this condition that the tendency of syphilitic women to miscarry, is attributed. Careful bimanual exploration will generally reveal more or less hypertrophy of the entire uterus. Parker considers these symptoms indicative of syphilis, because, according to his observation, they are found in about 60 per cent of the cases of confirmed lues; while they are not foimd with anything like equal frequency in women in whom a syphilitic history can not be otherwise established. The diagnosis of chancre of the uterus can generally be made by careful study of the physical conditions presented. The promptness with which the lesion yields to antisyphilitic treatment, will dispel any remaining doubts as to the character of the trouble. Secondary syphilis of the uterus, however, may readily be confused with hyper- plasia due to other infectious causes. A careful study must, therefore, be made, not only of the previous clinical history, but of the bacteriological features of the case. Treatment. — The treatment of these cases may be summarized as antisyphilitic. Chancre of the cervix should be cauterized, with either nitric acid, or the pure nitrate of silver. After the slough separates, the ulcer should be treated with iodoform, the vagina being kept packed with iodoform gauze. The parts should be carefully irri- gated, between dressings, with a l-to-2,000 solution of bichloride of mercury. Constitutional treatment should consist of the administra- tion of mercury, either in combination or alternating with the iodides. The more profound organic changes of the uterus may require atten- tion. Forcible dilatation of the cervix and vigorous curettage of the endometrium are the only means by which hypertrophy of the latter structure may be overcome. Echinococcous infection of the uterus, while not of common oc- currence, probably exists with greater frequency than is indicated by the records. The demonstration of booklets in many so-called " hydatid moles " of the uterus is an indication of parasitic origin of, at least, an important number of these cases. It would seem as if a more careful investigation of these intrauterine products would tend to eliminate pregnancy as an essential element in their produc- tion, and to restrict their etiology within the category of infections. That echinococci may, however, attack the decidual structures of a recent pregnancy, is beyond doubt. These organisms may also invade the muscularis of the uterus. When the parenchyma is the primary lo€i/s of infoctiou, the resulting parent cyst may develop, as does a myoma, cither beneath the mucous membrane, or beneath the perito- neum. One of the earliest cases on record — i. e., MacNeven's (New Yorh 394 A TEXT-BOOK OF GYNECOLOGY Journal of Medicine, 1849) — was an example of submucous develop- ment,, while a more recent case by Altormyan {Lancet, April 4, 1891) is a distinct example of subperitoneal development of the cyst. The same may be said of the case reported by Freiind and Chadwick {American Journal of Obstetrics, 1874-'75). The symptoms of echinococcous infection of the uterus are not essentially pathognomonic. There is tumefaction in the uterine region; a sense of weight, that may run through several months or years; ces- sation or irregularity of menstruation; increasing pressure on the bladder and bowels; while there usually occurs a progressive decline of general health. The tumefaction, which is ordinarily median at its commencement, may develop either to one side or the other, accord- ing as the tumour grows either to the right or to the left. The tumour, itself, in a case of parenchymatous infection, is generally described as smooth and elastic. When it presents in the uterine cavity or at the cervical margin, it is generally fluctuating at the presenting point, although the palpation wave is transmitted but in- distinctly to remoter parts of the growth. In the uterine cavity, the cyst may present many features in common with the amniotic sac for which it has been mistaken. In cases of echinococcous infection of the uterine cavity, the symjjtoms may be essentially those of pregnancy. The uterus becomes enlarged and softened, the cervix presenting a bluish aspect. The womb enlarges, progressively and symmetrically, the breasts enlarge and may contain milk, while there are not infre- quent reflex disturbances of the stomach. It is the occurrence of these symptoms which has generally caused infections of the uterine cavity by the echinococcus, to be looked upon as pregnancy, and the result- ing cysts to be designated as degenerated ova. In practically all these cases, however, the usual amenorrhoea of pregnancy is absent, while the patient complains of more or less constant dribbling of blood from the uterus. AMiile this is true, the fact must be recognised that infection of the uterine cavity by the echinococcus may coexist with pregnancy, as was true in MacNeven's case, in which a large echino- coccus cyst was expelled, intact, during a true labour and immediately preceding the rupture of the amniotic sac. The exact diagnosis can not be made without the demonstration of the booklets. Echinococcous infection of the uterus may occur at any age. Szancer {Zeitschrift fiir Gehurtshiilfe und Gyndkologie, 1879) reports a case occurring in a girl of twelve, while Hislop reports one aged seventeen, and it has been found in patients of more advanced years. Invasion of the uterus seems to be eifected through any abrasion in the mucous surface, although, in a number of cases, the infection of the uterus has been secondary to the invasion of remoter organs, notably the liver. Microscopicall)'-, the cysts consist of structureless stratified membranes, containing scoleces and separate echinococcic booklets. The cysts, themselves, multiply by endogenous prolifera- tion, the resulting mass consisting of a large mother cyst containing INFECTIONS OF THE UTERUS 395 numerous daughter cysts, varying in size from a millet seed to a pea, or even larger. Each cyst contains clear, limpid fluid, containing no sediment, but yielding traces of albumin. When evacuated by incision, the mother cyst does not collapse readily, showing the exist- ence, not only of structural development, but of extensive peripheral infiltration. Evidence seems to point to the lymphatics as the chief avenue for the migration of these infectious elements, particularly when con- sidered with reference to their secondary manifestation. These para- sites have, however, the ability to penetrate the normal matrix; even after evacuation of the parent cyst, progressive invasion of the tissues may occur, until the peritoneum, the bladder, or even the intestine, is penetrated. Treatment. — This consists in the evacuation of the cyst whenever accessible. The cyst cavity should be opened freely, its walls should be curetted vigorously, after which it should be irrigated, first with 25-per-cent solution of hydrogen peroxide, and subsequently packed with iodoform gauze. Drainage should be maintained until the cav- ity is thoroughly collapsed. If, however, the disease shows a tend- ency to progressive invasion of neighbouring structures, hysterectomy should be performed. When the infection is restricted to the uterine cavity, the expulsion of the cystic product generally results in the immediate recovery of the patient. CHAPTEE XXVIII NEOPLASMS OF THE UTERUS Neoplasms of the uterus in general ; varieties — Benign neoplasms — Fibromyomata : Causes, pathology, histology, secondary degenerations, diagnosis — Complicat- ing pregnancy — Treatment : Medicinal and electrical ; surgical, terms employed — Indications — Myomectomy — Supravaginal hysterectomy ; extra-peritoneal treatment of the pedicle — Panhysterectomy ; Reed's operation ; vaginal hyster- ectomy — Vaginal myomotomy — Extirpation of polypi. Neoplasms of the Uterus in General. — There is, perhaps, no organ of the body, in either tlie male or the female, which is so often the seat of tumour formation as the uteriis. The intrinsic causes of neoplastic diseases of the womb are usually as obscure as of those of any part of the body. Embryonic inclusions, nutritive disturbances, irritation, and heredity, play a certain role as predisposing causes, yet their relation to tumour formation is by no means always demonstrable. Neoplasms of the uterus may be considered in relation to the dilfer- ent parts of the organ from which they arise. They may be divided according to their main clinical features into benign and malignant, or, according to their histology, into connective tissue and epithelial new growth. The connective-tissue tumours occurring in the uterus are the fihromyoma, the sarcoma, the endothelioma, and some mixed tumours of minor importance. The epithelial neoplasms comprise the adenoma malignum, the carcinoma, and the syncytioma malignum. Benign Neoplasms of the Uteeus ^ The tumours variously designated as fibroma, fibromyoma, fibroid or myoma of the uterus, are the most common neoplasms that develop in that organ. They are derived from the muscular coat and are com- posed of involuntary muscle cells and ordinary fibrous connective tis- sue, mixed in varying proportions. Their causes are various. The time of life when fibromyomata usually occur is that of sexual activity, but there have been reported a number of cases of this kind in children and in women after the climacterium. A good deal has been written upon the subject of the influence of prolonged virginity and abstinence from sexual inter- course, married life, abnormal sexual irritation, sexual excesses, mas- turbation, and so forth, upon the development of fibromyoma. Hered- 396 NEOPLASMS OF THE UTERUS 397 ity has likewise been considered as a factor in the production of these neoplasms. Kace has been cited as a predisposing cause. It is well know^n that many American writers hold that myomata are much more common in the negro than in the Caucasian races. The statistics, the views and the theories of various experienced authors, are, however, so contradictory in many points, that we can not draw any definite general conclusions, and must for the time being leave open many questions as to the etiology of true fibromyoma. There is one class of fibromyomata, recently fully described in a classical monograph by von Recklinghausen, the adenomyomata, which in their origin clearly stand in a causal nexus with certain embryonic inclusions in the uterus. Yeit, in an article on the etiology and symptomatology of fibro- myoma, comes to the following conclusions: " So far as the common myomata (excluding the adenomyoma) are concerned, I hold that their origin from an embryonic inclusion (' anlage ') has not been proved. It appears, however, that heredity plays a role therein, and one is also able to understand that irritation, acting chronically upon the uterus, may give rise to the formation of myomata; the modus operandi of the latter^ however, is not yet clearly proved." Pathology of Fibromyoma Uteri. — Fibromyomata may arise from the museularis of the body as well as from that of the cervix. They vary a good deal in size and shape, and their particular position has a good deal of influence in this respect. They may be single, but more fre- quently they are multiple. One not infrequently finds in uteri re- moved for some cause, or obtained from the post-mortem table, very small myomata which have not given rise to any symptoms. On the other hand these tumours may attain an enormous size. Stockard saw in a coloured woman a myoma weighing 135 pounds, and Hunter re- ports the finding post mortem of a myoma weighing 140 pounds, while the rest of the body weighed 95 pounds. According to their seat and mode of origin, myomata are divided into submucous, interstitial, and subserous. Submucous myomata have their seat under the mucous membrane. They may be attached by a broad base to the museularis or they may, and this is more commonly the case, become pedunculated and project polyplike into the uterine cavity. These myomata are gen- erally rich in blood vessels and muscle fibres and comparatively soft. They usually grow rapidly but rarely attain a very large size If by their growth they are forced down into the cervical canal they some- times assume an hourglass or dumb-bell shape. They have a marked tendency to undergo degenerative changes and to slough. The de- scent of these submucous myomata is often due less to their own neoplastic growth than to oedematous swelling in consequence of circulatory disturbances and to contractions of the uterus. These muscular contractions of the womb may sometimes bring about the spontaneous separation and delivery of a submucous myoma. 398 A TEXT-BOOK OF GYNECOLOGY Interstitial fihromyomata develop in the middle stratum of the m^us- cularis uteri. They are, as a rule, well encapsulated, and can there- fore be easily enucleated. Only rarely is this variety intimately blended and connected by interlacing bundles of muscle fibres with the sur- rounding parts. If such interstitial tumours grow very large they may so stretch the parts of the uterus below that these form a kind of peduncle for the tumour. Such peduncles may in rare cases undergo torsion. The subserous fhromyomata are developed from the most super- ficial layers of the muscularis and project from the peritoneal sur- face. They are connected with the uterus by a more or less con- stricted short j)eduncle (Fig. 158). Smaller subserous myomata may also have a broad base, but the larger ones are generally pedunculated. The peritoneum firmly overlies the tumour and is intimately blended with it so that it can not easily be peeled off. These tvunours, in con- quence of their usual mode of attachment to the uterus, are generally more or less movable. The peduncle may un- dergo torsion or kinking. Subserous myomata are very liable to form adhe- sions with the neighbour- ing sexual organs, with the intestines, and with other structures. Myo- mata of this variety, springing from the lateral margins of the uterus, often grow into the broad ligament, separate its layers, and give rise to what is known as intraligamentous fihromyomata. Histology of Fihromyomata. — Histologically, the fihromyomata of the uterus consist of the same tissues as compose the muscularis of the uterus, namely, involuntary, smooth muscle fibres, and fibrous con- nective tissue. These two kinds of tissues are present in varying pro- portions. Some tumours may contain only a small amount of fibrous connective tissue, while in others it may so predominate that an almost pure fibroma exists. The muscle cells are arranged in bundles which cross each other and interlace with a great deal of variety and irregu- larity. Yellow elastic fibres are Hkewise found, also those particular cells known as "mast cells" and "plasma-mast cells." Fig. 158. — " They are connected with the uterus by a more or less constricted short peduncle." — Herzog. NEOPLASMS OF THE UTERUS 399 A particular variety of myoma is the adenomyoma. These tumours are ordinarily of moderate size, and are generally found near the serous surface in the posterior uterine wall and near the tubal angles. They are not encapsulated but shade off diffusely into the surrounding tis- sues and contain, besides the usual tissue elements of fibromyoma, epithelial structures. These latter are of a peculiar glandular type. There are generally seen a number of smaller ducts which communi- cate, like the teeth of a comb, with a larger duct. These epithelial structures are derivatives of remnants of the Wolffian duct and of the " urniere " of the Wolffian body, which have been displaced in development, and which, as embryonic inclusions, give rise to the appearance of these peculiar new growths. The latter, from a histo- logical standpoint, must be looked upon as a mix- ture of connective tis- sue and epithelial neo- plasms. Fibromyomata often bring about changes in the whole uterus. The muscular coat, particu- larly if the myoma is so situated that it causes uterine contractions, is liable to undergo some hypertrophy character- ized by an increase in size of the individual muscle cells. The uter- ine mucous membrane shows either a glandular or an interstitial hyper- trophy. Herzog has also frequently observed an extensive oedematous in- filtration of the mucosa, with or without capil- lary interstitial hemor- rhages. Tubes and ova- ries are likewise affected when large myomata are present in the uterus. Endosalpingitis, sal- pingitis interstitialis, and oophoritis interstitialis with condensation of the ovarian stroma and round-cell infiltration, have been described. Secondary Degenerations of Myomata.— The secondary degenerations occurring in myomata are quite numerous. Atrophy sometimes occurs Fig. 159.—" A shell composed of lime salts." — Hekzog (page 400). 400 A TEXT-BOOK OF GYNECOLOGY after pregnancy and after the menopause has heen established, and under other conditions. Calcareous degeneration is common, and small particles of carbonates and phosphates of lime are very frequently found in myomata. Or there may be formed a solid stone or a shell com- posed of lime salts. Herzog examined a case of the latter kind. The specimen was obtained by an operation performed by Dr. M. L. Harris, on a woman seventy years old. It formed an elliptical mass about 14 centimetres long, consisting of a shell several millimetres thick, composed of lime salts (Fig. 159). Eeed removed from an aged patient a large interstitial fibroid of lateral development which had distended the broad ligament carrying the ovary and Fallopian tube of that side nearly to the umbilicus (Fig. 160). On opening the tumour a shell of calcareous matter and several foci of calcareous Fig. 160 (Eeed).—" Eeed removed from an aged patient a large interstitial fibroid of lateral development which had distended the broad ligament, carrying the ovary and Fallopian tube of that side nearly to the umbilicus." — Herzog. degeneration were found (Fig. 161). Fatty degeneration is also fre- quently seen; it often leads to the formation of cystic spaces in the tumour. Myxomatous degeneration, inflammation, necrosis, and slough- ing, are observed in fibromyomata. Amyloid degeneration has been once NEOPLASMS OF THE UTERUS 401 described by Stratz. Of malignant clianges in a primarily benign myoma, the sarcomatous degeneration is the one most frequently met with. Von Eecklinghausen has seen several cases of carcinoma developing m Fig. 161 (Eeed).— " On opening the tumour a shell of calcareous matter and several foci of calcareous degeneration were found." — Heezog (page 400). adenomyomata. The other mixed tumours, myochondroma and myo- osteoma, have been described, as well as rhabdomyoma of a sarcoma- tous type. Diagnosis. — These tumours are common in women of all races and of all ages, though more frequent in negroes and in women between the ages of thirty and forty years. Although found prior to puberty in rare instances, these growths are essentially incident to the men- strual period of life. Unmarried and sterile women are especially prone to this disease. Hemorrhage, while not invariably present, is a common and con- spicuous symptom of uterine fibromata. Profuse and prolonged men- struation is a marked and characteristic symptom. It is not uncom- mon to observe the most profound anaemia in consequence, the patient's skin assuming a waxy, yellowish hue, with anaemic heart murmur and profound general exhaustion. Pain is a cons])icuous symptom in the majority of cases, and is the result either of pressure or of associated inflammatory disease of the Fallopian tubes and ovaries. The pain of pressure is determined more by the site of the tumour than its size. Thus, when growing 27 402 A TEXT-BOOK OF GYNECOLOGY from the lower uterine segment and packing the pelvic cavity, the pressure on bowel, bladder, and nerve trunks, will be more severe than when the tumour is situated higher and rises freely above the brim of the pelvis. The ovaries and tubes are often found in a mass of infiammator}^ adhesions, and hydrosalpinx and pyosalpinx are not uncommon accompaniments of these tumours. Such comj)lications may render small fibroid tumours painful in the extreme. Irritability of the bladder, and obstipation resulting from pressure of the growth, are common symptoms. The diagnosis of uterine fibromata is determined by recognising these symptoms in conjunction with careful i^hysical examination of the j)elvic organs. The bimanual touch will disclose the presence of a tumour, usually irregular in outline, and attached to the uterus. If the tumour is large, its firm consistence and nodular character may be detected by palpation through the abdominal parietes. Interstitial fibromata of S3mimetrical development may be mistaken for pregnancy (Fig. 162), an error more easily made from the fact that pregnancy Fig. 162. — "Interstitial fibromata of symmetrical development may be mistaken for preg- nancy." — McMuETEY. not infrequently coexists with these tumours. The soft fibroma, espe- cially if oedematous, is distinguished with difficulty from an ovarian cystoma; and when cystic degeneration has taken place in the fibroma, diagnosis is impossible. Diagnosis is also practically impossible be- tween polycystic ovarian cystoma with general adhesions, and sym- metrical uterine fibroma. The clinical importance of these difficulties, however, is offset by the practical fact that both classes of tumours should receive the same treatment, viz.: removal by abdominal sec- tion. The vaginal portion of the cervix is rarely involved by fibroid changes in the uterus (Fig. 163). A small fibroid in the posterior uter- NEOPLASMS OF THE UTERUS 403 Fig. 1 63. — " Tlie vaginal portion of the cervix is rarely involved by fibroid changes in the uterus." — McMub- TEY (page 402). ine wall may be mistaken for retroflexion of the uterus; and such a tumour springing from the supravaginal cervix may be interpreted by the touch as inflammatory exudate. Such errors can be avoided only by careful study of the symptoms and history of individual cases, with painstaking bimanual examination after the bladder and bowel have been thoroughly emp- tied. Instrumentation per vaginam and digital exploration per rectum will rarely afford any special advantage over these established means of diagnosis, and unless done with skill and with- out force, will inflict pain and prove harmful. Pregnancy as a com- plication of uterine myo- mata occurs with suf- ficient frequency to de- serve special considera- tion. It is a matter of great practical importance to determine whether the life of the mother is endangered and operation consequently imperative; or, whether pregnancy and parturition may be safely completed without surgical intervention. While it is exceptional for a woman with large uterine myoma to become pregnant, numerous cases are recorded where the uterus has proved equal to the demand and carried the child to safe delivery near to or quite at full term. Under the stimulus of preg- nancy, with its increased blood supply, fibroid tumours grow rapidly; and small tumours hitherto unnoticed may become conspicuous. It is also true that, after delivery, fibromata participate in the retrograde changes in the uterus and shrivel to insignificant proportions. In certain exceptional cases, where the tumour arises from the lower segment of the uterus and fills the lower pelvis, thereby obstructing the passage of the child, the vital question of operative intervention must be met and determined. A case of obstructive myoma in which a successful operation was done by McMurtry is illustrated in Fig. 164 {New York Medical Journal). Similar cases have been re- ported by Price, Hanks, Eeed, Vander Veer, Ross, and others. This question should receive the most conservative consideration, for, in many instances, the uterus will bear its additional burden, and if the tumour is above the pelvic brim, or can be pushed above when labour comes on, safe delivery of a living child may be accomplished. The operative procedure in hystero-myomectomy, wherein pregnancy is a complication, does not differ in any essential particular from the opera- tion when performed in uncomplicated cases. 404 A TEXT-BOOK OF GYNECOLOGY Treatment: Medicinal and Electrical. — Various drugs have been recommended as either curative or beneficial in the treatment of fibroid tumours of the uterus. Such medicinal agents as ergot, gallic acid, i^iG 164. — "A case of obstructive myoma in which a successful operation was done." — McMuETEY (page 403). hydrastis, and some preparations of iron, have enjoyed favour in this capacity, being especially in repute for controlling hemorrhage, arrest- ing growth, and diminishing the size of the neoplasm. It can be clin- ically demonstrated that such agents do not yield the benefits claimed for them, while by impairing digestion and producing constipation they are harmful in their general influence upon the system. Fibromata of the uterus are so constantly influenced by circulatory changes in the pelvic viscera, such as menstruation and impaired resistance, that errors of judgment may readily be made by the overconfident observer. The results formerly claimed for deep injections of ergot, and more recently for electrical applications, have proved misleading and have resulted in the discarding of these remedies. Such treatment is not only inefficient, but positively harmful, in consequence of the constant localized peritonitis produced thereby. The perfected operative treat- ment (Fig. 165) of modern surgery has taken the place of all treatment both with drugs and electricity. (See chapter on General Therapeutics.) When the tumour is of small size and unaccompanied by hemorrhage or other serious symptoms, no treatment whatever will be required. The requirements of individual cases must guide the practitioner in the determination of these important considerations. In approaching the surgical treatment it is well to have a distinct understanding of some of the terms employed. The terms myomectomy and Jiystero-myomectomy both indicate operative procedures for the re- NEOPLASMS OF THE UTERUS 405 moval of fibroid tumours of the uterus. Tlie former term is applied to the operation in which the tumour or tumours are removed and the uterus preserved; the latter indicates the removal of the uterus in part or in whole along with the tumour. Hysterectomy properly denotes removal of the uterus without regard to the presence of neo- plastic formations, hut is habitually used as synonymous with the term hystero-myomectomy in treating of fibroid tumours. Hysterectomy may be partial or complete. The term supravaginal hysterectomy is applied to amputation of the uterus at the internal os, leaving a cer- FiG. 165. — "The perfected operative treatment of modern surgery has taken the place of all treatment both with drugs and electricity." — McMuktey (page 404). vical pedicle (Fig. 166); complete hysterectomy, involving the removal of the entire uterus including the cervix, is often termed panhyster- ectomy. Indications for Operation. — The operations for the removal of fibroid tumours have reached a stage of perfection that elicits admira- tion and commands confidence. Since we have learned to control hemorrhage in these operations, the indications for the operation have advanced beyond the limitations that obtained a few years since. Those who have practised the removal of the ovaries for the reduction in size of a myomatous tumour, or for the purpose of staying the growth of such a tumour, know well that the convalescence in such cases 406 A TEXT-BOOK OP GYNECOLOGY is fraught witli serious complications that give the operator a great amount of anxiety. As a consequence of the rapidity with which a circulatory change takes place in these tumours after ablation of the ovaries, suppuration occasionally sets in, the tumour begins to break Fig. 166. — "Amputation of the uterus at the internal os, leaving a cervical pedicle." — McMuETEY (page 405). down, and the patient becomes desperately ill. An experienced oper- ator, therefore, will be more anxious to remove fibroid tumours entirely than to remove the ovaries alone. It is, therefore, becoming a serious question as to which operation in skilled hands, performed according to modern methods, is the more serious of the two. That is, whether the operation of abdominal hysterectomy or myomectomy, v/hen per- formed for the removal of moderate-sized tumours, is more serious than the removal of the ovaries from their position alongside such tumours. Indications for the removal of such tumours are, rapid growth, grave hemorrhages from the uterus, ascites, compression on important organs, suppuration or degeneration of the tumour, and pregnancy under certain circumstances. When the tumour grows rapidly it may undergo malignant degeneration, or become oedematous. Small pedunculated tumours are not likely to be reduced in size as a consequence of the removal of the ovaries, and when these tumours give rise to pressure symptoms their removal is necessitated. General Considerations. — The removal of small pedunculated growths is a simple matter. The uterus, ovaries, and tubes, are left intact and the patient has her sexual organs practically uninterfered with. There is a class of cases in which we may remove the tumour by a process of enucleation and leave the uterus intact. We have certain tumours deep down in the pelvis or in the broad ligaments that require enucleation. In some of these cases it is found impos- sible to control the hemorrhage without removing the entire uterus and we must always be prepared to go on and complete the more extensive operation. In all these operations it is important that we should be able to control the hemorrhage with ease as the operation proceeds. The elastic ligature is perhaps the most valuable aid we NEOPLASMS OF THE UTERUS 407 have. This should only be 1186:1 temporarily, and be aljandoned after the hemorrhage has been checked by other means. A few years since the serre-noeud of Koeberle was used, but this is now very largely dis- carded. The elastic ligature is passed around the cervix and broad ligaments, and is held in position by means of an artery forceps placed upon it after it has been pulled taut. It does not require very much pressure to control the hemorrhage. Myomectomy. — For removing the jDcdunculated fibromata the elas- tic ligature is placed in position, a needle armed with a double silk ligature is then passed through the pedicle, and the pedicle is tied in half sections. If the pedicle is very large and thick it is seized and compressed by clamp forceps while the tumour is cut off, and care is taken to leave a collar of peritoneum and capsule large enough to permit approximation across the face of the stumjo. The clamp is then removed and the furrow is pierced with a needle carrying a silk suture that is tied in several sections. The edges of the stump above are then approximated by interrupted sutures. The provisional elastic ligature is next removed, and if there is much oozing about the sutures, a few deeper ones must be placed. When large vessels can be seen during the section of the pedicle they are tied separately. The pedicle must not be returned to the abdomen until after all oozing has ceased. If the oozing continues, sufficient time must be given to permit of its arrest by the adoption of appropriate methods; and if it does not then cease something further must be done. It occasionally happens that the uterus, itself, will require removal be- fore the hemorrhage can be controlled. Too much time and blood must not be lost before the operator determines this fact. Indications. — When a tumour is single, or when there are but two or three nodules, the enucleation of interstitial myomata may be car- ried out. We must have our patients or their friends understand, how- ever, that if it is impossible to control the hemorrhage the entire organ must be removed. Very large single myomata of the interstitial variety may be removed by myomectomy (Fig. 167). Some operators have recommended the removal of both ovaries if other fibrous nodules are present and beyond our reach, but it seems only reasonable to suppose that, under such circumstances, it would be better to remove the uterus in the ordinary way by the method of supravaginal amputation. Unless the operation is combined with castration there is always a danger of the development of a second tumour that may be overlooked at the time of the primary operation. To avoid this danger it is necessary to remove both ovaries. As a con- sequence, this operation would seem to have but a limited field in cases in which it is not desirable to perform supravaginal amputation; in other words, it becomes an operation of expediency. Many a young married woman may have a fibroid tumour that requires removal. She is willing to have the tumour removed, but she is not willing to submit to the more radical operation of removal 408 A TEXT-BOOK OF GYNECOLOGY of uterus, ovaries and tubes. A subsequent pregnancy may, it is true, endanger her life owing to the Aveakness produced in the uterine wall by the enucleation of a myoma, but if she is willing to take her chances it seems but fair that we should perform the operation for her in preference to that of supravaginal hysterectomy. Fig. 167 (Reed).—" Very large single myomata of the interstitial variety may be removed by myomectomy."^Ross (page 407). Operation. — It is a well-known fact that these myomata bleed from the capsule and do not bleed from the central core, or tumour proper. To control the hemorrhage, therefore, it is necessary to compress the capsule. The elastic ligature when applicable should be placed i?i situ before the primary incision is made into the tumour capsule. These incisions should be made in such a way as to wound the small arterioles and not the large trunks. Incisions in the median line are less liable to bleed than those placed to either side. The incision must go through the capsule to the tumour mass (Fig. 168), and must be neopijAsms of the uterus 409 sufficient to permit the enucleation of the tumour. Enucleation should be done by a process of tearing and not of cutting; the vessels will, as a consequence, bleed less. A scoop, similar to that used for the removal of gallstones, or stones from the urinary bladder, may be used as an enucleator. Special instruments have been constructed for this purpose, but are rarely needed. The finger and the handle of the scalpel answer admirably as enucleators. Connective tissue will be found dipping down here and there between the meshes of the tumour and separating its outer wall from the inner surface of the capsule. It is in this connective tissue that the enucleation must be carried out. After the tumour has been removed, it is wise temporarily to loosen the elastic ligature placed around the cervix, for the purpose of tying vessels that may be seen to bleed specially. In this way HThOP.-diia .wf57-g«;;?£^ -.1 r,, Fig. 168 (Eeed).— " The incision must go through the capsule to the tumour mass."— Eoss (page 408). all the large vessels may be tied with catgut ligatures. The elastic ligature can be again tightened and the tissues stitched firmly by means of layers of continuous catgut sutures. Finally, the capsule wall is brought firmly together by a row of interrupted sutures or by a continuous suture of formalinized catgut (Fig. 1G9). The elastic 410 A TEXT-BOOK OF GYNECOLOGY ligature is finally dispensed with, and the parts are watched until all bleeding has ceased. It should be a fixed rule not to return the uterus to the abdominal cavity unless bleeding has ceased. One of the great dangers accompanying the operation is hemorrhage into the abdominal cavity after the return to it of the uterus, and after the relaxation of the blood vessels has taken place owing to the cessation of the tension. The uterine canal may be laid bare. When this is the case it is advisable to place a small strip of gauze down through the cervix and pack the cavity left after the removal of the tumour Fig. 169 (Eeed). — "Finally the capsule wall is brought iirmly together by . suture of formallnized catgut." — Ross (page 409). . a continuous (Fig. 170); or drainage may be effected by means of Eeed's self -retain- ing tube passed from the tumour nest out through the cervix and vagina (Fig. 171). Supravaginal Hysterectomy. — The difficulties to be encountered during the operation depend upon the location of the tumour and the extent of the adhesions. The important fact to be remembered is that the blood supply is obtained through the uterine and ovarian arteries. These arteries can readily be located by means of the thumb and forefinger with gentle pressure. The pulsations can be readily felt. When the blood vessels have been located it is easy to dissect down to them, provided we do not cut, but dissect with the handle of the scalpel, into the cellular tissues of the broad ligament, taking. care to avoid the large veins found in these cases. The ves- sels can be tied either en masse or separately as they are found. Just as we place a tourniquet upon the femoral artery before ampu- NEOPLASMS OF THE UTERUS 411 tating the thigh, so should we place our ligatures upon the two uterine and two ovarian arteries before attempting to amputate the uterus. If hemorrhage then occurs we may rest assured that we have failed Fig. 170 (Reed). — " The uterine canal may be laid bare ; - . . place a small strip of gauze clown through the cervix, and pack the cavity left after the removal of the tumour." — Eoss (page 410). in properly securing the vessels. Blood will flow from the upper or tumour side of the cut, hut the proximal side will be almost dry if the vessels have been properly tied. If the uterine cavity is opened, Fio. 171 (Kkei>;.— "Or draiiiaLn! may be eiructod by means of Kecd's sell'-rctaining tube passed from the tumour nest out through the cervix and vagina."— Ross (page 410). 412 A TEXT-BOOK OP GYNECOLOGY it is wise to disinfect it with a little pure carbolic acid before stitch- ing up the stump. Some operators pass down a small wick of gauze through the cervix into the vagina to admit of drainage. The great advance that has been made in this surgical procedure is due to the fact that we depend entirely upon ligation of the large blood trunks supplying the tumour for the control of hemorrhage, and that we have done away with the temporary or permanent clamp. Many operators scarcely ever use these aids to hemostasis. In performing this operation, great care should be taken to prevent loss of blood, to economize time, and to avoid subsequent hemorrhage. Loss of blood during the operation greatly increases the rapidity of the patient's pulse; loss of time increases the shock; and loss of blood after the operation will often prove fatal. It is never well to sacrifice thor- oughness for speed, but there is a happy medium to be obtained. There is no operation in the whole field of surgery that requires more deliberation. It is scarcely necessary to describe the operation as performed a few years since by means of the j^ermanent Koeberle serre-noeud. We rarely see the large ovarian tumours that were common twenty or thirty years ago, because such tumours are now removed when small. So it is with the myomata; they are removed much earlier owing to the diminished risks of operation. Technique of Supravaginal Hysterectomy. — The usual precautions are taken in pi-eparing the patient. A purgative is given the day before, an enema on the morning of the operation, the skin over the abdomen is thoroughly disinfected, and the armamentarium of instru- ments required laid out in a convenient place, after having undergone thorough sterilization. The patient must be well wrapped up on the operating table to prevent chilling of the body surface. The instruments required are: scalpel; large and small compression forceps; long-bladed clamp forceps; pedicle needle for transfixion; re- tractors; uterine sound; female bladder sound; heavy silk; catgut in various sizes; curved needles, various sizes; needles for closing abdomi- nal wound; scissors; rubber tubing for elastic ligature; serre-noeud with hysterectomy pin; glass drainage tube. The abdomen is now opened by a free incision. If adhesions are encountered great care must be taken in dealing with these, as the tumour surface will bleed at the points from which adhesions are removed. It is much wiser, in dealing with these adhesions, to ligate them in two places and cut them away, leaving a ligated portion still adherent to the tumour. If intestine is so intimately adherent to the tumour as to prevent this procedure, it must be separated with as light a touch as possible. Hot cloths placed over the spots from which adherent intestine has been removed will control the hemorrhage while it is left in situ. The tumour is now raised out of the abdomen. Sponges are packed down above it to retain the intestines, and, if the incision has been a long one, it is wise to draw its edges together NEOPLASMS OF THE UTERUS 413 above the tumour by means of one or two silkworm-gut sutures. In this way the intestines are ke2:)t in the abdomen and out of the way. We must now outline the bladder limits. This is done by means of a sound passed into the bladder by an assistant. This sound is pushed well upward until the upper confines of this organ are accu- rately determined. Small pressure forceps are then placed a little above this line to act as guides to the position of the bladder. The peritoneum is now incised over the front of the tumour, care being taken not to go deeper than the peritoneum, because any incision of the tumour capsule will cause hemorrhage. By means of the finger and the handle of the knife, the peritoneum, with the bladder, can then be easily entirely stripped down from the front of the tumour. The connective tissue lying immediately beneath it permits of this loosening process. There is thus no danger of wounding the bladder by the puncture of the pedicle needle. The ovarian artery on one side must now be felt for and secured, either by a ligature en masse, or by a single ligature. If the single ligature is used the veins must also be tied by means of another liga- ture. These veins are always very much enlarged. A forceps is now placed on the tumour side of the mesentery of the tube to control the regurgitant hemorrhage; and the mesentery of the tube, together with the broad ligament at this point, is cut across. Should any bleed- ing point be found, it is easy to control this hemorrhage by the appli- cation of another forceps. The connective tissue close to the tumour and inside of the veins of the pampiniform plexus can now be seen and pushed into with the finger. If this process is continued, one may grope down farther until the uterine artery, whose presence is made known by its pulsations, is found, and this artery may be followed well down to the cervix and may be there ligated, either en masse, or in a separate ligature. When the ligature is placed, care must be taken to pass the pedicle needle close to the cervix uteri and the loop should be carried u^pward and outward instead of outward, before it is finally tied. In this way we avoid inclusion of the ureter. A similar procedure is next followed on the opposite side. The blood supply to the tumour is now shut off, except what little it gets through the azygos vaginae artery and another small vaginal branch in front. The amputation of the tumou,r is next effected with a few sweeps of the knife. It occasionally happens that one or two vessels can be seen spouting from the anterior or posterior surface of the stump. These may be tied with small catgut ligatures. If, however, there is nothing but a slight general oozing, the operator will proceed to the next steps of the operation for the control of this hemorrhage. By means of a small curved needle that cuts on the flat, the wound is stitched up from the bottom with continuous catgut sutures; each stitch is pulled tightly and held taut by the assistant until the next stitch is taken. In this way the stump is gradually built up and puck- ered in until finally the outermost edges are approximated above just as 414 A TEXT-BOOK OF GYNECOLOGY the two flaps are brought together after an amputation of the leg. The peritoneum is stitched together over the surface, and this stitch- ing is continued on outward over each broad ligament so that nothing but peritoneum can be seen when looking into the pelvic cavity. A little hemorrhage may have been found about the downward dislocated bladder. If any vessels persist in oozing here they may be controlled Avitli small catgut sutures. The mere approximation of the bladder back into its old position, produced by the suture of the peritoneal edges before and behind the stump, is usually sufficient to control all hemorrhage. There is sometimes a little oozing for three or four hours after the patient has been placed in bed, and on this account many operators place a glass drainage tube in the cul-de-sac of Douglas from above or from below. If placed below, the vagina is packed with iodoform gauze to keep the drainage tube in situ. If the drainage tube is placed in the cul-de-sac of Douglas from above, it should be removed within a few hours after the operation. Con- siderable blood Avill drain from it for two or three hours, and then the quantity rapidly diminishes. The ligatures used on the ovarian and uterine arteries may con- sist of either catgut or silk. Some operators are not satisfied to use catgut owing to the difficulty experienced in tying it with sufficient firmness, unless the gut is of such a thickness as to make it difficult to completely sterilize it. Silk, if used, should not be any heavier than is necessary to accomplish the purpose for which it is intended. If the silk is of the first quality a much smaller strand can be used than if it is of an inferior quality. If hemorrhage still continues after the stump has been stitched together in the manner described, it is sometimes necessary to transfix lower down and tie the stump with very strong thread into two sections. This procedure can, however, scarcely be called for if the arteries have been properly ligated in the commencement of the opera- tion. AYhen such hemorrhage occurs, the arteries may be sought for and an efl^ort made to find the presence or absence of pulsation beyond the ligatures. It may even be advisable to throw another ligature around any or all of the vessels to insure their constriction, as the placing of a loop about the whole pedicle may produce sloughing of the tissue. Ross has seen this occur in one case. Extra-peritoneal Treatment of the Pedicle. — If it is decided to treat the pedicle according to an extra-peritoneal method, the technique of the first part of the operation is exactly similar to that just de- scribed. The vessels are ligated and the wire clamp is then passed down around the pedicle, inside of and above the broad ligaments that have now been divided and pushed away. A single or double pin is then pushed through the stump to hold it outside the abdominal cavity and to keep the wire from slipping ofi' the pedicle. The wire is then tightened up and the tumour rapidly removed. The wound is next closed about the stump so that the peritoneal surface of the NEOPLASMS OP THE UTERUS 415 stump comes in contact with the parietal peritoneum. The perito- neal cavity is thus shut off by adhesions in a few hours. The bladder must be carefully dissected down and pushed out of the way, in order that injury to the bladder and ureters by the wire of the clamp may be avoided. These unfortunate accidents have occurred on several occasions. Intestine must also be kept well out of the way. The stump is now tanned with a solution of perchloride of iron and glycerine, and covered with strips of dry lint. The serre-noeud is tightened frequently, and the pedicle sloughs off about the twelfth day, leaving a granulating surface that requires several weeks to heal. The so-called mummification of the stump is not of very great importance. Even though the stump mummifies, the tissues under- neath frequently suppurate. Another extra-peritoneal method of dealing with the pedicle is that by which it is transfixed and tied with chain suture, and then fastened in the abdominal wound without the use of any clamp. As a con- sequence of the position of the pedicle, this method prevents union of the abdominal incision by first intention and permits of a subsequent hernia through the abdominal parietes. There is nothing to be gained by leaving the pedicle in this situation. It was supposed that it could be readily lifted up and hemorrhage could be easily controlled, but this has proved to be an unnecessary precaution now that the ligation of the vessels is better understood. A great deal of this sort of surgery can, with profit, be relegated to the past though it has all served a useful purpose. The ideal operation, described above, is all that can be required for the removal of fibroid tumours where they occupy a i^osition in the fundus, or press outward into the broad ligament or into the pelvis. All can be removed by this procedure with ease and safety by experienced operators. At this stage of our knowledge, it is useless to recount the different methods adopted by different operators during the past ten or fifteen years. Most of these methods have been dis- carded, or, if they have not been discarded, they should have been. Panhysterectomy, as the name implies, means the complete extir- pation of the uterus. In practice, the ovaries and Fallopian tubes are generally, although not always, removed with the uterus. A number of operators recommend in this, as in other operations for the removal of the uterus, that an ovary, if entirely healthy, be left in situ, for the purpose of maintaining the menstrual molimen and of mitigating the nervous symptoms that frequently follow complete ablation of the genital apparatus. The technique of this operation, as practised by Ross, is similar to that described for the removal of the myomatous uterus by supra- vngirifil amputation, ''.llie cervix may readily be removed after the liKiiour has been cut away and is no longer obstructing the view. The 416 A TEXT-BOOK OF GYNECOLOGY vessels supplying the cervix are the same as those supplying the vaginal wall at its junction with the cervix, provided that the blood supply from the uterine arteries has been cut off. We may, therefore, expect to find the azygos vaginae artery spouting when the vaginal Fig. 172. — " The small clamf)s attached to the uterus are now hooked up by two fingers of the left hand, by which traction is made." — Eeed (page 417). septum is cut through at its junction with the cervix in the neigh- bourhood of the cul-de-sac of Douglas. No vessels of importance will bleed on either side, but another small branch or two will be found NEOPLASMS OF THE UTERUS 417 spouting in the vaginal septnin, where it is separated from the uterine neck in front. These vessels can be readily ligated with catgut. Reed's operation of panhysterectomy is as follows: All adhesions of the uterus and its appendages are first broken up and the uterus is lifted up into the abdominal incision. In some cases this manipula- tion can be done so satisfactorily with the patient upon her back that it is unnecessary to put her in the Trendelenburg position, although in most cases the latter posture is not only desirable but necessary. The broad ligament is then clamped upon one side, just beneath the ovary and Fallopian tube, the clamp extending from the margin of the broad ligament to the side of the cervix. Another and smaller clamp is now placed on the broad ligament parallel with the previous clamp but a quarter of an inch nearer to the uterus. The broad ligament is then divided between the clamps, from its edge to the side of Fig. 173.—" The uterine arteries which can be seen and clamped as soon as they are reached." — Keed. the cervix; the broad ligament on the other side, is similarly clamped and incised. The vesical fold of the peritoneum is now dissected away from the front of the uterus, as is the peritoneum covering the pos- terior side of the organ. The small clamps attached to the uterus are now hooked up by two fingers of the left hand, by which trac- tion is made (Fig. 172). As the uterus is drawn away from the vagina, the dissection is made by means of the scissors held in the right hand. Care should be taken in making this dissection to avoid wounding the uterine arteries, which can be seen and clamped as soon as they are reached (Fig. 173). From this time on, the dissection should be carried even more closely to the cervix, dividing the cervical tissues sufficiently to leave a slight ring in situ after the cervix is withdrawn. If this precaution is not taken, there is liability of wounding the azygos vaginae 28 418 A TEXT-BOOK OF GYNECOLOGY artery, the hemorrhage from which, while controllable, is embarrassing. When the vagino-cervical juncture has been reached, the point of the closed scissors may be thrust through into the vaginal canal. After this preliminary opening, the remaining division of the vaginal mucosa is accomplished with facility. The ovarian and the uterine arteries upon either side are next tied individually by means of formalinized catgut. All clamps are now removed, and the field of operation is inspected to make sure of complete arrest of the bleeding. If this is duly controlled, a piece of sterilized gauze is packed into the vagina from above, the upper part of the pack coming within and above the cut margins of the vaginal mucous membrane. The peritoneal margins are stitched together by means of a continuous catgut suture. Finally, the toilet of the peritoneum is made by means of dry sponging, and the incision is closed by laminated sutures. (See Abdominal Section.) The specimen removed will show a complete uterus with the append- ages and the exact area of the dissection (Fig. 174). If it is desired to use the angeiotribe for hemostasis, it can be applied just beneath the temporary clamp, which is then removed. Fig. 174. — " The specimen removed will show a complete uterus with appendages and the exact area of the dissection." — Eeed. Care should be taken that the end of the angeiotribe shall embrace the uterine artery within its clasp (Fig. 175). The instrument should be left on a few minutes, when it can be applied similarly to the other side. Doyen, who invented the angeiotribe, does not trust it NEOPLASMS OF THE UTERUS 419 alone to control hemorrhage under these circumstances, but applies a supplementary ligature, asserting as a sufficient advantage for using the instrument that it diminishes the volume of the tissues and renders less liable slipping of the pedicle. The electric clamp of Skene may Fig. 175.^" If it is desired to use the angeiotribe for hemostasis, it can be applied just beneath the temporary clamp, which is then removed. Care should be taken that the angeiotribe shall embrace the uterine artery within its clasp." — Eeed (page 418). be similarly employed (see Hemostasis), but whether forcipressure or heat is applied for hemostasis, the peritoneal margins should be stitched together to avoid retraction. The advantages of panhysterectomy are (a) the contamination of the field of operation, which is so liable to happen as the result of extension of infection from the endocervium in cases of supravaginal amputation, does not occur; (b) drainage by the vagina is easily and thoroughly accomplished; (c) with care in avoiding the azygos vagina artery, hemostasis is readily secured and safely maintained. The re- sulting condition of the pelvic diaphragm is one of equal, if not greater, strength than that secured by the supravaginal operation; {d) if the technique above described is carefully followed, the operation is done with greater facility than are others devised for the extirpation of the uterus; (e) myomatous uteri of considerable magnitude may be removed, en masse, by this means (Fig, 176). Vaginal hysterectomy is sometimes practised for the removal of small fliU'u.se jiiycjmaia of the uterus, associated with persistent and 420 A TEXT-BOOK OF GYNECOLOGY uncontrollable hemorrhage. The technique of the operation does not differ from that described in connection with malignant neoplasms of the uterus. (See Vaginal Hysterectomy.) Vaginal Myomotomy. — (a) Enucleation (technique). — The tumours most appropriate for enucleation are small and medium-sized, single Fig. 176. — " Myomatous uteri of considerable magnitude may be removed, en masse, by this means." — Reed (page 419). submucous tumours that are not pedunculated, and interstitial tumours distinctly encapsulated and projecting well into the cavity; also large tumours projecting into the os or partly extruded from the same. Very large tumours, if removed by vaginal myomotomy, are best ex- tirpated by morceUement or by combined morcdlement and enucleation. The cervical fibroids requiring enucleation are of rare occurrence. They may be extirpated as a rule without difficulty. After exposing them by means of a Sims's speculum and retractors, an ample incision is made through the covering of the tumour, which covering is sepa- rated from the tumour with the finger or handle of the knife (Fig. 177); then the uncovered portion of the tumour is seized with a strong volsella forceps and traction upon, and rotation of, the neoplasm is made, while NEOPLASMS OF THE UTERUS 421 the finger is inserted between the tumour and its envelopes, to sever its cellular connections. Should there be any dense bands of tissue ex- tending from the tumour into the underlying tissues, they should be severed with scissors. Emmet's right-hand, lesser-curved, blunt- pointed scissors, serve as an excellent substitute for the finger, and are ready at hand if needed to sever any bands. No great difiiculty presents and there is as a rule little hemorrhage. If needed, hot- water irrigation and packing the cavity with gauze will arrest bleeding. When the neoplasm to be enucleated is situ- ated within the uterine cavity, it is a matter of the first importance that the OS be widely dilated. This may be effected by laminaria tents, the steel dilator, or by lateral incisions of the cer- vix. The last method is preferable. The various steps of the operation may be stated as follows: The patient is placed in the dorsal position, with legs in holders or feet se- cured in the high stir- rups, and with buttocks projecting slightly be- yond the edge of the table. She has been pre- viously prepared. Wash out the vagina again with a bichloride solution; re- tract the perineum with a self - retaining specu- lum, preferably a Jones's with a short blade. Now seize the anterior lip of the cervix with bullet forceps and pull down the uterus. Incise the os with scissors or knife. Examine the tumour to determine its size and location, make ample incision through its covering over the most dependent accessible part. Separate the envelopes from the tumour for a short distance, and seize the neoplasm with a strong short-tined volsella or Museiix for- ceps. Now proceerl as indicated in describing the method of enucleat- ing the cervical fibroid. Thomas's serrated spoon saw (Fig. 178) will often be found serviceable in loosening the tumour attachments. Con- FiG. 177. — " An ample incision is made through the cov- ering of the tumour, which covering is separated from the tumour with the finger or handle of the knife."— Dunning (page 420). 422 A TEXT-BOOK OF GYNECOLOGY i h'lG. 178. " Thomas's serrated spoon saw." — Dunning (page 421). siderable force may be required to dislodge the tumour. Strong trac- tion may be employed, but the danger of lacerating the uterine walls or producing inversion of the organ, must be borne in mind. If the tumour is too large to be delivered whole, it may be cut into sections and removed piecemeal. (b) Morcellement. — When the tumour is very large, this method may be employed in preference to enucleation. Emmet is given the credit of priority in describing and putting into execution a systematic method of vaginal myomotomy by morcellement. It has often been denomi- nated Emmet's traction method, but it comprises most of the essential features of what is known to-day as vaginal extirpation by morcellement. It differs from enucleation in that after dilatation of the os, no effort is made to divide the capsule of the tumour, and sections of the neoplasm are made in the vagina. The neo- plasm is seized at its lower por- tion with strong hooks or vol- sella forceps and forcibly drawn downward. As it descends into the vagina, portions of the tu- mour are cut away and removed, the remaining portion is again seized and powerfully drawn upon, and once more the presenting part is cut away. And so the process is carried on, until finally the base of the tumour is reached. It will now be observed that, in consequence of the power- ful traction, a pedicle has been formed which, in some of Emmet's cases, was no larger than the index finger and consisted of the coverings of the tumour. This base is severed and the last of the tumour is re- moved. The traction upon the tumour stimulates uterine contraction, so that as the tumour descends, the uterus follows, closely encircling the neoplasm. If neces- sary, the descent of the uterus may be aided by pressure upon the fundus from above the pubes. Injections of hot water into the cavity of the uterus may be made if needed to stimulate contraction or to arrest hemor- rhage. In case of profuse hemorrhage dur- ing the process of extirpation, the tumour should be removed as quickly as possible, hot-water injections employed, and later, if necessary, gauze packing. Fig. 179. — Pean's forceps for mor- cellement. — Dunning (page 428). NEOPLASMS OP THE UTERUS 423 Pean's method of morcellement differs little in principle from Em- met's, the chief differences being in the use of specially devised instru- ments (Fig. 179), the j)reliminary severing of the vaginal and other attachments of the cervix as high as the lovi^er margin of the tumour, and the excision of the lips of the cervix and application of pressure forceps to bleeding vessels within the uterine cavity, if the hemorrhage is profuse. The following is a brief summary of Pozzi's {Medical and Sur- gical Gynecology, vol. i, pp. 267-272) excellent and elaborate descrip- tion of Pean's method: 1. Liberate the cervix by circular incision. Check hemorrhage by application of pressure forceps. 2. Incise the cervix bilaterally from the cervical canal. Incise the lower segment of the uterus if necessary to the level of the tumour. 3. Seize the anterior and posterior lips of the uterus with forceps and draw the organ toward the vaginal outlet. 4. Seize the most accessible portion of the tumour with forceps, drag it downward and cut off a section. Seize the accessible portion again, drag downward and cut away another piece. Repeat this pro- cedure until finally the remainder of the tumour comes within reach. Now, if pedunculated, sever the pedicle and remove the last of the tumour. If more easily effected, enucleate the remaining mass. Search for other tumours; if any are found, extirpate them in like manner. If there is no hemorrhage, irrigate the uterine cavity with a hot anti- septic solution and place one or two strips of gauze for drainage. Stitch the incised cervix. Stitch the incised vaginal walls to the cervix and pack the vagina lightly with gauze. If there is prolonged hemorrhage not checked by hot irrigation, excise the lips of the cervix, draw the uterus down to the vaginal outlet, mop out the uterine cavity, seize the bleeding vessels with long catch forceps and pack the uterine cavity lightly with gauze. As a final step, stitch the lower end of the uterus to the incised vaginal walls. Both Emmet's and Pean's operations in cases of large tumours are formidable and may in many instances be rejected in favour of vaginal or supravaginal hysterectomy. They are contraindicated when the uterus contains several tumours, and when there is suppura- tive disease of the uterine adnexa. In view of the fact that foci of fibroid development may, and often do, exist in such size and localities as to defy detection in the remaining uterine wall; and in view of the frequent recurrence of fibromyomatous growths in uteri which have been subjected to myo- mectomy, many o])erators, with good cause, reject the latter operation. It is undeniable that hysterectomy is to be preferred in the majority of cases. It is argued that myomectomy is always a serious operation, that, as already stated, it often fails to bring the patient immunity, and that there is difficulty in detecting other commencing growths. This 424 A TEXT-BOOK OF GYNECOLOGY is all avoided by hysterectomy, the immediate dangers from which are no greater than from myomectomy. It is true that a few women have conceived and borne children after myomectomy, but this result is rare; sterility or, in the event of conception, abortion may be set down as of commoner occurrence. Extirpation of Polypoid Growths from the Uterus. — The method of removal of a small polypus attached at or near the external os is simple. With a strong, long-handled catch forceps seize the pedicle near its attachment, and by traction on and rotation of it, the attach- ment is broken up. But little force is required, and little bleeding need be feared, unless too strong traction has been exerted. Should hemorrhage appear, it is best to cauterize the bleeding surface, if acces- sible, with the thermo-cautery. If the pedicle is broad and the polypus vascular, incise the base with scissors and cauterize the cut surfaces with the thermo-cautery. When the polypus is large, distending the vagina and obscuring a view of the pedicle, the point of attachment and the size of the pedicle should if possible be determined. This can usually be effected by a digital exploration, or, if the polypus is too large to permit this, a bent uterine sound can usually be carried round and above the polypus, when, by manipulation, the attachment can be felt and its size estimated. The loop of the wire ecraseur may be carried around the tumour and the whole instrument gently carried upward toward the cervix. If a strand of piano wire is used, there is usually little difficulty in encircling the pedicle. By leaving one end of the wire unfastened until the pedicle is reached, it may then be drawn tight and the unfastened end of the wire wrapped around the post of the ecraseur, when a few turns of the screw will sever the pedicle. Sometimes the polypus will be so large that difficulty is experi- enced in delivering it. Two courses are then open — namely, section of the tumour and its delivery piecemeal, or the application of an obstetrical or a specially designed forceps with which to make traction. When the attachment of the pedicle is above the internal os and the tumour presents at the external os or protrudes into the vagina, the polypus may frequently be seized with a forceps or tenaculum, traction made upon it, and the pedicle cut with scissors. No fear of hemorrhage or recurrence of the polypus need be entertained. If the polypus is wholly within the internal os, it is probable that the tumour is large or the pedicle short. To accomplish its removal, the cervical canal should be dilated by the steel dilator, or the cervix may be incised and subsequently dilated by the finger or steel dilator. None of these procedures is objectionable if conducted under antiseptic pre- cautions. With the cervix dilated, the anterior lip may be seized with a double tenaculum, the uterus drawn down, and the interior of the uterus explored with the finger. In this way small polypi may be located and scraped off with a NEOPLASMS OF THE UTERUS 425 sharp curette or cut off with long blunt scissors. It has been Dun- ning's practice for many years when the pedicle could be distinctly located and safely reached by blunt-pointed scissors to sever it with scissors in all cases of uterine polypi attached above the internal os. Should the tumour be very vascular and contain a large artery, a safe and feasible plan is to seize the pedicle in the bite of a long- curved pressure forceps and sever it between the forceps and the tumour. The forceps should be allowed to remain attached to the stump of the pedicle for two days. A large polypus with a short, thick, pedicle attached high up can be best extirpated by severing the pedicle with a wire ecraseur. In all cases of intrauterine polypi, after the removal of one polypus the cavity of the uterus should be explored, for occasionally more than one growth is present. Should hemorrhage follow the extirpation of the polypus from this region, the intrauterine douche of hot water will usually arrest it. Vinegar, in proportion of 1 to 3 or 1 to 2 is a valuable addition to the douche. If these plans fail, the uterine cavity should be packed with plain sterilized or chemically asepticized gauze. The operators may choose between the Sims and dorsal positions. Dun- ning and many other operators prefer the latter, with the limbs in the holders and the cervix exposed by a short, broad, Sims's or Jones's speculum. The removal of malignant polypoid growths has not been considered in tlie foregoing remarks. They are best treated by total extirpation of the uterus. (See Malignant Neoplasms of the Uterus and Vaginal Hysterectomy.) CHAPTER XXIX NEOPLASMS or THE UTERUS (Continued) Malignant neoplasms: (a) Syncytionia malignum; {i) adenoma; (c) sarcoma; (d) carcinoma — Treatment: (a) Palliative: topical medication, curettement, high amputation; (b) radical: vaginal hysterectomy; abdomino-vaginal panhyster- ectomy; the extended operation; electro-hysterectomy — Results. Malignant Neoplasms of the Utekus These will be considered in the following order: (a) syncytioma malignum, (h) adenoma uteri, (c) sarcoma iiteri, {d) carcinoma uteri, (e) exceptional forms. These growths, while differing in their histogenesis and in their histologic properties, have in common the clinical feature of malig- nancy; they are, therefore, neoplasms which, if left to themselves, will kill the patient by progressive invasion of tissue and by local and con- stitutional conditions that are thereby established. These changes will be described in detail in connection with the different diseases. It is desirable, in this preliminary paragraph, to emphasize the statement that the treatment of malignant neoplasms, to be curative, must involve the complete eradication of the growth. In view of the inherent ten- dency of these growths to invade the neighbouring tissues, some slowly, others rapidly, the operation should, manifestly, be undertaken as soon as the malignant character of the growth is determined. So long as the neoplasm remains within operable limits, nothing short of its com- plete extirpation should be contemplated or attempted. When, how- ever, it has passed the operable limit, and has invaded structures and organs that can not be dealt with surgically without an immediate fatal issue, the patient should be subjected to palliative treatment. The rule formerly entertained and adopted, that mild measures should be employed in incipient cases and radical measures only in advanced cases, should in the interest of humanity be absolutely reversed. Syncytioma malignum, known also as deciduoma malignum, malig- nant placentoma, carcinoma syncitiale, sarcoma deciduo-cliorio-cellulare, deciduo-sarcoma, cJiorio-epitheliom^a, is a degenerative malignant disease of the sarcomatous type, originating in the decidual structures of the pregnant woman, and tending to a rapidly fatal issue (Fig. 180). Maier published in VircJioiv's Archives for 1875 two observations on tumours of the body of the uterus; the tissue composing the tumours 426 NEOPLASMS OF THE UTERUS 427 was distinctly decidual in character. Hegar subsequently reported the death of one of these patients from what he considered to be cancer of the uterus. Sanger, in 1888, was the first to demonstrate this disease, and, in 1893, to draw attention to its essential histoge- netic character and to its pronounced malignant tendency. A number of cases have since been reported in various countries, and special studies of the disease have been made by Whitridge Williams in America {Amer- ican Journal of Gynecology and Oistetrics, June, 1895), and Eoger Williams in Eng- land. Maurice Cazin {La Gynecologic, February, 1896) made a careful study of the disease and did much to elucidate its jDathology. The literature of the subject has already grown voluminous. Pathology. ■ — • These tu- mours of the uterus when first observed gave rise to a great deal of confusion as to their true nature and histo- genetic classification. There are not yet a great many cases of this kind on record, because our attention has only recently been drawn to them. Syncytioma is found in the uterus after delivery at full term, abortion, or mole pregnancy. It forms soft tumours, bleed- ing easily, variable in size, generally roundish and small, very malig- nant, and with a tendency to form early distant metastases. The sub- ject of these tumours has been treated in our country in articles by Bacon, Williams, and Gaylord. These neoplasms are derived from the chorion epithelium of the placenta and they are therefore of foetal origin. On account of this fact they form one of the most peculiar malignant neoplasms met with. We have here a tumour spreading in the mother, which has taken its origin from foetal structures. There are of course quite a number of writers who assert that the syncytium of the placenta is of maternal origin. Herzog, from his own work on the histology of the placenta and from the recent contributions of Van Heukelom, His, Peters, and others, is convinced that the syncytium is derived from the foetal ectoderm, and he therefore classifies syncytioma malignum under epiblastic epithelial neoplasms. Histology. — The tissue of these tumours shows protoplasmic masses in which are seen many nuclei, without, however, any cell boundaries being recognisable. Those masses very much resemble syncytial buds (Fig. 181). There are also found cells having the character of those Fig. 180. — " Syncytioma malignum ... is a de- generative malignant disease of the sarcomatous type." — Heezog (page 426). 428 A TEXT-BOOK OF GYNECOLOGY Fig. 181. — " These masses very much resemble syncytial buds." — Herzog (page 427). of the Langhan's layer of the normal placental villi. Between the tracts of tumour cells are large open spaces filled with blood, and resembling more or less in character the intervillous spaces of the placenta. The syncytioma malignum, in other words, represents to a certain extent an atypical imitation of normal placental tissue. There are sometimes present whole chorionic villi, but all the tumour cells and structures always deviate from the normal placental type by marked anaplastic features. The causes of this disease are ob- scure. It is a suggestive fact, however, that of the 15 cases tabulated by Mar- chand, 12 gave clear histories of previ- ous "mole" pregnancy. Macnaughton Jones states that hydatidiform mole has been observed in 45 per cent of the cases. The conclusion is, therefore, forced upon us that this form of intrauterine infection predisposes to the disease, which conclusion may further prove suggestive in regard to the general bacterial or parasitic origin of malignant diseases. Be- yond this suggestive fact, the etiology of malignant degeneration of the decidual structures is shrouded in as deep a mystery as that of other malignant diseases. The symptoms of syncytioma malignum can not be said to be pa- thognomonic. The most significant symptom is severe, intermittent hemorrhage, following labour or abortion. This may occur imme- diately after the uterus has been emptied; or it ma}^ be delayed for some time, in which case its onset will be attended by the discharge of an hydatid mole. After the hemorrhage ceases, a foul-smelling dirty-coloured watery discharge generally ensues. Pain may or may not be present; but when it does exist, it is frequently provoked by efforts of the uterus to expel clots. The patient is generally cachectic, loses flesh rapidly, and speedily shows signs of advanced ansemia. Exploration of the pelvis will reveal a uterus more or less enlarged, even beyond what might be expected under ordinary circumstances at the same period following delivery. The cervix is generally found open, although this is far from a constant condition. Digital explora- tion of the uterine cavity will reveal coagula beneath which are found soft vegetating masses. Cazin calls attention to the fact that the neoplastic products are frequently of such consistence that they may easily be mistaken for clots. The enlarged uterine wall is oedematous and nonresistant, and may, therefore, be perforated with facility in the course of examination. The diagnosis of syncytioma must depend, so far as the clinical features of the case are concerned, largely upon the history of NEOPLASMS OF THE UTERUS 429 pregnancy followed by parturition at term or by abortion; or, par- ticularly, the history of hydatid mole. Due attention should be given to the symptomatology just recorded; the exact character of the genera- tive process, however, can be determined only by microscopic examina- tion of some of the tissue. This may be easily removed in some cases by the finger, in others by the curette. Another diagnostic sign of importance in cases of longer standing is the occurrence of metastases. These migrations, in consequence of the special tendency of this dis- ease to invade the blood vessels, are manifested at an earlier stage than in other malignant diseases of the uterus. The treatment must consist of nothing short of the complete removal of the uterus and adnexa. (See Vaginal Hysterectomy.) This should be done as quickly as the diagnosis can be made. It should be remem- bered, however, that metastases occur very early in the history of these cases, and that, if their existence is detected, the operation offers the patient no hope and is, therefore, unjustifiable. Roger Williams tabu- lated 14 cases of this disease that had been treated by vaginal hysterec- tomy; of these, 12 recovered from the operation, while 2 died; of the 12 primary recoveries, 5 died with recurrence within the first year; 6 of the remaining 7 were free from recurrence ten, nine, seven, seven, five and one half, and three months, respectively, after the operation; nothing was said of the after-condition of the other patient. Adenoma uteri, otherwise designated adenoma malignum, or ade- noma malignum carcinomatosum uteri, is a malignant degeneration of the endometrium possessing individual characteristics but having a tendency to assume the carcinomatous type. To Matthews Duncan probably belongs the distinction of first having directed attention to this disease, although at the time of his first report its histogenetic character was not recognised. Breisky and Eppinger reported undoubted cases in 1877, at which date the real literature of the subject commences. Veit was the first to demonstrate that what appeared primarily to be simple, benignant adenoma, might become a veritable adeno-carcinoma possessing all the characters of malignancy. In America, Thomas and Groodell were among the first to report cases of 'apparent malignant adenoma, while Mann was among the first to give a clear elucidation of the disease. Coe's contributions to the subject have been of great value. This neoplasm is looked upon by Herzog as probably not different from a carcinoma of a more common type, although it shows such characteristic histologic features that it is now generally classified separately. Glandular hypertrophy of the uterine mucous membrane may reach a very high degree, so that one might feel inclined to speak of it as an adenoma; and it has been asserted that such extensive glandular hypertrophies have a tendency to change into an adenoma malignum. Yet tbis assertion so far lacks proof. Typical adenoma malignum of the uterus, as shown in Oliver's case (Fig. 182), does not, as a rule, present a well-circii inscribed tumour, but a general diffuse 430 A TEXT-BOOK OF GYNECOLOGY thickening of the mucous membrane which has an irregular, juicy, velvety appearance. The uterus is generally moderately enlarged in all its dimensions. In very high degrees of glandular hypertrophy, we find the uterine glands often quite tortuous, divided twofold or threefold and invaginated upon themselves. In adenoma malignum the picture becomes still more com- plicated. The rapid pro- liferation of the glan- dular epitheliimi leads to one of two conditions. Either the newly formed epithelia grow toward the lumen of the gland, and in their growth carry inward toward the glandular axis the base- ment membrane, ade- noma malignum inver- tens (Fig. 183); or they grow outward, away from the axis, and then an adenoma malignum evertens is formed. Of course these two types may be more or less com- bined. It is not easy to form a clear conception of the microscopic pic- ture of these tumours even from a very minute description. Gebhard (PatJiologisclie Anatomie der W6ihliche Sexualor- gane, 1899), describing them in detail, states that nobody, even after studying a full description, should imagine himself able to distinguish every adenoma malignum from a glandular hypertrophy. Only a good deal of microscopical ex- perience can give safety in this respect. Herzog, who has examined sev- eral cases of adenoma malignum, saw one among them operated on by Henrotin which showed a very interesting histologic combination. The uterine mucosa showed the typical picture of an adenoma malignum, except in those parts where the tumour had extended into the cervix. Here were found regular solid alveolar cell nests, and it appeared that the epithelia were squamous in character. Herzog believes that there existed primarily an adenoma malignum of the corporeal mucosa. The Fig. 182. — " Typical adenoma malignum of the uterus as shown in Oliver's case." — Herzog (page 429). NEOPLASMS OF THE UTERUS 431 malignant process secondarily infected the cervical mucosa where it localized itself in squamous epithelia present there, either by a process of metaplasia or by one of substitution. The symptoms of adenoma uteri are not clearly defined, none of them being characteristic of the disease. The first fact of importance is the relative chronicity, adenoma being the least active of the various malignant degenerations of the uterus. The patient will, therefore, give a history cov- ering a longer period of time than would be the case if she were afflicted with carci- noma. Coe maintains that there is less pain, that the hemorrhages are less fre- quent and less profuse, and that the intervening watery discharges are less offensive, than in carcinoma. The dis- ease is not prone to metasta- tic manifestations, which oc- cur late, if at all. They were entirely absent in four of Coe's cases. The diagnosis depends upon the symptoma- tology above indicated, and upon the detection of papillomatous growths in the interior of the uterus. If uterine scrapings are examined by the microscope the result is likely to be negative, which would not be true if the disease were car- cinomatous. Adenoma is an insidious disease that runs a slow course of invincible malignancy. It is important that the relative good health sustained through a long period by patients with this disease, should not be construed as an evidence of even a tendency to recovery. The profuse hemorrhages, the intervening discharges, the pain and tender- ness, may disappear for a time, only to return a little later with added violence. The treatment, to be on the side of safety, should be arranged with- out reference to any remaining pathological question relative to the ex- istence, respectively, of benign and malignant adenomata, and should be based upon the axiom of Coe, viz.: " There is only one variety of true adenoma of the corpus uteri, and that is, both clinically and anatom- ically, malignant." In no other way can a patient be given the benefit of the doubt, at least, until the pathologists themselves can distinguish between the two alleged varieties, and can furnish to the practitioner the criteria by which he can tell the one from the other. Eepeated curetting is conceded to augment the malignancy of the disease, while the use of the galvano-cautery is equally objectionable. Complete ex- FiG. 183.— "The newly formed epithelia grow to- ward the lumen of the gland, and in their growth carry inward the basement membrane." — Hee- zoG (page 430). 432 A TEXT-BOOK OF GYNECOLOGY tirpation of the uterus is the only means that offers safety to the patient. (See Vaginal Hysterectomy.) The tendency to recurrence after opera- tion is less in this than in other malignant diseases of the uterus. Sarcoma uteri is a malignant neoplasm having its origin in the connective tissue of the uterus, and is characterized by an atypical pro- liferation of connective-tissue cells in a fibrous stroma. It occurs less frequently than carcinoma of the uterus. The first case was de- scribed by Mayer in 1860, the diagnosis being confirmed by a micro- scopic examination of the specimen by Virchow, but nine cases were recorded during the next eleven years. Since that time, however, much attention has been given to the subject, and the condition has a definite place in pathology and surgical therapeutics. Sarcoma of the uterus is not a disease of relatively frequent occur- rence. Franque reports only 16 sarcomata to 301: carcinomata of the uterus out of 3,366 cases seen during ten years at the Wiirzburg gyne- cological clinic. It occurs as a rule in middle and later life, but there have also been reported some cases in very young children. (See Causes.) It may develop primarily in the mucous membrane or in the muscular coat. Its seat may be the vaginal portion of the cervix, the cervix proper, or the body. The latter is more fre- quently the seat of sarcoma than the other parts of the womb. Sar- coma of the mucous membrane forms flat, irregular, roundish, or polyplike masses. In some cases the malignant new growth may spring from a small circumscribed spot and form a growth which macroscopically can not be distin- guished from an ordinary polypoid hypertrophy of the mucous mem- brane. It is of practical impor- tance to keep this in mind, because there are several examples on rec- ord where such harmless-looking polyps were removed, a micro- scopic examination not being made. Shortly after removal, quite unexpectedly, a rapidly growing malignant sarcoma made its ap- pearance. Microscopic examination of such polyps will, of course, reveal their nature. Sarcomata of the uterine mucous membrane are as a rule quite soft in consistence and have a tendency to spread rapidly. They may develop in the uterine cavity and even become pedunculated. Fig. 184. — "They may develop in the uter- ine cavity and even become peduncu- lated, as shown in a case of Eeed's." — Herzog (page 433). NEOPLASMS OP THE UTERUS 433 as shown in a case of Eeed's of which George E. Jones made a sketch (Fig. 184). They then infiltrate the nmscularis diffusely, and, when at the same time superficial sloughing takes place, as it frequently does, one is not able to ascertain definitely whence the malignant neoplasm originally started. A peculiar form of sarcoma of the mucosa is one sometimes found arising from the cervix. These sarcomata are of a papuliferous type, and, since the papilla are hypertrophic, the whole growth looks very much like a hydatid mole. Primary sarcoma of the uterine wall generally begins as multiple nodules or roundish masses. It likewise usually rapidly infiltrates the muscularis and the mucosa and soon leads to destructive processes in the latter. These malignant connective-tissue tumours, when growing in the uterus, frequently have the tendency to close the os internum in a valvelike manner. This leads to one of the constant objective symptoms of sarcoma of the uterus, namely, periodical discharges of an accumulated bloody-watery fluid. Sarcoma of the uterus spreads by continuity and not infrequently leads to a marked enlargement of the uterus in all its dimensions. There may, however, also occur a thinning of the uterine wall with inversion. Such a case has been reported by E. Williams. Distant metastases sometimes take place. Secondary sarcomatous degeneration of prima- rily benign myomata has been mentioned above. The histology of sarcoma uteri is that of these malignant connective- tissue tumours in general. The neoplasm may be composed of small or large round cells, spindle cells, and giant cells. The tumour cells as a ru^le take their origin from the adven- titia of blood vessels, and they proliferate diffusely in an infiltrating manner. A regular alveolar structure, like that of carcinoma, is rarely found. The sarcoma- tous tissue is very rich in blood vessels and free hemor- rhages are found. K is some- times difficult to distinguish a beginning sarcoma of the mucous membrane from a profound endometritis inter- stitial is. The expert, how- ever, will be able to make a diagnosis from the finer cyto- logic characteristics of the neoplasm. In sarcoma of the uterus, the tumour cells show marked variation in size and shape and they present atypical karyokinosos, such as multipolar figures, hyperchromatoses, nuclcMr fi-agmentation, etc. (Fig. 185). Ilerzog {Transactions of the 2i) Fig. 185. — "In sarcoma of the uterus the tumour cells show marked variation in size and shape, and they present atypical karyokineses." — Herzog. 434 A TEXT-BOOK OF GYNECOLOGY Chicago PatJioIogical Society, vol. iii, 1899) has described a sarcoma of the uterus showing a number of interesting histologic features; among them numerous atypical karyokineses and the presence of a large number of phagocytic cells. These, which are not to be confounded with leucocytes, are large tissue cells in the interior of which lympho- cytes, leucocytes, and red blood corpuscles, intact or in various stages of dissolution, are found. Secondary degenerations in sarcoma of the uterus are usually marked and appear quite early. Hemorrhage is one of the most con- FiG. 186. — " . . . The tumour, which was distinetly sarcomatous, was retroperitoneal, occu- pied the whole pelvis, and lifted the uterus quite to the umbilicus." — Reed (page 435). stant occurrences and it leads to the destruction of the neoplastic tissue. Besides such apoplectic destruction we find fatty, hyaline, and colloid degeneration. Our knowledge of encloikelioma of the uterus is still very meagre. Cases have been reported by Amann, Braetz, Gebhard, Grape, McFar- land. Pick, and Veit. These malignant tumours, in their macroscopic NEOPLASMS OP THE UTERUS 435 characters, are similar either to the sarcomata or to the carcinomata. The cases reported occurred in women between the ages of eighteen and fifty-two years. The endotheliomata take their origin from vascu- lar or lymphatic endothelial cells, and are more or less alveolar in structure. The researches of Kleinschmidt and Kahlden indicate that sarco- mata may arise from the connective-tissue elements of the blood vessels and lymphatics in the parenchyma of the uterus; while Virchow, Eo- kitansky, and Schroder, recognise that fibromyomata may undergo sarcomatous degeneration. (See Fibromyomata.) There is abundant evidence, however, that sarcomata, originating in the parenchyma and abounding in round and spindle celled elements, may possess sufficient fibrous stroma to give them a consistence by which they may be mistaken for fibro- mata. The so-called " recurrent fibroids " belong to this class. Some of them grow to enormous size. A case reported by Ott {Annales de gynecolo- gie et cV obstetrique) which had been op- erated upon by Le- bedeff, three years previously, and was followed by appar- ent cure, developed a retroperitoneal tu- mour which lifted the uterus nearly to the umbilicus. Eeed op- erated upon a similar case (Fig. 186) in the Cincinnati Hospital (1900); the tumour, whicli was distinct- ly sarcomatous, was retroperitoneal, occu- pied the whole pelvis, and lifted the uterus quite to the umbilicus. After the removal of the tumour with the uterus, the latter seemed relatively small as it was seen perched upon the mass (Fig. 187). The fiympl.om.fi of sarcoma of the uterus are hemorrhage, offen- sive discharge, and pain, difl'oi'ing in no essential particular from the symptoms of carcinoma. Pain does not occur as a rule in the earlier Fig. 187. — " After the removal of the tumour with the uterus, the latter seemed relatively small as it was seen perched upon the mass." — Eeed. 436 ' A TEXT-BOOK OF GYNECOLOGY stages of the disease, but is very constant in the later stages. The uterus is generally enlarged and if kept under observation will be found to increase more raj^idly than in true carcinoma. If the cervix is dilated to a degree sufficient to permit of digitation of the cavity, the neoplasm, if originating from the connective tissue of the endometrium, and if of the distinctly round-celled variety, will be soft and friable. In the majority of cases, it will be impossible to distinguish sarcoma from carcinoma, withput a microscopic examination. The more solid sar- comata of parenchymatous origin have about the same morphology as fibroids, from which they are distinguishable, as a rule, only by their more rapid growth; and even this point may be misleading when a tumour of the strictly myomatous type, in consequence of pressure, becomes suddenly oedematous. In-view of the fact that rapidly-growing solid tumours of the uterus are sometimes distinctly sarcomatous from the start, and, in view of the fact that those which are myomatous in the beginning may undergo sarcomatous degeneration, it is safer to look upon all of them as essentially malignant. The causes of sarcoma of the uterus are not determined. The fact that it is a disease of the extremes of life, and especially of old age, would indicate that age is a possible factor. It is difficult to reconcile the evidence on this point. Thus Eoger Williams finds that instances have been reported by Farnsworth at thirteen months, by Pick at two years, by Ahlfeld at three years and four months; and at various ages by Hereford, Clay, and Pick. Of 73 cases, by Gusserow, 4 began under the age of twenty-nine; 5 began from twenty to thirty; 15 began from thirty to forty; 38 began from forty to fifty; 18 began from fifty to sixty; 3 began above sixt3^ Pregnancy and the marital relation do not seem to exercise much influence. Of Gusserow's 73 cases, 35 were pa- rous women, who, between them, had borne fifty-one children; 25 of his cases were absolutely sterile, 4 of them being virgins. There is no evidence that even in parous women the traumatism of parturition bears any relation to this disease. The treatment of sarcoma, like that of other malignant diseases of the uterus, must consist of such means as will secure its complete eradi- cation. This can be accomplished only by the extirpation of the uterus. (See Vaginal Hysterectomy.) The disease is one of the most malig- nant and should, therefore, be attacked as soon as detected. An at- tempt has been made to treat sarcoma of the uterus, as of the more suj)erficial structures, with the toxines of er3^sipelas and the Bacillus prodigiosus. Coley, who is largely responsible for the introduction of the treatment, calls attention to the fact that collapse is liable to occur from too large a dose, especially when injected into a very vascular tumour, and that pysemia has resulted from the use of the serum. The toxines, to be of value, must be prepared from highly virulent cultures of the streptococcus of erysipelas. They seem to act upon sarcoma by inducing a rapidly progressing necrobiosis with fatty degeneration, to secure which the toxines are to be injected directly into the tumour. NEOPLASMS OF THE UTERUS 437 This treatment should never be employed in a ease amenable to opera- tion, while in one not amenable, any treatment which seems to rest upon a logical basis is justifiable. Franque reports that in 16 cases of sar- coma occurring at the Wiirzburg clinic, 1 case remained cured for five 3^ears after three operations. Another case was free from recurrence after two years and 4 remained well for one year. Two died on the table after operation. These results are more satisfactory than those reported by Eogivue, in 50 cases treated by hysterectomy. Of these but 3 remained cured, 33 were known to have had a return of the disease, 2 of them within a year after the operation. Carcinoma uteri is a malignant growth, consisting of epithelial cells embedded in a stroma of embryonal character, and of either congenital or post-natal origin. It is an affection which was known to Hippoc- rates and other ancient medical writers. The uterus is probably the most common seat of carcinoma in the human body, although older statistics give the stomach the first place. However, when these statis- tics were compiled, some affections of the uterus really carcinomatous in nature, such as the so-called papillomata and cauliflower excrescences, were not counted in their proper places. According to the statistics of the Eegistrar General, there died in England from cancer between 1847 and 1861, 87,348 persons. Of these, 25,633 were males and 61,715 females. About 25,000 of the latter succumbed to cancer of the uterus. It is now asserted that carcinoma in general, and carcinoma of the uterus in particular, is frightfully on the increase. Park has recently attempted to show the correctness of this assertion so far as one sec- tion of our country is concerned. Dlihrssen (Die Verhuetung des G-ebarmutterkrebses, Medicinische Woche, 1899), in commenting upon the horrible increase of cancer of the uterus, states that 25,000 die annually in the German Empire from carcinoma uteri, or three times as many as die in childbed from all causes. This author thinks that only from 10 to 30 per cent of all cases in Germany are still amen- able to operation when a definite diagnosis is first made, because it is, as a rule, made too late. He therefore recommends that women be made acquainted, through popular writings of medical men, with the dangers of carcinoma of the womb; further, that every means should be tried in every single case to arrive at a correct diagnosis early. After this is made, everything possible should be done to induce the patient to submit to an immediate operation. Winter (LeJu-huch der Gynd- kologischen Diagnostik, Leipzig, 1897, p. 216) upon this subject says: " The diagnosis of carcinoma of the uterus is the most responsible the physician is called upon to make. The price for every failure of diag- nosis, or for a diagnosis made so late that the cancer has already become unsuited for operation, is a human life. Under all circumstances, and with all means at our disposal, we must strive to diagnose cancer at the very first examination. To wait in a suspicious case until destruc- tive properties become manifest, as was so frequently done formerly, is to-day a most serious mistake." 438 A TEXT-BOOK OF GYNECOLOGY The above quotations are here cited to impress the student and practitioner with the importance of the earliest possible diagnosis of carcinoma of the uterus, in which alone lies the only possible salvation. After the very earliest stages, cases have, as a rule, become unsuited to operation and are beyond human aid. Cancer of the womb is rare before the age of thirty, more common between the fortieth and sixtieth years. It drops again after sixty years, but not so much on account of its real infrequency at that period, as on account of the smaller number of females alive after that age. Married life and childbirth have an obvious influence upon the liability to carcinoma. An hereditary predisposition is likewise manifest. PatJwlogy. — Carcinoma of the uterus may take its origin froiji the portio vaginalis, the cervix proper, or the body of the uterus. Carcinoma of the fortio vaginalis is variable in its macroscopic charac- ters, and a good deal in this respect depends upon the rapidity and the intensity of secondary, retrograde, destructive processes. The cauli- flower excrescences, or polypoid carcinomata of the portio, arise from the lips, and form either broad bases or somewhat constricted pedunculated tumour masses, v^arying in size from a hazelnut to an apple. The sur- face of these neoplasms is never smooth, but uneven with crevices and clefts. It may be pale and whitish or of a pinkish tint, but the colour of the tumour itself is generally hidden from view by a dirty, sero- purulent, bloody, greenish or yellowish, secretion. In another form of carcinoma of this part of the uterus, we find a difi'use infiltration and hardening of the portio. In early stages, ulcerations may be en- tirely absent and the surface may be smooth. When this form begins to ulcerate there may be present shallow ulcers only, while in the forms first described, the ulcerations usually lead to great destruction of the tissue and form craterlike cavities. In spreading, carcinoma of the por- tio vaginalis generally first reaches and then infiltrates the vaginal walls. Early spreading into the cervical mucous membrane is rare. Involve- ment of the corpus uteri in primary carcinoma of the portio is quite rare. In their further growth these cancers infiltrate the lateral para- metrium. The bladder is, as a rule, reached only late, and then from the anterior vault of the vagina. Involvement of the rectum is rare. The lymphatics involved are those following the course of the iliac vessels. Carcinoma of the cervix takes its origin from the surface or from the glandular epithelium of this part. It usually begins as a cir- cumscribed nodule or as a diffuse infiltration, involving either part or the whole of the circumference of the cervix. A very marked infil- tration formed in this manner may then ulcerate and lead to extensive loss of substance and excavation. Or, there may be from the start a slight degree of infiltration only, with early shallow ulcerations and destruction of the superficial layers. Spreading goes on from the cervix in the direction of the body. It may have the form of a super- ficial ulceration along the corporeal mucous membrane, or it may be a diffuse or circumscribed lymphatic infiltration into the uterine wall. NEOPLASMS OP THE UTERUS 43^ Spreading over the vaginal mucous membrane rarely, if ever, occurs, "but later on, an infiltration of tlie deeper layers of the vaginal walls is common. The pelvic connective tissue is generally invaded from the deepest part of the growth. The bladder is often involved early, the rectum, as a rule, late. Lymph-gland involvement is similar to that in carcinoma of the portio. Carcinoma of the tody of the uterus starts from the corporeal mucous membrane. In the diffuse form the whole mucous membrane is more or less involved and, in places, infiltrated with thicker roundish or irregular nodules. The further development of the new growth en- larges the corpus uteri in all its dimensions and the cavity becomes markedly enlarged so soon as ulcerative processes and sloughing set in. Sometimes there may be only a circumscribed limited carcinomatous process, while the major part of the mucous membrane is not involved. The polyjjoid form of carcinoma of the body is rare. When carcinoma of the corpus in its extension reaches the outer zone of the body, ad- hesions to surrounding jDarts become frequent, particularly to the intes- tines, which may become perforated by carcinomatous growth. In- volvement of the bladder and the rectum occurs late, as a rule. The lymph glands generally first involved are the lumbar glands in the neighbourhood of the aorta. There may be in all forms of carcinoma of any part of the uterus, an unusual involvement of lymph glands in consequence of reversed metastatic transport. Histology. — Carcinoma of the uterus is a malignant atypical neo- plasm arising from epithelial structures and showing, as a rule, the well-marked alveolar arrangement so characteristic of cancer. Since we find two different kinds of epithelia in the uterus we also find car- cinomata differing in the types of their cells. The cancers spring- ing from the portio are almost invariably squamous-celled carcinomata. The epithelfa lining the portio proliferate rapidly, and infiltrate the underlying connective tissue in the form of pegs or columns or pillars of cells. These cells in proliferating vary a good deal in shape, and deviate from the type from which they originally sprang. In the cervix where we normally have no squamous, but only cylindrical cells, we likewise find besides columnar-celled cancers, squamous epithelial carcinomata. This is probably not so much due as some believe to a preceding or coinciding metaplasia of the epithelia, as to a preceding substitution by which the columnar epithelium has been replaced by that of a squamous type (Fig. 188). Carcinoma of the cor- pus consists, as a rule, of epithelia of the columnar type. But it must be kept in mind, that as soon as we have a well-developed alveolar arrangement in the neoplasm, the epithelia have become so atypical in shape and size that one can speak with propriety, neither of colum- nar nor of squamous cells; the latter under these considerations also lose thfir prickles. It is very difficult to distinguish between glandular hypertrophy and beginning carcinoma. Eecourse must be had to atypical mitotic 440 A TEXT-BOOK OF GYNECOLOGY figures which always speak strongly for tumour formation. These features have been more fully mentioned above under the head of Sar- coma Uteri. Amann {Mikroskopische Gynakologisclie Diagnose, Wies- baden, 1897) attaches a good deal of significance to the direction of the polar spindle with reference to the surface on which the epithelia are situated, in the matter of diagnosis between simple hy- pertrophy or malignant neo- plasm. It is impossible here to go into the finer details of the microscopic diagnosis of carcinoma. In a well-devel- oped case, when it is, how- ever, usually too late to op- erate, the histologic picture is so typical that even a tyro can make a microscopic diag- nosis. While, on the other hand, in the very beginning, when there is still time for a hopeful operation, it often requires delicate fixation, ex- act orientation, and general careful preparation of the microscopical material, to enable even the expert to arrive at a definite conclusion. In trying to get at the latter it is perhaps better, as stated by Herzog in a paper on The Microscopic Diagnosis of Uterine Scrapings, to err on the side of too great a readiness to see atypical and malignant features, instead of being too ready and prone to overlook the former and to se^ only hyper- plastic processes; particularly, since the suspected cases, as a rule, with few exceptions, occur in women at a period when the uterus has ac- complished its object as a fruit bearer, and when its removal is not objectionable from physiological and social reasons. The causes of carcinoma of the uterus are by no means determined. The disease is liable to occur at any age. Pozzi mentions a case by Ganghoffer, of a child nine years old, who died from medullary carci- noma. Gusserow accumulated the records of 3,385 cases showing the age at which carcinomatous diseases began, as follows: Fig. 188. — "The columnar epithelium has been replaced by that of a squamous type." — Heezog (page 439). 17 years 1 case (Glatter). 19 years 1 " (Beigel). 20 to 30 years .. . 114 cases. 30 to 40 years... 770 " 40 to 50 years 1,196 cases. 50 to 60 years 856 " 60 to 70 years 340 " Above 70 years 193 " Pozzi maintains that poverty is a predisposing cause of carcinoma, and supports his contention by the statistics of Schroder, showing that the disease is 1.5 per cent more frequent in the charity wards of the NEOPLASMS OF THE UTERUS 441 hospitals than in private practice. These statistics are sustained by the observations of A. Martin. Dlihrssen^ on the other hand, quotes Eoger Williams approvingly to the effect that uterine cancer is not, as was believed, more frequent in the lower classes, but that predis- position to this disease is given by the over-feeding and comfortable position of those in better circumstances. Duhrssen further asserts that more women die annually in Germany from carcinoma than there were soldiers killed in the entire Franco-Prussian War, the mortality ranging from 0.5 to 1.0 per thousand; and that all classes alike are susceptible to the disease. The traumatisms of parturition have been looked upon as causes of carcinoma of the uterus; while the frequent observation of commencing cancer at the site of an old laceration, and the well-known tendency of cicatricial tissue to undergo malignant degeneration, have been quoted in support of the theory. Statistical tables bearing upon this point are valueless, in view of the fact that the majority of women are married and have children, and of the additional fact that individual cases are constantly occurring in unmar- ried and continent women. The question of the parasitic origin of carcinoma of the uterus in- volves the question of the germ origin of carcinomata in general. Edmund Andrews has conducted a series of investigations touching this point from which he concludes that, other things being equal, primary carcinoma is most frequent on those surfaces which, by their position, would be most accessible to free swimming microbes or spores derived from without the body; that the liability to cancer is increased if the epithelial surface is so situated that the spores can remain upon it for at least some hours without being washed away; and that the liability to cancer is great if the membrane has vast numbers of deep glandular follicles into which the spores can penetrate, and lie free from disturbance, and gain direct access to the more delicate epithelial cells. He has made an interesting computation showing the liability of different surfaces to carcinoma in proportion to their exposure to germs and their ability to afford to them an undisturbed lodging, by which he arrives at the conclusion that the cervix uteri is 5,776 times more liable to cancerous disease, than is a similar area of intestine, which he computes at unity and uses as a standard for comparison. It is interesting to note that the vagina is as 61 to 1 and the vulva as 364 to 1 in the same scale. A number of culture and inoculation experiments have been made with reference to demonstrating the bacterial origin of carcinoma. Francke {Muncliener medicinisclie WochenscJirift) be- lieved that he had confirmed the alleged discovery by Scheurlen of a bacillus of carcinoma. This bacillus was described as being 2 micro- millimetres long and 0.4 micromillimetres broad, and as producing in culture media a reddish-brown pigment. Subsequent investigation, however, failed to substantiate the claims of this bacillus to recognition as the essential organism of carcinoma. While this organism has not been isolated, evidence points in the direction of a bacterial origin of 442 A TEXT-BOOK OP GYNECOLOGY this disease. Hanan (Fortschritte der Medizin) transferred small por- tions of the secondary growth in the inguinal and axillary glands of a white rat, dead from carcinoma of the vulva, to the abdominal cavities of two other rats; one of these animals died at the end of two months, and there were found in its omentum fully developed nodules rich in the cellular elements of carcinoma; while in the other animal there were evidences of a successful vaccination of carcinoma. The repetition of these and similar experiments, especially by Italian investigators, has confirmed the inoculability of carcinoma, although the precise ele- ment upon which this inoculability depends has not yet been deter- mined. The most that can be concluded at present is, that the evi- dence points in the direction of the bacterial origin of carcinoma. The investigations now in progress under the supervision of Eoswell Park bid fair to result in more definite conclusions. The symptoms of carcinoma of the uterus are uncertain and indefi- nite in the earlier stages, the disease in the majority of instances being exceedingly insidious in its onset. Pain is rarely present until after the disease has made considerable j^rogress. When it is located in the cervix, the first symptom to arrest the attention of the patient will be a persistent watery discharge slightly tinged with blood; this may or may not be associated with foetor. A little later, the discharge be- comes distinctly sanguineous, and, as the disease progresses, irregular and violent hemorrhages occur. The uterus by this time generally becomes more or less painful — particularly if the endometrium is in- volved, or if there is an upward extension of the disease from the cervix. The occurrence of hemorrhage at the menopause, or following it, should be regarded with suspicion, and should always be the occasion for a careful local exploration. The diagnosis is generally obvious in cases of carcinoma involving the cervix. The finger will at once detect an enlargement of that segment of the womb; if in the earlier stages, the tissues will seem nodular and indurated; if in the later stages, after disintegration sets in, the surface will be irregularly granular and friable, bleeding upon the slightest touch. At this stage, to the experi- enced surgeon, the odour of the discharges is so characteristic that a diagnosis is made, as a rule, before the examination is begun. In cases of carcinoma involving the corpus uteri, diagnosis will be based, first, upon their rarity, and, next, upon the microscopic examination of some of the tissue removed. In all cases of suspected cancer of the uterus, when the disease is not so advanced that the diagnosis practically de- clares itself, a microscopic examination should be made of a piece of tissue removed from the diseased area. This is especially true when the disease is in its incipiency, manifesting itself by either an indurated nodule or a circumscribed erosion of the cervix. It is not important, from a practical point of view, to distinguish between carcinoma and sarcoma of the uterus, as the treatment is precisely the same in either case. As a matter of scientific interest, however, the investigations of Adamkiewicz {C entraTblatt filr die medicinisclien WissenschafUn, Berlin) NEOPLASMS OF THE UTERUS 443 are worthy of attention. He has endeavoured to establish distinctions between carcinoma and sarcoma by inoculation experiments. If fresh carcinoma tissue is implanted in the brain of an animal — preferably a rabbit — the animal will die in the course of two or three days, with severe lesions only to be explained by migration of the elements of the implanted carcinoma tissue into the interstices of the brain substance, and subsequent production of patches of inflammation and necrosis. Carcinoma tissue also responds with a typical reaction to " cancroin,'^ the trimethylvinylammoniumoxydhydrate base of neurine, the specific poison which kills the carcinoma coccidium. Adamkiewicz therefore suggests as an infallible means of distinguishing carcinoma to implant a scrap of the suspected tissue in a rabbit's brain. If it is not carci- noma, the tissue will be absorbed and the animal will remain in its usual health. This and the absence of the cancroin reaction indicate a non- carcinomatous character for the neoplasm. There are many complications of cancer of the uterus. Carci- noma may occur in a myomatous uterus; while myomata themselves are liable to undergo malignant degeneration — especially of the sar- comatous type. The coexist- ence of various benign and ma- lignant neoplasms in the same uterus, while not frequent, is occasionally encountered. The coexistence of sarcoma, carci- noma, myoma, and polypus, is reported by Keibergal {Archiv fib- Gynakologie, 1896) (Fig. 189). In cases in which car- cinoma or other malignant neoplasms have begun to dis- integrate, mixed infections of the endometrium speedily ensue. Pregnancy as a complica- tion of carcinoma of the uterus is occasionally encountered. It is always a serious compli- cation, and one that is a men- ace alike to the life of the foetus and of the mother. An interesting series of one hun- dred and sixty-six cases of cancer of the uterus, occur- ring between 1886 and 1895, has been compiled by George H. Noble, of y\tlanta, Ca. The complication is one which precludes the pos- sibility of normal delivery, even should pregnancy go to term, while aboi-tion is likely to prove fatal. Eeed has reported {Transactions of Fig. 189. — " The coexistence of sarcoma, carci- noma, myoma, and polypus is reported hy Neiberffal." — Keed. 444 A TEXT-BOOK OF GYNECOLOGY the Ohio State Medical Society) a case in which amputation of the cervix for carcinoma had been done by another operator in the presence of unsuspected pregnancy, and in which the patient was permitted to go to term; when labour began, the cervix was found to be distinctly car- cinomatous — a condition which, in the absence of necessary surgical aid,, speedily resulted in the death of both mother and child. When the cancerous uterus is found to be impregnated, vaginal hysterectomy should be done in the earlier stages of the pregnancy; or, if the woman is permitted to go to term, she should be delivered by Csesarean sec- tion or the Porro operation. Vaginal hysterectomy should be em- ployed so long as there is a reasonable opportunity of delivering the diseased and impregnated organ by that route; the Porro operation (abdominal hysterectomy) should be done in the later stages of preg- nancy, when there is a prospect of removing all of the malignant struc- tures; the conservative Cesarean operation, according to Noble, " ought to be emjjloyed in all cases with obstruction to the birth of the child by extensive exudate, or where there is not a reasonable hope of eradicating malignancy." The question of operative interference after the period of viability has been reached, is one which can not be settled by any definite criteria. The condition ought to be explained to the family and especially to the patient, who should be given an opportunity to choose between the desperate alternatives. The fact should be remembered, that a carcinomatous uterus may be able to carry a pregnancy to term, and that a living child may be born by either the Ceesarean or the Porro operations. At the same time, it should be clearly held in mind that, in consequence of a pregnancy, a carcinomatous uterus may be suddenly provoked to violent and fatal hemorrhage. The time for operation, and the character of the opera- tion, should be determined by the surgeon and the patient in full recognition of these facts. The prognosis of carcinoma if left to itself is that of inevitable fatal- ity. The average duration of life when the disease follows a natural course is from twelve to eighteen months. In cases in which disease is too advanced for radical operation, the conservative treatment by curettement stops hemorrhage and waste, and prolongs life, but, of course, only defers for a time the inevitable termination. Treatment: Palliative. — Topical Medication. — A quarter of a cen- tury ago, when the microscope was not in extensive use, cases of ulceration of the cervix, one centimetre or more in diameter, were encountered, which were looked upon as ulcers, chancres, or begin- ning cancers. It was the custom to treat such cases with lunar caustic, nitric acid, etc., making an application once in four or five days. Carstens has observed eases in which this treatment has been followed by perfect healing, though the disease was certainly not syphilitic. Hence the condition must have been benign or the be- ginning of a malignant growth. On the contrary, in some cases thus treated the patients were apparently cured but died a year or NEOPLASMS OF THE UTERUS 445 two later of cancer. It may be possible that those patients that re- covered permanently had a nonmalignant ulcer; while those who developed cancer in a year or two had ulcers that were cancerous in the first place, but, by the application of caustic, the removal of the neoplastic formation, and the stimulation of healthy granulation, the parts healed, although in the deeper structures cancer cells re- mained, which continued to develop and involve the whole womb and the surrounding structures. In more advanced cases the cervix was removed and then cauterized with chromic acid, pure bromine, mercuric nitrate, zinc chloride, etc. The various pastes and plasters used even to-day by quacks who call themselves cancer doctors, have long been discarded. The basis of all these plasters and jaastes has been either arsenic, lime, or zinc. Any of these preparations placed in quantity on soft tissues will destroy them in various directions and in a most irregular manner that can not be controlled. It was left to J. Marion Sims to put the nonsurgical treatment on a scientific basis, and his method has been followed with very slight modifications ever since by gynecologists. To-day, with all our sur- gical experience, we meet with many lamentable cases which are beyond our surgical skill. All we can do is to relieve symptoms, stop the hemorrhages, prevent the drain on the system, ease the pain, and prolong life. When the uterus is fixed or the broad ligament involved, perhaps even the base of the bladder or the vagina, a vaginal hyster- ectomy is of no use. In such cases Carstens proceeds as follows: All diseased tissues are thoroughly removed with the knife, scissors, or sharp curette, going over the ground repeatedly, so that the appar- ently healthy tissues are reached. When working at the base of the bladder or rectum, great caution must be exercised to prevent per- foration. The hemorrhage may be extensive at first, but as more healthy tissues are reached, the hemorrhage ceases unless the circular or uterine arteries, which may require the application of a ligature or the forceps, are opened. Sims's method was to apply iron perchloride to this large raw sur- face to stop the hemorrhage, removing it in twenty-four hours, and then applying caustic; but, as caustic is the best hemostatic, Car- stens always applies it at once as follows: A piece of absorbent cotton, of a size and shape to suit the cavity and made round or long accord- ing to indications, is attached to a string. This is dipped in a solution of zinc chloride, one ounce, to half an ounce of water. It is then squeezed as dry as possible, care being taken to dry the fingers imme- diately, to prevent damage to them, or, still better, to conduct the whole operation with rubber gloves. Having again dried the cavity, the cotton is carefully placed so that it comes thoroughly in contact with all the raw surface. If it is not dry enough, it will run down the vagina and cause trouble there. To prevent this accident, Sims suggested filling the vagina with absorbent cotton and saturating it will] sofJiiitn l)iciii'l)on;il(' which would immediately neutralize the zinc; 446 A TEXT-BOOK OP GYNECOLOGY but this method is improved upon by Carsteus, who takes a ball of dry absorbent cotton large enough to fill the vagina, and to which also a string is attached, and packs it into the vagina. The upper part catches any little discharge of the chloride of zinc, minimizing its caustic action and limiting it to the upper part of the vagina. In the string attached to the cotton containing the chloride of zinc, one knot is tied. In that attached to the dr}- cotton two knots are tied, in order to distinguish them and to indicate in wiiich order to remove them. This packing is allowed to remain for forty-eight hours, when it is removed and vaginal douches used. The slough that is formed by the caustic comes away in about ten days, often in one large piece, leaving beneath it a clean granulating surface, which rapidly contracts, and frequently entirely closes, except the small fistulous opening tlirough which menstruation can take place. It is astonishing how quickly women will recover and gain strength alter tiiis jjroccdure; the discharge ceases, the appetite improves, and the patient gains in weight twenty or thirty pounds in three months, in the course of time, however, recurrence takes place, sometimes within six months, sometimes not for a yi'ar or more. If the case is carefully watched, the foregoing procedure can be rej)eated at once on recurrence, and, if taken very early, the small point where recurrence takes place can be easily curetted and cauterized without the use of an ana\sthetic. Sec- ondary de])osits in the pelvic lymphatics or those of the intestines or stomach are. of course, beyond reach. Bromine is so volatile and dillicult to handle that it alVords no advantages whatever, and Carstens has entirely discarded it. Formalin has been recommended. Calcium carbide was recommended by the late J. II. Ktheridge, of Chicago, but its u.se in the hands of others yields no more benefit than, if as much as. is derived from the zinc chloride. The technique of the use of these various caustics is the same as that previously given for the zinc chloride. It seems that the latter remedy is the best that can be used in such lamentable cases. Tiie treatment of malignant growths by serum is still in its in- fancy. The consensus of the profession seems to be, thai in cancer it is of no benefit, but that in cases of sarcoma, a limited number seem to be benefited. Carstens lias tried it in quite a number of cases with absolutely no benefit, and it has been used in the hospital under his observation in many cases, for malignant growths of dif- ferent kinds and situated in difTerent parts of the body, without benefit. It has seemed to him that in some cases there is a spontaneous cure of sarcoma. He is sure that he has seen a number of cases in which a disease that had been pronounced sarcoma by various physi- cians, has entirely disappeared. But our knowledge is still so limited that little hope of benefit from serum therai)y can be entertained. If the future discovers the microbe of cancer, as may be hoped, we may hope also that an antitoxine will be produced which will chock the ravages of this terrible disease. NEOPLASMS OF THE UTEllUS 447 Cureltemenl, considered as a palliative measure in advanced cases, is an expedient in favour with many operators. With the patient under an aiuesthetic, the diseased parts may he scraped thoroughly with a Recamier or otiier sharp curette, with the Simon scoop, or with the Thomas spoon-saw. The scraping should be followed by daily vaginal injections with antiseptic solutions. Carstens never practises this method, on the ground that, if he did, he might as well practise cauterization (see ante), which he insists will accomplish more good. Iliyh amputation of the cervix is indicated in cases in which the disease has gone beyond the uterus, and where the discharge is so dis- agreeabk', and tlie hemon-hage so extensive, as to make life a burden. With the brilliant results of to-day, achieved by the complete removal of tlie uterus, so-called "high amputation" is practised but rarely, and should never be employed when the organ is removable. The j)atient, under the influence of an anaesthetic, is placed on her back with her buttocks on the edge of the operating table. After the vagina has been thoroughly cleansed, a retractor is inserted. The diseased parts are grasped with volsella forceps and the cauliflower growth re- moved with scissors, after which the vagina is again cleansed. Then, with a two- or three-pronged volsella forceps, the cervix is seized more flrmly, an incision is made all round the uterus at the junction of the mucous membrane of the vagina and of the cervix; the vaginal mucous membrane is next pushed back with the fingers, or with a blunt dissec- tor, for a quarter of an inch or so, and a conical piece removed from the uterus. The apex of this cone corresponds to the uterine canal. The hemorrhage is quite profuse when the circular artery is cut, and will require ligation of the vessel. Sometimes a simple tvidsting of the artery will be sufficient, but this measure is not trustworthy. The cavity thus produced can be packed with antiseptic gauze, but it is better to treat it with zinc chloride as before mentioned. The radical treatment of carcinoma of the uterus consists in the extirpation of the diseased organ, and of the neighbouring lymphatic glands when they are involved and removable. The operation has been extended in recent years to include the removal of lymphatic glands from the interior of the pelvis, and to the removal of a part or all of the vagina. The uterus may be removed by either the vaginal route (vaginal Jiysteredomij), or by abdominal section {ahdomino- vaginal panhysterectomy). Vaginal Hysterectomy. — The removal of the uterus by the vaginal route is not a new operation, having been performed in a limited num- ber of cases early in the present century by several operators, among whom Osiander, von Langenbeck, and Sauter were prominent. But the technique then practised met with such indifferent success that the procedure was practically abandoned until the advent of antiseptic sur- gery and improved hemostasis. Its revival is due to the work of Czerny in 1878, since which time it has by many operators been given the pref- erence in selected cases over the abdominal route. 448 A TEXT-BOOK OF GYNECOLOGY Instruments for Vaginal Hysterectomy Catheter, glass 1 Curette, small (Sims's modified) 1 Martin's 1 Forceps, long dissecting (Fig. 190) .... 1 Sliort dissecting 2 Long hemostatic 6 Medium hemostatic 6 Small hemostatic 6 Bullet 2 Xeedles, curved (Fig. 191), large 2 Small 3 Medium 2 Transfixion, right curved 1 Straight 1 Needle holders (Fig. 192) 2 Museux's Tolsella forceps 2 Hysterectomy forceps, Pean's curved . 2 Pean's straight 2 Paclier, vaginal (Fig. 193) 1 Retractors, 'large 1 pair. Next size smaller 1 " Small size. 1 •' Scalpels 2 Scissors, long 1 pair. Sharp-pointed 1 " Speculum, Jones's 1 Sims's medium 1 Simon's, with handles and four blades 1 Sound, uterine 1 Sponge holders (Fig. 194) 4 Tenaculum, Cullen's (Fig. 195) Straight Blunt 1 1 1 Round, sharp 1 An angeiotribe or a Skene's electro-hemostatic forceps (see Hemo- stasis), with attachments, should be at hand provided the operator de- sires to avail himself of these means of hemostasis. Technique of Vaginal Hysterectomy.- — The f)rocedure is as follows: The patient, prepared as is usual for vaginal and peritoneal section, is placed in the lithotomy position with the hips well over the edge of the table. The posterior vaginal wall is retracted by means of a Sims or Alvard, or preferably a Jones, self-retaining speculum, exposing the vaginal vault and cervix uteri. The anterior lip of the cervix is seized with the volsella forceps, and the uterus drawn down (Fig. 196), continu- ous irrigation with a solution of bichloride (1 to 4,000) being em- ployed from this point until the peritoneal cav- ity is opened. In septic, and some cancerous cases, the cer- vical canal should be curetted and swabbed with a 95-per-cent solution of carbolic acid. When extensive sloughing of the cervix has occurred, it is best to curette and cauterize it during the preparatory treatment of the preceding week, to eliminate as much debris and septic material as pos- sible from the field of operation. In all cases, curetting and cauteriza- 190. — Dissecthig forceps. — Kobi NEOPLASMS OF THE UTERUS U9 tion is followed by sewing together of the anterior and posterior lips of the OS, effectually closing it against leakage from the affected organ. This is accomplished by three or four interrupted sutures of the strong- est braided silk, the ends of which are left long for traction. A circular incision is made through the mucous membrane of the vagina, and carried round the entire cervix, keeping close to that or- gan except in carcinoma- tous cases where a margin of 2 centimetres (0.75 inch) should be allowed for possible cellular inva- sion. The electric cautery or the thermo-cautery is substituted for the knife or scissors by some oper- ators in making this dis- section, to obviate the use of catgut or silk ligatures not infrequently required on the vaginal arteries. ISTewman uses the in- dex and middle fingers to peel up the layer of con- nective tissue from in front of, and behind, the cervix until the perito- neum is reached. This can be recognised by the smooth gliding of its surfaces one ujDon another, and the small fluid accumulations in the cul-de-sac of Douglas. The irrigation of the vagina is now dis- continued, and sponging with gauze substituted. The peritoneum is seized with tissue or artery forceps, nicked with the scissors, and the finger thrust through into the peritoneal cavity. The opening is extended with the fingers, as far as the broad ligament upon either side. The outer surfaces of the uterus, its adnexa and surrounding structures, are carefully examined, adhesions broken up, and a gauze sponge with tape attached, to which a catch forceps is applied, should be carried up into the peritoneal cavity to protect the parts from infectious material, and prevent the protrusion of omentum and in- testine. In the separation of the bladder from, the anterior cervical attach- ments, great care should be exercised not to perforate or injure this organ or the ureters situated at the sides and front of the wound in its lower portion. Accident may be avoided by keeping the palmar sur- face of the dissecting fiugoi-s in close apposition to the uterine walls. 30 Fig. 191. — Curved needles. — Eobb (page 448). 450 A TEXT-BOOK OF GYNECOLOGY The vesico-uterine folds of the peritoneal membrane are opened close to their uterine attachment and the fingers inserted, enlarging the opening laterally, pushing the ureters carefull}^ to either side, and com- pleting the separation of the bladder. The uterus Avill now be found suspended in the pelvis by the broad and round ligaments alone. The clamping or ligating of this vascular area should be done with great care and precision, and, in each instance before the application of the clamp or ligature, its site should be drawn down and carefully inspected. With the cervix drawn well to the left, and using lateral retractors to bring the structures well into view, the base of the right broad liga- ment is seized between the left thumb in front and index finger behind, and the uterine artery palpated. The portion of the ligament containing the artery is now in- cluded in the bite of a strong ligament Fig. 192.— Keedle holders. — Eobb (page 448). Fig. 193.— Pack- er. — Kobe (page 448). Fig. 195. — Cullen's tenaculum. — Eobb (page 448). Fig. 194. — Sponge holders. — Eobb (page 448). forceps, or a strong silk ligature is applied about a centimetre distant from the uterus with a full curved aneurism needle (Fig. 197), and tied firmly. The structures are now divided with scissors between the clamp or ligature and the uterus, close to that organ; and the base of the left broad ligament, with the uterine artery of that side, is treated in the same way. NEOPLASMS OP THE UTERUS 451 Firm traction brings down the uterus for the placing of a second clamp or ligature immediately above the first on either side, and the tissues are incised in the same manner. Using the finger as a guide, a large blunt hook or the finger is now passed over the top of the broad ligament, one side brought do^vn suffi- ciently to permit the ap- plication of a third clamp or ligature, and the last incision is made, freeing the uterus entirely from its attachments upon that -side. The fundus is drawn down outside the vulva, the clamp or liga- ture easily applied to the remaining portion of the broad ligament, and the uterus cut away. Many operators vary this technique at the point where the uterine arteries have been se- cured by clamp or for- ceps, and the base of the broad ligament incised, by rotating the uterus forward through the an- terior vesico-uterine in- cision, or backward through the posterior cul-de-sac. As a rule, this is easily accom- plished by first pushing the cervix upward and forward, or backward, as the case may be, and then seizing the body of the uterus a little in advance of the cervix with a strong volsella forceps, and drawing it down either anteriorly or posr teriorly, as desired. A second forceps then secures the tissues a little higher up, rotating or dragging the fundus still farther downward until it can be grasped and drawn out completely inverted. Tlic ligation or clamping of the ovarian arteries or the upper por- tion of the broad ligament, now proceeds from above downward, close to the uterus if the ovaries are to be saved, or beyond both tubes and ova- ries along the tubo-infimdibular ligament, if they are to be sacrificed. Careful inspection shonlfl now bo made of the stumps of the broad ligament, which are gently drawn down for the purpose. If there is Fig. 196. — '' The anterior lip of the cervix is seized with the volsella forceps and the uterus drawn down."' — Newman (page 448). 452 A TEXT-BOOK OF GYNECOLOGY % any bleeding, the insecure clamp or ligature should be readjusted. The vagina is sponged free of clots, and the sponge or sponges removed from the peritoneal cavity. A running catgut suture, which should include peritoneal and vaginal tissue, closes the vaginal vault, and secures the stumps of the broad ligaments in either angle of the wound. Full-width gauze, or narrower, with edges hemmed to prevent fraying, is used to pack the vaginal vault. Where the forceps is used and suturing of the vault omitted, particular care should be taken to pro- tect the ends of the clamps from projecting upward and coming in contact with the intestines. In this case the gauze packing not only protects the ends of the forceps and serves for drainage, but, being carefully placed above between the stumps of the broad ligament, prevents hernia or protrusion of the intestines. Gauze should also be so placed about the shanks of the forceps as to prevent danger of tissue necrosis of the vagina or vulva. The usual vulvar dressings are now applied, the handles of the forceps wrapped with gauze, and the patient put to bed. The urine should be drawn every six or eight hours, and the external genitals bathed each time with 1-to- 4,000 bichloride. The forceps are removed in from 36 to 48 hours, but the gauze packing remains undis- turbed for from 24 to 48 hours longer. When the gauze is removed at the end of this time the patient should be in a good light and the packed area in full view, so that there may be no danger of disturbing the superimposed intestines. A careful douching of the parts with sterilized water or boric-acid solution, may now be used twice daily, taking care not to carry the douche point too high up, or to allow too great force to the flow. The bowels should be moved by a laxative pill or mild salines followed by an enema the second day, and each day thereafter. No straining at stool should be allowed. Liquid diet should be given for three or four days, followed by nourishing but easily digested soft foods, nutritious broths, soft-boiled eggs, custards, and the like. When the ligatures have been used upon the broad ligaments and fail to come away within a reasonable time after- the operation, in the second or third week they should be gently drawn upon daily, and if still resistant, Sims's speculum should be used, and the ligatures removed under ocular inspection by cutting the loop. In general, the patient may be allowed to sit up in bed at the beginning of the third week, and at its end may be up in an easy chair, and about the room in the fourth week of convalescence. ^ Fig. 197. — "A full curved aneurism needle." — New- man (page 450). NEOPLASMS OF THE UTERUS 453 All cancer cases should be carefully examined from time to time for recurrence of the disease. Among the later and more important modifications in the tech- nique of vaginal hysterectomy, should be mentioned that of removing with the cancerous uterus the pelvic lymphatic glands, a procedure analogous to the operation upon the axillary glands in mammary carci- noma; the operation described and done by Sippel, who opened into the ischiorectal cavity by lateral incision between the anus and the tuber ischii, and removed the vagina and uterus unopened and in their normal connection, claiming as advantages a good view, the accessi- bility of field, and the possibility of avoiding any contact whatever with carcinoma, or the contents of the vagina; and the use of the angeiotribe, or pressure clamp, to replace both retention clamps and ligatures for hemostasis of the broad ligament in vaginal and abdominal hysterectomy. Abdomino-vaginal panhysterectomy for malignant disease has been strongly advocated by some, where the uterus could not be pulled down on account of adhesions, and also for the purpose of more thoroughly removing diseased tissues and the lymphatic glands situated within the broad ligaments, near the crest of the ilium, or in the neighbourhood of the ureters. There are exceptional cases in which this operation is required. When vaginal hysterectomy by the clamp method was in its infancy and only one clamp was used on each broad ligament, the tissues would sometimes pull out and the hemorrhage could not be stopped, so that the abdomen had to be opened in order to control the bleeding. With the present technique, this seldom if ever occurs. When the disease is so far advanced that the uterus with the diseased tissues can not be removed per vaginam, surgical intervention is of no avail for ultimate cure, while the immediate mortality certainly must be great. When metastasis into the lymphatics has once taken place there is no guarantee that it can be overtaken. The experience of distinguished operators goes to show that secondary deposits are more liable to occur in the stomach, liver, or high up in the intestines, than anywhere else. Hence Carstens would not advocate abdominal section in malignant diseases except in cases of sarcoma where the uterus is very large and still movable. There are others, however, who assume that continued efforts should be made to eradicate, if possible, carci- nomatous glands of the pelvis. Although the operation is one of ex- treme severity it has a certain justification in the otherwise hopeless character of the disease. It ought not to be undertaken without hav- ing been first explained to the patient, who ought to be frankly advised of the desperate alternatives. It is, to-day, an operation from which nothing can be promised — although something may be realized. The extended operation for advanced carcinoma of the uterus in- volves llie rcnioval, not only of the diseased organ, but also of the infecterl lymphatics within the pelvis. The operation is graphically describof] (American Gynecological and Ohdelrical Journal, 1898) by 454 A TEXT-BOOK OF GYNECOLOGY Fig. 198. — " The patient is placed in a very steep Trendelenburg- position." — Eeeu. Emil Keis. The j^atient is placed in a very steep Trendelenburg posi- tion (Fig. 198) and an incision is made from the pubis to the umbilicus. The intestines either sink or are placed back toward the diaphragm, after which the surgeon inspects and palpates the pelvic organs and the large blood vessels from the aorta to Poupart's ligament and to the uterine artery. If during this examination enlarged and im- movable glands are found, it is advisable to cut the operation short and to do only such pallia- tive work as will afford as little danger to the patient's life and as much i^rotection against hemor- rhage, discharge, and pain, as possible. If there is no such en- largement of the glands, the op- eration continues as follows: First, the right infundibulo-pel- vic ligament is ligated close to the pelvic wall; a clamp covers the broad ligament between the ligature and the uterus, and the ligament is cut through between the ligature and the clamp. The peritoneum is now incised along the common iliac vessels, which are further exposed by blunt or sharp dissection. Pushing the peritoneum back toward the side, the ureter, which crosses the common iliac vessels on or near their bifurcation, is soon reached. The ureter is then laid bare from the brim of the pelvis down to its point of entrance into the bladder, with the aid of an incision through the peritoneum of the vesico- uterine pouch. As this is done under the constant guidance of the eye there is no danger of injuring the ureter. The blood vessels whicli are cut in this procedure are ligated or temporarily provided for with clamps. The uterine artery is plainly seen in this dissection at a point where it crosses the ureter, and can easily be ligated under the guidance of the eye at its starting-point from the hypogastric artery outside the ureter. After the ureter is thus laid bare and the uterine and ovarian vessels are secured, there is remarkably little hemorrhage from the procedure which follows and forms the most important new step in this operation — the removal of the lymphatics with the surrounding fat and connective tissue. This is done by dissection with either a blunt or a sharp instrument. The area which was cleaned out in this way extended in Eeis's cases over a surface limited by the lateral edge of the external iliac vessels superiorly, the pelvic Avail laterally, the blad- der anteriorly, the pelvic floor interiorly, and posteriorly by the meso- rectum which, however, was lifted up and freed from all accessible glands. Bleeding vessels are ligated, or the hemorrhage, when it comes NEOPLASMS OF THE UTERUS 455 from the side of the uterus, is checked by clamps, or simply by pull- ing hard on the uterus. Two edges of the peritoneum remain after the whole broad ligament and all the fat and connective tissue along the large vessels and the pelvic wall are removed. If adhesions exist between uterus and rectum, they are cut as close to the rectum as possible, be- cause they sometimes form the path along which carcinoma spreads. Then the procedure as done on the right side is repeated on the left, special attention being necessary here in order to empty the mesorectum as completely as possible without injuring too many of fhe hemorrhoidal vessels. The ureter and uterine artery are treated in the same way; the removal of fat and connective tissue with the lym- .-phatics being carried to the same extent as on the other side. The peri- toneum is left open for the time being, as on the other side, that the hemorrhage may be stopped by ligation of the blood vessels. Small ar- teries supplying the lymphatic glands sometimes give rise to some hem- orrhage and must be secured by ligatures. The round ligaments are •severed close to the anterior abdominal wall. The peritoneum of the cul-de-sac is now incised close to the rectum and tbe vagina is perfo- rated at this point, either against the finger of an assistant, or against .gauze introduced into the vagina. The vagina is severed after its walls have been secured by ligatures. The uterus is in this way freed all round and is removed. The wound can be closed toward the peritoneal cavity by suturing the peritoneal edges left in removing the broad liga- ments and the uterus. This suture runs across the bottom of the pelvis in a transverse direction, uniting laterally the edges of the peritoneum ■of the vesico-uterine and recto-uterine pouches, and in the median line the peritoneum of the bladder and the rectum. Before this part of the operation, the space between the peritoneum and the cut edges of the vagina is filled with iodoform gauze if there is any oozing, or, if everything is perfectly dry, the cut edges of the vagina and the peri- toneum can be closed in such way as to leave no dead spaces between them. The subsequent management of the case is the same as in abdomino-vaginal section for benign growths. Werder, of Pittsburg, has extended the operation of abdominal hysterectomy for cancer by removing, in certain cases, all or a part of the vagina. The operation is done as in an ordinary hysterectomy, only after freeing the bladder the dissection is extended down along the vagina, separating its anterior wall from the bladder as far down as it is desirable to remove the vagina; the recto-vaginal space is then entered and the posterior wall is stripped off the rectum so far as is necessary, and, finally, the lateral attachments of the vagina are loosened. The uterus is now pushed down into the pelvic outlet, the va- gina being inverted by making traction from below until it can be am- putated above the prolapsed fundus. Werder claims for tliis operation that it affords the best opportunity for maintaining an aseptic field, since it can be done without touching the diseased cervix with the fin- .gers. Ife has r(;porL('d sikh^cssI'iiI results from this rnetliod of operating. 456 A TEXT-BOOK OP GYNECOLOGY Byrne's Operation of Electro-hysterectomy. — An operation that has occasioned much confusion in the surgical world is that devised by John Byrne, of Brooklyn, and designated by him " high amputa- tion of the cervix." It consists in the removal of the whole uterus ex- cept a thin shell at the fundus (Fig. 199) and is, to all intents and pur- poses, a hysterectomy, the uterus being cut out by an electric knife, " followed by thorough dry roasting of the remaining ex- cavation." To designate it as " high amputation of the cer- vix " and to attribute its re- sults to " amputation of the cervix," is to impart the mis- leading idea that those results have been realized by the re- moval of merely the lower seg- ment of the uterus. The title mistakenly given to this opera- tion has itself, and Avithout any reference to the scope of the procedure, prompted many not overstudious operators to at- tempt the cure of cancer of the cervix by simple amjDutation of the neck of the uterus. The re- sult has been a tragic mortality, much of which might have been avoided; but which has, happily, resulted in the emphatic verdict of the profession that the surgical treatment of cancer of the uterus, to be successful, must involve the removal of the entire organ. Of the various operations for the removal of the uterus, none are more effect- ive, and certainly none are followed by more satisfactory ultimate re- sults, than the brilliant procedure of Bryne, as practised by himself, and described (Eledro-Hemostasis, Skene, p. 71) as follows: " A diverging volsella, after being passed well into the cervical canal, should be expanded to a proper degree and locked, so as to afford complete control of the uterus during the entire operation. By alternate traction and upward pressure of the uterus, an accurate idea may be obtained as to the proper point to begin the circular in- cision, so as to avoid injuring the bladder or opening into the cul-de- sac of Douglas. As to the latter, however, should it be found that the disease has involved the retro-uterine tissues, and that its excision or destruction by the cautery can not be effected without opening into the peritoneal cavity, there need be no hesitation in doing so. I have never known any harm to come from it whether it was done acciden- tally or by design. Should it be evident at tlie outset that the opera- tion, in order to be thorough, must include a portion of the cul-de-sac. Fig. 199. — "It consists in the removal of the whole uterus except a thin shell at the fun- dus." — Eeed. NEOPLASMS OF THE UTERUS 457 it will be better to make the line of incision anterior to this, until the cervix has been removed, and leave the incision of the retro-uterine parts by the cautery knife to be the final proceeding. Under these circumstances all that will be needed will be an antiseptic tampon prop- erly applied. In jaroceeding to make the circular incision, the cautery knife, slightly curved an,d cold, should be applied close up to the vaginal junction, and from the moment the current is turned on, should be kept in contact with the parts being incised. Before remov- ing the electrode for any purpose, such as change of position, or alter- ing the curve of the knife, the current should first be stopped and the instrument again placed into position while cool before resuming the incision. In other words, if the knife, though heated only to a dull red, be applied to parts at all vascular, hemorrhage more or less will certainly follow; whereas, the cool platinum blade being already in contact with moisture as the current is being transformed into heat, vessels are shrunken or closed even before they are severed. This is a very important point and should never be lost sight of in all cautery operations. The circular incision having been made to the depth, say, of a quarter of an inch, it will now be observed that by increased trac- tion the uterus may be drawn much farther downward, and by directing the knife upward and inward the amputation may be carried to any desired extent. In cases calling for amputation above the os internum, it will be better to excise and remove the cervix first; then, by dilat- ing the upper canal sufficiently to admit the diverging volsella, once more proceed as in the first instance, taking care, however, to keep within bounds. It will be found that the cupped stump can now be drawn down and made to project as a more or less convex body. In all cases the dome-shaped electrode should be passed over the entire cavity repeatedly so as to render the cauterization still more complete. It is important to add that, in carrying the knife toward the sides of the cervix, circular and other arterial branches are likely to be encoun- tered, and hence, in this locality particularly, a high degree of heat in the platinum blade is to be carefully avoided. As an additional secu- rity against hemorrhage, the convexity of the knife should be pressed against the external surface of each particular section cut, so as to close the vessels more effectually. It is well to state that the metallic parts of the electrode for the distance of about two inches should be covered with a strip of thin flannel, so that the vagina may be protected from injury through the reflected heat." (See Results of 023erative Treatment of Carcinoma Uteri.) Byrne claims for this operation that, by the action of heat on the surrounding structures, any possible remaining infection within them is destroyed, and that following the operation there is an absence of fever, and of almost all pain, either pelvic or peritoneal; that there is almost universal immunity of the scar tissue, after cauterization, from secondary attack in the event of the recurrence of the disease; and, finally, that in the event of i'('laj)Sf', the i'(!spite from reappearance of 458 ^ TEXT-BOOK OF GYNECOLOGY disease in remote parts, even in the more unpromising cases of un- doubted circumuterine infiltration, is longer than in other operations. The results of hysterectomy for carcinoma should be considered as {a) immediate, {h) remote. The immediate results are concerned with the surgical recovery of the patient from the operation. The remote results take into consideration the permanency of the cure thereby secured. One of the most interesting of recent statistical researches relative to the immediate results of vaginal hysterectomy has been conducted by Eicard, of Paris {La semaine gynecologique, October 31, 1899), who places the primary mortality of vaginal hysterectomy at the liands of French surgeons at from 16 to 19.68 per cent. Monclaire and Picque place the mortality in France at 8.9 per cent, this computa- tion being based upon 2,376 cases. Bigeard concludes, after a careful study of both the French and foreign statistics, that the primary mor- tality from this operation vacillates between 17 and 20 per cent. This is probably the representative figure. Hofmeier in 74 vaginal hyster- ectomies reported a mortality of 16.2 per cent. Munchmeier {Frauen- arzt) reported 80 vaginal hysterectomies with 4 deaths. Byrne finds that in 1,273 colpohysterectomies by 38 European and American sur- geons the average primary mortality is 14.6. The figures relating to the remote or uUimate results of vaginal hysterectomy for cancer, are less satisfactory than those relating to primary results, for the sole reason that it is exceedingly difficult to keep track of the cases after they once pass from the surgeon's hands. The reports on this point from various operators are strangely conflict- ing. Thus, Bouilly states that all his cases operated ujoon since 1886 are dead; and Jacobs reports the same of his annual series of cases running back respectively three, four, five, and six years. On the other hand, Thorn, reviewing the statistics of the Magdeburg Clinic, con- cludes that half the cases in which the disease is limited to the uterus, operated upon in that institution, have a permanent recovery. Kiche- lot has cases alive six, eight, nine, and twelve years, after operation. Freund reported nonrecurrence in a case eleven years after operation and Olshausen reported a case of immunity after twelve years. Reed has cases of nonrecurrence covering periods of respectively twelve, ten, nine, eight, seven, six, five years and less. McMurtry has a case of nonrecurrence after twelve years, and other American operators have cases of immunity after even longer periods. The extended operation for carcinoma of the uterus has been followed by results which seem to justify its employment, particularly when it is remembered that without it the condition of these patients is abso- lutely hopeless. Reis has collected the tables of cases on page 459. The primary results are not so satisfactory as in vaginal hysterec- tomy, but they may certainly be looked upon as justifiable when the otherwise hopeless character of the cases is taken into consideration. The adoption of this operation has been so recent that ultimate results are not yet determinable. NEOPLASMS OP THE UTERUS 459 Cases. 1 8 2 1 3 Recoveries. Deaths. Runipf, Berlin {Centralblatt fur Oynahologie, Aug., 1895) Clark, Baltimore {Bulletin of the Johns Hopkins Hos- pital, 1896) ." 1 7 2 2 1 Kiistner, Bi'eslau {Feiser Zeitschrift fur Geburtshulfe, 1898) ' Private coininunicatioii from Boston 1 Emil Reis 1 Total 15 12 = 80^ 3 = 20^ The results of electro-hysterectomy as practised by Byrne, can not be designated by any other term than brilliant. These results are sum- marized by Byrne himself in a paper before the American Gyneco- logical Society, 1896, which begins with an allusion to a previous report to that body, and is as follows: " I stated that in 40 out of 63 cases of cancer of the portio vaginalis (23 having strayed away) periods of exemption from relapse were obtained ranging from two to twenty-two years, being an average of over nine years for each; and of 50 out of 81 cases involving the entire cervix (31 being lost sight of), 10 had an exemption from recurrence for over two years, 11 over three years, 6 over four years, 8 over five years, 6 over seven years, 2 over eleven years, 1 over thirteen years, and 1 over seventeen years. Nor is this all, for the table would now bear important reconstruction — no less than 6 of these cases, and probably many more, having until now enjoyed a complete immunity. Moreover, one patient operated on in 1875, and a most un- promising case too, and who could hot be found at the time of my report, has since been discovered by Dr. Homer L. Bartlet, of Flatbush, with whom I saw her, and who was present at the ojjeration. Two months ago, or nearly twenty-one years after the operation, she was in perfect health." CHAPTER XXX CiESAREAN SECTION AND ITS MODIFICATIONS Definition and historical resume — Indications — Preparations — Instruments — Posi- tion of cliild and placenta — The operation — After-treatment — Sanger's method — Porro's modification. CiESAEEAN section is an operation whereby an opening is made in the abdominal wall^ and another in the uterus, through which* the foetus is extracted. According to Pliny, it is named Cesarean because the first of the Cgesars was so extracted from his mother's womb as she was dying. According to another version it is named from the operation itself, " cseso matris utero." This operation was at first done upon dead women at a more or less advanced stage of pregnancy. It is attributed to Xuma Pom- pilius, one of the first Kings of Rome, who enacted {lex regia) that a pregnant woman, deceased, must not be interred until the foetus was extracted. This law remained in operation throughout all countries under Roman rule, and was approved by the Church, as well as adopted as a civil law by the ISTorthern states of Europe, more especially Ger- many. For many years they dared not perform the operation upon a living woman, and in this way encouraged the performance of crani- otomy, as the passage of the foetus through the pelvis in cases of de- formity was impossible without mutilation. Levret and Mauriceau deny that this operation was known to the ancients, but Dionis and Gardien refer to Pliny's Natural History. Mansfield published a work On the Antiquity of Gastrotomy and Hys- terotomy on the Living. (Ueber das Alter des Bauch und Gebarmut- terschnitts an Lebenden. Braunschweig, 1824.) He states that even in an earlier work than Pliny's, named Mischnajoth, written about 140 B.C., there is this passage: "In a twin birth, neither the first child which by section of the belly is brought into the world, nor the one coming after, can attain the rights of heirship or priestly office." Xicolai Falconiis recorded a case at Venice in 1491. The case of Jacob Meter, the Swiss peasant who performed it upon his own wife, is frequently quoted, but most authorities are agreed that it was much later before it was generally attempted upon the living woman. In fact, we need only refer to the action of Mauriceau in the case treated 460 CiESAREAN SECTION AND ITS MODIFICATIONS 461 by himself and Chamberlin, where the operation was delayed until after death, although Mauriceau was in actual attendance for several days. He wrote : " The child had been dead to all appearance about four days, and I told all the assistants that she could not be delivered. They asked me to perform Cesarean section, which I did not wish to do, knowing that it was always certain death to the mother." This poor woman died with her infant in utero, twenty-four hours after- ward. Eousset, physician to Catherine de' Medici, and contemporary of Pare, published a work upon the subject in 1581. This book was translated into Latin about ten years later. The author attempted to prove the possibility of saving the mother and child by means of this operation, but his views were opposed by Pare, Guillemeau and others. In the middle of last century, the subject divided operators into two sections, the SympJiysiens and Ccesariens, or those who advo- cated division of the symphysis pubis and those who advocated Cesar- ean section. It may be taken as a recognised rule in midwifery that no woman should be allowed to die undelivered without some attempt being made to save her and her offspring, or, at least to save her, even at the expense of her child. Concerning the latter point, whether we are justified in destroying the infant when alive, there has been, and still exists, difference of opinion, due in some measure to religious belief, and likewise to the personal feeling of the husband, who often felt that very little hope was held out to him that his wife could be saved by section. Among such men we had Napoleon, who, when appealed to by Dubois, said: " Treat the Empress as you would a shopkeeper's wife in the Eue St. Martin, but, if one life must be lost, by all means save the mother." In marked contrast to him we had Henry VIII, who, when thus ques- tioned before the birth of his son Edward, exclaimed: " Save the child by all means, for other wives can be easily found." At the present time such men might be put down as either a good husband but a bad father, or a good father but a bad husband. The doctrine of the Eoman Catholic Church has been that, even though it would be impossible to extract the child without first killing it, to do so would be mortal sin; and likewise, until lately, it was held that the infant could not be baptized in the uterus, as it must be natus before it could be renatus by baptism. Of late years, the happy results following Csesarean section and Porro's operation have done much to efface the dreadful feeling, that we have in such cases to decide whether the life of the mother or that of the child is to have our preference, seeing that it is now quite 7)Ossib]o to save both. 7)Mrnos wrote: " Cajsarean section is resorted to with a feeling Mkin 1() despair. Embryotomy stands first, and must be adopted in every case where it can be carried out without injuring the mother. 462 ^ TEXT-BOOK OF GYNECOLOGY Ca3sarean section comes last, and must be resorted to in those cases Avhere embrj^otomy is either impracticable, or can not be carried out without injuring the mother. There is therefore no election. The law is defined and clear. Csesarean section is the last refuge of stern necessity." As against tliis statement, Barnes has recently said: " It is no longer permitted to us, without ample j^i'oof of clear necessity, to sacrifice the child in order to save the mother. The cases in which the two lives are supposed to stand in antagonism are vanishing before the light of modern science and skill." If anything is needed to sicken one at the revolting practice of craniotomy, it might surely be found in the relation of the obstetrical history of a rhachitic woman, who during her last three confinements was under the care of ]\Iurdoch Cameron: 1st 1862 Euibiyotomy. 2d 1863 Embryotomy (laboiu- induced). 3d 1864 Einbiyotoiiiy. 4th 1865 Induced labour at half term. 5th Embryotomy (Birmingham Lying-in Hospital). 6th 1868 Induced labour at half tei-m. 7th 1870 Embryotomy. 8th 1871 Embryotomy (eiglitli month). 9th 1873 Embryotomy. 10th 1874 Embryotomy. 11th 1875 Induced labour at half term. AVe must never forget that we have a sacred trust, and Cameron liolds that we have no right to sacrifice a child, however unequal its life may be in some cases to that of the mother. In advocating the preference for section as against craniotomy in the living child, Came- ron does so only after very mature consideration, and with a feeling that to do otherwise Avotdd be to sacrifice a life which Ave are bound to preserve. He thinks the time has come Avhen the lives of the mother and child may alike be saved, and jDrefers to think that an infant come to maturity is destined for something greater than to have its glimmering life extinguished by an accoucheur skilled in the use of a dreadful perforator. Let our motto be, " We live to save and not to destroy." In another case A\'here the obstetrical history Avas like the preceding one, Csesarean section was performed, and the mother has noAv attained her long-Avished-for desire, a living child. Burns in 24 cases gave 22 deaths, while others gave the death rate as from 50 to 100 per cent. With such results it is not to be wondered at that so many oj^posed the operation. In England, for example, accoucheurs condemned it absolutely. In Paris, during half a century, there Avas not a success- ful case, although it had been performed about 60 times. In the large maternity hospitals of Paris and Vienna, Avith from 4,000 to 8,000 C^.SARBAN SECTION AND ITS MODIFICATIONS 463 confinements in tlie year, not a single successful case of Cassarean section has been recorded. No doubt now exists that the great fatality was due to the fact that the operation was only resorted to after other measures had failed. Indications for the Operation. — As regards the general indications for the operation, of course they vary in the hands of different opera- tors, since some, still looking upon Csesarean section as a last resource,, divide the indications into absolute and relative. The absolute indica- tion exists where the deformity of the pelvis is so pronounced that the passage of even a mutilated foetus is impossible; while the relative, is where a mutilated foetus may be removed by the natural passage with as good a result for the mother as, or even better than, that afforded by embryotomy. It is here that difference of opinion exists. Baudelocque admitted Cesarean section in cases with a conjugate diameter under 24 inches; Cazeaux, under 2 inches; Farnier, 2 inches, and Depaul, from 1-^ to 2\ inches when the child was alive, and under 1-| inch when the foetus was dead. Stolz advocated Csesarean section W"henever the child was alive, and could not be brought through the natural passage. Other authorities lay down the limits as follows: Scanzoni, under 3 inches. Naegele, under 2 " Spiegelberg, under 2 " Barnes, under H- inch. Playfair, under 1^ " Leishman, undei' 1^ " Of late years, the good results following Caasarean section in the hands of Cameron, Leopold, Sanger and other operators, have materially changed the views of many authors, who now favour Csesarean section more than they have done in the past. Lusk, at the International Congress held at Washington in 1887, de- clared that Caasarean cection was preferable to embryotomy, even with a conjugate diameter from 2^ to 3 inches, when the child was alive. It can well be urged that — • (1) Embryotomy in a very contracted pelvis is as dangerous to the mother as C^.sarean section. (2) Embryotomy always sacrifices the life of the child, while Caesarean section gives a living child. (3) No person has any right to sacrifice a child where they can save it without exposing the mother to any additional risk. For these reasons the operation should be one of election when the child is alive, and it should be performed before the patient is exhausted; in fact, early after ]a1)oiir has commenced, or even at full term before labour sets in, especially in multiparse. In all cases it should be done before rupture of the membranes, and if possible the patient should be placed under the care of an experienced operator. Little difficulty is experienced in obtaining the consent of the patient and her friends, and it is better to have her under observation previous to the operation, so as lo regulate her diet, and have her pre- parffl for opcral ion bcfoi-cliand. 464 ■ A TEXT-BOOK OF GYNECOLOGY A very important 23oint in favour of Ca3sarean section is that the Fallopian tubes can be tied and divided, so as to prevent subsequent conception, whereas embryotomy may require to be performed ten or a dozen times. Besides deformity of the pelvis, other conditions, such as tumours or cancer of the cervix uteri, may exist, which would demand either Cesarean section or some modification of it. If the child is dead and the conjugate diameter not under 1^ inch, Csesarean section should be done. Eousset, the earliest writer upon this subject, recognised two classes of indications, the one furnished by the foetus, and the other by the mother. Under the first category he placed excessive size of the foetus, monstrosities, and faulty positions. Under the second, he placed marked contractions from whatever cause. Some operators would include placenta prsevia and j)uerj)eral convulsions. Csesarean section might be advisable in some cases of eclampsia, but a skilful obstetri- cian would never think of such procedure in the case of placenta previa. In fact, the operators who advocate this step are surgeons who have little or no experience in obstetrical practice. Our decision for operation should be based upon the degree of contraction of the pelvis, the size of the child's head, and its reduci- bility, unless the obstruction is due to some other cause, such as cancer or the presence of a tumour in the pelvic cavity. Every practitioner should be able to form a fair estimate of the amount of contraction, as it is easier to measure a contracted pelvis than a normal one, and it does not require a highly skilled obstetrician to say before labour has commenced, or during the early stage of the process, that the diameter of the pelvis is, or is not, less than 3 inches; and, as a matter of fact, such a pronouncement should be within the skill of the ordinary practitioner, who should be more than a generally useful person, otherwise he will sink to the level of an ignorant midwife. ISTot only must he be able to form an estimate of the amount of contraction, but by patient study of normal cases, he should qualify himself to form an opinion as to whether it will be impossible for a living child to pass, and also whether under the diffi- cult circumstances in which he may be placed, it would not be better to send the patient where Cesarean section could be safely performed, than to extract a mutilated foetus through a minimum diameter. With a diameter under 24 inches, where engagement of the head is impossible, no one should hesitate to advise Csesarean section, although there will always remain cases, as where the child is dead or a subject of hydrocephalus, in which craniotomy may be resorted to. Experience alone will enable one to avoid extreme measures in cases where the conjugate diameter measures more than 3 inches; in such cases, the skilled practitioner will weigh the chances between premature induction of labour and symphysiotomy. There can be no question that Csesarean section is a highly dan- CiESAREAN SECTION AND ITS MODIFICATIONS 465 gerous operation, but the danger, it should be remembered, de- pends for the most part on delay, and death most frequently results, not so much from the operation, as from previous operative abuse, which is the just term for all injudicious attempts to extract the fcetus through a deformed natural passage. Success depends upon prompt interference before the patient is ex- liausted, as then there is less danger from hemorrhage, delayed shock or peritonitis. When abdominal section has been resolved upon, another question presents itself, namely, whether Csesarean section or Porro's operation is preferable. If the former, there still remains to be decided whether the operation shall be accompanied or followed by a removal of the ■ovaries, or the patient be sterilized by the simple expedient of tying and dividing the Fallopian tubes. This has been done by Cameron in about fifty cases and no harm has resulted, although theorists would have it believed that such a procedure would be surely followed by liematocele. When there is a choice of operation, Csesarean section is to be preferred, as it can be completed much sooner, and is free from the danger of shock and peritonitis which may complicate Porro's •operation. The preparation of the patient will depend upon the urgency of the case. When she is under observation, it is better to confine her to bed for a couple of days beforehand, and the bowels should be moved by an enema and a slight laxative. The abdomen is washed and gently scrubbed, and the parts shaved while the vagina is cleansed and rendered aseptic. The preparation in fact is the same as for any other •abdominal section. The operator and his assistants who have to do with the case must be exceptionally careful in cleansing and disinfect- ing their hands, while the chief nurse should see that the instruments and sponges are sterilized and counted. Very few instruments are necessary. The list should comprise the following: •Scalpels 2 Blunt-pointed bistoury 1 Forceps, pressiu'e 8 Dissecting ... 2 Scissors. Director 1 Needles, Hagedorn's 2i-inch straight. 20 Pessary, compression 1 Silk, antiseptic. Silkworm gut. Adhesive plaster. Dressings. The catheter should always be passed into the bladder shortly be- fore operation. The needles should be threaded in pairs beforehand, with No. 3 Chinese twist silk ligatures, about 30 inches long, and placed in a towel wrung out of l-to-30 carbolic solution, ready for use. Palpation will reveal the position of the fcetus, and this is all the more important, as from this the attachment or site of the placenta Avill be known. Cameron's experience in Csesarean section has shown him that in "dorso-postorior positions the placenta is attached upon the anterior 466 A TEXT-BOOK OF GYNECOLOGY wall, while in dorso-anterior positions the placenta is upon the pos- terior wall. Thus: (a) In the first cranial position, or O.L.A., the placenta will be found upon the posterior wall, and somewhat to the right side. (b) In the second cranial position, or O.D.A., the placenta will be- upon the posterior wall, and somewhat to the left side. (c) In the third cranial position, or O.D.P., the placenta will be upon the anterior wall, and somewhat to the left side. (d) In the fourth cranial position, or O.L.P., the placenta will be upon the anterior wall, and somewhat to the right side. The fcetus and placenta will be found in the same relation in the various pelvic positions. From this information it is eas}^ to know when the uterine incision is likely to cut down upon the placenta, and an idea can also be formed as to how to extract the foetus. The Operation. — The abdominal incision should be made in the median line as in ovariotomy, and it will vary in situation according to the distention of the ab- dominal wall. Thus, if the abdomen does, not droop (Fig. 200), an inci- sion from 5 to 6 inches in length may be obtained with- out extending beyond the um- bilicus; but when it is pen- dulous (Fig. 201), the incision must of necessity extend more or less above the um- bilicus. Before opening the uter- us, the operator should satisfy himself that that organ is not only in the median line, but that it is not twisted upon its- axis. This is settled by locat- ing the position of the Fallo- pian tubes by means of the fingers. He will frequently find the left tube more or less in front, as the uterus is- usually rotated to the right. This displacement must be corrected, and, if necessary, an assistant can easily keep the uterus in position by pressing with his hand on the right side. When the placenta has its attachment upon the anterior wall the site is seen to bulge, and upon palpation has a fluctuating feeling akiiL to that of a large pointing abscess. Fig. 200. — " If the abdomen does not droop." — Cameron. CESAREAN SECTION AND ITS MODIFICATIONS 407 The next point is to open the uterus with as little loss of blood as possible, and this can be done by placing a flat Aoilcanite pessary upon the uterine wall around the point to be incised (Fig. 202). The operator, with the fingers of his left hand, applies pressure upon the pessary, while his assistant does the same on the opposite side. The incision is then made with two or three strokes of the scal- pel, and the blood sponged away by the assistant with his right hand. After this has been done, no more bleeding takes place until the placenta is attacked in front, as the pressure with the pessary thor- oughly prevents even oozing. Care should be taken not to puncture the membranes, which will soon be observed and recognised by their pearly colour. If the placenta intervenes, this method of pressure is beneficial, not only in preventing bleeding, but also in permitting observation of its tissue, which is recognised by its darker colour. Whenever the membranes are reached, a director is placed within the opening, which is then enlarged with a blunt-pointed bistoury upward and downward as far as the pessary will admit. At this stage, the compression pessary is removed and the incision extended upward and downward sufficiently to permit the passage of the foetus. The extension of the incision downward should be limited, as it is likely to interfere with proper contraction of the uterus. Should the placenta intervene, it must be dealt with as a placenta previa after completing the incision, that is, either separated upon one side, or if central, pierced by the hand. There must be no hesitation in extending the incision, which is made upward and downward from within outward in each direc- tion with a blunt-pointed bis- toury, to the length of about 5 or 6 inches. The left hand is inserted without rupturing the membranes till the head is being turned out, or the feet grasped, and then the child should be extracted without delay. On no ac- count should the hand be withdrawn after its insertion, unless during extraction of the foetus, as the uterus speedily contracts. If the shoulder presents, a hand shouhl bo placed upon it to prevent its expulsion, as it adds very Fig. 201.— "When it is pendulous, the incision must extend more or less above the umbili- cus." — Cameron (page 466). 468 A TEXT-BOOK OP GYNECOLOGY much to the difficulty when any portion of the child's body is allowed to protrude. The child having been extracted, the assistant places a large flat sponge over the upper angle of the abdominal incision, to prevent the bowels from escaping, and then with both hands grasps the uterus, so as to prevent bleeding. The cord having been tied and divided, the placenta is immediately removed with the left hand, great care being taken to secure the re- moval of all membranes and to prevent the entrance of blood into the peritoneal cavity. The assistant now everts the uterus from the cavity, and pushes a flat sponge behind it. The lips of the uterine wound are next everted, the assistant grasping the upper angle and wall with his right hand, and the lower angle and wall with the left. While the assistant holds the wound thus, the operator immediately inserts the silk ligatures, beginning at the middle, each suture grasp- ing the entire wall with the exception of the mucosa (Fig. 203). From seven to ten sutures should suffice, as, with the contraction of the uterus, the incision is greatly diminished. This accomplished, the sutures are gathered up, a large flat sponge laid over the anterior wall, and another behind. Firm compression or kneading is then made T^^'i^WMt,! through the sponges with the result that the uterus contracts firmly. The assistant should again seize the uterus as before, while the op- erator ties the sutures. When this has been ac- complished, the whole organ is enveloped in a large, warm, flat sponge, and firm comjaression is again made so as to in- sure thorough contrac- tion. Should any ooz- ing appear at the nee- dle punctures, a second warm sponge should be applied, and very slight compression will suffice to overcome any tend- ency to relaxation. Should the peritoneal edges gape at any points, a few superficial fine sutures should be in- serted to bring the margins together. The performance of hysterectomy for bleeding is bad treatment. Fig. 202. — "Placing a flat vulcanite pessary upon the uterine wall around the point to be incised." — Cam- eron (page 467). CESAREAN SECTION AND ITS MODIFICATIONS 469 and indicates that the operator has lost his nerve, as pressure with a warm sponge with both hands never fails to secure thorough con- traction. Several operators advise the introduction of a drainage tube through the cervix and vagina, and the leaving it there to act as a drain. Nothing could be worse. Of course, it is the procedure of a surgeon, but every one who has practised midwifery knows that the presence even of a clot in the uterus may lead to serious hemorrhage. Such a body as a tube, if not expelled, woiild in- duce hemorrhage, disten- tion of the uterus, and bursting of the incision with speedy death of the patient. This is no mere theory, but is what has actually taken place where drainage has been resorted to. On no con- dition should the uterine cavity be washed out or medicated in any way. The less the parts are in- terfered with the better. After the ligatures have been cut short, the next step is to ligature the Fallopian tubes with antiseptic silk and divide them, in order to prevent future conception. Of course, the consent of the patient for this procedure should be obtained be- forehand. Two ligatures are tied upon each tube, which is then divided be- tween those points. This method is effective, and leads to no complications or bad results, nor is menstruation interfered with. The cavity is next cleaned by the removal of all clots, etc., and the uterus replaced. The external wound in the parietes is closed in the usual way with silkworm sutures. The vagina should now be cleansed of all clots and sponged out, after which an antiseptic pad should be applied to the vulva. The wound should be dusted with iodoform, and a few layers of gauze placed over the wound. This should be secured with plaster, to prevent botli slipping of the dressing and strain on the sutures, Fig. 203. — "The operator immediately inserts the silk ligatures, each suture grasping the entire wall with the exception of the mucosa." — Cameron (page 468). 470 A TEXT-BOOK OF GYNECOLOGY in case of sickness or cough. A sheet of gamgee or other dry absorbent dressing is next ajDplied, and then the bandage. The after-treatment consists of sips of warm water, say a teaspoon- ful every fifteen minutes for twelve or twenty-four hours, after which milk and soda may be given in increasing quantities. For a few nights, half a grain of morjDhine in suppository is given. The urine should be drawn off every six hours for two or three days, care being taken to cleanse the parts thoroughly before doing so. On the fourth day, an enema of two teaspoonfuls of glycerine in two ounces of soapy water is administered, and, if necessary, some slight aperient by the mouth. The bowels having been moved, the patient is allowed chicken soup, fish, eggs, beef tea, etc. If the child is to be nursed, it may be put to the breast on the second or third day. The abdominal sutures may be removed in from ten to fourteen days, and the patient allowed to rise at the end of four weeks. She sliould always wear an abdominal belt, and should be warned against kneeling when scrubbing floors, etc., as this is apt to induce hernia from pressure and stretching of the cicatrix. In review, it may be explained that rupture of the membranes, either intentionally or by labour, means a contraction of the uterine wall, and as a consequence a greater wounding of the uterine tissue, in order to secure a sufficient opening to extract the child. Some operators, instead of using manual or pessary compression to prevent bleeding when opening the uterus, employ an elastic ligature. The uterus is first everted, and the elastic ligature is then passed round the cervix. This not only necessitates a much larger abdominal inci- sion, but also induces asphyxia of the foetus and causes inertia of the uterus, as the organ does not so readily respond to kneading. Its employment is therefore conducive to hemorrhage. Veit, Doleris, and Pajot, have blamed it for causing death from hemorrhage, and Zweifel, Sanger, and Lusk, have also noticed this complication. Carniso advised the early removal of the ligature. Sanger's method is another way of dealing with the uterine incision (Fig. 204). In this pro- cedure, the muscular wall of the uterus is closed with from ten to fifteen sutures which ap- proximate to, but do not include, the mucosa, and between each suture two superficial sutures are inserted to unite peritoneum to peritoneum. Formerly, the peritoneum was separated from the muscularis, and a wedge-shaped piece of muscularis was Fig. 204. — " Sanger's metliod is another way of dealing with the uterine incision." — Cameron. CESAREAN" SECTION AND ITS MODIFICATIONS 47 1 removed from each side, the base of the wedge being outermost. This done, the peritoneal flaj)s were folded into the wound and se- cured by the superficial stitches. Such a detailed process is quite unnecessary, as, the sutures as recommended by Cameron secure perfect apposition, not only of the muscular tissue, but also of the peritoneum. In fact, most operators now make use of only eight or ten deep sutures, and reserve superficial sutures to secure con- tact where there is any gaping between the stitches. Such uneven- ness can be readily avoided by beginning in the middle and working toward each end, and by taking care to keep the sutures at regular intervals. Porro's Modification. — The fatal results following the early Caesa- rean section led to a modification of the operation. It had been found by experiment that the uterus in pregnant rabbits could be removed with better results than by simple section, and therefore it was con- cluded that similar results would follow in the case of women. Blundell, in writing upon this subject, said such a method might prove an eminent and valuable imj^rovement, but he also wrote, in speaking of deaths from peritonitis after Cesarean section, that ex- perience sometimes contradicted our most cherished opinions, and that something of the kind would be found to occur in the cases under consideration, as he had no doubt that the risk of diffused peritonitis had been greatly exaggerated. How his surmise has proved true, is ■seen in the present-day position of abdominal surgery. Acting on the lines suggested, Storer, of Boston, in 1868, first prac- tised amputation of the uterus after section. The case was one of pregnancy complicated with a fibroid of the uterus. He was inter- rupted by such an alarming hemorrhage that he had to remove the body and fundus with the ovaries, but his patient died three days after- ward. This was an operation of necessity. Porro first performed the operation as a matter of choice, as he considered it impossible to secure the uterine incision in Ca3sarean sec- tion so fully as to prevent the flow of blood and septic fluid into the peritoneal cavity. The results obtained under antiseptics in other abdominal operations encouraged him to make the attempt, and in 1876 he did so with happy results. Others took up the operation, and very quickly the old Cscsarean section was superseded by it; but only for a few years, for Caesarean section can now be performed without the slightest danger from bleeding, peritonitis, septicsemia, or other dangers, that Porro's operation sought to avert. At the present day, Porro's operation is an operation of exception, that is, only necessary in some conditions, such as serious rupture of the uterus, or where labour is obstructed by a large fibroid. As regards the steps of the operation, it is at the beginning similar to Caesarean section. But after the uterus has been emptied it varies, inasmuch as at this point the uterus is everted and an elastic ligature applied round it. Just above the os internnin. The uterine tissues are then 472 ■ A TEXT-BOOK OF GYNECOLOGY compressed until the bleeding has ceased. Then the uterus is re- moved, the stump secured outside the abdominal wound, and main- tained in position by needles and a serre-noeud. Porro, upon emptying the uterus, transfixed it with a trocar and cannula at the union of the body and cervix. He then withdrew the trocar and passed two silver wires through the cannula, which was alsa withdrawn and the wires tied, one upon the right and the other upon the left side, including in their grasp the ovaries and tubes. This done, the uterus and appendages above the wires were cut away, while the stump was secured outside. The method has been improved by transfixing with needles and ligating with a serre-nceud instead of with separate wires. The stump is dusted with iodoform, and dressed with gauze all round. The needles should be raised to allow of proper packing. A layer of sublimated gamgee or other dry absorbent dressing should be placed over all. It may require to be dressed daily, and the ligated portion usually separates about the tenth day, but the raw cavity re- quires regular dressing until perfectly healed. It was urged as an important factor that Porro's operation pre- vented future conceptions, but this end is gained in Cesarean section by the more simple method of tying and dividing the tubes. Some operators now prefer to remove the entire uterus. CHAPTER XXXI MALFORMATIONS AND DISPLACEMENTS OF THE FALLOPIAN TUBES Absence and defective development of the tubes — Supernumerary and accessory tubes and ostia — Displacements of the Fallopian tubes. The Fallopian tubes develoj) from the upper ends of the two Miillerian ducts. Their anlagen are first solid and cordlike and later become hollow tubes, and their lower limit is marked by the milage of the round ligament. Below this level the Miillerian ducts unite to form the uterus and vagina. Their malformations may be marked by the characters of defect, of excess, or of altered relation. During foetal life each Fallopian tube shows several spiral convolutions. Absence and Defective Development of the Tubes. — ^Absence of both tubes is very rare, and when it occurs it is nearly always associated with absence of the uterus. A less rare anomaly is absence of one tube, and in such a case the corresponding ovary is said to be usually wanting also; but this is probably less often so than has been thought, for the gland may be present in a rudimentary state, as in the specimen de- scribed by Blot (Comptes rendus de la Societe de hiologie, 2. s., vol. iii, p. 176, 1857), or in an unusual position in the abdominal cavity. Very fre- quently the defect is associated with the uterine malformation known as uterus unicornis; it is easy to understand this combination of de- fects when it is borne in mind that the tube and the corresponding half of the uterus are both developed from the same duct of Miiller. Unilateral absence of the tube is not necessarily accompanied by in- terference with the reproductive functions, for Chavannaz (Journal de medecine de Bordeaux, vol. xxvi, p. 361, 1896) has recorded the case, of a woman of sixty who had menstruated regularly and had borne three children, and who yet possessed (as was found out at the autopsy) neither tube nor ovary on the right side. The kidney of the same side may also be wanting, as in Edridge-Green's case (British Medical Journal, 1895, vol. i, p. 416). The Fallopian tube may be absent in part, for Ballantyne and Williams (Structures in the Mesosalpinx, p. 20, 1893) have described a case of genital tuberculosis in which the outer two thirds of the right tube was completely wanting and the inner third ended in a tapering conelike extremity (Fig. 205). Some- times the tube shows its rudimentary development by its solid state or by iniperforation of its abdominal end, anomalies which a knowledge 473 474 ^ TEXT-BOOK OF GYNECOLOGY of embryology makes it easy to comprehend. Another form which rudimentary development of the tube may take, is persistence of the spiral convolutions which are normally present in foetal life; it is doubtful whether these twists represent a return to the foetal state or a continuance of it; they must predispose to the occurrence of hydro- salpinx, and they may lead to sterility and dysmenorrhoea. Pig. 205. — " A case of genital tuberculosis in which the outer two thirds of the right tube •was completely wanting and the inner third ended in a tapering conelike extremity." — Ballantyne (page 473). Supernumerary and Accessory Tubes and Ostia. — Cases of super- numerary or double tubes are exceedingly rare; but instances of acces- sory ostia or of small tubes attaclied to the broad ligament or to the Fallopian tube itself are comparatively common. It is not difficult to understand why this should be so, for in the former case it is necessary to suppose the existence of two Mlillerian ducts on one side, while in the latter the condition may be explained by anomalous development of a single duct. An example of true double tube (on the right side) was reported by Winckel (LeJirbuch, p. 595, 1886); there was a third ovary lying in front of the uterus, and attached to it was a cordlike structure with a fimbriated end which passed to the right side and was connected with the right Falloj^ian tube; the patient was sterile. The case described by Euppolt (Archiv fiir Gynakologie, vol. xlvii, p. 646, 1894) must be looked upon as one of constriction of a Fallopian tube by fcfital peritonitis, and not as true duplication of the tube. With regard to Wetherill's case of " supernumerary oviducts " {American Jour^ial of Obstetrics, vol. xxxiv, p. 373, 1896), some doubt must also exist as to whether the tubes running in the broad ligaments below and parallel with the normal Fallopian tubes were really salpingeal in nature or not. Accessory ostia and tubes are, as has been said, not so uncommon. Ballantyne and Williams {Structures in the Mesosalpinx, p. 25, 1893) met with two instances of accessory ostia in sixty-one pairs of tubes from MALFOEMATIONS OF THE FALLOPIAN TUBES 475 Fig. 206. — " Usually, one accessory ostium only is present." — Ballantyne. consecutive post-mortems at the Edinburgh Royal Infirmary. Usually, one accessory ostium only is present (Fig. 306), and it is situated on the upper margin of the tube not far from its normal ostium; but Fer- raresi (Annali di ostetricia, ginecohgia e pediatria, vol. xvi, p. 531, 1894) has put on record a re- markable case in which there were six ostia in all. They are either sessile on the normal tube or have longer or shorter pedicles connecting them with it. These pedicles may be hol- low, and generally the ostia are surrounded by fimbrice and communicate with the tubal lumen. They may arise either from imperfect closure of the groove in the germinal epi- thelium which ultimately becomes the ujDper end of the duct of Miiller, or from secondary opening of the duct after it has been closed. The structures which have been described must not be confounded with what have been called " tubal appendages " or " pedunculated tufts of fimbrige." These are solid stalks bearing nu- merous fimbrige on their free end, and they usually spring from the broad liga- ment in the neigh- bourhood of the par- ovarium. Ballantyne and Williams (loc. cit., p. 45) have shown how frequent- ly stalked cysts of the tubules of Ko- belt occupy this po- sition (Fig. 207), and it is quite possible, as Bland Sutton sug- gests, that the pe- dunculated tufts of fimbriffi are simply ruptured cysts of Kobelt's tubes. A com- parison of Ballantyne and Williams's representation of such a cyst and Kubc's case of accessory tubal appendages (Fig. 208) will strengthen tliis view. It is noteworthy, however, that in the dis- FiG. 207.— " Frequently stalked cysts of the tubules of Kobelt occupy this position." — Ballantyne. 476 " A TEXT-BOOK OF GYNECOLOGY cussion which followed the reading of Kube's j^aper (Journal ATcou- scherstva I Gienshich Boliesneij, vol. ix, p. 458, 1895), Massen stated that so-called parovarian cysts might arise from these accessory tufts of fimbrige. The question must, therefore, be left undecided in the mean- FiG. 208. — " Kube's case of accessory tubal appendages." — Ballantyne (page 475). time. Tubal diverticula are sometimes met with, and it has been haz- arded that their rujDture, followed by the prolapse of the tubal folds through the opening thus formed, may lead to the production of an accessory ostium. From the clinical standpoint, accessory tubal ostia and diverticula are not unimportant; indeed, the opinion has of late years been grow- ing that they stand in very close relation with the causation of extra- uterine gestation. Thus Henrotin and Herzog {Revue de gynecologie et de chirurgie ahdominale, vol. ii, p. 633, 1898) have reported two cases in which they regarded tubal malformations as the cause of ectopic pregnancy: in one, the abdomen was opened for symptoms of tubal rup- ture, and it was found that below the right tube was a small accessory tube with a complete ostium abdominale, and in it a sac containing blood clot, decidual cells, and chorionic villi; in the other, the uterus and appendages were removed for long-continued pelvic symptoms, and it was seen that from the left Fallopian tube near its middle a diver- ticulum projected toward the uterus, and in this there were also blood clot, decidual cells, and chorionic villi. On the other hand, an acces- sory ostium tubee may render possible the occurrence of jDregnancy when the normal tubal ostia on both sides of the body are closed by inflammatory adhesions, as in the remarkable case described by Sanger DISPLACEMENTS OP TPIE FALLOPIAN TUBES 4YY {Monatsschrift fiir Geburtshulfe und Gyndkologie, 1895, vol. i;, p. 21, Bovee {National Medical Review, July, 1899) reported a case in which, in an operation for adhesion of the appendages and retroversion of the uterus, examination of the right appendage showed two fimbriated tube ends. Through the upper tube a probe could be passed almost to the uterine cornu; the other was permeable to the probe for about 2 inches, but as the passage of a probe all the Avay to the uterine from the am- pullar end of a tube is rarely possible, it seemed probable that there were really two similar, normal tubes in this case. Displacements of the Fallopian Tubes. — The tube, like the ovary, may be congenitally displaced. It may, for instance, be at a higher level than normal in the abdominal cavity. In the case of a newborn infant, J. W. Ballantyne {Transactions of the Edinburgh Obstetrical Society, vol. xv, p. 56, 1890) found the right Falloj)ian tube adherent, through foetal peritonitis, to the peritoneal aspect of the caecum; and M. L. Harris {American Gynecological and Obstetrical Journal, vol. viii, p. 45, 1896) discovered, during abdominal section performed for men- strual pain, that the right tube was much longer than usual and passed to the right ovary which lay on the psoas magnus as high as the bifur- cation of the aorta. A case is on record (Hiiter, Monatsschrift fiir Gehurtshidfe, vol. xxv, p. 424, 1865) in which the tubes were displaced hackward, and were united behind the uterus by their ostia, forming a ring. Another type of tubal displacement is herniation. Just as hernia of the ovary into the inguinal canal may occur, so the tube may find its way in the same direction. Usually, the tube is herniated along with the ovary (see Malformations of the Ovary), but in exceptional cases it has been met with alone. Thus, Pierre Wiart {Bulletins et memoires cle la Societe anatomique de Paris, 6. s., vol. i, p. 59, 1899) has reported the case of a six-months'-old child with hydrocephalus, in which the uterus was displaced toward the left side, the tube and round ligament of the same side were engaged in the abdominal opening of the inguinal canal, and the tube inside the canal was disjDosed in the shape of an almost complete 0, the fimbriated end coming nearly into contact with the part immediately projecting from the orifice. The ovary lay near to the opening but did not engage in it. It is probable that this form of hernia is more common than has been thought; it may be present at, or soon after, birth and be reduced by the rearrangement which takes place among the abdominal and pelvic viscera in the first year of life. If it persists, it may give rise in later life to dysmenor- rhoea, perhaps also to sterility. CHAPTER XXXII NEOPLASMS OF THE FALLOPIAN TUBES Benign neoplasms: papillomata ; cj'stomata; lipomata; fibromyomata — Malignant neoplasms: carcinomata; sarcomata. Adventitious growths of the Fallopian tubes are of comparatively rare occurrence and of but relatively small clinical importance. Little has been written upon this subject, and, for our present knowledge, we are indebted chiefly to Bland Sutton, Orthmann, Clark, and Doleris. A systematic study of these growths must be based upon the fact em- phasized by Coe that the Fallopian tubes are but extensions of the uterus itself and contain the same histologic elements; and that they are, therefore, liable in a certain degree to the same neoplastic changes. Growths originating in these structures, like those originating else- where, are divisible into benign and malignant. The benign neoplasms of the Fallopian tubes, so far as described, are (a) pajDillomata, (h) cystomata, (c) lipomata, (d) fibromyomata. Papillomata occurring in the Fallopian tubes have been carefully studied b}- Clark. Doran was the first to call attention to the subject which has been carefully elaborated by Sanger and Barth. Bland Sutton, who has reported two cases, has demonstrated the fact that the mucous membrane of the Fallopian tubes contains glands the adeno- matous tissue of which may become the starting point of true homolo- gous papillomata. This theory, however, has been rejected by Sanger and Barth. Papillomata in the tubes manifest themselves by the de- velopment of a tumour, which is generally the first symptom to attract the patient's attention. This growth becomes painful and may confine the patient to bed with repeated attacks of peritonitis. The tumour may be globular, elastic, and fiuctuating, and may possess a varying degree of mobility. It may be small or it may be large enough to pro- duce lateral displacements of the uterus with obscuration of its fundus. In Slansky's case, which comprised the basis of Clark's article, the tumour was about half the size of a man's head, presenting at one spot an amputated surface about 4 centimetres square, at one point of which was a short pedicle having the appearance of the enlarged uterine end of the Fallopian tube; close to the point of amputation was an irregularly torn opening through which the contents of the cyst had escaped. The external surface of the tumour was smooth, containing a few large dilated blood vessels and showing in the deeper 478 NEOPLASMS OP THE FALLOPIAN TUBES 479 layers occasional necrotic areas. The internal surface was covered witK a thick papillary growth, consisting of multiple funguslike excres- cences which, in some areas, were massed together in thick, dense clumps, presenting a typical cauliflower appearance. The papillae varied from delicate flmbrite to large, fusiform projections containing small cysts. There were occasional areas devoid of excrescences. The morbid histology of tubal papillomata is accurately described by Clark (Bulletin of the Johns Hopkins Hospital), who found that sections through the circular folds showed a greatly attenuated cyst wall meas- uring only 0.05 to 0.1 centimetre in thickness. Peritoneum, circular muscle fibres, a thin stratum of connective tissue, longitudinal muscle fibres, followed by a denser layer of connective tissue upon which rested one layer of columnar epithelium, arranged in regular order, were shown upon the slide in consecutive striae. Except in the baylike projections- between the folds, the epithelium was nonciliated, and, even in these spaces, the ciliated cells were only rarely found. Clark's further de- scription of the microscopic appearances is as follows: " Numerous large dilated blood vessels occupy the connective-tissue layer beneath the epithelium. The folds of the Fallopian tube, as such, are no longer present, but are represented by sessile and pedunculated papillary growths. " The low sessile projections are composed of dense connective tis- sue, like that seen in chronic inflammation of the tube, whose cells ex- tend at right angles from the underlying circular fibres, forming warty prominences clad with one layer of columnar epithelium which gradu- ally shades off into the low columnar and cuboidal variety as the domes of the projections are reached. Besides the sessile excrescences there are a few long, slender processes to which are attached daughter off- shoots. The main stem in all instances contains large dilated blood vessels. The connective tissue forming the stroma of these papillse shows a marked variation in its structure in different areas. At the bases of the papillge the cells are closely crowded together and contain deeply-staining spindle-shaped nuclei. This appearance is maintained until the apices or domes of the growths are approached, when the cells gradually become hyaline, and in turn shade off into a pure mucoid degeneration. " Sections from the thicker portions of the cyst wall (0.5 centimetre thick) show unstriated muscle fibres scattered very sparsely among the connective-tissue fibres which make up the chief part of the sec- tion. The internal surface of the cyst wall is covered with innumer- able, vigorous growing papillomata, whose main stems extend far out into the lumen of the cyst, forming the most complicated, coral-like systems. The offshoots have, in many instances, coalesced, forming spaces which contain small papillary growths. " In some instances the main stems have become adherent to each other, inclosing much larger glandlike spaces. The mucoid degenera- tion noted above is even more marked here, and in the large fusiform 480 " A TEXT-BOOK OP GYNECOLOGY ends of some of the branches the entire stroma has undergone this transformation^ giving the cystic appearance noted in the macroscopical description. Hemorrhage has occurred into some of these spaces con- taining the mucous tissue^ leaving a granular debris which stains a hright yellow by Van Gieson's method. " The ends undergoing degeneration are covered by one layer of shrunken cuboidal epithelium, which rests upon a thin layer of hyaline connective tissue. Besides the cystic spaces formed by the fusion of the papillomata, others are found occupying a deeper portion of the cyst wall, lined by cuboidal epithelium and surrounded by a dense con- nective-tissue stroma like those seen in ' sacto-saljainx jDseudo-follicu- laris.' (Martin.) " In one of these spaces a small papilloma is seen in process of formation. The single layer of cuboidal epithelium lining the cavity forms an uninterrupted line, except at one point, where it assumes a columnar shape and becomes heaped upon a delicate connective-tissue papilla projecting from the main stroma." The symptoms of papillomata of the ovary are simply those of an intrapelvic tumour. They are painful but not more so than certain dermoids. Their tendency to rupture of the tube or cajjsule in which they develop, results in the escape of blood and of the products of degeneration into the peritoneal cavity, causing inflammation of that membrane. In none of the cases so far reported, only six in num- her, has a diagnosis been made before operation. The treatment con- sists in the removal of the tumour by abdominal section. In view of the fact emphasized by Williams that all papillomatous growths have a tendency to undergo malignant degeneration, this form of neoplasm, rare as it is, furnishes another reason for prompt intervention in the presence of a pelvic tumour of undetermined character. Cystomata of the Fallopian tubes are generally of rare occurrence, ■of insignificant size, and of but little clinical interest. They may originate either within the serous coat or the muscularis, although their favourite site of development is from the vestibular mucosa. It is probable that they are inflammatory products, in the sense that mucous follicles have become occluded and thus converted into re- tention cysts. Sutton has reported a large cyst which developed in the muscularis and attained the size of a walnut, the probable origin of which was similar to that observed by Kiwisch in the submucosa, and which was demonstrably of inflammatory origin. A. Martin has published an interesting picture showing the cysts and other growths that develop about the vestibule (Fig. 209). Lipomata can hardly be spoken of in the plural, when indicating these growths as they develop in the Fallopian tubes. Their existence, so far as available records indicate, depends upon the report of a single case by Eokitansky. The neoplasm in that case was about the size of a walnut. The condition is symptomless and without clinical interest. NEOPLASMS OF THE FALLOPIAN TUBES 481 Fibromyomata may develop from the muscularis of the tube. Hypertrophy and hyperplasia of this tunic are not infrequent sequelae of salpingitis, and have been noted by Sutton as accompaniments of fibroid degeneration of the uterus. These areas of hyperplasia may be Fig. 209. — " A. Martin has published an interesting picture showing cysts and other growths that develop about the vestibule." — Eeed (page 480). more or less limited by bands of constriction which give to them the appearance of myomatous degeneration. As pointed out by Coe, how- ever, they are not true neoplasms. These latter are relatively of smaller size, rarely more than from 1 to 2 centimetres in diameter, although Speth's case, which is accepted as reliable, was about 4 centimetres in diameter. These nodules may be interstitial, but are generally sub- serous and pedunculated. They abound more in muscular than fibrous tissue. They belong to the curiosities of pathology, and are rarely productive of symptoms. Malignant neoplasms of the Fallopian tubes are (a) carcinomata and (b) sarcomata. Carcinomata occur in the tubes usually as the result of extension of the disease from the corporeal endometrium. It has been asserted that metastasis of carcinoma from the uterus to the tubes is of very rare occurrence. Kiwisch found carcinoma of the tube only 18 times in 73 cases of cancer of the uterus, and Dittrich in only 4 cases out of 94 of general carcinomatosis. Orthmann, in a communication on this sul)ject to the Gynecological Society of Berlin (Centralblatt filr GyndJcologie), stated that a careful research of the literature of the subject yielded accurate descriptions of only 13 cases, in 9 of which the uterus and in 4 the ovaries wore primarily affected. The disease 482 ' A TEXT-BOOK OF GYNECOLOGY may occur primarily in the tubes. This was true in 1 out of 3 cases, occurring in Martin's clinic. The fact that metastasis to the tubes is of such rare occurrence is explained^ according to Olshausen, by the distribution of the lymphatics, which do not favour the migration of morbific elements from either the ovaries or the uterus to the oviducts. Sarcomata are of infrequent occurrence in the Fallopian tubes. The reports of the few cases which have been recorded raise some doubt as to the exact character of the neoplasm. The histologic elements are usually so diverse that the growth itself is hardly susceptible of exact classification. The preponderance of connective-tissue elements, occurring in connection with other forms of cell growth, has gen- erall}^ resulted in the designation of the tumour as a sarcoma, or, more properly, a myxosarcoma. These tumours rarely attain the size reached by true sarcomata in other localities. Their growth is gener- ally more rapid than that of benign neoplasms, or, indeed, of the papillomata, the benignity of which is open to suspicion. Their symp- tomatology is simply that of a pelvic tumour, the existence of which should always be regarded as an indication for an incision undertaken for diagnostic purposes. In this suggestion lies the correct indication for treatment of these cases. CHAPTEE XXXIII INFECTIONS AND INFLAMMATIONS OF THE FALLOPIAN TUBES Infections in general — Bacteria of the Fallopian tubes in health — Bacteria of the Fallopian tubes in disease — Relations of infections to inflammations of the tubes — Catarrhal salpingitis — Morbid histology of salpingitis: (a) acute, (b) chronic — Hydrosalpinx — Hematosalpinx — Pyosalpinx — Symptoms and diag- nosis of salpingitis. Infections of the Fallopian Tubes. — The Fallopian tubes are fre- quently the seat of infection. It may be said that, aside from neo- plasms, which are rare, and malformations, which are still more rare, infections of the Fallopian tube cause, either directly or indirectly, practically all the diseased conditions which in those structures demand the attention of the practitioner. It is true that many of the in- fections of the Fallopian tube can not be distinguished from each other by present clinical methods; this fact, however, must not be accepted as a final barrier to either the present consideration or the future investigation of these conditions from the standpoint of their causation. The constant improvement in methods of investigation is resulting in the progressive revelation of new and important facts relative to the bacteriology and the histo-pathology of the Fallopian tubes, as of other structures of the body. While this fact is recog- nised and acted upon, the outlook must be accepted as promising. Thus, Eeymond {Annals of Surgery) found streptococci in a number of cases which a few years previously would have been considered sterile salpingitis, but in which, by means of improved methods, the micro-organisms were discovered. Practically all the progress which has been made in this department has been realized, step by step, by such painstaking investigations. The point at which we have arrived, justifies the consideration of all inflammatory diseases of the Fallopian tubes as of infectious origin, although the dominant micro-organism upon which the infection depends, can not be isolated in all cases. A systematic consideration of the subject must take into account (a) the bacteria of the Fallopian tube in health; {!)) the bacteria of the Fal- lopian tube in disease; (c) the general pathology of inflammation of the tubes induced by infections in general; {d) individual infections; find ((') treatment. 483 484 A TEXT-BOOK OP GYNECOLOGY The bacteria of the Fallopian tubes in health have been investigated by Sinclair, who points out the fact that, from the bacteriological point of view, it is well to keep in mind that the Fallopian tube has two openings, one extremely narrow, connecting it with the cavity of the uterus, and the other, the wide abdominal orifice connecting it with the peritoneal cavity. Invasion of the tube by bacteria may occur from either end, or through its walls under special conditions. The cavity of the uterus in health is free from germs and so is the peritoneal cavity. Inva- sion through the walls of the tube only occurs in adhesion to the intes- tine or from bacterial disease in the pelvis. Consequently in a state of health the Falloj^ian tube is entirely free from germs. Witte examined freshly extirpated and apparently healthy tubes in 11 cases. In 9 cases, the cultivation remained absolutely sterile. In one of the remaining cases he found both the staphylococcus and the streptococcus, in the other only a sparse growth of the staphylococ- cus. The corresponding uterus in each case was examined at the same time, and, in the cervical canal of the first, the streptococcus and staphylococcus were found. In the second uterus, the staphylo- coccus was discovered in the cavity of the body. In spite of the obvious cause of the presence of bacteria in the tubes, Witte drew the general inference that the healthy tubes might contain micro- organisms. Winter examined 40 tubes which had just been obtained by opera- tion. He emj^loyed the usual methods of cultivation in searching for bacteria, and, although there were a few exceptions of which he con- sidered the explanation satisfactory, he concluded that the healthy tube was free from bacteria. Menge examined 83 tubes obtained from 50 women operated upon for various reasons. Exact examination by the microscope and by cultivation experiments in various ways may be assumed. He came to the same conclusion as Winter, namely, that " the normal tube is always germ-free." It is possible that the tubercle bacillus may be found in or about the apparently healthy tube in very minute areas of infection, but it is a circumstance which must be extremely rare, and not to be dis- cussed here without entire disregard of proportion. The pathogenic bacteria of every other sort produce marked tissue changes immediately after invading the tube. The bacteria of the Fallopian tubes in disease are of extreme im- portance, for, as already stated, and as emphasized by Sinclair, among the diseases of the tubes which must be referred to bacterial invasion, we find all, almost without exception, with which we have to deal in gynecological practice. For the production of a serous collection in the Fallopian tube (hydrosalpinx), two things are necessary: on the positive side, the oc- currence more or less remotely of sufficient perisalpingitis to close the INFECTIONS AND INFLAMMATIONS OP FALLOPIAN TUBES 485 abdominal orifice; and on the negative, the absence of such an amount of bacterial infection as will permit the fluid distending the tube to remain clear. The most common form of hydrosalpinx, that with the walls thin and translucent owing to the great distention of the tube, usually shows signs of pre-existing inflammation in addition to the sealing up of the ostium abdominale; but it is hardly conceivable that any virulent bacterial infection at any previous time could leave so few traces of its existence. In the form of hydrosalpinx, where the walls are thick and com- paratively hard, the anatomical changes may be, and most likely are, produced by the work of pathogenic bacteria of such a modified viru- lence, or in such small quantity, as not to produce pyosalpinx. To leave theory and come to the results of the comparatively small amount of work that has been done in the bacteriology of hydro- salpinx; the examinations made by Menge on 20 cases of hydrosal- pinx and 3 of hematosalpinx gave an absolutel}^ negative result. The usual care was exercised, and a great variety of cultivation methods were adopted, including the methods and media employed in the search for the bacillus tuberculosis, and yet the results indicated the entire ab- sence of any germs which could be seen with the microscope or culti- vated by any of our known methods. It is interesting to notice that the conservative method of dealing with hydrosalpinx by simple incision, or its equivalent, has received post-factum justification from the bacteriologists. The bacteria of purulent inflammations (pyosalpinx) are beginning to be better understood. It is only a short time since we hardly knew of the existence of diseases of the Fallopian tubes. In the last decade and a little more, they have been more exactly and effectively studied, owing to the wealth of material obtained by the introduction of radical surgical treatment. The tendency now is to set down all the more severe forms to bacterial invasion, especially by the gonococcus and the pathogenic bacteria, which produce endometritis in childbed. Ever since Westermark, in 1886, announced the discovery of the gonococcus in the pus of a pyosalpinx, innumerable investigations to prove or disprove the bacterial origin of tubal disease have been undertaken, and the contributions to the bacteriology of the subject have been voluminous in the extreme, and, as usual, many-voiced and often con- tradictory. In addition to the study of the gonococcus and other pathogenic micro-organisms, many observations, both clinical and bacteriological, have been made upon the phenomena of tuberculosis of the tubes and ovaries with an exactitude unknown before the era of gynecological surgery. The conclusion which receives practically unanimous support is, that the gonococcus is hy far the most frequent cause of purulent sal- piru/ilis. Wer-thcirn, who was among the first to publish any considerable I! II III her' of (;xa(;ily o])S(;rv(!d cases froiri the bactet'iological standpoint. 486 A TEXT-BOOK OF GYNECOLOGY found that ont of 2-i cases, the jDroducts of inflammation were sterile in 6; the gonocoecus was found in 16; in 1 case the streptococcus was found, and in 1, the pus contained a bacterium which he could not identify. Wertheim, like most observers, found that the gonocoecus held the first place as the j)roducer of pyosalpinx, and that other bac- teria were the agents only occasionally. He did not see reason to believe that the gonocoecus prepared the way for secondary invasion by pyogenic organisms. As a rule, when the gonocoecus is present no other bacteria are found. Menge's results in his first series of cases in which the Fallopian tubes were the seat of inflammation, were much the same as Wert- heim's. The gonocoecus was the most common cause of the dis- ease, but the streptococcus and staphylococcus were occasionally found, and, in a very few cases, the Diplococcus pnewnonice and the Bacillus tuberculosis. In the great majority of cases, the pus in pyosalpinx sacs was sterile, and a mixed infection was found to exist in the tubes only when they were adherent to other viscera. Adhesion to the intestine owing to bacterial inflammation appears to lead to the pas- sage of bacteria bv softening of the tissues, or by actual communication through an orifice formed by destruction of tissues. The other, more ordinary, wa3'S in which bacteria gain access are well known. They are chiefly by extension of endometritis of bacterial origin upward, or by invasion from above, usually by the tubercle bacillus. The war of words and opinions regarding " mixed infection " has been waged chiefly around pyosalpinx and the relations of the gono- coecus to other pyogenic organisms. It is agreed that the gonocoecus does not incline toward symbiosis, but there can be no doubt that it is found occasionally in company with saprophytes and pathogenic organ- isms. The discussion has some bearings on practical gynecology, e. g., there can be no doubt that gonorrhoea may extend to Fallopian tubes alread}^ invaded by the slowly acting Bacillus tuberculosis; and the clinical facts, as well as bacteriological investigations, show that an acute puerperal endometritis, primarily due to the streptococcous infec- tion, may be influenced for the worse by the spread of gonococcous in- fection from the cervix. Isolated observations like that of Kronig, in which a gonorrhoeal endometritis was cured through a puerperal infection by the streptococcus, and a vulvo-vaginitis by an attack of erysipelas in the neighbourhood of the parts, are as yet mere riddles with no place in any ordered set of well-supported opinions. Upon the whole, however, it may be confidently alleged that the subject of " mixed infection " is of interest almost entirely for the bacteriologist as distinguished from the gynecologist. The bacteriology of chronic salpingitis is of considerable interest. In cases operated upon, the tissues are often so much hypertrophied as to give the impression, at the time of pre-operation diagnosis, that a tumour, or even a cystic tumour, exists. The disease is usually of bacterial origin, often set up by the gonocoecus, and, like endometritis, INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 487 'Carrying infiltration and hypertrophy in its train; yet examination of the secretion and the tissues in chronic salpingitis hardly ever shows the presence of bacteria. With regard to purulent salpingitis with or without pyosalpinx for- mation, Menge's examinations and his results appear to state the whole •case. His material consisted of the tubes from 122 cases of purulent salpingitis, to part of which reference has already been made. The secretion and the tissues of the tubes w^ere examined, and cultivation •experiments were carried out on a large scale. Shortly stated, the results were the following: In 122 cases, the contents of the tubes were free from bacteria 75 times; they contained bacteria 47 times. In 28 cases, the gonococcus was found alone; in 9, the tubercle bacillus alone; once, a pyogenic .staphylococcus alone; once, the colon bacillus alone; once, an anaerobic diplococcus alone. In 47 cases, then, in which bacteria were dis- covered, the culture was pure in 44 and mixed in 3. The presence of the gonococcus was ascertained partly by cultivation, and partly by jaicroscopic examination, identifying the organism by the use of Gram's method. Menge gives numerous details of anatomical changes which are of interest from other than the bacteriological point of view. One ob- servation will be borne out by all who have had any considerable experience in the surgery of the parts, that it is impossible during operation to distinguish a pyosalpinx due to tubercle from one due to other causes. The discussion of primary and secondary tubercle of the female sexual organs in general, and of the tubes in particular, hardly belongs to the present subject. It is, however, a striking re- sult of bacteriological examination of cases actually operated upon for tubal disease, that nearly 10 per cent were found to depend upon the tubercle bacillus alone for the anatomical and other changes which gave rise to the symptoms. The tubercle bacillus appears, therefore, to play a more important part as a parasite of the tubes than the streptococcus and staphylococcus. The Bacterium coli commune and the anaerobic pathogenic bacteria are still less important. Perhaps, says Sinclair, sufficient attention has not been called to the fact that, in the great majority of cases of pyosalpinx, the secretion and tissues of the walls are found to be germ-free. This must imply that the bacteria have died out and that the pus is consequently sterile. It is to this fact, almost certainly, that we owe the comparative innocu- ousness of pus spilled into the pelvic cavity during operations on the pus tubes. It is probably in these obsolete cases, when no secondary invasion has taken place, that the symptom of fever does not exist. The bacteria have ceased to produce toxines. But this subject, lying between bacteriology and clinical gynecology, is still wrapped in mystery. The relations of infections to inflammations of the tubes are demon- strable. 488 A TEXT-BOOK OF GYNECOLOGY Infections of the Fallopian tubes result in inflammation of those structures. In the earlier classification of inflammatory diseases of the oviducts, the gross, or macroscopic appearance, of the tubal en- largements, together with their contents, was taken as the guide for nomenclature. Thus the terms hydrosalpinx and pyosalpinx signify, in the one instance a watery or dropsical, and in the other a purulent, col- lection within the tube, without regard to the causation or pathology of the disease. This classification still prevails, and quite justly so, for laboratory methods have not as yet led to a more accurate or specific nosology capable of being successfully adapted to clinical diagnosis. Without question, the classification of diseases according to their etiology would be preferable, on account of its greater scientific accu- racy, but, so far, neither a careful bacteriological examination, nor microscopical sections, are sufiicient to reveal the primary infecting or exciting agent in a majority of cases. Tuberculosis is an exception to this rule, for its microscopical lesions are so characteristic as to be quite pathognomonic; but even this disease is frequently not recognised clinically at the time of operation. (See Tuberculosis of the Fallopian Tubes.) Gonococcous and streptococcous infections are likewise susceptible, although in a less definite degree, of individual study; but even these micro-organ- isms, while exercising a dominant and determining influence over the course of subsequent morbid events, ordinarily occur in company with other pathogenic bacteria. The closer study of the causes of inflam- mation in recent years, says Clark, has established the fact that it is never an idiopathic process, for it can not originate de novo. Of late, he adds, it has also been conclusively demonstrated that the mechanical and chemical causes (exclusive of bacterial toxines) seldom play a causative role, and that the prime factors in the production of sur- gical inflammations are of bacterial origin. To classify accurately inflammatory diseases according to the speciflc organism which pro- duced them, would be a scientific ideal; but as this, with the exceptions already noted, is not at present practicable, the older nomenclature to which we have become accustomed through long usage should be re- tained, until after the discovery of more positive means by which the different varieties of inflammation, classified according to their causa- tion, may be further distingushed from each other. Concerning the significance of names in these various conditions, there has been con- siderable discussion, but as this is not of great moment, for the obvious reasons just pointed out, the usual terms will be employed; when necessary, the newer terms will be indicated as synonyms in the con- sideration of the general morbid changes that are induced. In the present state of our knowledge, it is best to consider infections of the Fallopian tubes from (a) the standpoint of morbid histology, and, (b) as far as possible, from the standpoint of the individual infectious element. INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 489 Catarrhal Salpingitis (Salpingitis C atarrhalis) . — Before taking up the morbid conditions of the Fallopian tubes, it may be well to recall quite briefly the essential points in their normal anatomy. As each tube emerges from the cornu uteri it is of exceedingly small calibre, its lumen barely admitting a fine bristle. From this point (ostium uterinum) it continues narrow for at least one third of its length, then gradually widens into a trumpet-shaped termination which again con- tracts somewhat at the abdominal opening (ostium abdominale). JSTor- mally, the tube runs in almost a straight course outward for half its length, then curves gently downward and dips into the pelvic cavity posteriorly to the broad ligament. Its mesentery is formed by two folds of the broad ligament within which it is situated. The three layers of the tube consist of the enveloping peritoneum, muscle (longitudinal and circular), and mucosa. As the mucosa is the portion of the tube primarily affected in endosalpingitis, the earliest stage of salpingitis, a more minute consideration of its finer histology will not be out of place. This coat is continuous with the lining membrane of the uterus, but, unlike it, has no glands, although the depressions between the folds are so strikingly similar as to have caused Hennig, and later Bland Sutton, to describe them as true adenoid structures. The gen- eral consensus of opinion among the best histologists of the present time is against this acceptation, and the mucosa may therefore be con- sidered as a simple nonglandular tissue. The interstitial, or uterine, portion of the tube resembles in shape the letter H, and is lined by one layer of columnar ciliated epithelium; in the extra-uterine part of the tube, the mucosa assumes a rugous appearance, being thrown up into exquisite villous or coral-like projections. The connective-tissue stroma contains delicate vascular twigs which run out at right angles from the circular blood vessels of the tube, and terminate as a rich anastomosis beneath the epithelium. As the abdominal end of the tube is approached, the mucosa is more and more thrown into duplicatures until it terminates in the fimbriated extremities. A sharp line of de- marcation indicates the line of union between the mucosa and peri- toneum at the tips of the fimbriae. Morbid Histology of Acute Salpingitis. — With this brief resume of the essential points in the normal histology of the tube, we may take up, with a clearer understanding, the various inflammatory changes that occur in that structure, all of which, regardless of their mode of origin, start first as a simple salpingitis. This condition may very quickly merge into either the purulent or the hemorrhagic type, but so far as the primary pathologic phenomena are concerned, the classic signs of inflammation — calor, rubor, dolor, and tumor — are present, and accompanying them are the vascular injection, the transmigration of the leucocytes, the increase in round-celled infiltration, and the swell- ing of the epithelium, all characteristic histological changes in acute iMfl;iiiitii;ilion. in llic; acute; stage of iiiflainuiation, the noiTiial secre- 490 A TEXT-BOOK OF GYNECOLOGY tion of the tube is only slightly changed. Its consistence is at first fluid, later mucoid, the colour being transparent whitish, milky, or reddish, according as it is mixed with desquamated epithelium and leucocytes or with red blood cells. One of the most striking macro- scojDical changes in the acute i^rocess is the marked congestion of the blood vessels, which are greatly reddened and injected and present a riblike appearance beneath the peritoneal covering of the tube. With the increase in length and thickness of the tube through these morbid changes, the tube usually becomes kinked and twisted upon itself, be- cause the mesosalpinx maintains, without any relaxation, its normal relationship to the tubes; consequently the latter, as it becomes length- ened and enlarged, is throT^m into a distorted shape. The fimbriated end of the tube, being the seat of terminal vessels, is greatly congested, of a bluish-red colour (cockscomb colour), and a stringy, glairy mucus is either seen escaping, or may be expressed from, the abdominal orifice. From the very beginning of the inflammatory process, the secretion of the tube may assume a purulent character. Menge asserts that this is the rule in gonococcous infection, and yet Doderlein, to a certain extent, negatives this statement by the report of a case of double gonor- rhoea! tubal inflammation in which myriads of gonococci were found; on one side there was a pyosalpinx, while on the other, only a simple tubal catarrh had occurred. The mucosa is greatly increased in thickness, both on account of the hypertrophy of its constituent cells, and because of the vascular congestion of the villi. At this stage, a transverse section of the tube presents a rosettelike appearance, the mucosa projecting rather promi- nently over the peritoneal edges. In the acute stage of the inflamma- tion, the morbid changes may be conflned entirely to the epithelial lining, and the immediately underlying connective-tissue stroma, whence the term endosalpingitis. So long as the inflammatory condition is strictly limited to the mucosa, the outward appearance of the tube, with the exception of the vascular injection and reddening, presents no other changes. In- deed, in the acute stage, especially when there is no increase in the tubal secretion, the appearances are strikingly like those of the tube in its period of normal congestion during the menstrual flux. Notwithstanding a considerable increase in the secretion of the tube, due to the local irritation of the infectious agent, the tubal epithelium remains intact much more frequently than would be sup- posed. The underlying connective-tissue stroma, and not the epithe- lium, is the chief seat of the initial inflammatory changes in acute catarrhal salpingitis. On section, the mucous membrane presents many folds and duplica- tures which form, through contact of their free ends, baylike or loculate spaces. The stroma cells are much richer in nuclei and the blood vessels are greatly widened, and show considerable transmigration of polynuclear leucoc3d;es. INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 49I Througliout the vstroma, in a section by Whitacre, a variable amount of round-celled infiltration with beginning suppuration is observed (Fig. 210), depending upon the nature and activity of the local infec- tion. In isolated areas, minute extravasations of blood are seen. Not- withstanding a local irritation sufficient to incite these changes, the epithelial layer usually remains intact and does not even shed its Pig. 210. — " Throughout the stroma, in a section by Whitacre, a variable amount of round- celled, infiltration with beginning suppuration is observed." — Clark. cilia, although the cells appear congested and swollen. From this stage on, the course and termination of the inflammation depends upon a number of conditions, such as the variety of infectious organisms, the strength of their virulence, and the local resistance of the tissue. Thus, there is occasionally observed a loss of the epithelium and complete replacement of the mucosa by a cylinder of pus cells (Fig. 211). If resolution does not occur in the acute stage before detailed, the inflammatory process tends to become chronic, when the extent and general characteristics of the pathologic lesions may become most diversified. Morbid Histology of Chronic Salpingitis (Salpingitis chronica). — With llie continued action of ilie ii-ritating agent, be it the primary infectious micro-organism or the toxines generated by it, the acute innaiiiiiiJiiory stage merges into a chronic condition, and a marked 492 A TEXT-BOOK OF GYNECOLOGY involvement of the muscular portion of the tube occurs. The ser- pentine course of the tube becomes more pronounced and sharp twists and kinks result. The tube assumes a more bluish or congested appear- ance, and many vessels, which previously appeared as capillaries, be- come quite prominent. Through the sharp kinking of the tube, micro- FiG. 21] (WniTACREj. — " Thus, there is occasionally observed a loss of the epithelium and complete replacement of the mucosa by a cylinder of pus cells." — Clark (page 491). scopical sections not infrequently show two or more views of the tubal lumen, cut transversely or obliquely. As in all chronic inflammations, there is an excessive formation of new connective tissue, which renders the tube stiffer and much less flexible than normal. The extravasations of blood, which are microscopical in the acute stage, may frequently become so marked as to be visible to the naked eye as bluish-red spots. Through hypertrophy and hyperplasia of the connective tissue and muscular portions of the tube, its wall may reach a thickness of 2 centimetres, or even more, in long-standing cases, as a result of the continuous irritation and destruction of the tubal epi- thelium; the club-ended villous projections of the mucosa adhere to- gether, which not only decreases the primitive lumen of the tube, but gives it, even on macroscopical examination, a loculate appearance. Notwithstanding the fact that this condition appears most frequently in the isthmiac portion of the tube, a complete atresia seldom occurs. For instance, Eeymond found it only once in 94 cases. INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 493 Sooner or later in the course of the chronic process, plastic lymph is thrown out about the tube, which organizes and forms adhesions of varying density between the angles of the distorted tube, and between tlie tube and neighbouring viscera. The most frequent and important changes effected by these adhesions is the closure of the fimbriated end of the tube (see Hydrosalpinx and Pyosalpinx). In the course of this atretic process, the abdominal end of the tube may gradually be nar- rowed until an opening not larger than a robin's quill remains. Through this gradual narrowing, the secretions may be more or less hemmed in, with now and then an intermittent discharge into the pelvis, giving rise in some cases to an extensive pelvic peritonitis. The narrowing of the ostium abdominale may occur, either through the gradual adhesions of the peritoneal edges of the fimbriae, or, as is not infrequently, but in fact, is usually, the case, the fimbrise become invaginated within the tube, and are then incarcerated. The small round-celled infiltration which at times occurs beneath the mucosa in the acute stage becomes generalized in the chronic pro- cess, until, as seen in a section by Whitacre, the entire tubal wall may become involved (Fig. 212). From delicate villous termini the folds of the mucosa are transformed into rounded fusiform ends filling up the lumen of the tube and lying in close contact with each other. On account of this contact the epithelium becomes destroyed, and the projections adhere together and establish isolated loculi or diverticula. These spaces may be gradually obliterated through a typical granula- tion process, or the epithelium may remain intact, and, through the accumulation of a catarrhal secretion, be transformed into larger cystic cavities; or from a ciliated cylindrical type the epithelium may undergo retrograde change until it assumes a flattened or endothelial-like ap- pearance. Through the projection of the fusiform villi into the tubal lumen, adhesions may take place between opposing ends and thus establish connective tissue bridges from one part of the tube to another. The occurrence of the glandlike space has further strengthened Hennig and Bland Sutton in their belief in the true adenoid nature of these structures. As stated in preceding pages, this theory has found but few supporters, for the adventitious way in which these spaces are formed becomes too manife.st on critical examination. In view of the fact that these spaces are the unmistakable products of a pathologic process, Martin prefers the term salpingitis pseudofol- licularis to salpingitis foUicularis as employed by some writers. In the chronic stage the tubal secretion may vary, Just as in the acute form, from a transparent catarrhal to a purulent character. Upon the nature of the secretion depends the nomenclature. The usual terms employed in describing the varieties of chronic salpingitis are catarrhal, hemorrhagic, and purulent. The hemorrhagic salpingitis (Salpingitis hmmorrhagica) , so far as its liistologic clianK;t(;ristics are conc(!rned, presents no essential variation 494 ^ TEXT-BOOK OP GYNECOLOGY from the foregoing descrijDtion further than that induced through the deposition of blood pigment in the areas of extravasation and upon the inner walls of the tube. The tubal secretion is of a reddish or chocolate-brown colour, due to its mixture with red blood corpuscles in various stages of disintegra- FiG. 212. — " The small round-celled intiltratiou which at times occurs beneath the mucosa in the acute stage becomes generalized in the chronic process, until, as seen in a section by Whitacre, the entire tubal wall may become involved." — Clark (page 493). tion. Polynuclear leucocytes crowded with blood pigment are seen in various parts of the tissues, and are especially numerous around the ecchymotic areas. In chronic purulent salpingitis the tubal secretion consists largely of pus, varying in appearance from a flocculent sero-purulent character to a thick yellowish or greenish colour. If, as a result of a severe infection, purulent salpingitis sets in at the very beginning without an appreciable catarrhal change, the local inflammatory changes be- INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 495 come most pronounced, consisting in an excessive transmigration of leucocytes, a rapid round-celled infiltration, and a rapidly increasing oedema of the mucosa. Through these hypertrophic changes, the tube assumes a size much greater than the normal. Martin has attempted to establish a differentiation through microscopic examination between the acute septic salpingitis and the acute gonorrhoeal salpingitis. According to our view, unless the infectious micro-organism is rec- ognised either through cultures or through cover-glass preparations, we do not believe this differentiation through a simple histological examination is possible except in the hands of an expert microscopist, and even then the results must be viewed with considerable scepticism. Through the closure of the ostium abdominale, the tube becomes more or less distended, and, according to the nature of its secretion, is called a hydrosalpinx, hematosalpinx, or pyosalpinx. Hydrosalpinx {Hydrops tubarum, Sadosalpinx) is a pathologic col- lection of serous fluid within the Fallopian tube due to a partial or complete stricture in some part of the tube. While a pathologic atresia may occur at any point in the tube, the usual seat is at the fimbriated end. In rare cases, more than one stricture may take place, which divides a simple hydrosalpinx into two or more chambers. According to Eokitansky, the occlusion of the fimbriated end is due to the adhesion of the peritoneal surfaces of the fimbriae, which become inverted within the tube. Klob ofi^ers a similar explanation and attrib- utes the adhesions to a tubal catarrh, perisalpingitis, or pelviperitonitis. According to Klebs, atrophy of the fimbrias may result from a local- ized inflammation leading to an inversion of the flmbrige and a filling in of the ostium abdominale with scar tissue. While these strictures of the tube may result, in rare instances, from other than inflammatory causes, as, for instance, the dropsical accumulation in the tube in cer- tain cases of myoma, nevertheless, the chief inciting factor is un- doubtedly a perisalpingitis. Whether the inflammatory condition is always of bacterial origin, is as yet an open question. Menge and others have, for instance, described numerous cases in which the occlu- sion occurred through a sterile process, such as the chemical irritation of hemorrhagic accumulations, and from the mechanical congestion due to the pressure of tumours, etc. These cases, however, are com- paratively rare, and, as a rule, the first cause may be accepted as the chief one. While it is generally conceded that hydrosalpinx is sui generis a dropsical accumulation, yet such eminent authorities as Zweifel and Bland Sutton believe that it may result from the resolution of a pyo- salpinx, the purulent matter undergoing a transformation into an aqueous accumulation. Menge, Kleinliaus, and others, as the result of careful observation, state with positive assurance that such a retrograde metamorphosis is not possible, for they say tliat, although pus may become thick and 496 A TEXT-BOOK OF GYNECOLOGY inspissated, it never undergoes liquefaction, and also that the his- tological changes in hydrosalpinx are radically different from those observed in pyosalpinx. Upon the basis of Clark's observations an unqualified support to the latter opinion may be given. As a general rule, hydrosalpinx is attributable to puerperal rather than to gonorrhceal infection. Menge, for instance, holds very strongly to the belief that the gonococcus is a pus-producer, that, consequently, a purulent salpingitis or pyosalpinx is usually produced by it, and that only in rare instances does hydrosalpinx result from this micro-organ- ism, and then only as a secondary process. In explaining the latter statement, he says that the primary gonorrhceal salpingitis may have reached its climax and be undergoing resolution when, as a result of a secondary pelvic peritonitis, the ostium abdominale may become oc- cluded with a simple hydrosalpinx as a sequel. Von Eosthorn maintains with forcible argument that hydrosalpinx is always induced by a pelvic peritonitis. He says that streptococci or staphylococci gain entrance to the tube, and, because of attenuated virulence, only a simple catarrhal salpingitis is inaugurated, and that later, through continuity of structure, the pelvic peritoneum becomes involved and the tube is thus sealed by adhesions. Coincidently with this occlusion, the secretion of the tube begins to accumulate, first distending the abdominal end, then progressively extending toward the isthmiac, or uterine, extremity of the tube. Quite naturally the dis- tortion decreases toward the uterus on account of the greater resistance offered b}^ the tube. The escape of fluid is prevented or greatly retarded through ad- hesions, organic occlusion, mechanical torsion, or kinks at the uterine juncture of the tube. As stated under the head of Salpingitis, an actual closure of the lumen of the isthmiac portion of the tube through inflammatory changes is comparatively rare. With the increase in the accumulation of fluid within the tube, its wall undergoes a gradual thinning, and, although a marked pressure atrophy may ultimately take place, the visible landmarks of the longitudinal folds of the mucosa will appear as ridges running direct from the vestibular to the isthmiac extremity of the tube. Upon the degree of distention depends the variation in the mor- phology, the size ranging from that of a lead pencil, with more or less conformation to the normal undulations of the tube, to a very large fusi- form tumour with a smooth glistening exterior. As the tube is gradu- ally transformed from its normal shape it may assume a sausagelike, serpentine, or what is more usual, a retort or pipe shape. In rare instances, the tube may reach very large dimensions, and the morpho- logic characteristics may be so obscured as to render its identification very difficult on account of the close resemblance to a tubo-ovarian, ovarian, or parovarian cyst. Even in cases of moderate distention, the muscular and connective-tissue layers may become so attenuated as to allow the contents of the tube to be seen through its transparent wall. INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 497 The tubal secretion may be of a clear limpid, a yellowish lemon, or a slightly blood-tinged colour, and its formed elements may consist of leucocytes, epithelium, red blood cells, and sometimes cholesterine crystals. To the latter. Bland Sutton ascribes the greenish colour occasionally noted in the fluid. With the progressive increase in the size of the tube, the mucosa loses its coral-like or villous appearance, becomes greatly stretched, and may undergo such complete atrophy as to leave only the small ridges before described, or, as is seen in some cases only, small blunt teatlike eminences. Of the mucosa the epithelium alone remains, and this is usually transformed into a cuboidal or flattened variety; in the deep angles and protected areas it may, however, still maintain its cylindrical character, and even the cilia may remain intact. As a unique and rare production, bonelike or calcareous plates are found in the walls of the tubes, or, as illustrated by Cullen's case, the tube may contain a calculus. Hydrosalpinx does not, as a rule, reach a large size, although cases are reported in which the contents measured a litre or more. With regard to the comparative frequency of single or double hydrosal]3inx, it is usually stated that the double form is the more conunon. To the contrary, however, Cullen states that in a series of 27 cases, he found 17 unilateral while the remainder were bilateral. Types of Hydrosalpinx. — Certain deviations in morphology from the simple form just described constitute special types of hydrosalpinx. Occlusion of the tube in salpingitis pseudofollicularis, with its sub- sequent enlargement, constitutes hydrosalpinx pseudofollicularis. In this condition the tube rarely reaches such a large size as the simple form, from purely mechanical reasons, for it is self-evident that a cavity divided into numerous loculi can not distend, on account of increased resistance, .with the same facility as a unilocular cavity. Cross sections of the tube present a spongelike or irregular punched-out appearance, the larger cavities being lined with cuboidal, the smaller with simple cylindrical or ciliated epithelium. In some vSpaces, desquamated ejDithelia are seen. As a special variety, named, not because of its histological deviation from the simple variety, but on account of its intermittent discharge of fluid into the uterus, is the hydrops tubce profluens. In these cases the tube may reach a very large size before the sphincterlike action at the uterine cornu is overcome, when a profuse serous flux is noticed by the patient. This is a comparatively rare condition, only isolated instances having been reported from even the largest clinics. This peculiar intermittent action of the tube is attributed to sev- eral causes. According to Landau, the muscular walls at the uterine juncture are greatly hypertrophied, and only when this constriction is overcome by the vis a tergo of the serous accumulation is the periodical flow inaugurated. 33 498 A TEXT-BOOK OP GYNECOLOGY Other investigators have attributed this condition to a stricture of the tube which, like the kinked garden hose, is only overcome by the gradual increase in pressure behind the point of constriction. The last variety of hydrosalpinx, known as tubo-ovarian cyst (Fig. 313), is a pathologic condition in which the hydrops tubte is associated,, by organic union, with a cystic condition of the ovary, the fluid from one cavity mingling with that of the other. These aqueous tumours vary from a very small to a very large size, reaching in some instances a diameter equivalent to that of a child's head. With a free conununication between two secreting cavities, such as one finds in these cases, it is quite natural for the cystic tumour to reach much larger dimensions than the simple hydrosalpinx. The Fallopian tube is situated upon the upper surface of the tumour and usually appears as a large club-shaped or retort-shaped body, which Fig. 213. — "The variety of hydrosalpinx known as tubo-ovarian cyst." — Clark. is fused at its fimbriated extremity onto the surface of the ovary by adhesions of more or less density, depending upon the chronicity of the inflammatory process. The communication between the cystic portion of the ovary and the tube may be established, either by the primary adhesion of the spread-out fimbriae upon the surface of the cyst with a subsequent rup- ture into the tube, or the free fimbriae may become incarcerated within the ruptured opening of a cystic Graafian follicle or other ovarian cyst. In general appearance, the tubal portion of this combined tumour does not difi^er from the usual hydrosalpinx, while the ovarian portion con- forms to the usual classification of the simple unilocular, multilocular, or glandular cysts. Where the adhesions are quite dense and the tube and ovary are fused together in a very close organic mass, it may be difficult or INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 499 impossible to recognise macroscopically the loeuli which originate in the ovary from those of the tube. In such instances, however, a dis- tinction may be made microscopically, through the recognition of the characteristic ovarian stroma and constituent cells of the Graafian fol- licle. Hematosalpinx (Sadosalpinx hcemorrhagica) is a collection of blood within an occluded tube, similar to the serous collection in a hydro- salpinx. Until quite recently all hemorrhagic tubal collections have been placed under this classification. Veit, however, has shown that this is an error, as the hemorrhage incident to a tubal pregnancy or to a malignant growth is merely an accidental product, and should, therefore, not be given this misleading name. Hematosalpinx is produced through sharp kinks and torsion of the tube, thrombosis of the tubal vessels, and from simple hemorrhage into a hydrosalpinx. Less common causes are acquired or congenital atresia of the uterus or vagina, traumatisms of the inner genitalia, and the injuries of severe labours. Although the majority of cases may be attributed to some one of these easily recognised causes, there is still a considerable number of cases in which the minutest history and most painstaking physical and microscopic examinations have failed to reveal the true etiology. Martin ascribes some cases to vicarious menstruation, while others attribute this condition to a reflux of menstrual blood from sud- den spastic uterine contractions. Sanger asserts that an aseptic accu- mulation of blood in the pelvis may induce a localized peritonitis, through which the abdominal ostium becomes occluded while the tubal hemorrhage is still in action. The pathologic changes observed in these cases depend upon the primary cause of the hematosalpinx. When the intratubal hemorrhage is induced through a strangulation of the tube, the vessels are thrombosed and numerous areas of extrava- sation within the tubal wall are found, and in some instances large in- farctions may occur. The tissues always stain badly and microscopical sections frequently show very much obscured histologic characteristics. More or less ex- tensive hemorrhagic necroses frequently take place, but are sharply limited by the line of strangulation. In the simple cases where the blood is either shed from the mucosa into a hydrosalpinx, or where it reaches the tube as a reflux from the uterus, the histologic picture presents no essential structural devia- tions from those observed in hydrosalpinx. The inner wall of the tube is covered with a pigmentary deposit and the mucosa may be the seat of minute capillary extravasations. Leucocytes laden with blood pigment are also found within the vessels and as wandering cells in the tissues. Pyosalpinx (Sadosalpinx purulenta; suppuration of the tube) is a purulent collection within the Fallopian tube, which arises as a result of offliisioii in some part, usually at the ostium abdominale, of an in- 500 A TEXT-BOOK OF GYNECOLOGY flamed tube. Quite naturally, an agent sufficient to induce this secre- tion of pus is of a more irritant nature than that found in a simple catarrhal process, consequently the inflammatory reaction is usually much more marked. The extent of the involvement is variable, and the size of the tube and the thickness of its walls depend upon the degree of distention. When the quantity of pus is small, the tubal walls are usually greatly swollen and the thickness may exceed the normal many fold, whereas in a large tense pyosalpinx the opposite condi- tion may be noted, just as in a hydrosalpinx. So far as size is con- cerned, a 23yosali)inx as a rule does not reach that of a hydrosalpinx, although instances are recorded in which an enormous abscess has developed. Upon the intensity and chronicity of the inflammatory process also depends the appearance and character of the pyosalpinx, for with the long jDersistence of the infection there is a steady increase in the amount of connective tissue, which transforms the tube from a flexible to a stiff resistant condition. JSTotAvithstanding the presence of a very irritating infectious matter the lining epithelium may remain intact a surprisingly long time; but sooner or later it is completely destroyed in those areas exjjosed to the contact of the pus, and is supplanted by granulation tissue. As a result of the direct extension of the inflammation through the wall of the tube or from local infection of the enveloping peritoneum by escape of the pus from the ostium abdominale, the tube is usually covered with adhesions which bind it to the neighbouring organs. The organization of the adhesions often binds the ovary into an indistin- guishable mass with the tube, and in such cases abscesses often form in the sjjaces between these organs, or between the intestines and tube (perisalpingeal abscess), thus converting the mass into multiple suppurating loculi. Just as the tubo-ovarian cyst, described in preceding pages, is formed, so may these cases be converted into tubo-ovarian abscesses. The ovary, however, notwithstanding its close proximity to the tube, is very often free from infection, there being only a simple peri- oophoritis which does not penetrate beyond the tunica albuginea. The contents of a pyosalpinx vary in consistence from a thin yel- lowish purulent fluid to a thick inspissated cheesy matter, consisting of disorganized pus corpuscles and red blood cells, flbrin, degenerated epithelium, and granular detritus. As a rule the culture and microscopic evidence of micro-organisms give negative results. In the earlier stages of the pyosalpinx, granulation tissues may take the place of the mucosa and the underlying tissue become richly infiltrated with round cells; later, however, the granulations are trans- formed into dense scar tissue and ordinary connective tissue. As the inflammatory process becomes chronic, the muscular tissue undergoes marked atrophy until mere traces only may remain. The vessels be- INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 501 neath the peritoneum become thick and tortuous, and sooner or later show hyaline degeneration. In some cases the tubal wall may become quite oedematous. Even in simple cases, isolated spaces, like those in salpingitis pseudofollicularis, are seen, which are lined by granulation or scar tissue and contain pus. When a typical case of salpingitis pseudofollicularis is converted into a pyosalpinx, cross sections of the tube show an exaggerated loculated appearance. As a result of simple inflammation or from the deposition of lymph which undergoes organi- zation, the peritoneum may become very greatly thickened. Symptoms and Diagnosis of Salpingitis. — Although we may have a morbid process strictly confined to the tube — a salpingitis — we much more frequently find that other tissues have been implicated at the same time. -More especially is this true of the pelvic peritoneum; and in many cases, therefore, the symptoms of a salpingitis are largely modi- fied by the virulence and extent of the accompanying peritonitis. General Considerations. — The symptoms of inflammation of the uterine appendages and the pelvic peritoneum vary with the extent and character of the infection. The less virulent the infecting agent, and the greater the resisting power of the various anatomic structures it encounters, the more limited is the extent of the morbid process and the less severe its general and local effects upon the organism. In primary tubal infections, Nature often prevents the direct exten- sion to the other pelvic tissues by sealing the fimbriated end of the tube. It is true that the morbid process sometimes, though very seldom, makes its way through the walls of the tube, but in such cases the battle is prolonged, and the resistance being greater, the other tissues of the pelvic cavity are only implicated to a limited extent. When the inflammation has been only just severe enough to seal up the fimbriated extremity of the tube, the mucous membrane may be left in a practically unaltered condition, but the normal secretion being poured out dilates the cavity. If this condition is speedily re-, lieved by the escape of the exudate into the pelvic cavity or into the uterus, the symptoms, so far as the tube itself is concerned, may be imperceptible. But since the tube is much less sensitive to pain than the uterus and ovaries, even when the exudate is localized and retained in it, but little disturbance may be caused. For this reason the milder catarrhal inflammations, even when acute, may cause symptoms too slight to fix the patient's attention definitely upon the diseased part. They may, indeed, run their course and disappear without ever having been recegnised, leaving behind hardly any perceptible trace. So fre- quently do these processes escape notice, that it may be said that in an acute or chronic catarrhal salpingitis the symptoms are seldom of a prominence sufficient to give rise to the suspicion that any disease is present. In th(; cases which present symptoms there is more or less localized [tfiin or fliscomfort, the nature and intensity of which varies within vvidf liiiiiis. ''I'll IIS, sonictinies the patient complains rather of a dull 502 A TEXT-BOOK OF GYNECOLOGY aching or burning sensation, which only becomes a real pain when she mores about or goes up or down steps, or when local pressure upon the parts is exerted by walking, defecation, or the various manipula- tions of the examining physician. And yet, desi^ite this, the tube may be distended and almost ready to burst (Fig. 230). In the so-called colica scortorum the attack is characterized from the beginning by sharp colick}^ pains in the region of the tubes. These come on in paroxysms, while in the intervals the patient enjoys com- parative comfort. This intercurrent pain is considered by Schauta to be characteristic of salpingitis isthmiaca nodosa. In other cases, as has been said, the intense pain points rather to extension of the process to the peritoneum or the ovaries. To a large extent the sufferings of the patient are due to mechanical causes. It can be readily seen that greatly dilated and swollen tubes, especially when the filling up has been rapid and the tissues have not had time to adapt themselves to the stretching, might give rise to intense pain, particularly if the pelvic tissues around are inflamed and sore. Hence the mechanical symptoms may be numerous. The pres- sure or dragging upon the different tissues may give rise to painful defecation and micturition, difficulty and pain on standing or moving about, together with pressure neuralgias and symptoms referred to the digestive tract or the cerebro-spinal system, all of which may be reflex in origin. At the time of menstruation, the congestion of the ovar\% which is often bound do^\Ti together with the tube by firm adhe- sions, resisting its expansion, doubtless accounts for not a little of the pain. The great possible variety and intensity of these mechanical disturbances should always be kept in mind. Though, as a rule, it ma}" be said that marked aggravation of the symptoms with nausea, fever, abdominal distention, tenderness, drawing up the thighs, and a pinched expression of the face, point to the development of a general peritonitis, we may sometimes at operation be agreeably surprised to find that the inflammation is localized to one or more parts of the peri- toneum, and that the mechanical factors of pressure or traction have been sufficient to give rise to indications of the existence of the more alarming condition. During the monthly period the pathologic congestion is increased, so that dysmenorrhoea is common. In most cases of tubal disease there is usually an increase, rather than a decrease, in the menstrual flow, and even menorrhagia may be present. Absent or scanty men- struation should make us suspect tuberculosis. Sterility is a common symptom in tubal disease, and is due, either to mechanical obstruction to the passage of the ovum or spermatozoa, or to the distinctive influ- ence exercised upon them by the poisonous material which they en- counter in the tube. In a large number, one might say in the majority, of cases of pelvic disease, a satisfactory diagnosis can only be arrived at after an examina- tion under anaesthesia. The relaxation of the abdominal muscles en- INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 503 ables us to examine more thoroughly^ and at the same time does away with the necessity of using any violence. Hence the safety of the patient is secured, as well as the means of making a more satisfactory diagnosis. A thorough evacuation of the bowels and of the bladder should always be provided for. Combined internal and external palpa- tion is necessarv'. The right hand being placed over the h}7>oga.strium assists the left index finger in the vagina; or the index finger may be inserted into the rectum and the thumb into the vagina. In cases of adnexal disease it will generally be possible to make out on one or both sides a mass, which in most cases proves to be the inflamed tube, or this together with other structtires implicated, according to the char- acter or extent of the process. To decide as to the nature and limits of the various component parts of the mass is often difficult or even impossible. Again, there are quite a number of conditions which may be confused with adnexal inflammation, the principal of these being: 1. Tumours of the uterus, tubes, broad ligaments, intestines, sacrum, and ilium. 2. Appendicitis. 3. Intestinal adhesions. 4. Faecal accumulations. 5. Extra-uterine pregnancies. 6. Uterine displacements. 7. Parametritis. 8. In rare cases a displaced kidney, spleen, or other abdominal visctis. may simulate a pathologic condition of the adnexa. A myoma developing lateralward from the uterus may simulate in form and location a sactosalpinx. As a rule, however, the former, being more closely incorporated with the uterus, causes an enlarge- ment of the body. ^Myomata develop gradually, are frequently pain- less, and are characterized by more profuse menorrhagia than is com- mon itt tubal disease. Again, while the symptoms due to pressure are more marked, those indicative of inflammation are absent in uncom- plicated myomata. In neoplasms of the tubes and broad ligaments, we have an absence of a history and of symptoms of infection. Again, new growths are less painful, of slower development than the masses resulting from adnexal inflammations, and at the same time they are not so likely to produce adhesions so early. Only when such do not exist, will the recognition of the masses as distinct from the adnexa be possible and render the diagnosis certain. Ovarian tumours are often distinguished from instances of sacto- salpinx only by means of an exploratory incision. The following points of distinction, however, should always be remembered: A tumour of the ovary is more likely to assume a somewhat globular shape, while a sactosalpinx is rather elongated. Again, the saetosalpinx; can often be made out to be nearer the uterus, and if the ovary can be isolated in addition to a tumour between it and the corpus, the diagnosis is ren- 504 A TEXT-BOOK OF GYNECOLOGY dered comparatively easy. Large ovarian tumours can be distinguished by their size, but in the case of small parovarian or ovarian cysts and solid tumours, when the course of the tube can not be followed from the uterus to the ovary, a diagnosis is usually impossible. Sometimes a distended tube may be felt above the brim of the pelvis and may simulate very closely a suppurating ovarian c3'Stoma. Here, the history and examination give us no help toward a diagnosis. Appendicitis. — When there exists no tubal disease, the history and symptoms coupled with the physical examination will aid us in making our diagnosis. Again, the pain of an appendicitis is more often local- ized, or at any rate has a maximum intensity, over McBurney's point, while that of adnexal disease is most prominent lower down, in what is known as the ovarian region. When, however, an appendicitis, as happens not infrequently, com- plicates a salpingitis, a diagnosis of the former condition is generally made only at operation. Intestinal adhesions and intestinal obstruction from pelvic inflamma- tion, except when a loop of intestine is adherent to the tubes or broad ligaments, can generally be made out by physical examination, espe- cially when the tubes are not imjDlicated. In intestinal obstruction, the onset is generally more sudden, and the symjjtoms on the part of the bowels are suggestive. Fcecal accumulations in the rectum can be made out with the ex- amining finger. Extra-uterine pregnancy has usually begun in the tube, and we may therefore feel what appears to be an inflammatory sactosalpinx. Here, however, we have a history and certain symptoms pointing to preg- nancy. Enlargement of both tubes excludes an ectopic pregnancy except in those very rare instances in which we have a sactosalpinx on one side and a tubal pregnancy on the other. Uterine displacements may frequently lead to confusion. A dis- placed corpus uteri may often simulate an inflammatory mass, but the recognition by means of conjoined palpation and, when necessary, the use of the sound, will seldom fail to guide us to a correct diagnosis. The diagnosis of parametritis and its relation to adnexal disease have been discussed in another place. Hematoma. — Here the history will aid us. With a large flow of blood into the pelvic cavity from rupture of a tubal gestation or other cause, we have generally acute pain, without signs of inflammation, but with those of more or less severe internal hemorrhage. Only when the hematoma has become infected, will signs of pelvic abscess appear. Finally, it may be said that, even after we have arrived at a diag- nosis of adnexal disease, it will often be impossible to decide absolutely whether the tube or ovary or both are implicated. Nor shall we always be able to say before operation, in the case of tubal disease, the exact condition which exists, or to arrive at the etiological factor. INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 505 until a bacteriological examination has decided the matter. Suggestive information can often be obtained from examination of the vaginal dis- charge. Having referred to the symptoms and diagnosis of disease of the adnexa in general, it will be well to take up the different forms of sal- pingitis separately and give somewhat more in detail their distinctive characteristics. Hydrosalpinx. — When the inflammation has been only sufficient to glue the fimbrige together, it is quite possible for the tube to be dis- tended with a serous exudate (the natural secretion which is now pent up) without giving rise to any symptoms, unless indeed the resulting tumour should be of a size sufficient to cause mechanical disturbances. But the distended portion of the tube hardly ever exceeds the size of an average orange, and the neighbouring parts easily accommodate themselves to their slight change in position, especially if it comes about gradually. When the process has invaded the serous membrane with more virulence, we have, as might be expected, a degree of pain corresponding to the grade of inflammation and the number and ex- tent of the adhesions. Leucorrhceal discharges are common in the majority of pathologic conditions affecting the uterus or the adnexa. In a pure catarrhal con- dition confined to the tube, the discharge is generally of a whitish char- acter. A muco-purulent discharge points rather to inflammation of the endometrial lining of the uterine cavity, and is not caused by a localized peritonitis. The jDresence of an endometritis more probably indicates a possible purulent salpingitis than a hydrosalpinx. As generally happens in any case of pelvic inflammation, men- strual disturbance is often present in hydrosalpinx; the flow is gen- erally too frequent and is increased in quantity. In hydrosalpinx, constitutional symptoms may be entirely absent. The temperature is normal or only slightly elevated, the patient may have a good appetite and may feel well. She may be able to perform her daily duties and live in comfort. At other times, however, exertion may bring on pain in the pelvic region on one side or on both. Diagnosis. — It would seem that a diagnosis of hydrosalpinx should be easily made after a careful physical examination. As a matter of fact, this is true in some cases. When we find a kidney-shaped tumour, generally unilateral, in the position normally occupied by the Fallopian tube and near the ovary, we may feel quite certain that we have to deal with a salpingitis. Again, since the tube is normally divided into compartments, when we find this sausage-shaped tumour sacculated, we may conjecture with great probability that we have a tube which is distended with fluid, whether it be serum or blood, and consequently we may make a diagnosis of hydrosalpinx or hematosal- pinx. And yet, even after we have decided that the tumour present is part of a distended tube, we shall often remain in doubt as to the exact character of its contents. As a rule, however, in hydrosalpinx 506 A TEXT-BOOK OF GYNECOLOGY the walls of the tumour are thin and the mass gives to the finger a sense of elasticity, the degree of which is largely dependent upon the size of the growth and the consequent thinness of the walls. The lack of adhesions is always an important factor, and mobility of the tumour is more characteristic of a hydrosalpinx than of a pyosalpinx. When, however, the tube is greatly distended, the tumour takes on a rounded form and resembles more an ovarian cyst. The other principal conditions liable to be confused with a hydro- salpinx are small ovarian or parovarian cysts, hematosalpinx, and ex- trauterine pregnancy. A typical hydrosalpinx is movable, sausage- like, or reniform in shape, and its course can be followed, as it comes off from the uterus, in the position occupied normally by the tube. The ovarian tumour or cyst is rounded and separated from the body of the uterus. A parovarian cyst may be movable, but it is more usually of a rounded than of an elongated form. Extra-uterine pregnancy is distinguished by the history and by various signs pointing to pregnancy. Again, as has been said, sal- pingitis causes dysmenorrhoea more often than amenorrhoea; and the latter, together with enlargement of the breasts and other more or less definite symptoms, should always suggest a possible ectopic pregnancy. Later, rupture with the classic symptoms of internal hemorrhage makes the latter diagnosis certain. With respect to the diagnosis between hydrosalpinx, hematosalpinx, and pyosalpinx, more will be said later. Hematosalpinx. — Here, instead of a serous fluid, we have a sacto- salpinx containing blood. As a rule, the symptomatology and physical signs are much the same in both conditions. The tumour is in the same position and of the same shape as a hydrosalpinx. Hematosalpinx, except as a result of tubal pregnancy, is simply a hydrosalpinx into which a hemorrhage has occurred, and naturally therefore in its simple form is a rarer condition than hydrosalpinx. Various tables are found in text-books showing the important distin- guishing points. But, when all has been said, the fact remains that as a rule neither the history nor the symptomatology affords a sufficient basis for a positive diagnosis between these two closely allied conditions. Pyosalpinx. — AAHien a purulent focus exists in either one or both tubes the process often extends to the ovaries or the pelvic peritoneum. The symptoms vary according to the intensity and extent of the in- fective process. In the acute stage, which lasts a week or more, the pain is intense. The patient lies in bed with the knees drawn up and looks and feels very ill. The pain complained of is sometimes localized, but it m^^st be remembered that, without any general peritonitis the pain and tenderness may be diffuse and may be referred over the whole abdominal region. The temperature ranges from 100° to 105° F.; the pulse is rapid, 100 to 120; when pus is present, the patient frequently complains of chills or chilly feelings, and she may also suffer from sweats. The abdomen is tense and tender, sometimes sufficiently so to suggest the INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 507 presence of a general jDeritonitis, although in reality the process may be more or less strictly localized. In favourable cases, after a few days the temperature becomes lower, although it may still be one or two degrees above normal with remis- sions. The pulse rate remains slightly above the normal. In such cases the patient may often be able to get about, but every now and then she will have a setback and suffer for a few days from high fever and pain, after which the temperature falls again. These relapses are probably due to the escape of a small amount of pus from the abscess with a resulting peritonitis. When a large abscess ruptures suddenly a general peritonitis may be set up, and unless prompt operative in- tervention occurs, the result is likely to be fatal. This recurrence of attacks may go on for years. The patient is never well, and at intervals is dangerously ill. Such cases have often been cured by removal of the pus sacs. In cases of gonorrhoeal salpingitis, we can often obtain a history of a sudden attack of vulvitis or vaginitis which has sooner or later been followed by abdominal pain. It may, however, be difficult to obtain so direct a history from the patient, as it may be months or years before she comes to us with symptoms referable to the tubes or pelvic perito- neum. Many patients give no history of gonorrhoea, but they may com- plain that they have been suffering for some weeks or months from pain in the lower part of the abdomen with, perhaps, painful micturition and defecation. They may also tell us that they think they have had fever, and that at intervals they have had chilly sensations or definite rigors. Despite the length of their illness, however, we may find them with fair appetites, little or no fever, and, generally speaking, in excellent condition except for the local symjatoms. A streptococcous infection generally dates from a labour, an abor- tion, or local treatment. It is usually ushered in with a chill and the fever rises rapidly. This continues for some days, and the pinched look and anxious expression of the patient show very visibly the effects of the absorption of septic material. Abdominal tenderness and distention are marked. After the acute stage has passed, the patient may get out of bed, but she usually still has a septic tempera- ture and hardly ever attains the relative health of the gonorrhceal cases. Obstinate constipation is sometimes present, usually because the patients fear to have a stool on account of the severe pains that are excited by the efforts. Occasionally partial or complete obstruction is caused by bands of inflammatory tissue stretched across and confining the lumen of the bowel (Fig. 214). Painful micturition is not likely to be present when the purulent process is confined to the tube; often, however, the bladder is pressed upon by the inflammatory mass or becomes infected with the specific poison (Fig. 215). In the most favourable cases, if not submitted to operation, weeks or months elapse before the poison has worn itself 508 A TEXT-BOOK OP GYNECOLOGY out. Only in rare instances does the patient regain complete health, and then, as a rule, only after months of suffering and inconvenience. After the disease has become subacute, the symptoms, though less severe, are still present, and exacerbations may occur from time to time. A persistent suppurative process in the tube or in the pelvic perito- neum gives rise to vari- ous pains, especially to a bearing -down feeling, headache, backache, often to a chronic puru- lent discharge, and some- times to painful micturi- tion and defecation. A gonococcous infection often wears itself out in this way. Exacerbations occur with a sudden rise of temperature, which in- dicates that there is a further lighting up of the process or that it has ex- tended into the perito- neum. Sometimes all the signs of a general peritonitis appear, and the prognosis in these cases is grave. In the diagnosis of suppurative processes in the tubes the history ■ is of great importance. If the patient dates her ill- ness from an acute attack with the symptoms be- fore mentioned, begin- ning after a labour or an Fig. 214. — "Occasionally partial or nuiiiilcte obstruction is caused by bands of inflammatory tissue stretched across and confining the lumen of the bowel." — Robb (page 507). abortion, or during the course of local treatment to the uterus, a streptococcous infection is strongly to be suspected. Some patients will give a clear history of a preceding gonorrhoea, while from others, careful questioning will elicit an account of an attack of vaginitis which we may safely put down as of gonorrhoeal origin. In still other cases, no date can be assigned by the patient to the onset of the disease, which has come on insidiously. Leucorrhcea may have been noticed for some time, with increasing pain at the menstrual period, or perhaps menorrhagia. The patients who are suffering with INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 509 a pelvic peritonitis are generally in a much worse condition than those in whom the suppurative process is limited to the tubes. But much variation may be looked for. Some women, despite the existence of a localized suppurative process, look well and robust though they com- plain of pain at times; while others are completely broken down, and Fig. 215. — "Often the blaJdci i^ pitb&td upon b} tliL mllauunatory mass or becomes infected with the specific poison." — Robb (page 507). show in their faces and in their general behaviour that they are chronic invalids. Some are without pain so long as they sit still or lie down, but the slightest movement or jarring may evoke severe suffering. When the pelvic abscess is situated elsewhere than in the tubes, the diagnosis by means of the physical examination taken in conjunction with the symptoms of pain, chill, fever, and rapid pulse, is compara- tively easy, especially when the attack has followed parturition or abortion. When a mass is felt which bulges out the vault of the vagina and is very tender to the touch and fluctuates, we may safely conclude that we are dealing with suppuration of the tube or ovary, or both, with pelvic peritonitis. When the inflammation has been mainly con- fined to the tubes the diagnosis is more difficult, but it will often be possible to feel a mass coming off from the side of the uterus and, though intimately connected with it, having a mobility of its own. On attempting to move the mass we find it possible to do so to a slight extent, unless it has been bound down too firmly with peritonitic ad- hesions. Sometimes a mass is found on either side of the uterus, and in these cases we may be confident that there is tubal or tubo-ovarian disease on both sides. It is not always possible to recognise the pres- ence of pus by pal])ation, since fluctuation may not be obtainable owing 510 A TEXT-BOOK OF GYNECOLOGY to the thickening of the walls of the tube and the dense adhesions. Sometimes, however, Avhen on gentle palpation the tumour has ap- peared to be solid, by manipulating the external and internal fingers so that the tumour is brought between them, a very distinct sensation of fluctuation can be obtained. Again it must be remembered that in not a few cases of pyosalpinx there are only a few drops of pus in the tube. In making a diagnosis of pyosalpinx the history is of great assist- ance, and it is often also of service in determining the etiology of the suppurative process. The following data liave been given b}^ Kelly to aid in the diagnosis between a pyosalpinx of gonorrhceal and one of a streptococcous origin: GONORRHCEAL TXFECTION Slow in its onset, often preceded by in- flammation of the external genitals and urethra. Pain localized in one or both ovarian regions. No signs of general peritonitis. Suffers more or less constantly, but may have no fever. Temperature 98.5° to 102° F. (38.9° C). Pulse accelerated, but of good quality and volume. Attack lasts from five to fifteen days. Often presents the appearance of good health. Gonococci usually found in coverslip prep- arations from the cervical, urethral, or vulvo-vaginal glandular secretions. History of marital gonorrhoea. Streptococcous Infection Onset abrupt, following miscarriage, nor- mal labour, or topical treatments. Pain more general and severe in the lower abdomen. Usually signs of peritonitis. Suffers constantly, and usually has a septic fever. Temperature 101° to 105° F. (38.3° to 40.5° C). Pulse feebler and moi'e rapid. Attack seldom lasts less than a month, and may continue three months or more. Anaemic and weak. Gonococci not found in the secretions. Husband sound. Pj^osalpinx is sometimes confused with ai^i^endicitis and other con- ditions to which we have already referred. As points serving to distin- guish pyosalpinx from hydrosalpinx, Dudley gives the following: Hydrosalpinx Systemic disturbance relatively slight. Less fever, pain, and adhesions. Bursting of the tube and discharge of its contents into the abdomen may give relief. Walls of the tube distended, thin, smooth, elastic, and fluctuating. Pyosalpinx Systemic infection often marked from absorption of pus. More fever, pain, and adhesions. Bursting of the tube and discharge of its contents may cause dangerous perito- nitis. Walls of the tube thick, hard, sometimes stony, resistant, nodular, less elastic, and less fluctuating. INFECTIONS AND INFLAMMATIONS OF FALLOPIAN TUBES 511 Hydrosalpinx Pyosalpinx More usually associated with catarrhal More usually associated with purulent endometritis. endometritis. Thin, overstretched tubal wall easily rup- Walls usually not so easily ruptured. tured. It may be said that a hydrosalpinx, while often very elastic, on acount of the great distention does not give fluctuation. Sometimes the wall of a pyosalpinx, instead of being thickened, is as thin as that of a hydrosalpinx. Great care should be exercised during the examina- tion not to rupture any fluctuating tumour that may be found, as, by so doing, the risk is run of infecting the whole peritoneal cavity. In some cases a pyosalpinx forms a large tumour projecting above the symphysis, or more commonly toward one or other groin Just above Poupart's ligament. With the history and combined internal and ex- ternal examination, the existence of a suppurative process can be deter- mined, but often only an operation can decide its exact nature, whether it is a suppurating cystoma of the ovary or a pyosalpinx. Tuherculoiis Salpingitis. — In secondary tuberculosis of the adnexa, the sym|)toms are usually masked by those arising from the tuberculous process elsewhere in the body. Although the possibility of a primary tuberculous process in the tubes should always be borne in mind, ex- perience has taught that there is nothing in the symptomatology char- acteristic of the condition. Even at the time of operation it has again and again escaped detection and has only been discovered later by the aid of the microscope. CHAPTEE XXXIV . INDIVIDUAL INFECTIONS OF THE FALLOPIAN TUBES Infections by: (a) Gonococcus; (&) streptococcus ; {c) Bacillus tuberculosis; {d) Bacil- lus coli communis ; (e) pneumococcus ; (/) staphylococcus ; {g) saprophytes ; Qi) septic vibrion ; (i) actinomyces. Individual infections of the Fallopian tubes are, many of them, yet in course of preliminary investigation. Those whicli have been determined with reasonable accuracy and which, consequently, will be considered, although briefly, in this work, depend upon (a) the gono- coccus, {b) the streptococcus, (c) the Bacillus tuberculosis, (d) the Bacil- lus coli communis, (e) the pneumococcus, (/) the staphylococcus, (g) the saprophytes, (h) the septic vibrion, (i) the actinomyces. Gonococcous Infection of the Fallopian Tubes. — Infection by the gonococcus of Xeisser (see Micrococcus Gonorrhoese), according to the general consensus of competent observers, is responsible for a majority of purulent accumulations within the tubes and for those inflamma- tory changes which are induced thereby. This infection of the female genitalia, more conspicuously than any other, may be designated as of the ascending type; by which is meant that an infection beginning externally or within the vagina, gradually travels upward, chiefly, if not exclusively, by progressive invasion of the mucous surface until it reaches the Fallopian tubes. There remain, however, some unex- jDlained facts in connection with this phenomenon: thus, gonococcous infection of the vulva and vagina is not uncommon among children (see Infections of the External Genital Organs); yet pus tubes are prac- tically unknown in childhood. Of course, the immature development of the uterus before ]3uberty offers a certain physical barrier to the upward extension of this afl'ection in children; but it would seem that at least occasional instances would be forthcoming in which the obstacle had been overcome. There is a strong probability that in- vestigation will establish the fact that the uterine mucosa of childhood with its dearth of epithelium is an uncongenial soil for this micro- coccus. With the develo]3mental impulses which come at puberty, how- ever, these conditions are changed, and there are established a certain luxuriance of epithelium and a certain deepening of the utricular folds which are favourable to the propagation of the germs of gonorrhoea. (vSee Infections of the Uterus.) 513 INDIVIDUAL INFECTIONS OP THE FALLOPIAN TUBES 513 Gonococci in the Fallopian tubes are found in the pus and upon the sui-face of the mucous membrane. They have been reported as being observed in the deeper layers of the tubes, but these observations have been seriously questioned by competent observers. Westermark was the first to demonstrate the organism in intratubal pus. His ob- servations have been confirmed by Orthmann, Zweifel, Witte, Doder- lein, Schauta, Morax, and numerous other observers in various coun- tries. It is not always demonstrable in this medium. Eeymond reports the observations of nine investigators, who have demonstrated the pres- ence of gonococcus in tubal pus 78 times in 399 cases. The fact that it is not present in the pus of a given case at a given time is not to be construed as evidence that it was not the essential element of in- fection, for these micro-organisms perish in their own toxines, and thus disappear from the pus for the existence of which they are respon- sible. Gonorrhoeal pus of recent intratubal origin reveals leucocj^tes of increased size, which contain groups of gonococci and epithelial cells also enlarged and inclosing the same micro-organism. A limited num- ber of free gonococci are generally observable. Many observers have failed to find the gonococci in the mucous membrane in cases in which their presence has been demonstrated in the pus. This, as suggested lay Eeymond, is probably due to defective methods of staining. Gram's method is generally employed, but recent investigators have been able to demonstrate the presence of the gonococcus by the methylene blue and pure tannin method of NicoUe, after failing to find it by Gram's method. In a section prepared in this way by Morax there •are observable, a layer of piis adhering to the mucous surface; leucocytes in the stroma of the mucosa; numerous epithelial cells that liave lost their positions, form, and dimensions, but contain no gonococci; and, finally, both leucocytes and detached epithelial cells, which do contain gonococci. A distinguishing feature of these changes is that the epithelium is not thrown off en Hoc, but the cells are shed individually. This manner of desqviamation is the exact re- verse of that which occurs in streptococcous infection. (See Strepto- coccous Infection of the Fallopian Tubes). The fimbriae are studded with migrated leucocytes; the surface of the epithelium, says Reymond, is covered with a purulent layer, which is composed of a large number of leucocytes and detached epithelial cells. It is in this superimposed stratum that the gonococci are readily discoverable, not only in the epithelial cells and in the leucocytes, but lying quite free between the cells. It seems that these micro-organisms but rarely invade the epi- thelial cells which remain in situ, while the leucocytes which lie be- tween the epithelial cells are likewise but rarely invaded. Competent observers have failed to discover the gonococci deeper than the adven- titious layer that has just been described, although Wertheim asserts that he has found them in deeper structures. In this infection the muscularis is always engorged, its vessels being apparently multiplied in niirnbor find inci'oased in calibre, while the lymphatics are filled with 514 A TEXT-BOOK OF GYNECOLOGY leucocytes in course of migration to the mucous surface. The gono- cocci are not demonstrable in the muscularis, or within the leucocytes in that tunic. Wertheim's statement, cautiously made to the con- trary, lacks confirmation, his alleged observation being explained by other investigators as due rather to defective methods of staining than to the actual detection of the micro-organisms. The inflammatory changes induced within the deep layers of the tube, however, and, particularly, the infiltration which occurs at the vestibule, are sufficient to cause an inflammation of the peritoneum, with resulting exudation and occlusion of the distal ostium of the tube. (See Infections of the Peritoneum.) Nevertheless, the gonococci themselves have been dem- onstrated on the peritoneal surface in these cases, both Gushing and Michaelis having reported instances of undoubted accuracy. It is probable that the explanation of this circumstance is to be found in the escape of the micro-organisms from the lumen of the tube be- fore the closure of the vestibule. (See Morbid Histology of Salpin- gitis.) The route by which the gonococcus travels from the seat of primary infection to the tubes, has been a source of speculation, which has, as yet, brought forth no definite conclusions. There are those who con- tend that it travels by progressive invasion of the mucous surfaces, by direct passage through the tissues, and by traversing the circulatory systems, respectively. Each of these three hypotheses has its advo- cates. That the mucous surfaces from the ostium vaginae to the tubes are progressively invaded, seems to rest upon ample testimony. It is exceedingly probable from the observations of Camescasse, Eosthorn, and others, that, in the presence of a vaginal infection, the uterus is invaded in a much larger percentage of cases than was formerly sup- posed; while Steinschneider, after finding the gonococcus present in the cervix in every one of 34 consecutive cases of vaginal infection, concludes that the invasion of the endometrium is a universal incident of gonorrhoea in women. While this conclusion is certainly too sweep- ing to be justified by the observations upon which it is based, it is nevertheless to be looked upon as one of great significance. The be- haviour of the gonococcus on the epithelial surfaces indicates that they offer to it the avenue of least resistance for its migration; and that, once within the uterus, and within the utricular folds of the endo- metrium, there is nothing to keep it from extending its invasion to the tubal epithelium. There seem to be ample grounds for doubting that the gonococcus invades the deeper tissues without reference to circulatory media of communication. The fact, however, that it does reach the circulation, both sanguineous and lymphatic, rests upon indisputable evidence. Blumer, Thayer, and Lazear have cultivated it from the blood, while Flexner has demonstrated it at autopsy in lesions of ulcerative endo- carditis. The latter observer states that the endocarditides associated with gonorrhoea, are commonly caused by the gonococcus, and that, in INDIVIDUAL INFECTIONS OP THE FALLOPIAN TUBES 515 these cases, a general infection with the micro-organism may take place. Inflammations of the pleura and pericardium, and supj^urative myo- carditis, have been caused by it. These facts establish beyond question that the gonococcus may invade the blood and be carried by that medium to remoter parts of the system. The common clinical phe- nomenon of suppuration of the inguinal glands (gonorrhoeal buboes) in cases of acute gonorrhoea, shows the possibility of invasion of the lymph channels, while pelvic lymphangeitis, of similar origin, has a similar significance. These facts being established, it follows that the contention of Eeymond and Magill, that the gonococcus does not travel from the seat of primary infection to the tubes through either the lymph or the blood channels, is not supported by analogy. If it is granted that the blood vessels may be invaded by this micro-organism, and that the lymphatics may likewise become the media of infection, it would seem that subepithelial structures are liable to invasion through these avenues. The controversy between Wertheim, on the one hand, and Eeymond, on the other, and between their respective fol- lowers, touching this point, can only be settled in the light of further direct observations. The symptoms of gonococcous infection of the tubes are not specially distinctive. The infection may follow either a virulent acute infection of the external genitalia, or it may be the result of a primary infec- tion, so mild in character as to have escaped attention. The interval between a known primary infection and the manifestation of the disease in the tube, may be so great that the connection between the two may not be recognised. The natural history of the micro-organism and its pathogenic characteristics, is such that its activities are inter- rupted, and the patient may enjoy periods more or less prolonged of symptomatic health. When invasion of the tubes has taken place, how- ever, there is generally an initial chill, which may be very slight, fol- lowed by an elevation of temperature, which may not go above 100° F.; while, on the other hand, these symptoms may be very intense. Pain is complained of at the base of each lower quadrant of the abdomen. This pain may be either sharp or lancinating, or it may be pulsating and may radiate into the lumbar region, or find expression in the sacral plexus or along the sciatic nerve. The pain is increased on external pressure or by the concussion incident to walking. Bimanual examination will reveal foci of tenderness in the neighbourhood of one or both Fallopian tubes, which will generally be found large and cedematous. These symptoms may be interrupted by a discharge of pus, either through the uterus or the intestine, followed by a period of apparent cure. Their return, however, is only a matter of time. The actual diagnosis of gonococcous infection can be based only upon a demonstration of the micro-organism in the pus. (See Diagnosis of Inflammatory Diseases of the Uterine Appendages.) Tbc treatrnxnt of gonococcous infection is given under the head of Treatment of Infections of the Fallopian Tubes. 516 A TEXT-BOOK OF GYNECOLOGY Streptococcous Infection of the Fallopian Tubes. — Infection of the FallojDian tubes by the Streptococcus pyogenes generally occurs as an acute virulent inflammation — although this micro-organism is some- times present when least suspected in the more chronic forms of pyo- salpinx. Eeymond and Magill, in their masterly contribution upon this subject {Annals of Surgery, 1896), state that they found the streptococcus in these cases only with difficulty. It would not respond to the culture tests made with ordinary media until after it had been revitalized, as it were, by successive inoculations. It would seem that the diminution in the virulence of the micro-organisms in some of these cases, accounts for the chronicity of s3anptoms following its entrance into the tubes. These authors, in a number of their cases, were unable to detect the presence of streptococci until after they had made repeated observations in cases which would ordinarily have been designated as sterile salpingitis. (See Streptococcus Pyogenes.) The symptoms of streptococcous infection of the Fallopian tubes are to be studied in the light of the fact that, in the chain of morbid events, the invasion of the tubes always occurs secondarily to invasion of the uterus. While this is true, an equally important fact to be remembered is, that invasion of the tubes occurs so promptly after the primary infection of the uterus that the symptomatology of the two conditions is, in the majority of cases, essentially coincident. It is only in those cases in which the micro-organisms seem to have a diminished viru- lence, and in which the symptoms of uterine infection have subsided, that there are presented any distinct signs of involvement of the Fal- lopian tubes; for, in the presence of acute streptococcous infection of the uterus with associated involvement of the lymphatics and gen-- eral engorgement of the pelvic tissues, the condition of the tubes is, as a rule, completely masked. The demonstrated existence of strepto- coccous infection of the uterus and of the surrounding structures may, however, be accejited of itself as a symptom of involvement of the tubes. It is true that in a limited number of cases this rule may fail, but even then it remains the safer guide for the treatment of the case. The constitutional symptoms of this form of infection are, in effect, those of similar infection of the uterus. (See Streptococcous Infection of the Uterus.) In a few instances the diagnosis may be confirmed by i^alpation of the enlarged tubes by bimanual manipula- tion; but it should be remembered that this is a dangerous expedient, as even slight manipulation may result in forcing some of the virulent pus from the tube into the peritoneum. The use of the aspirating needle for diagnostitial purposes in these acute cases is an even more dangerous procedure. The fact of a recent puerperal infection, the history of streptococcous invasion of the uterus, and the demonstrated existence of large tubes, are facts upon which a presumptive diagnosis may safely be based. The isolation of the streptococcus by microscopic examination and by culture and inoculation experiments, will clear up any remaining doubts as to the character of the disease. INDIVIDUAL INFECTIONS OP THE FALLOPIAN TUBES 517 The pathology of salpingitis of streptococcous origin in its general fea- tures is not unlike that already given. (See Morbid Histology of Sal- pingitis.) The morbid processes established by the streptococcus and the behaviour of the micro-organism itself,, however, present some features that call for special mention. The thorough studies of this subject by Eeymond and Magill (Ihid.), upon which this chapter is largely based, show that the pus from the tubes contains a relatively small number of leucocytes, but a great quantity of eliminated de- formed epithelial cells, whose perinuclear protoplasm has often been lost. There are also present cells from a deeper layer, which seem to have fallen from the frame of the fringes. The streptococci are rarely in the leucocytes, more frequently in the epithelial cells, but most frequently between the cells. A slide mounted with the pus of streptococcous salpin- gitis from one of Rey- mond's cases (Fig. 216) shows desquamated epi- thelial cells, sometimes without their nuclei, connective -tissue cells, granular fatty degenera- tion, and numerous streptococci. The mi- crobes are sometimes strung out in long chains, while in other cases they appear as dip- lococci, or as chains of three links, each one slightly elongated. The mucosa is gen- erally found at the be- ginning of the affection to have undergone but slight modification. The epithelial cells are yet in position and have retained to an important extent their cilia, the fimbrise alone being a little thickened and infiltrated with leucocytes. In re- cent infection the streptococci are found in the calibre of the tube, while, according to Bumm, the streptococci throng about the epi- thelium of the pavilion, although they do not infest the calibre of the tube at its uterine third. It is inferred from this that the micro- organisms must have travelled over some other highway than that of the lumen of the tube itself, to have reached the vestibule. At a later period of the salpingitis, if the lumen remains open, the mucosa shows lesions of relatively less gravity than are manifested in the other tissues. The lymphatic situated in the centre of each fimbria is greatly dilated, and contains leucocytes and streptococci. The epi- FiG. 216. — "A slide mounted with pus of streptococcous salpingitis from one of Eeymond's cases." — Keed. 518 A TEXT-BOOK OF GYNECOLOGY thelimn in places, while almost intact, is not provided with vibratile cilia. At certain points, groups of streptococci are found beneath superimposed layers of epithelium, which is occasionally detached en Hoc, leaving the fimhrige denuded. The tissues underlying this de- nuded area are found more or less infiltrated with streptococci. These changes in the epithelium explain the presence of the detached epithe- lial cells in the pus. It is noticed that in streptococcous infection the superficial cell is not attacked by its free surface as in gonorrhoeal sal- pingitis, but that the invasion comes from the deep surface. This is an essential distinguishing point in the pathology of the two infections. As a result of this assault upon the epithelial cells from their base- ment membrane, they fall in masses, and not singly as is the case in the presence of gonococcous infection. This desquamation, say Eey- mond and Magill, is so abundant as entirely to fill the calibre of the tube with the detached cells, which mass together and can clearly be distinguished from the fringes in a section. The changes that take place in the terminal branches of the blood vessels are difficult to determine, and it is even more difficult to de- termine the relation of the streptococci to the blood vessels. The changes are, however, found most frequently at the periphery, where are sometimes noticed thrombi containing streptococci; at other times the endothelium of the vessels is seen to send out 23romontories into their lumen, and here are found streptococci both within and without the free passage of the vessels. These changes are all grajDhically shown in a section of a fimbria in streptococcous salpin- gitis, by Reymond and Magill (Fig. 217). These observers find in the re- lation of the streptococci to the vessels in these cases, confirmation of the conclusion of Labadie- Lagrave to the effect that " upon the blood is imposed the duty of destroying and attenuating the streptococcus." The micro-organ- ism is found, particularly at the beginning, scattered through the cellular tissue of the aileron, and in the subperitoneal tissue also, as the adhesion is formed with the tube or the ovary. An abundant cellular infiltration is formed beneath the serosa, whose disappear- FiG. 217- — " These changes are all graphically shown in a section of limbriaj from a case of streptococcous salpingitis, by Eeymond and Magill." — Eeed. INDIVIDUAL INFECTIONS OP THE FALLOPIAN TUBES 519 ance leaves a point still marked by a group of leucocytes mixed with streptococci, which are also found in the cellular infiltration pro- duced between the muscular sheaths. Tuberculosis of the Fallopian tubes (Fig. 218) is the most frequent type of tuberculous disease of the female genital tract, and is char- ¥i(}. 218.— " Tuberculosis of tlic Fulloi.iiUi tubes is the most frequent type of tuberculous disease of the female genital tract."— WniTAOUE. 520 A TEXT-BOOK OP GYNECOLOGY acterized by the formation of miliary tubercles in the walls of the tube^ by tumour formation, and by a progressive infection of the re- mainder of the genital organs. A full appreciation of the frequency and clinical importance of the condition has only recently been obtained. While the monograph of Hegar (1886) did much to bring this about, that of Williams (1892) gave the condition a rank of prime importance, by demonstrating a. very much greater frequency than had ever before been imagined, and by showing that a great many tubes, previously removed as adherent and inflamed appendages or passed over on the autopsy table without notice, were in reality tuberculous. These tubes gave no macroscopic appearance of tuberculosis and were called by him cases of " unsus- pected genital tuberculosis." This possibility, when associated with the fact that excellent results are obtained by the removal of tubes in a condition of even advanced degeneration, has made it a leading sub- ject in gynecology. The method of infection of the tube by the tubercle bacillus forms an important, and at the same time a very difficult, question. We distinguish a primary and a secondary infection according as the tuber- culous process arises primarily in the tube or is the result of an in- fection from a primary focus in the lung, intestine, or peritoneum. The latter is by far the most frequent mode of infection. Hegar has differentiated an ascending and a descending form of in- fection, of which the latter is always a secondary tubal tuberculosis, while the former furnishes all the primary cases and ma}'- be a second- ary tuberculosis. In the ascending type of infection, the tubercle bacillus must be mechanically deposited in the vagina or uterus by dirty fingers or instruments, from the clothes or the fasces of the patient who suffers from tuberculous enteritis, by coitus, or from a tuberculous ulceration of the vulva or vagina. It is conceded that the primary form of infection may be the result of coitus with men suffer- ing from a tuberculosis of one or more of their genital organs. This belief is supported by these facts: (a) That tuberculosis of the female genital organs occurs with greatest frequency between twenty and forty years of age; (b) the recognition of the tubercle bacilli in the semen of such men (Dewille); (c) the demonstration of tubercle bacilli in the apparently sound genital organs of phthisical men (Fernet, Jani); and, finally, (d) the demonstration by Schuchardt of tubercle bacilli in the urethral secretions of gonorrhoea. The method of the transfer of the germs from the vagina to the tube without infection of intermediate organs is a point difficult of solution. The escape of the intermediate tissues (vagina, cervix, uterus) has been very justly compared to the immunity of the nose, throat, and larynx, in lung tuberculosis and is explained by their natural protective forces. The tube lacks protection and seems to offer a most suitable nidus for bacterial development. The spermatozoa, by reason of their peculiar motion upward, would seem to be the most natural INDIVIDUAL INFECTIONS OF THE FALLOPIAN TUBES 521 carriers of adherent infectious material, and this method of transfer is accepted by Menge, Pozzi, Chiari, and Veit, but lacks definite proof. Hegar believes that the tubercle bacillus may enter by slight or ex- tensive abrasions of the mucous membrane of the vulva, vagina, or uterus, travel in the regular course of the lymphatic stream, and find a lodgment in the outer end of the Fallopian tube or the ovary. This belief is suj^ported (1) by the observations of Maier, who has shown that puerperal inflammation of the Fallopian tubes generally begins at the outer end; (2) by the fact that this channel of transfer has anatomical support; and (3) by the frequent occurrence of tuberculous salpingitis after childbirth and abortion. The descending type of infection is more easily explained, since Firmer has demonstrated that fine bodies (cinnabar or Chinese ink) injected into the peritoneal cavity will soon find their way into the tubal ostium through the tube and into the uterus. Added to this, we have the demonstration that the tubercle bacillus and other bacteria may pass through the intestinal wall in the floor of a tuberculous ulcer and float free in the peritoneal cavity (Mosler, Jans). The ex- planation here would seem to be complete. The tube may also become diseased through direct extension in continuity of tissue from a neigh- bouring tuberculous organ, usually from the peritoneum. W. Mayer has collected 194 cases of secondary tuberculosis of the female genital organs, in which number the peritoneum was diseased 110 times; in- deed, a number of authors have considered this to be the almost exclusive method of tubal infection. A secondary disease of the Fal- lopian tube does not invariably result from a tuberculous peritonitis, however, as will be shown by the fact that Schramm found an idio- pathic tuberculous peritonitis without disease of the tube 33 times in 3,356 autopsies. Tuberculous tumours of the rectum, sigmoid, or mesenteric glands, may also communicate the infection directly to an adherent tube. An infection by way of the blood stream (hematogenous infection) remains to be mentioned, and there is no reason why this method should not be given the importance as a causative factor in the genital tract that is attached to it in bone, joint, and brain tuberculosis. The point of entrance of the germs may show no tuberculous changes and the only lesion in the entire body may be that in the tube; or the primary focus in the lung or in a bone, from which the embolus came, may be so small and difficult to find that a mistaken diagnosis of a primary disease may be made (Williams). Morhid Anatomy. — The lesions of tuberculous salpingitis are usu- ally bilateral although present in a different degree on the two sides. The general appearance of the organs will vary greatly with the stage, character, and severity of the inflammatory process. The type desig- nated by Williams as '' unsuspected tubal tuberculosis " will of course not be observed, and the more advanced cases will present every change fforn sli'dii r'nl;ir"'oirK'nt to the most extensive mattinff together of 522 ^ TEXT-BOOK OF GYNECOLOGY pelvic contents and the formation of abscesses. The tubes that we usually see have already undergone a more or less high degree of change and their form does not vary as a rule in any way from that presented by ordinary pus tubeS;, and they present the features of a well-developed tuberculosis (Fig. 219). This picture of tuberculosis is formed by the presence of typical grayish-yellow or transparent mili- ary nodules on the surface; the lumen is dilated and filled by caseous Fig. 219. — "The features of a well - developed tuberculosis": A, tube wall tliiekened ; £, mucous membrane of the tube in a condition of adenomatous hyperplasia; C, broad ligament, much thickened; Z>, miliary tubercles on the peritoneal surface and in the mucosa; E^ the lumen of the tube sui-rounded by a zone of caseous degeneration. — Whitacre. material, and adhesions bind the tube down in the pelvis. The ab- dominal end may be open, when the fimbriae are swollen and pushed over the opening; or, the ostium may be closed by a plug formed of pseudomembrane and tubercle tissue, when the tube may become dilated to almost any degree (Fig. 220), and may assume most sur- prising shapes. Veit has seen a case in which the isthmus of the tube was so distended as to give the appearance of an extension outward of INDIVIDUAL INFECTIONS OP THE FALLOPIAN TUBES 523 the uterine cornu (Fig. 221). The tube contents, according to their constituents, may be fluid, millcy, of the consistence of cream or cheese. Fig. 220 (Veit). — " The tube may become dilated to almost any degree." — Whitacee (p. 522). or at times chalky. The usual type is a grayish-yellow cheesy mass. The mucous membrane also shows marked changes and is covered by Fig. 221. — " Veit has seen a case in which the isthmus of the tube was so distended as to give tlic appearance of an extension outward of the uterine cornu." — Whitaoke. 524 A TEXT-B(;OK OF GYNECOLOGY tubercles in every stage of metamorphosis. In prolonged cases it may be entirely replaced by a necrotic caseous mass. The wall of the tube is usually thickened. The form of such tumours does not differ from that of tubes other- wise inflamed. Tumours of sausage^ retort, and torpedo shape are the usual forms, while Hegar has jDlaced special weight, first, on a rosary-shaped swelling, and, secondly, on a swelling at the isthmus of the tube that gives the aj)pearance of an extension outward of the horn of the uterus. A closure of the outer end may result in a dilatation of the tube and a collection of pus that may reach two quarts (Stemann). The tumour will be further modified by the development of peritoneal products and adhesions. The position of the tumour shows all the variations that we might expect in severe inflammatory change. Swi- talski reports a case in which a tubal tumour the thickness of a finger was found in front of the uterus, lying on top of, and involving, sec- ondarily, the bladder wall. According to the manner of beginning, the lesions may be divided into an acute and a chronic tubal tuberculosis. The former usually fol- lows a secondary, and the latter a primary, infection. The acute form is characterized by an involvement mainly of the ampulla, and a rapid breaking down of the tuberculous mucous mem- brane which becomes changed into a cheesy detritus. Through this process the muscle is destroyed in part or in its entirety, and the lumen is widened to a certain extent. Microscopically, the mucous membrane shows a rich round-celled infiltration and numerous miliary tubercles but very few giant cells, owing to the promptness with which a central necrosis occurs in the tubercles. As the process advances, the mucous membrane becomes changed into a detritus containing many tubercle bacilli. The muscle layer shows distinct miliary tubercles between the fibres or caseous areas. In the chronic form, the abdominal end of the tube becomes promptly closed and a pyosalpinx forms. The destruction of the mucous mem- brane is much slower, the tube may be very much dilated by pus formation, and the thickening of the muscular wall may reach such a high degree that the tube is changed into a hard, stiff formation. Microscopically, this form begins by the deposit of minute miliary tubercles in the mucous membrane beneath the epithelial surface. These tubercles are discrete, typical in their structure, show very little tendency to caseate, and remain confined to the mucosa for a long time (Fig. 222). This stage forms the type of "unsuspected tubal tuber- culosis," described by Williams, and will be revealed only on micro- scopic examination. An increased number of tubercles, however, will result in an infiltration and swelling of the folds of the mucous mem- brane, and the dilated lumen will be filled by what seems to be a caseous tuberculous mass but is found microscopically not to have broken down in any part (Martin). At other times the tubercle bacillus excites decided proliferation in the glandular elements to the degree of dis- INDIVIDUAL INFECTIONS OF THE FALLOPIAN TUBES 525 Fig. 222. — " These tubercles are discrete, typical in their structure, . . . and remain confined to the mucosa for a long time." — Whitacbe (page 524). tinct adenomatous tumour formations. This has been observed with sufficient frequency to call for special mention (Wolff, Orthmann, Friedlancler, Landau, Eheinstein, and others), and is considered to be a hyperplasia analogous to that of the epithelium in lupus. These growths may be confused with ma- lignant tumours and it is important to remember their tuberculous origin. The tubercles of the chronic type have many giant cells and few tuber- cle bacilli. The muscu- laris does not become involved until very late in the disease, and its marked thickening must be looked wpon as a hy- pertrophy of the muscle and connective-tissue ele- ments, and not as a tuber- culous growth. Tubercles may be found in the mus- cularis in the late stages. The serosa may be thickly covered by hemp- seed-sized tubercles and the tubal ostium is usually closed by adhesions. A true pyosalpingitis manifests itself in relatively few cases (Schroder, Winckel, Martin, Miinster). That not all cases permit of these lines of division into an acute and a chronic form is certain, but in general it will serve as a working basis. Williams has made a division into three forms: a miliary, a chronic diffuse, and a chronic fibroid form. His miliary form corre- sponds to the early stage of the chronic form described above; while the chronic fibroid form is described as one characterized by a rich formation of fibrous tissue in and around the miliary tubercles, and showing almost no tendency to caseation. Both the closing of the tubal ostium and the fibrous thickenings found in the chronic forms seem to be a curative effort on the part of Nature. Yet it must be remembered that the caseous contents 7naij escape from the open end of a tube into the free abdominal cavity (Hegar), and furthermore that encapsulation does not always occur when this does take place (Knauer). Spontaneous healing may also certainly take place by a calcification of the focus (Kiwisch, Rokitansky), while a tuberculous abscess may heal by rupturing into the rectum, the vermiform appendix, or the .small intestine (Veit). The gonococcus has boon found a number of times in tuberculous 526 A TEXT-BOOK OF GYNECOLOGY tubes^ and it would seem probable that a pre-existing gonorrlioeal sal- pingitis would predispose the tube to a tuberculous infection. Symptoms. — The symptoms of the disease are in general those of ordinary salpingitis, and may range in severity from entire absence in the miliary form to the most severe symptoms of salpingitis and pelvic abscess. Indeed, the symptoms, subjective and objective, are so little characteristic that the abdomen of such patients is usually opened for adherent tubes and ovaries or for pyosalpingitis. Not infrequently a family history of tuberculosis or the discovery of tuberculosis in other parts of the body or in the husband (Menge), serves as a starting point for the accurate interpretation of the symjDtoms. In cases of primary tuberculosis of the tubes, an important symptom is a more profuse and painful menstruation (Martin), while amenorrhcea is of course present in the cases of coincident phthisis. The pain may occur on one or both sides, but it must remain a question as to how much of the j)ain depends upon the tube and how much upon the peritoneum. The temperature is not elevated. Ascites may be present. Symptoms may persist practically unchanged for a long time, as has been shown by "Werth, who reported a case in which the tuberculous process re- mained confined to the tube for two years and a half. An extension of the process to the peritoneum gives much more characteristic features to the symptoms. A progressively increasing pelvic trouble, chronic in its nature and associated with tumour forma- tion, the matting together of the intestines, disturbance of the rectum, and encj^sted ascitic fluid extending above the pubes, generally indi- cate tuberculosis. A secondary infection by the pyogenic cocci will of course initiate the more acute symptoms of sepsis. Lastly, a primary tuberculosis of the tube may lead to tuberculous peritonitis, phthisis, marasmus, or septic peritonitis. Diagnosis. — From what has been said of the symptomatology it is apparent that the diagnosis is extremely difficult; indeed, Gehle, in 1881, stated that a positive diagnosis of genital tuberculosis could not be made. This statement, of course, loses all authority with reference to the accessible parts of the genital tract since the discovery of the tubercle bacillus, but it still holds true in a marked degree of those cases of tubal and ovarian disease in which the uterine curettings do not contain tubercle bacilli. The history of the patient, heredity, and the existence of tuber- culosis in other organs, are important points in the diagnosis. Hegar believes that a rosary-formed swelling of the tube occurs more fre- quently in this than in any other form of tubal disease, and has placed special stress upon a swelling of the isthmus of the tube at its exit from the uterine horn (Martin). Other writers believe that a swelling in the outer end is the common form of tumour formation. Attention has also been called by many observers to the hardness of the tumour, but it is certainly true that these features of form and consistence may be present likewise in pyosalpingitis. INDIVIDUAL INFECTIONS OF THE FALLOPIAN TUBES 527 If the tubes are not too firmly bound down, the diagnosis may be greatly facilitated by feeling tuberculous nodules on the surface of the tube, on the pelvic peritoneum, or on the posterior surface of the uterus. Edebohls lays great stress on a plaquelike thickening of the peritoneum. Osier says " the association of a tubal tumour with an ill-defined anomalous mass in the abdominal cavity should arouse sus- picion at once." Tubercle bacilli may be found in the secretions of the uterus even though that organ be uninvolved, and Edebohls has once aspirated an abscess of the tube and discovered tubercle bacilli in the pus. Prognosis. — The prognosis is always grave in either the primary or the secondary form. In the former, because of the marked tendency to extend to the peritoneum or lungs, and the tendency to a secondary pyogenic infection of a caseous mass; in the latter, because all these symptoms are added to the seriousness of the primary disease. The brilliant results obtained by the gynecologist, even in advanced cases, have done much during the past few years to counteract the absolutely bad prognosis of earlier writers, and we now know that a complete cure of the condition will follow excision in a great many of the primary cases, and that life will be much prolonged in the advanced cases. We are indebted to Hegar for this radical change in prognosis. Treatment. — The prophylactic treatment of tuberculous salpingitis consists in cleanliness on the part of the physician and patient and in abstinence from marriage and coitus by people siiffering from genital tuberculosis. By reason of the great difficulties, nay, the impossibility, of making a diagnosis in many cases of primary tuberculosis, we are not often called upon to decide the question of treatment. Yet when the disease is discovered during an operation done for other conditions or when a diagnosis is made, there can be no question as to the advisability of radical removal. When the tubal disease is associated with tuberculous peritonitis, this condition gives an additional reason for operation rather than a contraindication. In patients suffering from phthisis, the treat- ment of a secondary tubal disease becomes a much more difficult prob- lem. In general, the condition of the patient must be carefully con- sidered and her chances of life weighed with and withoiit operation. In other words, early cases should be operated on, late cases should not. A double tuberculous salpingitis does not necessarily call for hyster- ectomy, even though the uterus does show involvement in a majority of cases, since curetting, combined with the natural resisting power of the endometrium, may overcome a mild infection. A tonic treatment, pnre air, and good hygienic surroundings, have the same value as in tuberculosis of other parts of the body. The operative treatment of these cases is the only rational one, and the excellent results reported by a number of operators will justify excision, even in those cases in which the disease has extended far beyond the appendages. 528 A TEXT-BOOK OP GYNECOLOGY Bacillus Coli Infection of the Fallopian Tubes. — The Bacillus coli communis lias been found to be the essential micro-organism in certain cases of tubal infection. Deaver {Virginia Medical Semimonthly) states that there is frequently a close relationship between acute catarrhal appendicitis and right-sided acute salpingitis. While he mentions these as separate conditions, calling for consideration of their respective symptomatology for diagnostitial purposes, the causal relationship between the two is nevertheless suggested. The role of the Bacillus coli communis in appendicitis is well understood, but the extension of its influence to the Fallopian tube is not so easily comprehended or so generally recognised. Cases of salpingitis, however, in which the bacil- lus coli was present, have been reported by Morax, Girode, Hartmann, Doyen, and Keymond. Individual cases have also been reported by Guyon, Tuffier, and Schauta. The causation of this infection may be summarized under the head of intestinal adhesion. The intestinal origin of this infection is em- phasized by Eeymond, who failed to find it in a single case in which the tube was not adherent to the intestine. Actual perforation of the intestine, however, does not seem to be essential to enable the bacillus coli to migrate from its native habitat to the lumen of the Fallopian tubes; on the contrary, there is ample evidence that the infection takes place by direct passage through the adhesions. There is no evidence, however, to justify the denial of a possible invasion of the tubes by progressive infection of the mucous tract through the vagina and uterus. The fact that the bacillus coli has been found in the vagina indicates the possibility of a general infection of the genital tract by that route. In six cases studied by Eeymond and Magill, the condi- tions were all favourable for direct infection from the intestines. In one case in particular the right tube was adherent to the intestine and contained the bacillus coli, while the left tube, which was not attached to the intestine, did not contain that micro-organism. It would seem that the bacillus coli never occurs singly as an infectious element in the Fallopian tubes; on the contrary, other fine bacteria appear to accompany the colon bacillus, but they have not been classi- fied. These bacteria have been observed by Witte, Morax, and Eey- mond and Magill, as small rods much more slender than the colon bacillus, immovable, colourable by Gram's method, and of variable length. They seem to add to the offensiveness of the pus in which they are found. The symptoms of bacillus coli infection of the Fallopian tubes are essentially those of a pyosalpinx. In view of the fact that this bacillus has not been demonstrated in the tube in the absence of tubo-intestinal adhesions, and of the further fact that such adhesions only occur as the result of a previous infection of the tube, it follows that the history of the case must embrace the symptoms of the preliminary infection. This may be gonococcous infection or a streptococcous infection, or it may be a so-called mixed infection, by which is implied that un- INDIVIDUAL INFECTIONS OP THE FALLOPIAN TUBES 529 differentiated infection which is probably responsible for the majority of pus tubes. When, however, the bacillus coli penetrates the Fallopian tubes, the symptoms are more or less violent, the temperature running very high, sometimes to 105° F., following an initial chill. The rigors may be repeated, followed each time by exacerbation of the tempera- ture, with increasing evidences of systemic intoxication, verging to the fatal point. Spontaneous relief may occur, however, by the abscess breaking into the intestine and thus draining away. The pathology of this form of infection does not differ in essential particulars from that already given, (See Morbid Histology of Sal- pingitis.) The bacilli are found in variable quantity in the pus; some- times in such quantity as to suggest a drop of culture bouillon. This, however, is exceptional, as in other cases the bacteria are so rare that microscopic examination of the pus is negative, the existence of the micro-organisms being revealed only by cultures. Leucocytes are rare in the pus, while the epithelial cells are more numerous. The manner in which the bacillus coli attacks the epithelium does not seem to be settled. If it is granted that the organism finds its way into the tube through the septum formed by tubo-intestinal adhesion, it follows, as a logical result, that it must approach the epithelium from beneath; whereas, if the method of invasion is through the uterus, it, like the gonococcus, attacks the epithelium from its free surface. Eeymond and Magill record the significant fact that in all sections made and coloured by them with NicoUe's method, they were never able to find the bacteria elsewhere than in the salpingo-ovarian pocket, in the midst of eliminated cells, and at the surface of the wall. The progres- sive accumulation of pus is more rapid than in the ordinary infections, and results in extreme distention of the tube which may rupture either into the peritoneal cavity, or, as more frequently happens, into the intestine. Pneumococcous Infection of the Fallopian Tubes. — The infection of the Fallopian tubes by the pneumococcus is rare, Eeymond and Magill never having observed a case, although one each has been reported by Wertheim, Zweifel, and Frommel. It would seem that in this form of infection the mischief is always limited to the tube and does not ex- tend to the ovaries. The majority of the cases are unilateral, the pus being small in quantity and the tube being closed at its pavilion. The investigators have not recorded any peculiar appearances in the micro- scopical sections from these cases. The symptoms in the cases on record are those of an acute onset followed by high temperature. It would seem either that the pneumo- coccus is of varying virulence, or that the patients possess different degrees of susceptibility, since the escape of pus into the peritoneum in Zweifel's case caused no accident, while it proved rapidly fatal in the cases reported by Frommel and Witte. The causation of this form of infection seems to be shrouded in mystery, for no satisfactory explanation has been made of the manner 530 A TEXT-BOOK OP GYNECOLOGY or means by which this micro-organism is conveyed from its natural habitat to the Fallojaian tubes. In none of the cases has pneumonia been present, although Stroganoff has observed a pelvic abscess that contained capped diplococci in several cases following pneumonia. It is stated that in cases of salpingitis no history of general disease which might be considered the primitive cause has been recorded. An exami- nation of all the testimony tends to render untenable an hypothesis of the systemic origin of the infection. The probability of its entrance through the genital tract seems to be better founded. The cases of Witte and Frommel show that the infection was consecutive to puer- peral accidents; while gonorrhoea was the antecedent factor in the cases of Girode and Zweifel. The facts, however, that the pneumo- coccus exists normally in the saliva, and that among certain people of depraved habits the saliva is sometimes used as a lubricant in vaginal manipulations, may explain its presence in that canal, where Doyen and others assert that they have found it. In view of the fact, how- ever, that its normal medium is alkaline, it is hardly to be assumed that it will find a congenial environment in the presence of the acid products of the bacilhis of Doderlein. The assumption, therefore, that the pneumococcus is to be classified among the normal bacteria of the vagina seems to be gratuitous. Staphylococcous Infection of the Fallopian Tubes.— This condition has been assumed to be of frequent occurrence. This assumption, which does not seem to be well-founded, is manifestly based upon the important role which the staphylococci play in infections in general. These micro-organisms are not demonstrably present in a large propor- tion of salpingitides. Schauta found them but 4 times in 144 examina- tions. Menge found them once in 26 cases, Morax once in 33, while Witte found them but tv/ice. Boisleux reports that he has observed them several times. It is a notable fact that several observers who have found them have discovered other pathogenic micro-organisms present in the same cases. Eeymond and ]\Iagill have failed to find them, and, while not denying the accuracy of other observations, suggest that con- fusion may have arisen from the fact that there are found in and near the Fallopian tubes, saprophytes which may easily be confounded with the white and golden staphylococcus. The microscopic illusion is heightened by the fact that these saprophytes offer the same appearance on the slide and show cultural properties similar to the staphylococci. Saprophytic Infection of the Fallopian Tubes. — Witte has observed harmless bacteria, in company with those possessing pathogenic prop- erties, in the Fallopian tubes, but, like Eeymond, has not come to a conclusion as to their proper classification. The latter notes the significant fact that they resemble the species which normally inhabit the lower portion of the genital tract, but is not prepared to believe that they are indigenous to the tubes. The conclusion of Sinclair, that the Fallopian tubes are normally free from bacteria, is in accordance with this view. (See Bacteria of the Fallopian Tubes in Health.) The INDIVIDUAL INFECTIONS OF THE FALLOPIAN TUBES 531 explanation of their presence in the tubes rests upon purely theoretic grounds. The fact that they are always found in connection with pathogenic bacteria suggests that they migrate thither under the escort of their more virulent congeners. They do not penetrate deeply into the mucosa but live upon its surface. In those cases in which they seem to be more deeply embedded, it is found, upon careful exami- nation, that they are actually within an epithelial cul-de-sac which has become more or less displaced by the inflammatory thickening of the membrane. They are not discoverable in the muscular tunic. Septic Vibrion Infection of the Fallopian Tubes. — Infection by the vihrion septique of Pasteur {Bacillus oedematis maligni) has been found in the I'allopian tubes by Witte. This organism, which has rounded edges, and varies from 0.8 /* to 1 /a in thickness and from 2 //. to 10 /a in length, was obtained in pure cultures by Liborius. It produces in the lower animals a hemorrhagic oedema in the subcutaneous tissues into which it is injected. The infection in such cases is limited to the immediate area of injection until after death, when it becomes rapidly diffused throughout the system. It is believed to be the cause of emphysematous gangrene in the human subject — although the role that it was presumed to play in producing gaseous phlegmons, is now known to be shared by the Bacillus aerogenes capsulatus. The gaseous manifestations were present in Witte's case of pyosalpinx. It has also been found by Giglio in company with the Staphylococcus pyogenes aureus in perimetric abscess. Its method of invasion of the Fallopian tubes, and the exact part that it plays in general pathology, are not accurately understood. Actinomycosis of the Fallopian Tubes. — This condition has been observed by Zemann, the lumen of the tube being filled with pus in which the parasite abounded. The micro-organism (Streptothrix actino- myces) attacked the walls of the tubes, which were thickened and granular. The origin of the infection was not determined. CHAPTEE XXXV TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES The natural course and termination of inflammatory diseases of the Fallopian tubes — Hygienic treatment — Medicinal treatment — Local treatment — Massage — Electricity— Drainage : Indications ; varieties — Vaginal incision or puncture — Inguinal or inguino-vaginal incision — Abdominal and abdomino-vaginal incision — Rectal puncture — Aspiration — Conservative operations on the tubes — Radical treatment — Salpingectomy — Tait's operation ; modifications of Tait's operation — Abdominal panhysterectomy — Doyen's operation (vaginal hysterec- tomy) ; modifications, indications, and limitations. The Natural Course and Termination of Inflammatory Diseases of the Tubes. — The treatment of any given disease should be based upon the knowledge of the natural history of that disease. The application of this rule to the treatment of infections of the Fallopian tubes, in- volves primarily a consideration of the natural termination, uninflu- enced by operative treatment, of the inflammatory diseases induced by the infection. This, as stated by Clark, can not be done accurately in our present state of knowledge, for the reason that, during the last decade, in which the most advanced studies in gynecology have been made, there has been much greater activity in the operative field than in that of simple palliative treatment, or the treatment by topical appli- cations and douches; consequently, no series of cases sufficiently large to offer reliable statistics has been reported. Notwithstanding this deficiency in statistics, general observations, as recorded by many gyne- cologists, point very strongly to the possibility of a restoration ad inte- grum in many cases of salpingitis which have hitherto been subjected to radical operations. In considering the prognosis in the acute in- flammations of the tube, two principles in the pathology of these organs must be borne in mind. First, many tubal infections are self -limited; and, secondly, the mucous membrane of the tube is extremely difficult of destruction. With a decrease therefore in the virulence or cessation of the infection in the simple acute inflammations, the second factor becomes active and tends to restore the tube to the normal condition. Whether a perfect restoration occurs, depends upon the extent of the injury. While we accept unhesitatingly the statement that the ma- jority of cases of simple tubal catarrh, and even of purulent salpingitis, terminate in a return to the normal, just as do acute catarrhal and sup- 532 TREATMENT OP INFECTIONS OE THE FALLOPIAN TUBES 533 purative processes in other mucous membranes, nevertheless when a widespread, round-celled infiltration of the muscular layers of the tube occurs, with a subsequent formation of new connective tissue, which renders the tissues dense, nonvascular, and more or less of a low vitalized type, an anatomic restoration is manifestly impossible. From the purely functional standpoint, however, this question is to be considered in another light. Accepting as true the statement that sterility in the latter class of cases is the rule, we should not by any means unqualifiedly infer that these patients will become chronic in- valids, for according to our observation, some women even with exten- sive adhesions and distortion of the tubes still suffer little or no pelvic pain. With the conservative spirit which now prevails among gynecolo- gists in regard to the treatment of this special class of diseases, we shall no doubt find with the accumulation of accurate records that in simple catarrhal inflammations, and even in cases of undoubted hydro- salpinx, a self-limitation of the disease occurs, especially under the influence of rest, freedom from sexual intercourse, and the proper ap- plication of douches and other remedies. The ordinary pyogenic cocci, such as the streptococcus, staphylo- coccus, colon bacillus, etc., appear to be more virulent in their imme- diate action than the gonococcus, but the latter is much more persistent and is especially prone to recur. When the ordinary pyogenic cocci gain access to the tube, their cycle of activity ends with the acute attack, after which, absorption in the case of hydrosalpinx, or even of pyosalpinx, may occur, whereas the gonococcus is frequently very per- sistent and is self-perpetuating. Once infected with it, the pathological process may extend over months and years, now better, now worse, de- pending upon the renewed activity of the gonococcus. These patients, therefore, are prone to become chronic invalids. There is little danger to life in the acute or recurrent gonorrhoeal attacks so far as the immediate effect is concerned, but the patient may drag out a miserable existence, suffering more or less pelvic pain for years. So far as the ultimate prognosis is concerned, our present knowledge seems to indicate a more permanent recovery in those cases which survive the primary infection from the ordinary pyogenic organ- ism than from the gonococcus, at least so far as a restoration of the patient to a condition of freedom from pain and discomfort is con- cerned. Hydrosalpinx, while often very painful, is not dangerous, and patients tend to recover without operation, the fluid being absorbed just as in similar collections in other cavities. Wlien aided by inci- sion and puncture, the return to the normal is greatly facilitated. While the pus of a pyosalpinx may, as stated, ultimately be ab- sorbed, this appears to be the exception rather than the rule, for as in other collections of pus, Nature attempts to establish an exit; at least this is true in cases in which the pyosalpinx reaches a consid- erable size. 534 ' A TEXT-BOOK OF GYNECOLOGY When the tube is small^ slow gradual inspissation of the pus may occur, leaving, in its later stages, only a granular, cheesy matter. In some of these cases, small calcareous bodies, which ajjpear to be the residual debris of the inspissated pus, are also found. With the progressive accumvilation of pus in the tubes, the coincident perisal- pingitis results in firm adhesions to the surrounding organs, that prevent the ruj)ture of the tube into the abdominal cavity. Pelvic peritonitis from contiguity of organs is quite common, in fact is almost an invariable rule, but widespread general peritonitis is quite excep- tional as a result of purulent contamination through the rupture of the tube. For this reason, a procrastinating policy, so far as operation is concerned, should usually be pursued in gonorrhoeal salpingitis, even if pyosalpinx is formed; for it is better to wait for the organisms to expend their virulence and die, rather than to operate in the acute stage when the temperature is considerably above normal. The tube, when dis- tended with pus, frequently drops down into the pelvis posteriorly to the uterus, and often in cases of double pyosalpinx the retort-shaped vestibular ends come into contact. Following the rule with all puru- lent collections, the pus tends to rupture in the direction of least resistance. The isthmiac end of the tube being either occluded or very resistant, offers an effectual bar to the escape of the purulent mat- ter into the uterus. The situation of the bladder, anterior to the uterus, while the pyosalpinx is posterior, renders this viscus a comparatively infrequent channel of egress. The intestinal canal, therefore, forms the most likely cavity into which the abscess will tend to evacuate itself. Because of the dependent position of the tubes in Douglas's cul-de-sac and of the intimate adhesion of the upper third of the rectum and the lower portion of the sigmoid flexure to them, rupture usually occurs at these points, although the small intestine may prove Nature's point of election. AYhen once evacuated, the further secretion of pus may cease and obliteration of the cavity by granulation may oc- cur; or, on the other hand, reinfection by the colon bacillus or other in- testinal organism may take place through the intestinal opening, and a well-nigh interminable purulent process be inaugurated. Certainly, after a rupture into the intestinal canal has occurred, a reasonable time should be given for the closure of the fistvilous tract before an operation is resorted to; for these are very unfavourable cases, the intestinal lesion introducing a dangerous factor into the operative treatment. In some cases, the pus points in the inguinal region, or gravitates down- ward under Poupart's ligament, appearing as a fluctuating swelling in the femoral canal. Clark concludes a careful study of the natural history of inflam- matory diseases of the Fallopian tvibes with the statement that, while palliative treatment should, hy all means, he employed in the simpler non- purulent inflammations of the tuhe, so far we can see no reason to modify the surgical rule to liherate the pus hy means of an operation rather than to ivait for its natural evacuation ; for Nature's method is usually TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 5^5 "very inferior to the clean, careful work of a good surgeon. If left alone, the patient is subjected to many months of very serious invalidism, whereas proper 02:>erative treatment is followed by much more certain and radical relief. Hygienic Treatment. — While the prognosis in acute salpingitis varies according to the etiology, whether simple, gonorrhoeal, or sejatic, the aim of the medical treatment in each variety is practically the same. We can not expect to arrest the process after it has once ex- tended to the tube, but we can assist Nature's method of cure, which consists in the absorption of inflammatory products, the occlusion of the distal end, or the adhesion of the diseased tube to adjacent organs so that infectious fluids are shut oif from the general cavity. Abso- lute rest in the recumbent position must be insisted upon, the patient not being allowed to leave her bed for any purpose. Sexual excitement is especially to be avoided — the husband being strictly cautioned as to this point. If the menstrual flow appears during the acute attack, these precautions are still more necessary. The regulation of the bowels is of primary importance, as thorough purgation often cuts short an attack, or at least limits the inflammatory process. Half- grain tablets of calomel, one every half hour, followed by teaspoonful doses of siilphate of magnesium or phosphate of sodium, are usually followed by several loose movements. If the stomach is irritable, six or eight ounces of a saturated solution of salts, may be introduced into the bowel through a long rectal tube. After the bowels have been opened, the saline laxative should be repeated daily. If the tempera- ture is elevated above 101° F., an ice bag or cold-water coil, applied over the lower abdomen, not only relieves pain, but often controls the accompanying peritonitis. Some patients can not tolerate cold, but find more relief from hot stupes or poultices. Hot vaginal douches (110° to 115° F.) are exceedingly useful in the acute stage, but they should be given every six hours, not less than a gallon of water being used each time. High enemata of saline solution not only relieve tym- panites, but stimulate the renal functions. Pain is best relieved by codeine supiDositories, hypodermatic injections of morphine being given only when absolutely necessary. Strychnine is a more reliable stimu- lant than alcohol. In short, the treatment of a case of acute saliaingitis is identical with that of localized peritonitis, with the details of which the reader is suf- ficiently familiar. If adopted promptly and carried out thoroughly, most nonseptic cases will either go on to resolution with more or less restora- tion of function, or the patient will recover with thickened and adherent tubes, to become the subject of future medical or surgical attention. In the nonsurgical treatment of chronic salpingitis the physician seeks to relieve pain and disability, to promote the absorption of exudates and the stn.'tcliing of adhesions around an imprisoned tube, and to restore its physiologic functions so lliat conception may become a possibility. WhJI<; considerable confidence may be felt in reparative natural pro- 536 A TEXT-BOOK OP GYNECOLOGY cesses, since the physician can not know the exact anatomic condition without opening the abdomen, he should be careful about promising- a complete cure or entire freedom from subsequent attacks under con- ditions favouring fresh traumatisms or infection. It is assumed that the cases under consideration are those in which the tube is merely thickened and adherent, especially in Douglas's pouch, with or with- out accompanying disease of the ovary. A patient with this condition must be taught to take the best care of herself. She should, while tak- ing daily exercise in the open air, be constantly on her guard against over-exertion, indulgence in violent sports (golf, bicycling, or bowling), exposure to cold, in fact, anything which might light up a fresh attack of inflammation. If sexual intercourse can not be interdicted, it should occur at infrequent intervals, with due cautions against violence or excess. Unless the cheerful co-operation of the husband can be se- cured, all treatment will be unsatisfactory. Eest during menstruation is a desideratum, at least during the first two or three days. Patients must be taught that this is the period when they are most liable to recurrent attacks. The deleterious influence of pregnancy and abortion upon old tubal troubles is well known, so that it is quite within the province of the physician to caution against the risks attending conception in subacute cases, especially those of gonor- rhoea! origin. Medicinal Treatment. — Various drugs have been mentioned as hav- ing almost specific action upon tubal disease, such as bichloride of mercury, chlorate of potassium, and the iodides; but this action, when apparently beneficial, must be due rather to the improvement effected in the general health, especially in syphilitic subjects. Tonics and laxa- tives are always indicated. Careful regulation of the bowels by cas- cara, podophyllin, or salines, with occasional high enemata, should be a routine measure. Warburg's tincture, iron, and strychnine, are never amiss. For the correction of gastric disturbances and excess of uric acid, teaspoonful doses of phosphate of sodium in hot water act most satisfactorily; indeed, when this simple remedy is used habitually it is usually unnecessary to give any other laxative. The action of the kid- neys should be stimulated by the daily ingestion of large quantities of pure water. Alcoholic stimulants are to be avoided, unless strongly indicated on account of the weak condition of the patient, especially during menstruation when they are apt to be used in excess to relieve pain. The temptation to resort to morphine to relieve dysmenorrhoea is strong, but should be resisted as far as possible. If opium must be used, codeine, in the form of suppositories, is preferable, or the coal- tar derivatives may be employed without overlooking their depressing effect on certain subjects. Counter-irritation over the abdomen with blisters, leeches, or the thermo-cautery, often aft'ords temporary relief to local pain, but no actual effect upon the pathologic condition within the pelvis is to be expected. The same comment applies to painting the vaginal fornix with tincture of iodine. In scanty menstruation, iron TREATMENT OP INFECTIONS OP THE PALLOPIAN TUBES 537 and manganese are indicated. Menorrhagia is treated with small doses of strychnine, ergot, and hydrastin, or stypticin in 2-grain doses every four to six hours until the profuse flow is checked. Since in these cases the endometrium is in a state of hyperplasia, curettement is usually the most direct method of relieving the symptom. It is hardly necessary to add that the hot vaginal douche is indispensable in the treatment of chronic, as well as of acute, salpingitis. Local Treatment. — In the medicated tampon we have probably the best local agent for the treatment of diseased and adherent tubes. In many cases it certainly relieves pain and assists in the absorption of exudates, as proved by the marked diminution in the size and sensi- FiG. 223. — " Aside from the advantage gained by supporting enlarged and displaced tubes, the habitual use of the tampon seems to improve the pelvic circulation."— Coe. tiveness of the pelvic tumour. That a restitutio ad integrum can be thus obtained, only an ultra-enthusiast would assert. Yet the per- sistent use of the tamponade has relieved many women from a state of invalidism when an operation seemed inevitable, so that they be- came practically well and were able to conceive and bear children. Glycerine, boro-glyceride, and iehthyol, are the medicaments usually employed — the two latter in a 10-per-cent solution in glycerine. Aside from the advantage gained by supporting enlarged and displaced tubes (Fig. 223) (especially when the uterus is retroflexed), the habitual use of the tampon seems to improve the pelvic circulation, while the ichthyol-glycerine seems to have almost a specific action upon firm exu- dates, which soften and melt away under its influence. In order to ac- complish decided results the tampon should be inserted at least two or three times weekly. The patient being in the knee-chest position and 538 A TEXT-BOOK OP GYNECOLOGY the vaginal fornix exposed with a Sims's speculum, two pledgets of ab- sorbent cotton saturated with the ichthyol solution, are pushed up firmly against the tumour and a dry tampon is applied on them. As the patient becomes more tolerant greater pressure can be exerted, the number of tampons being increased with the view of stretching adhe- sions and lifting the mass out of the pelvis. The patient is instructed to leave them in situ for thirty-six or forty-eight hours, meanwhile wear- ing a napkin on account of the discharge which always occurs. After they are removed, hot douches are used until the next treatment. While patients learn to introduce the tampons themselves, it is a question if they ever push them beyond the cervix. To meet this objec- tion King has devised a tube for injecting the solution into the pos- terior fornix, a dry pledget being afterward inserted to retain it in the vagina. In 23i'actice it has been found that, in order to accom- plish the desired result, the tamjjon must be carefully introduced by the physician in the way described. It is impossible to do this prop- erly through a bivalve speculum. Massage. — So much has been written about pelvic massage that it is impossible to do more than touch ujjon it here. While Coe does not disparage this method of treatment, which has given such excellent re- sults, he is not enthusiastic with regard to its application to the separa- tion of intrapelvic adhesions. The unexpected extent and firmness of those often found on opening the abdomen, and the difficulty of sepa- rating them, even under the direct guidance of the eye, leads one to infer that the relief experienced from the massage of adherent tubes and ovaries, is due rather to improvement of the pelvic circulation and the general conditions of the patient, than to the actual absorption of exudates and the breaking up of bands of organized lymph. A^^iile an expert might venture in carefully selected cases to attempt the evacua- tion of pus and other fluids by " stripping " a distended tube into the uterus, the practitioner will do well to confine his manipulations to cases of thickened and adherent tubes in which there is no evidence of subacute inflammation, and where the first careful attempt is not followed by unpleasant reaction. The technique is briefly as follows: The patient lies upon a Ioav couch, with her clothing thoroughly loos- ened, the knees flexed, and the hips raised on a cushion. The operator, sitting on a low chair at one side, introduces one or two fingers into the vagina and exerts steady gentle pressure against the mass, while his other hand makes counter-pressure over the abdomen. Some re- sistance may be experienced at first, but with patience the tension of the muscles will be overcome, so that the opposing fingers may be approximated, grasping the mass between them. Light kneading with the abdominal hand enables him to put the adhesions on the stretch. The rule in pelvic massage is, not to begin with the exudate, but to direct the strokes upward and outward, with the view of emptying the pelvic veins. The first seance should be tentative, not being prolonged beyond five or ten minutes. If marked pain is experienced during the TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 539 treatment, or pain and infiammatory reaction afterward, it is more than doubtful if it will prove beneficial. Should the first treatment be satisfactory, it may be repeated two or three times weekly for ten or fifteen minutes at a time. It is wise to suspend treatment just before and after the menstrual period. In order to save what has been gained in the way of stretching adhesions, it is well to introduce as firm a tampon as the patient can bear. In a favourable case, j)er- sistent massage will restore a considerable range of mobility to the adherent uterus and adnexa, so that it may even be possible for the patient to wear a soft rubber pessary with comfort. Circumscribed exudates are softened and absorbed and become insensitive, menstrua- tion becomes regular and less painful, and the patient's general health is sensibly improved. It need not be added that pelvic massage, as thus outlined, is not to be confounded with the forcible separation of adhesions under aneesthesia, an operation which calls for special tactile dexterity and is not free from risk. Electricity. — The extravagant claims of former electro-therapeu- tists are no longer regarded seriously. It is admitted that one need not look for any mysterious action of electricity upon diseased organs, whereby an anatomical cure may be obtained. It is simply an adjuvant in the treatment of pelvic diseases, serving to relieve pain and to stimulate the pelvic circulation. While, for the scientific apj^lication of this agent, elaborate and expensive apparatus is necessary, for ordi- nary office practice a good galvanic battery (preferably the dry-cell variety) is suliicient for gynecological treatment. A milliamperemeter, while usefiil, is not indispensable, since the patient's sensations and the after-efi^ect of the treatment are the best guides in its apj^lication. Local pain is tlie indication for electricity. As in the case of mas- sage, the contraindications are subacute inflammation and the pres- ence of a suspected pus focus in or around the tube. A ball electrode, covered with wet clay, chamois, or absorbent cotton, and connected with the negative terminal, is introduced into the vagina and pressed against the sensitive mass, while the positive electrode (clay or wire gauze covered with cloth) is placed over the lower part of the abdomen. Beginning with a weak current, this is gradually increased up to 30 milliamperes, or until the patient feels a distinct warmth or burn- ing sensation, but no pain. Women differ greatly as to the degree of tolerance, but it is not well to exceed 50 milliamperes. The seance lasts from five to fifteen minutes and may be repeated two or three times a Aveek. The patient should experience subsequently a general feeling of well-being, with relief of the local pain. If it is found after two or three applications that the pain is increased, or if there is any other unpleasant reaction (rise of temperature, etc.), it is wiser not to persist with it. Intrauterine galvanization with the positive pole may be practised when monorrhagia is a marked symptom, but this is not generally recommended in connection with pelvic exudates. An equally good sedative efrect is obtained by using the fine wire faradic 540 A TEXT-BOOK OF GYNECOLOGY current with a bipolar vaginal electrode, and there is seldom any re- action. The patient's sensations form the best indications as to the strength of the current. In touching briefly upon the nonsurgical treatment of salpingitis, Coe would emphasize (1) the fact of its limitations; (3) the necessity for accurate diagnosis and care in the selection of cases; and (3) that an anatomical cure is not to he expected. It is the aim of the physician, with the intelligent co-operation of the patient, to relieve symptoms and to preserve organs which, though diseased, are not a menace to life, and may under judicious treatment be restored to functional use- fulness, if not to a normal condition. Operative intervention may in the end be necessary, but the patient's wish to make a fair trial of less radical methods should be regarded, and the results, even in cases which at first appear to be purely surgical, are often so good that an operation is avoided. If it is eventually performed, the patient's local and general condition have been so much improved by the preparatory treatment that the operation is rendered much easier and safer, and more satisfactory in its ultimate results. Treatment by Drainage. — In certain cases of purulent accumula- tions, not only within the Fallopian tubes, but in the lymphatics and in the ovaries, the condition of the patient is such that a judicious operator may deem it advisable to improve her condition before attempting the radical operation. The initial step in such a course of treatment must be the removal of the pus. The indications and limitations of drainage as a means of treatment in pelvic disease should be distinctly recognised. It may be said to be indicated in all cases in which there is manifestly an extensive accumu- lation of pus, and in which the active constitutional symptoms indi- cate that the causative pathogenic micro-organisms are not only yet alive, but virulent. In such cases, to attempt the removal of the Fal- lopian tube, for example, by abdominal section, would simply mean to expose the patient to an unnecessary hazard through the liability of rupturing the tube and consequently of contaminating the peritoneum. In all such cases it is better to evacuate the pus by some sort of punc- ture than, under the circumstances, to attempt the ablation of the appendages by either vaginal or abdominal incision. While this is true, it is nevertheless important to recognise that the treatment is essentially tentative; in other words, that it is a means of affording the patient only temporary relief, and of placing her in a reasonably safe condition for the more radical operation which, in the majority of cases, should follow. This is the only representation that the operator is justified in making to his patient. In numerous cases, however, symptomatic cures have followed drainage, but this result is never to be counted upon. It may be stated, as a rule, therefore, that pelvic drainage as an elective operation should only be employed as a tem- porary expedient, by which the patient may be put into a proper general condition for a radical operation. TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 54I The varieties of drainage, or, in other words, the various avenues and instrumentalities by which drainage may be effected in these cases, may be summarized as follows: (a) vaginal puncture; (6) inguinal and inguino-vaginal incision; (c) abdominal or abdomino-vaginal incision; (d) rectal puncture; (e) aspiration. Drainage when once established may be maintained by a tube, by gauze, or by open incision. The vaginal incision, in certain cases more properly called vaginal puncture, is the method of election in the majority of cases. The cases which are best adapted to this method of drainage are those in which the purulent accumulation lies behind the uterus in the cul-de- sac, or behind the posterior folds of the broad ligament upon either side, or in which the suppuration has oc- curred primarily in the lymphatics of the pelvis and has burrowed thence posteriorly or laterally round the uterus and the upper portion of the vagina. In such cases, the prod- ucts of sujDpuration can be most easily removed through the vagina. The operation is done in various ways. The patient should in all in- stances be carefully prepared. Some operators prefer to place the patient in a recumbent posture, with her knees flexed well upon her thorax, the extreme Simon position, and, in- serting a perineal retractor, to locate the most dependent portion of the purulent sac or cavity, which is then opened with a bistoury. This is far from being a safe method of pro- cedure, for the reason that in prac- tically all these cases there is more or less distortion of the tissues and consequent displacement of the blood vessels. A free incision, therefore, in a locality which, under normal condition.s, will be entirely safe, may result, in these cases, in the division of the blood vessels and a consequent serious and often fatal hemorrhage. It is better, therefore, to adopt the method de- scribed many years ago by Clinton Gushing and to make this opening by means of a dilating plunger. Fig. 224. — "Keed uses a sharp-pointed curved dilator" (page 542). 542 A TEXT-BOOK OF GYNECOLOGY This consists in a pair of sharp-pointed dilators which are easily inserted^ and, when opened, simply tear an orifice large enough to per- mit free drainage. Eeed nses a sharp-pointed curved dilator (Fig. 224) and prefers to have the patient in a recumbent posture with her knees but moderately flexed, to have no perineal retractor, but to use his finger, exclusively, as a guide for directing the instrument, which can thus be inserted with greater accuracy in any direction (Fig. 225). Fig. 225. — "Keed prefers to use liis tiuger, exclusively, as a guide for directing the instrument." The index finger should be inserted into the orifice thus formed, no hesitancy being experienced in exei'cising the necessary force to accomplish this end. A free exploration of the cavity is thus made, the abscess sac is washed out, first with a clear sterilized saline solu- tion, and afterward with pure peroxide. Eeed has latterly thrown in freely a solution of 95-per-cent carbolic acid, rinsing the part imme- diately with pure alcohol, and has found it the most effective anti- septic procedure that he has ever employed. After this, the cavity may be packed with sterilized bichloride gauze, or the drainage may be kept up, either from the start, or after the removal of the gauze by a self-retaining tube. This is easily prepared, as shown in Fig. 46, page 115, a T being formed. The arms of this T are together clasped in the tip of long forceps by means of which the tube is carried through the orifice at the vault of the vagina and the fiaps allowed to expand in the pus cavity. A tube thus made and inserted may be worn for a week or even months without removal (Fig. 226). The inguinal or inguino-vaginal incision is practised in certain cases where the pus has accumulated in the retroperitoneal structures. TREATMENT OP INFECTIONS OF THE FALLOPIAN TUBES 543 and has lifted up and practically obliterated the folds of the broad ligament. Such accumulations occasionally occur in positions so re- mote from the vagina, and so distinctly above or surrounding the important blood vessels to the side of the uterus, that it is necessary to avoid the vaginal avenue of approach. It sometimes happens that a diagnosis of the exact condition and location of this accumulation can not be made until after the peritoneal cavity has been opened. The median incision, therefore, merely subserves an exploratory pur- FiG. 226. — " A tube thus made and inserted may be worn for weeks or even months without removal." — Keed (page 542). pose. With the finger on the inside of the peritoneal cavity and acting as a guide, an incision is made along the line of Poupart's ligament, just above its upper border, 3 to 5 centimetres in length. This incision is carried down through the fascia, below the peritoneal duplication, which is lifted by either the finger or a blunt dissector or the handle of a bistoury, the instrument thus employed being pushed forward until the pus cavity is reached. The operation may stop at this point, the pus cavity being treated by careful irrigation with a saline solution followed by peroxide, and then by 95-per-eent carbolic acid, followcfl, in turn, by the alcohol. It should then be packed with gauze or treated with drjiiiiagc l)y tube. If the pus pocket has been found 544 A TEXT-BOOK OF GYNECOLOGY : Fig. 22"? . by making two openings, one a little above the other." — Reed. to be sacculated and to contain a considerable amount of granulation tissue, it is probable that suppuration will be more or less indefinitely continued; to dispose of it, it would be better to secure throvigh-and- through drainage and thus to take advantage of the force of gravity in disposing of the discharge. This is readily done by introducing within the pus cavity the index finger of the right hand, carrying Eeed's dilator through to the vaginal vault or to the fornix, as the case may be, and with the in- dex finger of the other hand acting as a guide in the vagina, pushing the dilator through and into that canal. The removal of the dilator is followed by the insertion of the intravaginal finger into the pus cavity. The lumen of the tube between these perforations should be obliterated by ligating, or simply dividing off and everting it. This is readily done by making two openings, one a little above the other (Fig. 227), and each long enough to permit the passage of a tube of similar size through it. The forceps is then passed through each opening (Fig. 228), the end of the tube is folded over and seized, and the tube is drawn through itself (Fig. 229). The result is that we have practically two tubes, one opening upon one side Fig. 228. — " The forceps is then passed through each opening." — Eeed. Fig. 229. — " . . . and the tube is drawn through itself." — Reed. and the other opening upon the other side of a septum (Fig. 230). Thus made, the tube is carried through the inguinal opening, through the opening in the cul-de-sac, and out through the vagina (Fig. 231). The drainage tube should be kept from dropping too far into the wound, and from thus coming out through the vagina, by carefully inserting a safety pin through one side of the tube at a point corres]3onding to the cutane- ous surface. The superficial incision may then be closed, except so much of it as is required for the accommodation of the tube. Abdominal and abdomino-vag-inal incisions are practised for the purpose of abdominal drainage in cases in which the purulent accumu- TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 545 lation is situated beliind the peritoneum, and is so large that the hitter is pushed above the brim of the pelvis to such an extent as to permit the fixation of the peritoneal sac to the margins of a median abdominal incision. When this incision has been made and the abscess sac is found thus presenting, and it has been determined to practise drainage, the peri- toneal surface of the sac should be fixed either by a few interrupted sutures or a single continuous suture at the peritoneal margin of the abdominal incision. After it has been thus fixed, an aspirator needle, (Fig. . 332) or a small curved trocar may be inserted and a large quantity of the con- tained pus drawn ofl^. After this has been done, the cavity should be opened by an incision, inserting the finger for the pur- pose of careful exploration of the inside. The pus should then be washed out and the cavity should be treated as indicated in the preceding paragraphs. If it is deemed desirable to practise through-and-through drainage, as is the rule in the majority of cases, the tube, already described, may be inserted (Fig. 233) by observing precisely the same pre- FiG. 230.— •• The result is that we have practically two tubes, one opening upon one side and the other upon the other side of a septum." — Keed (page 544). Fio. 231. — "Thus made, the tube is carried through tlie inguinal opening, through the open- ing in the cul-de-sac, and out througli the vagina." (The uterus is cut away in the drawing, tlic left tuhc being sliown.) — Keeu (page 544). 36 646 A TEXT-BOOK OP GYNECOLOGY cautions as already indicated. (See Inguinal and Inguino-vaginal In- cision.) Rectal puncture was devised by the elder Byford as a method of election in those cases in which purulent accumulations seemed to press into and point toward the rectum. In certain of these cases a digital exploration of the rectum will indi- cate a soft fluctuating point. Byford in- serted an aspirator needle at this point and drew oflE the pus, and in certain cases even went to the extent of making a more pal- pable puncture. It was a convenient point of drainage and, contrary to what may be imagined, did not result in the formation of a fa3cal abscess or fistula. When, however, the latter accident did occur, as has hap- pened in a surprisingly limited number of cases, it proved to be so embarrassing as to seriously militate against the expediency of the operation. It is now but rarely adopted. Aspiration may be considered as a means of evacuating to a certain extent an accu- mulation of pus, rather than as a means of drainage; for the moment the needle is withdrawn the escape' of pus is discontinued. It may be used, however, with a degree of safety through any of the avenues of ap- proach at the most presenting point of a pelvic abscess. Conservative Operations on the Tubes. — The indicalioiis for conservative operations on the tubes are more limited than in the case of the ovaries, since the main object aimed at is to favour conception. Hence the preservation of portions of the tubes im- plies that the uterus and one or a part of one ovary are left, otherwise the tubes would be useless. There can be little room at the present day for discussion as to the propriety of not sacrificing the internal generative organs entirely unless they are hopelessly diseased; for experience has proved that, even when marked pathologic changes are present, recovery may take place without impairment of function, as shown by the persistence of menstruation and the occurrence of conception. Surgeons are now most concerned with the question of the limits of conservatism, in which there is much room for the exercise of the individual Judgment. The objections urged against the preservation of portions of dis- eased tubes, are the immediate risk of septic infection, subsequent exten- sion of the disease requiring a secondary operation, and the probability Fig. 232. — Aspirator (page 545). TREATMENT OP INFECTIONS OF THE FALLOPIAN TUBES 54,7 of the reforming of fresh adhesions. Most important of all, from the patient's standpoint, is the possibility that pain may be only tempo- rarily, or not at all, relieved. These points the surgeon must consider at the time of the operation, being guided in his decision by the history of the case, the extent of the disease, the result of the bacteriological examination of fluid retained within the tubes, and, above all, by the expressed wishes of the patient, assuming that she is of an age when child-bearing is still possible. In general it may be stated, according to Coe, that when the operator feels reasonably sure that no extra risk will be entailed, a portion of one, or of both tubes should be left. Fig. 233.- -" If it is deemed desirable to practise through-and-througli drainage, already described, may be inserted." — Keed (page 545). the tube, The simplest conservative procedure consists in liberating adherent tubes by gently separating all adhesions, beginning at the distal end and working upward with the fingers or blunt-pointed scissors, toward the uterus, care being exercised not to tear the delicate fimbriEe (Fig. 234). The tube and mesosalpinx must be entirely freed, straightened, and brought up to the normal position. A fine probe should then be passed down to the uterus, great gentleness being necessary to avoid a false passage. If the tube tends to prolapse, it is well to fix it to the ovary with one or two catgut sutures, which should include the serous coat, at a point near the fimbriated end. Fixation of the latter to the surface of the ovary so as to occlude the lumen, may result in the formation of a tubo-ovarian cyst. 548 A TEXT-BOOK OF GYNECOLOGY The distal opening of the tube may be closed either by adhesions, or by the rolling in and agglutination of the fimbrige without enlarge- ment of the tube. The septum is laid open by radiating incisions with scissors, and the mucous membrane is united to the perineum with two or three interrupted sutures of fine silk or cat- gut. If fluid escapes on opening the tube, the sur- geon must regulate his procedure according to its character. Blood or serum fluid may be evacuated by gently stripping the tube toward its distal end on a pad. Should pus be pres- ent, it may still seem ad- visable to save one tube, especially if the bacterio- logical examination shows that it is sterile, and if it is necessary to remove the other. After squeezing out the pus the tube is syringed out with normal saline solution, then with pure peroxide of hydro- gen, and finally with salt solution. The tube is catheterized and restored to the pelvis, being su- tured in its normal posi- tion. When the outer third or half of a tube is dis- eased, it is divided straight across with a scalpel, bleeding points being caught with forceps. The stump is catheterized and the end slit upon two sides; the mucosa is then sutured to the serous covering as before. The end is then attached to the surface of the ovary in such a way that it can not become occluded. If the tube is generally thickened or nodular, and is strictured in its middle third, the same procedure is applicable, or the strictured portion may be excised and end-to-end anastomosis performed, as in resection of the intestines. Tubal abscesses adherent in Douglas's pouch are treated like other collections of pus in the pelvis — by vaginal incision, irrigation, and drainage. Kelly has suggested the treatment of such cases by the intra- peritoneal method, by opening and cleaning the pyosalpinx, dropping the tube back into the pelvis and draining per vaginam. The same con- FiG. 234. — " The simplest conservative procedure con- sists in liberating adherent tubes by gently sepa- rating all adhesions." — Coe (page 547). TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 549 servative treatment is applicable to eases of tubal abortion in which the opposite tube must be extirpated on account of extensive disease. (See Surgical Treatment of Sterility.) The radical treatment of suppurations of the Fallopian tubes con- sists in the removal of the affected tube or tubes; and, when the infec- tion has extended to the ovaries and produced destructive changes in those organs, they, also, are removed. Salpingectomy. — While, according to Doleris, salpingitis is not a recently discovered disease, having been described by Spronius and mentioned by Morgagni in his thirty-eighth letter, its surgical treat- ment has been a matter of but recent development. It is curious to note, however, that according to Schlesinger {Centralblatt fur Gynd- hologie) a successful laparo-salpingotomy was performed in Eussia in 1784. Dr. Seydel was the operator and the patient was a woman aged forty-two, the mother of three children, and had aborted two years previously to the disease which required the operation, viz., a small, round, and firm tumour observed in the summer of 1783. It was situ- ated on the right side of the abdomen, and in size and consistence bore some resemblance to the uterus in the third month of pregnancy. The tumour grew visibly, especially during the courses, was accompanied b}' very violent pains, and finally reached the size of the head of a two-year- old child, at the same time becoming evidently softer. Vaginal exami- nation showed that the tumour was connected with the uterus by a round and firm pedicle. In the winter of the same year the catamenia changed in type, while the pains occurred also in the intermenstrual period. The author explained to his patient (a student at his course for midwives) that he believed the right ovary to be diseased and, in his opinion, not to be curable without operation. The patient, though informed of the risk of the operation, consented. The operation was performed on February 21, 1784, in the town of Sarepta, situated in the government of Astrakhan. The patient was prepared with baths, some doses of light laxatives and Peruvian bark; before the operation she received a small quantity of tincture of opium and saffron, syrup of white poppy, and Hoffmann's drops. After dividing the external abdominal coverings and the muscles in a line drawn from the umbilicus to the right inguinal region across the middle of the tumour, the author severed the peritoneum with a button bistoury, guided by the finger; three arteries were ligated; the pro- truding intestines were crowded back into the abdomen by means of a napkin soaked in warm milk; the spherical tumour, which was in- closed in a thick, firm capsule, and contained a fluctuating fluid, was connected with the uterus by a pedicle, and its upper limit reached the crest of the ilium; on the posterior and lower surface of the tumour the greatly enlarged fimbrias of the tube were perceptible. The lower and lateral surfaces of the tumour were so closely adherent to the ad- joining muscles and organs that it could not be isolated as desired; the author, tliercforo, concluded to open it. Tliis having been done by a 550 A TEXT-BOOK OF GYNECOLOGY long incision, there exuded a thick, sticky fluid, without odour, and of chocolate colour, weighing one pound and a half. Careful examina- tion proved beyond doubt that the aiithor had to deal with a tumour of the tube and not of the ovary: " Qua quidem investigatione certo et indubitato cognovi tumoris huius sedem non ovarium fuisse, sed tubam." A decoction of Peruvian bark and a solution of myrrh were then poured into the cavity of the tumour, and a wad of charpie soaked in Balsamum Arc^ei was placed in the wound of the wall of the tumour. After the intestines had been isolated from the parietal peritoneum by pieces of linen dipped in oil of rose, the author bandaged the ex- ternal abdominal wound with plaster and linen, but subsequently closed it by " sutura3 cruentee." This ojDerator seems to have been a man of keen surgical intuitions, for nothing else would have prompted him to undertake the operation, while his subsequent conduct of the case made him a prophet of the latter-day canons of surgery. In the first few days after the operation, he endeavoured to secure a free outflow of the fluid which showed a tendency to form in the tumour cavity, to aecomjjlish which he had recourse to tents; these proved inefficient and he used a silver tube, which likewise proved inefficient, when the zealous surgeon with his mouth to the wound sucked the foetid fiuid from the cavity. He re- peated this operation four times daily, the patient being directed to lie in the interval with her abdomen turned downward to favour drainage. The fever was thus kept down, the purulent secretion gradu- ally diminished, the odour vanished, the wound contracted, and the patient recovered. The scientific recognition of these morbid states and their treat- ment by ablation of the uterine appendages is due, however, to the masterly genius of the late Lawson Tait. In contributing this knowl- edge to science, this great surgeon conferred upon womankind a boon equal to that of ovariotomy itself. This achievement, among the many which stand to his credit, is of itself sufficient to entitle his name to a place upon the scroll of immortality. That the operation has been abused, does not militate in the least against its intrinsic worth, or against the fact that it is annually the means of restoring to life and health thousands of women whose untimely death could not otherwise be averted. It was Tait who first insisted that pus in the pelvis was subject to precisely the same laws of surgical treatment as pus in any other accessible portion of the body. This axiom, the acceptance of which was strenuously resisted by many who were manifestly unfa- miliar with the technique necessary for carrying it into execution, has, in the twenty-five years which have elapsed since it was first enun- ciated, been accepted by the entire medical profession. To-day there are no dissenting voices. The extirpation of the uterine appendages, how- ever, places beyond hope of redemption the loss of the reproductive function. This is always a matter of serious moment, and is a result to be avoided whenever possible. The beneficent impulses of the TREATMENT OF INFECTIONS OF THE FALLOPIAN TUBES 551 medical profession have naturally become active in efforts to avert the extreme destruction induced by a naturally destructive disease. Efforts are, therefore, being made to conserve the organs and to perpetuate their functions. This conservative tendency, however, is not in con- travention of the law of Tait, for the elimination of pus and the arrest of infection are just as much aimed at by conservative as by radical measures. There is a strong probability that the efforts at conservatism have thus far resulted in a larger proportion of failures to arrest the infectious processes, than is to be attributed to the radical operation; while the restoration of function, particularly as it relates to con- ception, while realized in but a small number of cases, must stand as the vindication of efforts to save the tubes or the ovaries in whole or in j)art. The present tendency and the present necessity, as stated by Coe, are, not so much to ascertain the limitations of the radical operation, as to determine just when the recognised conservative method should, and should not, be applied. It may be taken as a rule to which there are but few exceptions, that a tube that is the seat of infection resulting in purulent accumulation, associated with occlu- sion of both the uterine and distal orifices, is not amenable to any other treatment than that of extirpation. The exceptions to this rule, if there are any, can not be determined before operation. It has not yet heen demonstrated that fimbria that have been curled inward and sealed by plastic exudation, have ever afterward become spontaneously disentangled with the restitution of the tubal orifice; nor has it ever heen demonstrated that a Fallopian tube thus sealed can, without sur- gical intervention, again subserve the purposes of an oviduct. Con- servative measures, such as drainage, may conserve the structural in- tegrity of the tube, but they can not be expected either to restore or to perpetuate its functions. The conservatism thus practised must, therefore, have its distinct limitations. The expediency of conserving a functionally useless structure, which thereafter can be potent only for mischief, is open to serious question. The restoration of tubes which have been the seat of former infection may be undertaken as an operation of election in cases of sterility, in which the re-establish- ment of the reproductive function is a matter of extreme necessity. (See Operative Treatment of Sterility.) Tait's operation for removal of the Fallopian tubes, as practised by Tait himself, included the removal of the ovaries, and is known as abdominal salpingo-odphoredomy. There were several reasons why the procedure was made thus comprehensive. In the first place, the ovaries were generally found to be the seat of disease sometimes as active and as destructive as that in the tubes themselves; in the next place, an ovary without a tube is useless for reproduction; in the third place, an ovary left in position may subsequently become the seat of neo- plastic or degenerative changes, if not of infection, and thus be a source of danger to the patient; and, finally, the ovary could be removed with the tube without adding to the hazard of the operation. These 552 A TEXT-BOOK OF GYNECOLOGY reasons seem cogent enough and are yet to be recognised as having extreme weight. Bland Sutton and others, however, have insisted with reason upon the importance of leaving a healthy ovary or a part of an ovary m situ, to avert the neurotic storms which attend the sudden precipitation of the menopause, following the complete ablation of the appendages. This innovation, however, does not modify to any im- portant degree the essential technique of the operation. The patient is prepared and the incision is made in accordance with the directions already given (see x\bdominal Section). As soon as the abdominal cavity is opened, the patient being, during the entire operation, in the dorsal recumbent posture, the surgeon introduces one or two fingers, permitting their palmar surface to glide down the parietal peritoneum over the collapsed bladder to the fundus of the uterus. This is the important landmark from which subsequent ex- ploration of the pelvis is to be made. Feeling to one side of the uterus, the condition of the Fallopian tube and of the ovary upon that side is thoroughly ascertained. Going back to the fundus of the uterus and exploring the other side, the other tube and ovary are likewise examined. It is sometimes diihcult to outline these structures, as in the presence of a recent inflammatory exudation, or, in the presence of old and firm adhesions, the identity of tubes and ovaries may be lost in an apparently homogeneous mass. The next step should con- sist in a search of what Joseph Price so aptly designates as a point of cleavage. As soon as this is found, one finger should be used to gradually and firmly, but gently enucleate the inflammatory mass from the parietal peritoneum. In conducting this manipulation it is im- portant, first, to have obtained a correct idea of the approximate loca- tion of the diseased tube. It generally occupies a position behind the posterior fold of the round ligament, or even in the cul-de-sac of Douglas, but it may be found lying between the uterus and the bladder, or attached to the omentum, or, as in one of Eeed's cases, to the meso- colon {Cincinnati Lancet-Clinic). Care should be taken — especially in acute cases associated with high temperature — to avoid rupturing the pus sac and thus bathing the peritoneum with the virulent ele- ments of infection. This accident may be guarded against by previously packing the pelvic cavity with a gauze napkin, which should be so arranged as to prevent the dissemination of the pus. When the tubes have been peeled out of their nests, first one and then the other should be brought up into the abdominal incision. The pedicle formed by the ovarian ligament and the broad ligament is next transfixed by passing through the broad ligament a needle loaded with the ligature. Tait employed what is called a Staffordshire knot. This consists in bringing the loop of the ligature back, over and around both the tube and the ovary; the looped end is then placed between the free ends of the ligature and drawn tight; the free ends of the ligature are then securely tied by a surgeon's knot and are cut, leaving not less than half an inch beyond the knot. In applying this ligature, care is taken TREATMENT OP INFECTIONS OF THE FALLOPIAN TUBES to have it impinge on the tube at its uterine juncture and to have it encircle the ovarian ligament. The tube and ovary are then cut away by scissors, care being taken to leave enough of the pedicle to prevent the slipping of the ligature. In certain of these cases the en- gorged mucosa will obtrude from the pedicle, in which case it should be cauterized by passing a probe, previously immersed in pure car- bolic acid, into its lumen. The appendages on the other side, if dis- eased, are treated in a similar way. The toilet of the peritoneum is now made. This, as practised by Tait, consisted in flushing the peri- toneal cavity, or more properly the pelvic cavity, with pure boiled water. If there was any oozing or if a pus tube had been ruptured, Tait inserted a glass drainage tube. This consisted of a piece of glass tubing long enough to reach from the cutaneous margin of the ab- dominal incision to the floor of the cul-de-sac; it had a number of small perforations in the lower 2 or 3 centimetres of its wall, and it was made to flare slightly at the top. Through this drainage tube, blood and serum was pumped by means of a suction apparatus, at in- tervals varying from half an hour to an hour until oozing ceased. The abdo- men was then closed by interrupted su- tures, Tait using silk both for the pedicles and for the abdom- inal incision. Tait's dexterity in perform- ing this operation was the marvel of surgery in his day. His technique is to- day religiously fol- lowed by many of the most eminent and successful operators. Modifications of Tait's operation have altered its technique to a slight degree without in the least modifying its princi- ple. Thus, the Tren- delenburg position is largely employed. The ovaries are now occasionally left in situ, the diseased tubes alone being removed — a line of practice which is yet dis- tinctly in its experimental stage. A hydrosalpinx is now occasionally Fig. 235.- . . . Draining per vaginam ... by gauze is gen- erally preferred."— Keed (page 554). 554 A TEXT-BOOK OF GYNECOLOGY incised, drained, and dropped back — a method of treatment that yet awaits justification. In ligating the pedicle, but few operators now em- ploy the Staffordshire knot, those who still cling to the en masse method, preferring to use that known as the figure-of-eight ligature. Many operators, however, prefer to control the ovarian artery primarily by snap-forceps, and then, after cutting away the ovary and the tube, to ligate the vessel, with its associated veins, individually; the peritoneal folds of the broad ligament being sutured over the ligated extremities of the vessels. Catgut is now very generally employed instead of silk for both ligatures and sutures. Drainage, in the presence of assured hemo- stasis, is but rarely employed, and when it is, Martin's method of open- ing the floor of the cul-de-sac and draining per vaginam, either by a self-retaining tube or by gauze, is generally preferred (Fig. 235). In the presence of persistent oozing, a gauze pack is sometimes adjusted Fig. 236. — "In the presence of persistent oozing, a gauze pack is sometimes adjusted." — Keed. (Fig. 236). The toilet of the peritoneum is now generally made by means of pieces of dry sterilized gauze, by which the cavity is mopped out. The abdominal incision is noAv closed by many operators by means of the laminated suture. (See Abdominal Section.) Abdominal panhysterectomy has been adopted by many operators (Fig. 237) for the radical treatment of purulent infections of the uterus and adnexa. The technique does not differ in any particular from that already described. (See Abdominal Panhysterectomy.) The reasons for adopting this operation are practically those which prompted Doyen, Pean, Segond, and the French school in general. TREATMENT OP INFECTIONS OF THE FALLOPIAN TUBES 555 to adopt vaginal hysterectomy in these cases. In the first place, in certain of the infections, notably that by the streptococcus (see Strep- tococcous Infection of the Uterus), the parenchyma of the uterus is invaded, with the result that more or less permanent changes are estab- FiG. 287. — '' AbdomiDal panhysterectomy has been adopted by many operators . . ." — Reed (page 554). lished; even in cases of gonococcous infection, in which the patho- logic changes have been manifested in the deep utricular glands and in the muscular stroma with which they are surrounded, hyperplasias of a more or less j^ermanent character are established. These are the cases which furnish the distressing examples of persistently pain- ful uteri following ablation of the appendages. It is to be acknowl- edged that the removal of pus tubes does not restore many of these cases to even symptomatic health. In many cases an infected uterus, in spite of repeated curettage, remains an infected uterus after the removal of the diseased appendages. For this reason the French school of surgeons, with practical unanimity, has adopted the practice of removing the diseased uterus with the diseased adnexa. The results have justified the practice. According to the observation of Eeed, the primary surgical recovery from this operation is more uniform and attended with fewer embarrassing incidents than that following the ablation of the appendages. The choice between panhysterectomy and supravaginal amputation in these cases rests upon no debatable ground. If the operation is undertaken because of infection of the uterus, it would be manifestly improper to leave a part of that in- fected organ in situ, particularly when its complete removal can be as ■easily and as safely effected. Reed prefers the abdominal to the vaginal section, for the reason that it places all possible complications under more complete control. Doyen admits that abdominal section is the operation of choice in the presence of large adnexal tumours and also of probable tuberculous peritonitis. Pryor, with equal frankness, acknowledges that vaginal ablation should not be attempted in the presence ol; coruplicuting intestinal lesions. In these acknowledgments 556 A TEXT-BOOK OP GYNECOLOGY are found important limitations of the vaginal method, and equally important reasons why the operation should be done by abdominal section. The frequency with which unsuspected adhesions between the tubes and the intestines are encountered, and the known impossibility of diagnosticating all, or even a majority of these cases, before explora- tory incision, constitutes sufficient reason for invading these cases from above. The remoteness, in an anatomical sense, of many of these com- plications renders impossible their detection by vaginal exploration. Eichelot, a former partisan and present friend of vaginal hysterectomy, states {Annals of Gynecology and Pediatry) that in 1 out of every 3 cases in which he did vaginal exploratory incision, he found con- ditions which rendered the other route more desirable, and that he consequently had occasion to regret his diagnostic ability, but "to- day," he adds with captivating naivete, " I no longer have any regrets, because total abdominal hysterectomy gives me complete cures."' Miller {Bulletin of the Johns Hopkins Hospital) concludes, after a care- ful bacteriological examination of 68 uteri removed by operation, that " in uncomplicated cases of hystero-myomectomy, hysterectomy for inflammatory cases or ovarian tumours, in operations for extra-uterine pregnancies, and in all such cases where the vagina and cervix were normal except probably for invasion by the gonococcus, the safest route so far as infection is concerned is the abdominal." Miller, how- ever, fails to explain why invasion by the gonococcus should be made an exception. Zweifel employs the abdominal method of complete hysterectomy, and in 65 of his cases, studied by Abel and reported in 1894, both the primary and ultimate results were uniformly satis- factory. Fritsch, Martin, and Jacobs, object to the retention of the cervix or any part of it in hysterectomy for infections involving the uterus and appendages, urging as a reason for their position, that the cervical mucosa, however carefully treated, may act as the nidus of infection, which, under such circumstances, may and frequently does invade the field of operation. Doyen's operation for infections of the Fallopian tubes consists in a vaginal hysterectomy including the removal of the Fallopian tubes and the ovaries with the uterus. The operation was first done for this purpose in 1887, although Doyen had previously adopted practically the same technique for nonsuppurative diseases of the appendages. The operation is performed by placing the patient upon her back with her knees well flexed, when the perineum is retracted and the cervix is seized with a strong forceps, one forceps being applied to each lateral lip. The cervix is now drawn down by firm traction and an incision is made in the posterior cul-de-sac by means of curved scissors, a bistoury never being employed. The peritoneum, if free, is opened by the second or third cut of the scissors, permitting the escape of a few grammes of normal peritoneal fluid. The right index finger is now introduced into the serous button-hole for the purpose of exploring the posterior surface of the uterus and that of the append- TREATMENT OP INFECTIONS OF THE FALLOPIAN TUBES 557 ages. If adhesions are found to exist in a moderate degree, they are broken up so far as they can be reached. This preliminary explora- tory incision is insisted upon as an essential part of the technique, and as the means by which it is to be determined whether to conclude the operation by the vaginal route or to make an abdominal section. The condition of the proximal serous surfaces, the fundus of the uterus, the sacto-salpinx if it exists, and the ovaries, may thus be readily explored. If the cul-de-sac is obliterated by inflammatory adhesions, the latter may be broken up by passing the finger with its palmar surface to the uterus. The exploration of the true pelvis being com- pleted, and fluid accumulations being evacuated, it is easy to determine whether or not to complete the operation. The radical operation being decided upon, the cervix is drawn downward and backward, a short- bladed retractor is introduced anteriorly, and the circum-cervical in- cision is completed with the scissors. The bladder is separated with the right index finger as high and as far to either side as possible. The uterus is then isolated before and behind from any neighbouring organs to which it may be attached. The neck is drawn down near the vulva, when, with scissors, the anterior wall is split from the cervix to the anterior peritoneal cul-de-sac. This now comes into view and is freely divided, after which the median semisection is carried to the fundus of the uterus. At this stage a loop of the intestine, of the omentum or the sigmoid, or sometimes of the vermiform appendix, may be found adherent to the uterus, or may be drawn down beneath the retractor. If this is found to be the case, the isolation of the fundus of the uterus is easily made under vision. The body of the uterus is easily everted, the cervix hanging over the fourchette. The appendages on both sides are now explored with the index finger and their extirpation can be undertaken, beginning upon either side, at the choice of the operator. It is well to begin by utilizing the index finger to break down any remaining adhesions, after which the tube and ovary may be readily drawn down by moderate traction, after being seized by the index and little fingers. If there are serous cysts, or if the purulent accumulations are too large, it is easy to evacuate them in the course of the manoeuvres. It is exceptional when the extraction of the adnexa by this manipulation is not complete. A clamp is then applied above and below to each broad ligament; a smaller clamp being applied outside each larger clamp, to prevent the retraction of the pedicle. Care should be taken, in applying the small forceps, to seize the uterine and ovarian vessels respectively. Doyen removes the large clamps at the end of four hours and the smaller ones after ten hours. The sterilized gauze with which the vagina is packed up to the peri- toneum, is permitted to remain in situ until the third or fourth day. Beginning on the fifth day, unless sooner indicated, vaginal injec- tions are practised to the extent of five or six every twenty-four hours. Modifications of Doyen's operation have been adopted by various operators. Pean commenced the operation by isolating the cervix from 558 A TEXT-BOOK OP GYNECOLOGY the vaginal mucosa and by applying hemostatic forceps to the uterine arteries on each side. He divided the cervix bilaterally, thus forming an anterior and a posterior flap; these were then seized by a fresh grip of the volsella, by which progressive traction was exercised upon the uterus. As the organ was dragged down, the lateral tissues were seized by hemostatic forceps and the lateral incisions of the uterine wall were carried step by step to the fundus. The obvious objection to this method is the absence of the preliminary exploration practised by Doyen, and the use of a large number of useless clamps to encumber the field of operation and to render difficult that which ought to be easily accomplished. Pryor, who has done more than any one man to introduce the vaginal method of operation in America, has adopted several important innovations. He utilizes the procedure of Landau Fig. 238. — Pryor " has invented and employs a very valuable traction forceps." — Reed. in making complete semisection of the uterus — i. e., dividing not only the anterior wall, as does Doyen, but the posterior wall also. He has invented and employs a very valuable intrauterine traction forceps (Pig. 338). Por splitting the uterus, he uses large curved grooved directors, one being passed above and behind the uterus anteriorly, and another posteriorly, care being taken that no fold of intestine or of omentum is caught between this director and the uterus. A probe-pointed, slightly curved bistoury is now used for dividing the uterus, the blunt point following the groove in the directors. First, one half of the uterus with its adnexa is drawn down, and the broad ligaments are secured by clamps, in the application of which great care is exercised. One clamp is applied to the upper margin of the broad ligament, and is locked with its point embracing about the upper half of the ligament, care being taken that the ovarian artery is included in its grip; the other forceps is applied to the lower half of the broad ligament, care being taken that the uterine artery is embraced within its grip. In this way the broad ligament folds upon itseM without injury. The pelvis is now packed with sterilized gauze pads secured by strings with which to facilitate their removal. Le Bee ligates the pedicles and draws TREATMENT OP INFECTIONS OP THE FALLOPIAN TUBES 559 them down into the vagina; and^ in cases in which there is no probable remaining infection of the pelvic cavity, the ends of the broad liga- ments are drawn together on the median line, thus closing the peri- toneal cavity. The indications and limitations of Doyen's operation should be understood. The raison d'etre of the operation is the fact that the results following ablation of the appendages are not always satisfactory. This depends upon permanent changes in the muscularis of the uterus and in its lining membrane, causing the organ to be persistently painful after the removal of the diseased adnexa. In the presence of acute streptococcous infection of the uterus and the Fallopian tubes, the indi- cations for complete ablation are positive; while in the presence of long- standing chronic infection of both the uterus and the tubes the indica- tions are almost equally strong. In many cases belonging to the latter class, the uterus not only remains painful, but is a persistent fons et origo of a purulent discharge which can not be controlled even by repeated curettage. The result is a failure to restore the patient to health. The preservation of the now functionally useless womb is no argument against the operation. The procedure, however, has its limitations. Eichelot, while personally preferring vaginal hysterec- tomy, recognises its limitations and practises abdominal panhysterec- tomy. Doyen says that abdominal section is indicated in the presence of large tumours of the adnexa and in the presence of probable tuber- culous peritonitis. Pryor concludes that vaginal ablation should not be attempted through a vagina so narrow as to necessitate incision of the perineum, as practised by Segond. He also states that, in the presence of complicating intestinal lesions, the latter are to be recog- nised as the principal indication for intervention, which under these circumstances, should be done exclusively by abdominal section. He fails to state, however, just how these complications may always be recognised. The personal preference of the operator, and his familiar- ity with a given technique, must always be recognised, however, as a cogent reason for its employment. CHAPTER XXXVI MALFORMATIONS AND DISPLACEMENTS OF THE OVARIES Malformations: Absence; rudimentary development; accessory ovaries; coexist- ence of ovaries and testicles— Displacements : Descensus ; prolapsus ; hernia. Malformations of the Ovaries. — Since the ovary, like the testicle, begins its development at a higher level in the abdomino-pelvic cavity than that which it iTltimately occupies, cases occur in which its descent has been arrested, and in which it is found, in the adult, above the plane of the pelvic brim. Since, further, the ovary, unlike the testicle, does not normally pass into the inguinal canal, it must be counted as a displacement when it is met with in that canal, or beyond it in the substance of the labium majus. The ovary, also, is liable to malforma- tions by defect and by excess. Absence of the Ovary. — Complete absence of both ovaries in an individual furnished with a uterus and external genital organs of the female type, must be regarded as an almost undemonstrated occurrence. For its demonstration, it would be necessary to examine post mortem, not only the pelvic cavity, but also, and with great thoroughness, the abdominal cavity as well. Its occasional occurrence in grossly de- formed foetuses is, however, beyond doubt. The absence of one ovary is not so uncommon, and, when met with, is usually associated with defect of the corresponding Miillerian duct (absence of the Fallopian tube, uterus unicornis, and unilateral vagina), and sometimes with ab- sence of the corresponding kidney (as in the case reported by Dela- geniere, Progres medical, 2. s., vol. xx, p. 256, 1894). Rudimentary State of the Ovary. — Although actual absence of the ovaries may be one of the extreme rarities of teratology, functional absence (i. e., their rudimentary state) is a well-established and not very uncommon maldevelopment. The glands may be so ill-developed, and may show such an approximation in their microscopical characters to the appearances seen in the earliest period in intrauterine life, that it may be difficult to decide from their examination alone whether they are ovaries or testicles. In form they may resemble the foetal or in- fantile type, and they may be associated with the foetal, the infantile, or the bicornate uterus. Further, they may coexist with other an- omalies such as rudimentary tubes, stenosis of the aorta, and hypo- plasia of more distant organs. Eudimentary development is also often combined with congenital displacement, which is indeed itself a form 560 MALFORMATIONS AND DISPLACEMENTS OP THE OVARIES 561 of rudimentary development. If one ovary alone is in a rudimentary state^ the anomaly may not appreciably influence the reproductive life- history of the individual in whom it exists; but if both glands are imperfect, the menstrual flow is either entirely absent, or is imperfectly established, there is defective hirsute development on the mons veneris, there is absolute sterility, and there is a condition of general infantil- ism with or without chlorosis and vascular hypoplasia. Cases have, however, been put on record, in which the rudimentary state of the ovaries has been associated with a normal development of the uterus and with all the signs of general bodily and mental vigour, and even with indications of sexual desire. The diagnosis of the anomalous con- dition of the genital glands may be made provisionally from a con- sideration of the symptoms, but with certainty only by means of a laparotomy. Manifestly, if it exists in association with rudimentary development of the uterus, it will be of little use to spend time and energy in therapeutical efforts directed against the latter organ. Where acute menstrual sufferings and marked nervous phenomena of the nature of epilepsy and insanity exist, it may be well to consider the question of removal of the rudimentary ovaries; but it by no means follows that the nervous manifestations will cease, for they can not always be regarded as consequences of the ovarian defect; indeed, they and the defect may quite possibly be the results of a common cause. Rudimentary ovaries may be due to ar- rested development during the embry- onic period of intra- uterine life, or to peritonitis during the fcetal epoch, or to ovaritis from the supervention of one of the exanthemata in childhood. Accessory Ova - ries. — With the ex- ception of the case of third ovary de- scribed by Winckel (Lehrhuch, p. 595, 1886), no genuine example of duplica- tion of the female genital gland has been put on record, and even Winckel's case is in the opinion of Nagel (in Veit's Ilandbuch der Gyniikolof/ie, Bd. i, p. 562, 1897) open to doubt by reason of the presence of gland ducts in the supposed ovarian body. On the other hand, accessory ovaries, or, as it is more cori-ect, perhaps, to name them, " con- 37 Fig. 239. — "'Constricted ovaries' are much less rare." (Der- moid cyst in constricted portion.) — Ballantyne (page 562). 562 A TEXT-BOOK OF GYNECOLOGY stricted ovaries " (Fig. 239)^ are much less rare. One such ovarian frag- ment was seen by Ballantyne and Williams in a series of 61 consecutive autopsies on females dying in the Edinburgh Eoyal Infirmary; it was as large as a j^ea and was made up of ovarian stroma with Graafian follicles; it was attached to the anterior border of the right ovary by a stalk consisting jjartly of fibrous tissue with a covering of low cubical epithelium, and partly of solid colunms of epithelial cells inclosed in the fibrous tissue; and it showed a cicatrix pointing to the dehiscence of a Graafian follicle at some time in the life of the indi- vidual. As many as three accessory ovaries have been found in one case, and an ovary has been noted divided into two almost equal parts. It is supposed that the constriction of the ovarian substance is pro- duced by foetal peritonitis. Clinically, accessory ovaries are of im- portance in explaining the want of success which sometimes follows removal of the ovaries performed in order to induce a premature menopause; they also offer an explanation of the occurrence of preg- nancy after a double ovariotomy, and of the jDresence of three (or more) separate ovarian cystomata. Coexistence of Ovaries and Testicles in the Same Individual. — The presence of one ovary and one testicle or of two ovaries and two testicles in the same individual, constitutes the anomalous condition described as true hermaphroditism. Of the hilateral form (that in which an ovary and testis are present upon both sides of the body), no abso- lutely conclusive example in the human subject has yet been recorded; the two-months' old, premature, and otherwise malformed infant de- scribed by Heppner (Archiv fiir Anaiomie, Physiologie, unci wissen- scliaftliche Medicin, p. 679, 1870) had a rudimentary uterus and a vagina, and, on both sides, a normal ovary, parovarium, and tube, and near to each ovary was a body resembling a testis and containing tubules running toward the hilum; but whether the last-named bodies were really testicles, is a hard question to settle, especially as the drawings are unsatisfactory. Lateral hermaphroditism, which may be defined as the presence of an ovary on one side and a testis on the other, has been met with in a few cases, of which those reported by Obolonsky (Zeifschrift fiir HeiTkunde, vol. ix, p. 211, 1888) and Schmorl (Archiv fiir patliologisclie Anatomie und Physiologie, etc., vol. cxiii, p. 229, 1888) are the most clearly established. In SchmorPs patient, an individual twenty-two years of age, there was hypospadias, which was successfuly operated upon; a swelling appeared in the groin, which was regarded as a degenerate testis and was excised, but death occurred. At the autopsy, it was found that the body in the left groin was an ovary, there was a uterus bicornis, and, on the right side in the scrotum was a testis with a rudimentary epididymis. Blacker and Lawrence {Transactions of the Obstetrical Society of London, vol. xxxviii, p. 265, 1896) have described what is apjDarently the only genuine case of unilat- eral hermaphroditism (ovary or testis on one side, with ovary and testis on the other) in the human subject. The case was that of a foetus, other- MALFORMATIONS AND DISPLACEMENTS OF THE OVARIES 563 wise well formed^ in which was found a uterus iinicornis, a normal ovary and tube on the right side, and on the left side an ovo-testis, with a vas deferens and epididymis. The left gland (ovo-testis) in one part showed cell columns, cell nests, and Graafian follicles with a large quantity of stroma (ovarian portion); and in a second part ex- hibited an abundant stroma, with definite tubules filled with cells, and forming at the hilum a retelike structure (testicular portion). It may, therefore, be accepted that the occurrence of what may be termed anatomic hermaphroditism in the human subject has been demonstrated — that is to say, in one individual genital glands have been found, one of which had a structure which could be justly called ovarian, while the other showed appearances warranting the conclusion that it was testicular in nature. No case, however, has yet been met with in which functional hermaphroditism was present — ^that is to say, no individual has ever been known to possess two kinds of genital glands both showing functional activity. It is extremely doubtful whether any such association ever will be demonstrated. Displacements of the ovaries are of frequent occurrence. They may exist in any degree from a slight descensus to a complete prolapsus, or even a hernia. The anatomical connections and relations of the ovary render it difficult to determine the precise normal locus of the organ; attached, as it is, by the ovarian ligament, and resting, as it does, on the fold of the broad ligament, it enjoys normally a considerable range of mobility. This seems to be a wise provision of Nature whereby the sensitive organ is enabled to evade what would otherwise be painful pressure from neighbouring structures, such as the uterus, the caecum, the sigmoid, and even the overloaded bladder. The ligamentum ovarii proprium is firm and round, consisting of fibro-muscular elements, is covered by peritoneum, has a length of about 2.6 centimetres, and is essentially inelastic; while the duplicatures of peritoneum, which comprise the remaining suspensory apparatus of the ovary and permit that organ to ascend with the fundus uteri during pregnancy, are highly elastic. It is to be seen, therefore, that, to an important extent, the position of the uterus determines the position of the ovary. The ovary moves with the uterus and, to some extent, independ- ently of it. Descensus and Prolapsus. — ^When these variations of position occur, however, they do not involve the establishment of either traction or pressure upon the organ whereby its circulation becomes mechanically disturbed, nor is the ovary prevented from returning within what may be recognised as its normal bounds and limits. There are cases, however, in wbich the organ is forced into a distinctly abnormal posi- tion. Thus, it is occasionally found posterior to the uterus and riding upon the utero-sacral fold of the peritoneum; in other instances it gravitates into the cul-de-sac, often becoming adherent (Fig. 240); in a few cases it has been found adherent between the uterus and 564 A TEXT-BOOK OF GYNECOLOGY the bladder^, while in still other cases it has been found adherent to the intestines and drawn by them well above the brim of the pelvis. Uterine fibromata are frequent causes of ovarian displacement, the organ often becoming diseased in consequence of repeated trau- matisms inflicted by the neoplasm. The symptoms of pro- lapsus uteri include pain, which is generally re- ferred to the normal locus of the organ with- out reference to its dis- placed position; and, generally, nervous re- flexes of the most vague and indefinite character, with a tendency to in- crease in complexity and seriousness. The diag- nosis, however, must rest upon careful physical ex- ploration, under anses- thesia if necessary. The treatment should be addressed primarily to any recognised causal condition; thus, in the presence of a retro-devia- tion of the uterus, that condition is to be reme- died before attention is given to the displace- ment of the ovary. If the cure of the causal condition does not re- sult in relief of the remaining symptom and in restitution of the ovary to its normal position, surgical treatment should be addressed to the ovary itself. It may be stated as a rule to which there are but few exceptions, that an ovary which has acquired the habit of descensus can be made to remain in its normal position only by means of surgical fixation. This may be done in many cases by short- ening the round ligament by Alexander's, or preferably by Mann's, method. If the latter oi)eration is selected, a suture may easily be passed through the utero-ovarian ligament, by which the ovary may be anchored in its normal position. The ovary itself should not be injured, even in a surgical way, unless it is the seat of disease. Hernia of the ovary is of occasional occurrence; it may exist at birth, or it may develop in old age; and it generally consists in a descent of the organ through the canal of ISTuck, which persists in Fig. 24(J. — •' ... It gravitates into the cul-de-sac, often becoming adherent." — Reed (page 563). MALFORMATIONS AND DISPLACEMENTS OP THE OVARIES 565 many cases. It is encountered clinically as an inguinal hernia. Men- ciere lias reported 4 cases of hernia of the ovary occurring in children and has been able to find 7 others on record. All 11 were inguinal, 9 were on the left, and 2 on the right side, and in one instance the uterus, as well as both tubes and ovaries, lay in the sac. Browne, after a careful study of hernia of the ovary, concluded that the condition was of more frequent occurrence than was gener- ally supposed. He attributes congenital hernia of the ovary chiefly to arrest of development during intrauterine life; and finds that it is always inguinal, often double, and when single, generally on the left side. The formation of this condition is favoured by the persist- ence of the canal of ISTuck and by the size and shape of the ovary, which is at first a long flat body with its apex pointing toward the canal. The fact that, at birth, the ovaries are situated above the ilio- pectineal line, and descend during the first few months into the true pelvis, is also recognised as a contributory causal circumstance. Hernia of the ovary is generally associated with corresponding descent of the Fallopian tubes, and, as in Menciere's case, the uterus, too, may be found in the sac. Acquired hernia, on the other hand, is not always inguinal, but may occur through any ordinary hernial opening. The condition generally occurs with pre-existing intestinal or omental hernia. The condition is generally unilateral, occurring more frequently on the right side. Labour and the postparturient re- laxation of the tissues are recognised as the chief causes. The symptoms of ovarian hernia may be confusing from the fact that omentum or intestine may be present in the sac. In the con- genital form, this complication is less likely to occur. In such cases, the hernia exists as a small painful nodule, lying at the orifice of the inguinal canal. In consequence of the contraction of the tissues after the descent of the organ, the hernia is generally irreducible, any effort to push the tumour back being the cause of extreme and depressing pain, which may produce symptoms of shock. The absence of crepitus in the tumour, and of the usual reflex intestinal symptoms, indicates that the bowel is not involved in the protrusion. The tumour may, however, be the seat of important changes, induced either by strangula- tion, or by organic degeneration of the ovary. In the acquired form of hernia, the intestine and omentum are more liable to be found in the hernial sac, which, as already intimated, does not always protrude through the inguinal canal. One of the most perplexing forms of hernia of the ovary is that in which the protrusion occurs through the obturator canal. Von Eogner Gusenthal describes a case in a patient sixty-six years old. There were symptoms of strangulation, with pain and indistinct gurgling, but no distinct tumour, in the right groin; femoral hernia was diagnosticated. On operation, the crural canal was clear, but a bulging was seen under the pectineus muscle. The muscle was divided and the sac of the hernia, in a gangrenous condi- 566 A TEXT-BOOK OP GYNECOLOGY tion, bulged forward. This contained the right ovary and tube, and a coil of intestine, all gangrenous. The treatment of these cases consists in incising the hernial sac and extirpating the ovary, which will generally be found to have undergone such morbid changes as to render its return to the peritoneal cavity unjustifiable. In infantile cases, however, the organ may be saved in many instances. In 11 cases collected by Menciere, cure resulted in 10; in 8 by radical operation, in 2 by reduction and bandaging. CHAPTEE XXXVII INFECTIONS AND INFLAMMATIONS OF THE OVARIES Classification: Hypersemia; acute inflammation; chronic inflammation — Bacteria of tlie ovaries — Individual infections: Streptococcous infection; gonocoeeous infection ; pneumocoecous infection ; Bacillus eoli communis infection ; un- usual bacterial infections ; tuberculosis. The classification and description of the inflammatory lesions of the ovary presents many difficulties, because, first, of a confusing nomen- clature; and, secondly, the ovary can scarcely be said to stand alone in its pathologic lesions, since its close association with the other organs ■of the pelvis, anatomically and physiologically, makes its lesions in a vast majority of cases only a part of a pathological picture. A primary statement in this chapter must correspond with that on inflammatory lesions of the Fallopian tubes, to the effect that all in- flammatory lesions of the ovary are due to bacterial infections. Only after such a dogmatic and sweeping statement may we qualify it by saying that malpositions, irritations, strangulations or new growths, may produce hypersemias and subsequent changes in the tissues, which are very closely related to those changes brought about by a long- continued action of the less virulent germs. In other words, the class containing the cases of greatest number and clinical importance is the bacterial, and the minor class is that which depends upon mechanical causes. Hyperaemia of the ovary is a physiologic condition during men- struation (see Menstruation), sexual excitement, and pregnancy. In this connection, however, we consider only those hypergemias which overstep the physiologic limitations. This is exemplified, for example, in a case in which there exists a malposition of the ovary with twist of the mesovarium, thus interfering with the venous circulation; it is also shown in the case of prostitutes who are subjected to excessive natural or unnatural sexual excitement; also, inflammation in other pelvic organs and pressure from neighbouring tumours and pessaries, are among the recognised causes of this persistent excess of blood in the ovary. Bacterial toxines, or the germs themselves, may induce a hyperaemia from which the essential phenomena of inflammation are absent. A hypera;Tiii;i of iliis class is easily transformed into an active infhirnmation tlirongli llu^ influence of infection by even the less 5G7 568 ' A TEXT-BOOK OF GYNECOLOGY virulent bacteria. The excessive blood supply may continue to in- crease, until, by sheer force of mechanical pressure, there occurs transu- dation of the liquor sanguinis and migration of the leucocytes. A hyperaemia may thus become transformed into an inflammation. The organization of the transuded elements constitutes a true hyperplasia, while, as a result of the persistent excessive nutrient supply, pre-exist- ing histologic elements may become enlarged, thus establishing a true hyiDertrophy. In any event, the change in the stroma is such as to render it unyielding to the premenstrual blood pressure, this condition inducing extreme pain during the few days preceding the onset of the monthly flow. A passive hypersemia of the character herein described exhibits, on microscopic examination, dilated, normal vessels, well filled with blood, the walls of the blood vessels thickened, and some- times thrown into folds which project into the lumen. In some cases, the walls of the vessels have been found to be the seat of hyaline degeneration. In other cases, however, marked perivascular changes are noted; the stroma of the ovary may show a round-celled infiltra- tion, and, as already indicated, a decided hyperplasia. The walls of the follicles may yield to the blood pressure, the fol- licles themselves becoming the seat of slight hemorrhages, and their walls, when cut and mounted, giving the appearance of minute punc- tate hemorrhages. The hypertrophic changes in the stroma itself may interfere with the spontaneous rupture of the follicles, which, as a result, undergo degeneration. The most frequent consequence of hyperemia of the ovary is that form of hemorrhage known as hema- toma. (See Hematoma of the Ovary.) The prognosis of hyperemia of the ovary is favourable in its early stages and before it has resulted in marked trophic changes in the organ itself. When these changes have occurred, however, the condi- tion becomes essentially progressive. The treatment in the early stages may be said to be confined to efforts to remove the causative condition; this once accomplished, the hypergemia itself will subside. In the later stages, however, when the ovary has become the seat of hyperplastic and hypertrophic changes, and, particularly, when the follicles have undergone degeneration, the condition is irremediable by any other means than ablation of the organ. (See Oophorectomy.) Acute inflammation of the ovary manifesting, in all of their inten- sity, the phenomena of vascular engorgement, circulatory stasis, tissue infiltration, and the migration of corpuscles, and resulting in sup- puration, always depends upon infection. The same may be said of those inflammations of the ovaries that do not result in the destruction of tissue — for it is to be remembered that ovarian tissue, like other tissues, has the power within certain limits of resisting invasion by micro-organisms, although the defensive effort induced by the presence of the germs may be productive of all the essential phenomena, short of suppuration itself. The resulting changes in the tissues may be more or less permanent, manifesting themselves in increased density INFECTIONS AND INFLAMMATIONS OF THE OVARIES 509 of the stroma, in permanent enlargement of previously distended blood vessels, and in organization of the inflammatory products. Acute oophoritis is usually the result of streptocoecous infection. The ovary is swollen, soft, and of elastic consistence, the blood vessels are strongly injected, the stroma is infiltrated by serum and pus, and the surface of the organ is the seat of a general peritonitis which is accompanied by a deposit of fibrin, a pseudomembrane, and pus. The stroma is filled by minute abscesses, and is indurated; the undeveloped follicles are highly infiltrated by small round cells, and the more mature follicles lose their epithelium and are transformed into pus sacs. The sheaths of the blood vessels are infiltrated by small round cells. This condition may continue, to the complete destruction of the ovarian stroma by a fusion of abscesses; or, with the subsidence of the inflammation, the ovary may return to its normal size, but be left indurated and bound down by adhesions, and rarely retaining a functional value. A corpus luteum is apt to serve as a focus of especial activity and early abscess formation. The gonorrhoeal infections may undoubtedly produce an acute oophoritis (Wertheim, Menge) but the lesions are usually confined to the surface of the ovary. Abundant adhesions are formed. The follicular contents become turbid and almost purulent, or they may be blood- tinged. There is an infiltration and thickening of the stroma by small round cells — a lesion which has a considerable importance in the ex- planation of follicular cyst the result of a toughened follicular capsule. Chronic inflammation of the ovarian tissue manifests itself pri- marily in a proliferative activity in the stroma, 'which leads to an in- filtration by small round cells and the deposit of new connective tissue. The blood vessels will be somewhat dilated and their sheaths infil- trated by small round cells. The parenchyma or G-raafian follicle will be unchanged in the early forms, but the gradually increasing deposit of firm fibrous tissue in both the connective tissue and muscular elements of the stroma, presses on, and will cut off, more and more, the nutrition of the follicle, to a degree of destruction which may range from the mildest interference to a complete obliteration of all specific ovarian elements. This connective-tissue change may, however, be limited to the surface of the organ, and, even though the Graafian follicle persists, it is rendered functionless by the complete encasing shell of the albuginea. Such ovaries may be larger than normal, cystic, and presenting a smooth surface; or the interstitial connective tissue may contract after its formation to give an organ which — smaller than usual- — has a roughened and distorted surface, and is in reality a dense, new, interstitial connective-tissue ball. In the latter type of inflam- mation, the Graafian follicle is usually entirely absent, and the arteries are tortuous and have much thickened walls. In those types which present enlargement, many of the Graafian follicles are transformed into cysts of varying size and the vessels are widely dilated, especially the veins. 570 ^ TEXT-BOOK OF GYNECOLOGY Chronic oophoritis is usually preceded by an acute inflammation, but may gradually develop as the result of long-continued mechanical irritation or obstruction in the blood flow. The morbid changes present a variety which has led to the designation of several classes of chronic ooi^horitis; but the divisions scarcely seem to be justified on a com- 23reliensive study of chronic inflammations of this organ. Bacteria of the Ovaries. — It can hardly be said that, as yet, there is any bacteriology of the ovaries as distinct from the facts and considerations already brought forward in reference to the Fallopian tubes. Yet the mode of entrance and the resulting pathologic lesions vary with the variety of germ j)resent, to a degree that makes a rather detailed study of the bacteria concerned in ovarian infections necessary. The anatomic structure of the ovary, the peculiar physiologic activity as expressed in a periodic congestion and the rupture of a Graafian follicle, the liability to the development of new growth, and the tendency to torsion of the ovarian pedicle, lay the ovary open to invasion by bacteria in a way from which even the tubes are to some extent free. Furthermore, we must class, as predisposing causes, almost every inflammatory condition of the female genital tract, a statement given its greatest force by a mere reference to the ex- treme frequency of the tubo-ovarian abscess in gynecological prac- tice, which shows that the tubes and ovaries are often subject to the same bacterial ravages. This fact is further borne out by the statistics of Martin, which show that out of 4,948 polyclinic ovarian patients, 1,464 sufl:ered from subacute or chronic endometritis, and 834 from chronic metritis. Yet another causative factor is found in the fact that when new growths of the ovary, belonging to the class of cystoma, undergo changes such as result from torsion of the pedicle, they are liable to the inroads of the Bacillus coli communis and of saprogenic saprophytes, from adhesion to the intestines. Con- sidering our theories of invasion, it must be held to be a remarkable thing that the occurrence of abscess in a cystic ovarian tumour is so rare, yet, follicular abscess the result of bacterial infection is much more common. This fact may be due to the open wound produced by the rupture of a follicle giving an easy entrance into the ovarian tissue to the pathogenic organism, thus forming a point of departure for further inroads. The modes of entrance of bacteria to the ovary are, in general, iden- tical with those already discussed under the head of infections of the Fallopian tube. These channels are: First, the lymphatics and blood vessels which establish a direct line of transmission from the external genitalia, and the mucosa of the vagina and uterus, to the ovary. (See Tuberculosis of the Fallopian Tubes.) This is specified as the channel of preference for all bacteria except the gonococcus. Secondly: The female genital tube connects the surface of the ovary with the external air, and any infection may traverse this distance from the surface of the body (practically from the vagina) to the surface of the ovary, to INFECTIONS AND INFLAMMATIONS OF THE OVARIES 571 cause an inflammation. This is siDecified as the channel of preference for the gonococcus. Thirdly: It has been clearly demonstrated that bacteria may pass through the wall of the intestine (especially at a point of ulceration), gravitate to the pelvis, and cause infection of the ovary (Grrawitz, Stoecklin), or that bacteria may pass from the intestines through adhesions which bind them to it. This will be specified as the channel through which the Bacillus coli communis usually passes. A study of the specific characteristics of each type of infection, and their relation to each other, will be best carried out by considering separately the most important of the bacteria that may cause ovarian disease. Yet, this treatment of the subject is only possible after a very positive statement already made (see Fallopian Tubes) to the effect that every infection in the genital tract is a mixed infection. Individual Infections of the Ovaries. — Streptococcons infection of the ovaries is of frequent occurrence. These bacteria reach the ovaries through the avenues of the lymphatics and blood vessels, by which they are distributed directly to the parenchjana and inaugurate their activities by the development of small miliary abscesses. A section of ovarian stroma will show a small abscess cavity the pus of which abounds in streptococci, and the surrounding stroma will be studded with migrated leucocytes (Fig. 341). Sooner or later, small segments of ovarian tissue become de- tached and are found in the pus of the gradually enlarging abscess cavity. Such detached segments of tissue will show it to be studded with strepto- cocci (Fig. 242). These abscesses may develop at any point from the cen- tre to the circumference of the ovary, even in its wall. They form irregu- lar cavities, and are con- sequently liable to be mistaken for purulent cysts. In many cases, however, there is no dif- ficulty in establishing their real character. Sev- eral foci of suppuration may be simultaneously established, resulting in the coalescence of their cavities and the consequent development of one relatively large abscess. An ovary that is the seat of this form of infection is very liable to become adherent to its neighbouring Fallopian tube. A remnant of necrotic partition may be observed in some cases between coalescing pus cavities (Fig. 243). The suppurat- Fig. 241.- -" A small abscess cavity, the pus of which abounds in streptococci." — Keed. 572 A TEXT-BOOK OP GYNECOLOGY m ing cavity in the ovary, however, is generally separated from the purulent accumulation within the tube by a barrier of formed tissue, which may itself be the field of more or less diffuse infection by the streptococcus, and luelt down to form a wide communication be- tween the tubal and ovarian ab- scess cavity. A streptococcous infection of the ovary may, how- ever, result in abscess of that organ to its complete destruction, without the formation of pus in the tubes, and with the tissue between the two entirely intact (Fig. 244). In studying the pathology of infection of the ovaries by the streptococcus, it is important to bear in mind the antecedent chain of morbid events. The in- fection having occurred primarily through some traumatism or abrasion in the uterus, generally in connection with parturition or the puerperium, the micro-organ- isms may manifest their activity in the uterine muscularis; or they may find their way through the lymphatics into the surrounding cellular tis- sue; or they may continue their journey and invade the adnexa. The invasion may be arrested at any one of these three stages, or a given case '•.2-- M Fig. 242. — " Detached segments of tissue will show it to be studded with streptococci." — Reed (page 571). " -■;;?;r:?4 ;/\>v-' :':;S>;-.V-.^i:!7,,^ v^^->^;^ ■ V^f^ -v.- :'■•>> >•'; :.:j^ {:^\;-/-:>i^i;<^ .;:■; l'-'^^')^" ■^i^ Fig. 243. — " A remnant of necrotic tissue may he observed in some cases between coalesci pus cavities." — Keed (page 571). ng INFECTIONS AND INFLAMMATIONS OF THE OVARIES 573 may exemplify all three of the stages, and this, occasionally, with such rapidity, that they may appear to be coincident. The virulence of the micro-organisms and the susceptibility of the patient are the two factors which determine the clinical conduct of the infection at the various stages of its invasion. Thus, an infection of the uterine wall may be ar- rested, either spontane- ously or by treatment, and resolution may fol- low; or active suppura- tion may develop. A similar infection of the circumuterine tissues may have a similarly variable course and the same may be true of the appendages. The inter- val between either of these progressive stages of invasion may be of variable length. It thus happens that the strepto- coccous infection of the uterine appendages may develop remotely in point of time from the original infection; or it may be practically a si- multaneous occurrence. In any event, the history of the case and the revelations of histological examination will alike shoAV that the in- vasion has taken place through one or the other, or both, of the circula- tory media. It is entirely apparent that the ovarian lesion is only a part of the clinical picture presented by such a streptococcous infection. The lesions in the uterus and the Fallopian tubes have been previously described; yet it seems desirable to call attention at this point to the severe " perioophoritis " that occurs in these cases. A variable degree of peritonitis is always set up which results in the destruction of the peritoneum, in large deposits of fibrin, and in adhesions that bind down the ovary to surrounding organs, until it is so completely covered in, that its liberation becomes one of the most difficult operations of the surgeon, and can only be accomplished by actual dissection, which leaves a raw cavity. In fact, the symptoms from which the patient suffers after the subsidence of a pelvic peritonitis, are explained almost wholly by this perioophoritis with the accompanying adhesions. In- deed, tliis part of the ovarian lesion has led to a distinct classification Fig. 244. — " A streptococcous infection of the ovary may result m abscess of that organ to its complete de- struction." — Eeed (page 572). 574 A TEXT-BOOK OF GYNECOLOGY by some authors as " adherent and bound-down ovaries," and this diag- nosis will be found in many case books as the indication for operation. Gonococcous infection of the ovaries is of relatively the most frequent occurrence. The iniiammation in these cases manifests itself primarily upon the surface of the organ. This is accounted for by the fact that, in at least a vast majority of cases if not in all, infec- tion of the upi^er genitalia by the gonococcus occurs by the progressive invasion of contiguous mucous surfaces. In this wa}^, the infection travels from the vagina through the endometrium, through the tubal mucosa, until it reaches the surface of the ovary. Here, it becomes the exciting cause of an inflammation which is manifested more distinctly in the enveloj)ing tunic (perioophoritis), than in the deep stroma (par- enchymatous oophoritis). Yet, a moment^s reflection upon the anat- omy will show that the division of the inflammation of that organ into superficial and interstitial can not be justified, as neither the cellular nor the circulator}^ arrangement of the ovary will permit a definite limitation of the iniiammation to either one or the other structure. It is a fact of ordinary observation, however, stoutly affirmed by Reymond, that the gonococcus attacks the surface of the ovary and is never demonstrable in the pus of an ovarian abscess; nor has he ever seen the cyst of an ovary become purulent in the presence, or in consequence, of gonorrhoeal salpingitis. He has, however, ob- served as the result of gonorrhoeal contamination of the surface of the ovary, peripheral sclerosis and the formation of numerous follicular cysts beneath the sclerotic envelope. It is precisely the development of this sclerosis in the peripheral layer of the ovary that prevents the rupture, and causes the subsequent degeneration, of the gradually maturing Graafian follicles. (See Small Cysts of the Ovary.) It must be further stated, however, that even though the above represents the usual conditions, a transmission of the gonococcus by contiguity and passage through the tissues, and its transfer by the blood and lymphatic vessels, are not only possibilities, but are held by Luther and Wertheim to be frequent. A mixed infection in gonor- rhoea is, perhaps, the rule, and any reasoning concerning the course of the transfer must be qualified by this possibility. The inflammatory reaction of the neighbouring peritoneum, and the production of adhesions in a gonorrhoeal inflammation of the ovaries, will be very similar in their nature to the processes caused by the streptococcous infection, and will vary with both the intensity of primary infection and the duration of its action. Pneumococcous infection of the ovaries, although rare, is on rec- ord. Von Eosthorn, Zweifel, Frommel, and Witte, have each reported cases in which this micro-organism was demonstrated in the pus of an ovarian abscess. In each instance, it occurred independently of either pneumonia or pulmonary tuberculosis. Microscopical sections showed the abscess Avail to contain numerous pneumococci, mingled with broken-down tube wall and ovarian tissue. Both inoculation and_ INFECTIONS AND INFLAMMATIONS OF THE OVARIES 575 tube cultures yielded the pure micro-organism. It would seem that, in its manner of invasion, and in its effects upon the ovarian tissues, the |)neuniococcus differs from the streptococcus (see Pneumococcous Infection of the Fallopian Tubes) in these points, viz.: First, it may enter by way of the general circulation; secondly, there is a remark- ably severe invasion of the jjeritoneum as shown by the severe adhe- sions; thirdly, the macroscopical appearance of the pus, which is thick and very tenacious, and resembles that seen in empyema following pneumonia caused by the Micrococcus lanceolatus; and fourthly, the fatal cases of Frommel and Witte speak of a very high degree of viru- lence. Martin suggests the possibility of a diagnosis in the absence of a history of labour at term or interrupted, a gonorrhceal infection, and in the presence of an evident severe perimetritis. The Bacillus coll communis is a well-established cause of ovarian abscess in a small percentage of cases. It is a significant fact in con- nection with the mode of infection, that a colon-bacillus infection never occurs except in an ovary which has previously been adherent to the bowel. It would be rash to declare that the other channels may not serve as the means of transfer for this germ, but such has not been observed. The bacteria are found entirely in the pus and on the surface of the abscess wall. The main characteristic of such a bacterial invasion is the supervention of acute constitutional and local symptoms upon a previous pelvic inflammation. The unusual bacteria found in ovarian abscesses are actinomyces, described by Zemann; the bacillus of malignant oedema by Witte and others; the Bacillus proteus Zenkeri by Robb; and inoffensive sapro- phytic bacteria by many observers. Tuberculosis of the Ovary. — Many of the older writers, including Virchow and Rokitansky, have stated that tuberculous oophoritis is of such rare occurrence, even if it ever occurs, that its consideration is useless. At the present day, however, we know that it is a relatively frequent disease of the ovaries, that it may be either primary or second- ary, and that it deserves practical attention on the part of the gyne- cologist. As before mentioned, the order of frequency with which tuberculous disease of the female genital organs occurs in various loca- tions is, tubes, uterus, ovaries, vagina, cervix, and vulva. Schottlander has collected 153 cases of reported tuberculous oophoritis, but accepts only 30 of these, in which a microscopic examination was reported. He admits that many of those in which the microscopic examination was not made, were undoubtedly tuberculous, yet thinks they can not have a scientific value. It is only since the advent of the means for exact research, and the cultivation of routine methods of examining all material obtained from the autopsy table or the operating room, that the frequency of this condition has been demonstrated. Such methods have nuule it clear that ovaries showing no macroscopical change may yet contain nnniefous miliary tiibei'clcs (Wolff, Schottlander, Franque). 576 A TEXT-BOOK OF GYNECOLOGY The mode of infection by the tubercle bacillus is variously ex- plained by authors. Klebs believes that the tube is the usual source of infection, and that the infection is transmitted in continuity of tissue, rather than by means of the blood. Others believe that the blood is the most probable carrier of the tubercle bacilli (Mosler, Guillemain), yet Jani and Westermeyer-Jacksch have failed to find the tubercle bacil- lus in the aj)parently healthy ovaries of a series of phthisical patients, and the latter investigators obtained a positive result in only one case, by the inoculation of the peritoneum of animals by such ovaries. Schottlander believes that the peritoneum is the usual source of infec- tion, yet accepts a tubal origin, and believes that the bacteria may often enter by an abrasion in the vagina or vulva, and ascend to the ovary by way of the Ijonphatics without a lesion at the point of inoculation. Franque has directly traced such an infection from an abrasion in the vault of the vagina. A primary localization of the tubercle bacillus in the ovary is extremely rare. Jacobs has reported such a case of one- sided tuberculosis of the ovary, where the Fallopian tube showed only an interstitial inflammation and the lungs were certainly only in- volved after the operation. Cases in which the process is primary in the genital tract are not so rare (Franque, Schottlander, and others). Morbid Anatomy. — The anatomical changes characteristic of ovarian tuberculosis are the formation, in the majority of cases, of smaller or larger caseous foci, while the merely miliary form is seldom met with. Along with these changes, there is usually present in the organ an inflammatory condition of a more specific character, which results par- ticularly in an atrophying process in the follicle. The caseous masses vary in size from that of a millet seed to that of a marble, may run to- gether to form apple-sized cavities in which almost all ovarian tissue is destroyed, or, as has occurred in certain reported cases, the ovarian na- ture of the huge abscess cavity may be difficult of demonstration. Be- sides these changes, there exists a simultaneous adhesive tuberculous pelviperitonitis of varying degree. Heiberg has often found a forma- tion of small caseous foci in the dilated follicle, closely resembling a degenerated rupture follicle, yet the process seems to localize by prefer- ence in the stroma. This fact has been demonstrated as the rule in the collected cases, and has been further demonstrated by the experi- ments of Acconci, in which the injection of a pure culture of tubercle bacilli into the ovary always resulted in an interstitial deposit of tubercles, but never so when into the follicle. Schottlander has ob- served follicle tuberculosis, however, in rabbits. It is a well-established fact that a miliary tuberculosis may exist in the apparently healthy ovary of tuberculous women (Schottlander). H. J. 'V\Tiitacre has observed a perfect Graafian follicle in the midst of ovarian stroma which was in a state of complete tuberculous infiltra- tion (Fig. 245). The miliary tubercles are usually found in the super- ficial zone of the ovarian tissue, but sometimes find their way deeper, and always possess the usual characteristics of epithelioid, giant, and INFECTIONS AND INFLAMMATIONS OF THE OVARIES 577 Fig. 245. — " A perfect Graafian follicle in the midst of ovarian stroma which was in a state of complete tuberculous iuiiltratiou." — Whitacee (page 576). round-celled tubercles, but the tubercle bacilli are seldom found. Wliitacre and Wolff have noted the appearance of considerable num- bers of very large giant cells^ completely alone and apart from other tuberculous products, in the stroma of the organ (Fig. 246). Schottlander has called attention to the fact that the normal fol- licle, especially when cut just to one side of the ovum, will give rise to a collection of cells that very much resemble a miliary tubercle. The same confu- sion may also arise from an atrophied follicle. Frerichs has further stated that caseous foci in the ovary are not necessarily of tuber- culous origin. It becomes apparent that this confusing feature in the usual histological picture (Fig. 247) of tuberculosis, when associated with the extreme difficulty encountered in demonstrating the tubercle bacillus, will render even a microscopic diag- nosis difficult. The symptoms of the disease vary with the extent of the involvement both of the ovary and of the peritoneum. The miliary form of the disease will give no symptoms, while the more advanced case- ous forms may give rise to the most se- vere symptoms of pelvic abscess. The diagnosis of the condition pos- sesses a scientific rather than a practi- cal interest, since it is impossible to recog- nise the earlier I onus by any known means, and the later forms are either associated vvitJi disease of other organs, or are operated on under a 38 Fig. 240. — " Wliitacre and Wolff liavc noted the appearance of very large giant cells." — Wiiitaoke. 578 A TEXT-BOOK OF GYNECOLOGY mistaken diagnosis. Martin states that we may diagnosticate a tubercu- losis of the ovary when the tube end is not enlarged but the ovary is represented by a tumour the size of a goose's egg, which is glued to the side of the uterus and only slightly sensitive. Hegar considers the glu- ing of the tumour to the uterine ligament, as in parametritis, a character- istic feature. That mis- takes can be made, even in the microscopic exami- nation, is certain (Mad- lener), yet the appear- ance of perfectly typical miliary tubercles in some part of the structure is the rule, and the regular ar- rangement of the epithe- lial cells of a follicle with cement substance be- tween them, will usually serve to give a correct di- agnosis. Again, the pres- ence of giant cells does not remove every diffi- culty of diagnosis, since an egg follicle with a moderately thick epithe- lial layer, and filled by granular material, my resemble greatly the giant cells of tuberculosis. Yet, in giant cells, the nuclei are less regularly arranged than in a follicle, and the long axis of the nucleus is tangential in the follicle and radial in the giant cell. It becomes apparent that a thorough microscopic examination is an unavoidable necessity. Treatment. — The treatment of ovarian tuberculosis will be almost exactly that of the tubal type, and will depend upon much the same reasoning with reference to the general condition of the patient. One of the unexplained results of abdominal surgery is the almost constant recovery of cases of tuberculous peritonitis, following even exploratory incision of the abdominal cavity. These cases, even when associated with extreme ascites, appear to undergo resolution, following the open- ing and irrigation of the peritoneal cavity. Eeed has cases alive and well seven years after operation, the peritoneum at the time of opera- tion being thoroughly studded with tuberculous deposits. Fig. 247. — " The usual histological picture of tuberculo- sis." a, Graafian follicles ; f>, circumscribed collection of epithelioid cells containing bodies that appear to be giant cells ; yet this is not a miliary tubercle, but a Graafian follicle. — Whitacre (page 577). CHAPTER XXXVIII TREATMENT OF INFECTIONS OF THE OVARIES Preliminary considerations — Natural terminations — Palliative treatment — Con- servative treatment — Radical treatment: Oophorectomy, indications; unilat- eral — Effects: Primary, secondary. The treatment of infections of the ovaries can not be discussed in- telligently without taking into consideration the coincidence of similar infections of the Fallopian tubes and, frequently, of the pelvic lym- phatics. The former of these complications has already been dis- cussed (see Infections of the Fallopian Tubes), while the latter will be presented in a subsequent chapter. (See Infections of the Pelvic Lymphatics.) The ovary, however, presents special points for con- sideration when it is looked upon as the organ of ovulation, and when its unique morphology is taken into account. Its removal or complete organic destruction, when occurring on both sides, implies irremediable sterility, the exceptional cases of fecundity following oophorectomy not being worthy of consideration as exceptions. The preservation of the ovaries or of their function, in all cases in which reproduction is desirable, is, therefore, a matter for primary consideration after the preservation of the patient's life has been assured. It goes without saying, that treatment should have for its object the preservation of these organs, when this can be accomplished with safety to the patient's health or life. When surgical intervention should take place, as also its extent, must be determined by a knowledge of the natural history of the morbid changes induced by infections. The natural termination of infections of the ovaries depends largely upon the character and virulence of the preponderating micro-organism in the individual case. Streptococcous and pneumococcous infections are more dangerous to life than those depending upon the gonococcus. The primary danger to life from these infections has, probably, been exaggerated. This fact was emphasized by Chrobak {La Semaine medicale), who stated in 1893 that the statistics of the Anatomico- Pathological Institute of the General Hospital of Vienna showed that there had been but 14- deaths from inflammatory diseases of the uterine adnexa in about 42,000 cases of that affection, although Schauta thought that they were of more frequent occurrence, since he, himself, had seen 4 deaths from pyosalpinx in a single year. It is highly prob- 579 580 A TEXT-BOOK OF GYNECOLOGY able that these infections, taken as they come, if left to themselves would yield a much higher mortality than that indicated by either of these observers; but even granting this to be true, it does not follow that infection of the appendages is the uniform menace to life that is ordinarily supposed. It is unfortunate that facts are not at hand upon which a more accurate conclusion could be based, for, upon the determination of this point rests the justification or condemnation of radical intervention — particularly in the presence of acute inflamma- tions; but both Chrobak and Schauta agree that, although life is rarely compromised by these diseases, they nevertheless expose the patient to the most serious complications. These complications vary somewhat in character according to the predominating element of infection. Thus, gonococcous infection presents a different picture from that de- pending upon the streptococcus. The gonococcus, which, according to Reymond, is not found in the pus of an ovarian abscess, and which, according to all observers, is of less virulence and is shorter-lived in the peritoneal cavity than elsewhere, produces inflammation that is manifested with relatively greater virulence on the surface than in the parenchyma of the ovary. The result of such an infection is to produce an inflammatory exudate on the surface of the ovary and on the proximal peritoneal surfaces, resulting, in the majority of cases, in adhesions between the two. It also produces, first, thickening, and, subsequently, sclerosis of the in- vesting tunic. As a result of these changes there occurs follicular degeneration. (See Morbid Histology of Ovaritis.) The clinical results of these changes are very distressing and very permanent. An ovary that is studded with unruptured and degenerated follicles, the pressure of which has resulted in the atrophy and practical disappearance of the stroma of the organ, is functionally useless. An ovary which is the seat of these changes frequently presents to the sense of touch a tension greater than that which exists in the eye. It can readily be understood that terminal nerve filaments in the ovary are subjected, under such circumstances, to an agonizing pressure. As a matter of fact, this condition is the most painful with which a woman can be afflicted. The exacerbations of pain incident to the premenstrual afflux of blood and to the futile efi'orts at ovulation, are agonizing in the ex- treme. Patients thus afilicted manifest every phase of the so-called reflex neuroses, and, not infrequently, are the victims of equally dis- tressing psychoses. Hysteria, hystero-epilepsy, and their congeners, are sequela of frequent occurrence; while constipation, indigestion, self-intoxication and the ana?mias, are frequent elements of the clinical picture. Wliile this is true, it must be recognised that there are cases, relatively few, perhaps, in which there appears to be complete recovery of the organ. In streptococcous infection, however, the invasion takes place directly into the ovarian stroma, resulting in multiple coalescing abscesses and the consequent destruction of more or less of the ovary. As elsewhere pointed out, these purulent accumulations may become TREAT31ENT OF INFECTIOXS OF THE OVARIES 5S1 ven- large and may find a spontaneous outlet through the intestines, the bladder, or the pelvic wall, or directly into the peritoneal cavity. Symptomatic recovery may follow any one of the three former, but death is the usual result of the last-named complication. Suppura- tion of the ovan,- involviag a considerable destruction of the stroma, may be di-aiued, either spontaneously, or by operative intervention, leaving a certain amount of ovarian tissue which, being yet studded with primordial cells, may subserve the function of ovulation. But, unfortunately, in at least the majority of these cases, suppuration of the stroma is associated with so much inflammation of a peripheral character that adhesions residt, causing essentially the same painful and intractable conditions as have already been described as the results of gonococcous infection. When this occurs, there become established the essential underlying causes of chronic invalidism. It follows, therefore, that, viewed in the light of their natural termina- tions, even when these are the most favourable, infections of the uterus demand surgical intervention, generally of the most radical kind. It is to be hoped that the further revelations of experimental surgery may develop some means by which these organs may be either con- served, or replaced by stnictiires with functional possibilities. Palliative treatment of infections of the ovary must be considered with reference to (a) acute, and (&) chronic cases. In acute inflamma- tions of these organs, particularly when the history of the case or bac- teriological examination of it points to infection dy the gonococcus. treat- ment should be based upon full recognition of the fact that these micro-organisms in the peritoneal cavity are of diminished virulence and of short life. The inflammation which they establish may be slight or severe, according to the susceptibilities and conduct of the patient. 3?hat there are some cases that react with greater intensity than others to inflammatory influences can not be denied: while exercise, particularly if violent, is calculated to augment an inflammatory pro- cess that has become established. The indications in these cases are for rest and elimination. The patient shonld be put to bed and should be given a saline cathartic. Opium should be avoided, and anodynes, if indicated, should consist of other agents of recognised value which do not arrest peristalsis. The hot vaginal douche, with glycerine tam- pons in the interval, should be employed systematically during the first four or five days. In mild cases the symptoms will disappear promptly after free catharsis induced by the salines; but patients should be kept in bed for several days after the subsidence of the pain. Ice-packs over the groin are generally of more value than applications of the opposite extreme of temperature, and should be applied from the start. In streptococcous infection the symptoms are generally more active, constitutional intoxication being more profound. If, in a given case, the symptoms do not indicate extreme virulence, the palliative measures already indicated may be relied upon: but where there exists manifest infection of the uterus, together with implication of the 582 A TEXT-BOOK OF GYNECOLOGY pelvic lymphatics, palliative measures beyond those elsewhere discussed (see Streptococcous Infection of the Uterus) should not be relied upon. So soon as the enlargement of an ovary, with associated symptoms, indicates the presence of pus in that organ, surgical intervention is indicated. Pneumococcous infection comes under the same rule. It should be stated here that surgical treatment should not be withheld while await- ing a precise diagnosis of the character of the infection, but should be adopted at once in the demonstrated presence of pus. In chronic cases, the treatment is not addressed so much to the infection as to its consequences. As a matter of fact, in gonococcous infections, which comprise the majority of these cases, the micro-organ- isms are eliminated as active factors in the case during the acute stage. Under these circumstances, and in the absence of renewed infection, that which is generally recognised as recurrent inflammation is hyper- a?mia, induced mechanically by the action of adhesions or by the pre- menstrual wave, by the progressive accumulation of unruptured fol- licles, by engorgement of the portal circulation due to constipation, or by the traumatisms arising either from accident, or from sexual inter- course. Eest, laxatives, douches, and tampons, will generally relieve the distressing sjanptoms, the recurrence of which may, however, be counted upon in the renewed presence of the same exciting causes. The conservative treatment of infections of the ovaries has for its object the perpetuation, so far as possible, of the functions of these organs. Whether in the presence of acute or chronic inflammation, treatment should be addressed to preservation of the organs, whenever this can be done consistently with the health and life of the patient. It would seem, as an abstract proposition, that an ovary the seat of parenchymatous suppuration, should no more be extirpated than a finger, the seat of a felon, should be amputated. Unfortunately for this hypothesis, however, the morphology of the ovary is such that an inflammation, once established in its parenchyma, generally results in its functional, if not its organic destruction. (See Morbid Histology of Ovaritis.) Cases have been reported in which an ovary, the seat of suppuration, has been brought down through a vaginal incision, punctured, the pus cavity packed with gauze, and the organ returned to the pelvis, with the result of complete recovery. The fact that an organ thus inflamed must remain inflamed for a time after opera- tion, and that, during such persistence of inflammation, it is liable to develop adhesions, must stand as a barrier to the success of this treatment in any considerable number of cases. While the infection may be relieved, the consequences of the inflammation can hardly be averted. In chronic cases, in which the surgeon has to deal, not with the infection, but with its consequences, there seems to be a better prospect of restoring the organ. Eeed has repeatedly excised a cyst or cysts of the ovary, stitched up the incision, and dropped the ovary back (Fig. 348). The results of these operations have not always been TREATMENT OF INFECTIONS OF THE OVARIES 583 satisfactory, and no guarantee can be given to the patient that she will be freed from pain. On the contrary, in a series of six such cases operated upon by Reed, all the patients applied for the radical removal of the organ before the expiration of three months. Schroder, accord- ing to A. Martin, was the first to attempt to remove only the diseased portion of an ovary, leaving the appar- ently healthy part. Martin adopted this method of practice in cases of adherent appendages in which the patency of the tube could be dem- onstrated, and con- cluded (Volkmann's Sammlung Minisclier Vortrdge) that the removal of the dis- eased portions of the ovary did not affect recovery from the operation; that exci- sion of the closed or otherwise diseased portion of the tube did not affect the healing process; that women who had suf- fered such partial removal of the ad- nexa, were no more liable to an exten- sion of the disease to the healthy portion of the resected or- gans than women whose ovaries were normal; and, finally, that in all these cases of excision, menstruation persisted and conception was possible. Several cases of pregnancy have begn reported following the adoption of these conservative measures. If such measures are contemplated in a given case, they should only be practised with the knowledge and by the consent of the patient, who should be informed frankly of the lia- bility of failure, and of the i)robable necessity of subjecting herself to a second and radical operation before she can be restored to health. HOthiNi;. Fig. 248. — " Keed has repeatedly excised a eyst or uysts of the ovary, stitched up the incision, and dropped the ovary back." — Eeed (page 582). 584: A TEXT-BOOK OF GYXECOLOGY The radical treatment of infections of the ovaries consists in the remoTal of the diseased organs. As the Fallopian tnhes without the ovaries are useless structures, and as they are generally diseased and can be removed under these circumstances without embarrassing the recovery of the patient, they too are generally removed. Oophorectomy is the name given to the operation for removal of the un enlarged ovaries; it is also known as Batte}^"s operation, and as normal ovariotomy. It was first performed by Dr. Eobert Battey, of Eome, Ga., on the ITth of August, 18T2, for the purpose of caus- ing the artificial and premature occurrence of the menopause in an otherwise incurable patient. The operation succeeded and the patient was restored to health. Battey, during the remainder of his life, op- erated frequently on this indication and with remarkable success. His purpose was to arrest the menstrual molimen, and to abolish thereby a painful and nervous class of sj^mptonis which all other treatment in his hands had failed to cure. "With this premature and forced change of life, came also a suspension, and finally an abolition, of the class of troublesome symptoms which culminated at the monthly period. In neurotic patients the}^ frequently explode in violent hysterical attacks, while in aggravated cases insanity has sometimes resulted. During the same year, February 11, 1872, Lawson Tait, in Eng- land, removed the ovaries and tubes for the cure of chronic inflamma- tions and pus collections in the uterine appendages, and Hegar, in Germany (July 27, 1872), removed the ovaries to arrest the growth of small fibroid tumours of the uterus, and the hemorrhages caused by their presence. Tait's operation, upon what are now known as " pus tubes," is referred to in another part of this work. (See Infections of the Fallopian Tubes.) Several of the conditions for which Battey operated are now relieved by less formidable treatment. The wave of sacrificial pelvic surgery seems to be passing, and a conservative tide, having for its object the saving of one ovary and part of the other if possible, is rising. (See Unilateral Eemoval of Ovaries.) The sudden and stormy onset of the change of life is thus prevented, and, while the diseased tissues have been resected, enucleated, or otherwise removed, the woman does not feel unsexed, as she calls it, and " so totally different from other women." The operation was, for a time, overdone. Too many ovaries were re- moved by youthful inexperienced operators. The pendulum began gradually to swing the other vraj, till now, surgeons hesitate somewhat to perform oophorectomj^ even in the few cases where their best Judg- ment dictates it to be the operation best suited to cure their patients. The indications for oophorectom}^, as now practised, are chiefly in- fections of the ovaries; inflammations and their consequences; certain rare and otherwise incurable cases of dysmenorrhoea; certain otherwise incurable cases of ovarian pain, independent of the periods, and mak- ing the patient an incurable invalid; clear cases of menstrual epilepsy; TREATMENT OF INFECTIOXS OF THE OVAFtlES 5S5 menstrual insanity, when the attacks occur only during the menstrual lA'eek, the patient being free from them during the interral; osteo- malacia; and bleeding uterine fibromata, of small size, where the patient declines hysterectomy and other means fail. Eecently, oopho- rectomy has been proposed as a cure for mammary cancer, but authentic reports of favourable results are lacking upon which to found an in- dication. The technique of the operation and the preparation of the patient, the surgeon, the nurses, and the operating room, do not differ materially from that of any median abdominal section until the abdomen is opened. (See Abdominal Section.) As there is no tumour, the in- cision need not be more than 2^ or 3 inches long. Two fingers, pref- erably^ of the left hand, are passed down to the top of the uterus and out along the tube and ovarian ligament to the ovar}-. Any adhesions are gently separated and the ovary, being grasped between the two fingers, is drawn up to and out of the abdominal opening. The tube should be well dra\\Ti up, also, and the pedicle transfixed as near the uterine cornu as possible, embracing the tube in its sweep. The loop of the ligature should be drawn through at least 6 inches and cut, thus making two ligatures, one being tied on one side, and one on the other, of the included tissues. Should any doubt exist as to the security of the constriction, one thread may be carried round the whole mass in the groove formed by previous ligatures, and the stump thereby doubly secured against any subsequent bleeding. A sufficient button of tissue should always be left where the ovary and tube are cut away, to prevent the ligature from slipping off during the vomiting and restlessness of the patient while recovering from the effects of the anaesthetic. The other ovary and tube are found in the same way as the first, brought to the surface, ligated, and cut off. As in many cases the aim in oophorectomy is to arrest menstruation with all that it implies, great care should be exercised in such cases to remove every vestige of both ovaries and tubes down to as near the uterus as possible. In order to remove the nerve supply which, it is asserted by Arthur W. Johnstone, of Ciacinnati, and others, presides over the menstrual act, some surgeons remove a V-shaped piece of the uterine cornu and stitch together the sides of the cavity instead of applying the regulation ligatures to a pedicle. There is rarely any loss of blood, and the peritoneal cavity not having been soiled in any way, no delay is necessary to complete a " toilet," and the abdominal incision is closed in the usual way. (See Abdominal Section.) The operation is frequently completed by an expert g}Tiecological surgeon in fifteen minutes, and certainly shoiild not consume more than half an hour by any one. The unilateral removal of the ovaries or of the uterine appendages, leaving t]ie otlicr and apparently healthy appendages in situ, remains one of the moot questions of surger}^ and one which presses itself for consideration in connection with conservative measures. The removal 586 "A TEXT-BOOK OF GYNECOLOGY of any organ not already the seat of disease, is against the instincts and impulses of surgery; and, yet, the frequency with which the re- maining and apparently healthy ovary has become diseased in patients from whom the other and infected ovary has been removed, has raised the question as to the expediency of removing both organs at the first operation. In approaching a decision of this question, it is to be re- membered again that the majority of all these infections are gonor- rhoeal in character; that an infection may travel up the uterus and out through the tube on one side, before passing up and out through the tube on the other side; and that a remaining ovary is, therefore, liable to inflammation caused by the later extension of the infection through the Fallopian tube of that side. On this point we may well accept the observations of Lawson Tait {American Journal of Obstetrics, 1887), as follows: "Actuated by the sound principle that no organ should be removed which is not diseased, in all the cases of the varie- ties of chronic, inflammatory, mischief in the uterine appendages, which have come under my care, I have not, in a single instance, removed the second set of appendages when they have been ascer- tained to be healthy. ... I have been made painfully familiar with the frequency with which operations of this kind have proved absolutely useless for the purposes of the operation, and where the disease has recurred in the other side and demanded a second surgical interference. . . . But the opinion which I have formed ... is that if a patient is suffering sufficiently to justify an abdominal section for chronic in- flammatory disease of the uterine appendages, and only one side is found to be affected, the operation, to be of that lasting and complete benefit to the patient which we desire all our operations should have, must be made bilateral. On such a point as this, of course, the desire of the patient must be paramount as upon most others, and if a patient placed herself under my care for such an operation, and made it an imperative condition that I should not, under any circumstances, re- move the second set of appendages if they were found healthy, I should yield to her decision; but I should argue the question with her, and advise her not to subject herself to the risks of a second operation, as seems to be by far the greater tendency in unilateral operations." The effects of removing the ovaries must be considered with refer- ence to their (a) primary and (6) secondary effects. Primary effects take into consideration the mere question of sur- gical recovery — the healing of the wound, and the getting up of the patient. The question of mortality from the operation has established the safety of the procedure. Numerous operators have had long series of cases without a death. Tait once reported a series of 139 consecu- tive operations, the majority of them involving the removal of the ovary, without a death. The mortality from the operation should be studied with reference to (a) the character of the infection; (b) the constitutional state of the patient at the time of operation; (c) the TREATMENT OF INFECTIONS OF THE OVARIES 587 environment of the patient; and (d) the technique adopted. It may be stated without hesitancy that cases of streptococcous infection, whether operated upon early or late, yield the largest percentage of deaths. Eecent acute infections in which the pus is yet virulent, are more dangerous subjects for operation than those in which the micro- organism has reached its vital limitation. This latter remark, how- ever, must not be accepted as a reason for permitting the pus of active and virulent infection to become innocuous before operation, for such delay without constant observation is fraught with extreme hazard to the patient — a hazard greater than that of operation. This leads natu- rally to a consideration of the constitutional state of the patient at the time of operation. Oophorectomy done in the presence of an acute constitutional sepsis is always attended with a high mortality; and yet the majority of these cases can be said to have no prospect of recovery at all without operation. It is in these cases of acute virulent infec- tion with more or less pronounced constitutional intoxication, that the conservative measure of tentative puncture and drainage should be practised. (See Vaginal Drainage.) The surroundings of the patient have much to do with her recovery. Nothing is more clearly demon- strated than the great advantage of a well-appointed and properly con- ducted hospital in the management of these cases; and it may be said with equal force that a poorly conducted and an improperly constructed hospital is more dangerous to the patient than any other possible sur- rounding. The mortality from abdominal section in cases of this class, may be conservatively placed at from 15 to 20 per cent when done either in poor hospitals or in no hospitals, and at less than 5 per cent when done in well-appointed and well-conducted institutions. The question of technique can not be discussed without taking into con- sideration the more personal element in the equation presented by the operator himself. It goes without saying that these operations, to be most highly successful, must be done with the greatest skill, and that skill can not be expected except as the result of training and experi- ence on the part of the operator. The lives that are constantly sacri- ficed by untrained men who simply wish to try their hand at abdominal surgery, would fill a scarlet book of horrors. The secondary, or remote, results should be considered with refer- ence to {a) menstruation; (&) the sexual function, including repro- duction; (c) the menopause; {d) the intrapelvic state; and (e) the gen- eral constitutional condition. Menstruation is arrested in the majority of patients from whom both ovaries have been removed. Pfister studied 179 cases operated upon by Kuhne, between 1880 and 1896, and collected statistics from various other sources. He found, on a basis of 715 cases, that men- struation ceased in 87.5 per cent, the percentages of cessation in the various lists varying from 75.6 to 97.3 respectively. In a majority of cases there occurs a sort of post-operative metrostaxis, which may recur a few times after intervals of varying length, but this is not 588 ' A TEXT-BOOK OF GYNECOLOGY to be looked upon as normal menstniation. A few patients menstruate during the first few months following complete extirpation of the ovaries and then cease. The reasons for the perpetuation of menstrua- tion in the 12.5 per cent of Pfister's cases — and they are alluded to only because they may be accepted as an index of cases in general — are not given^ and in the nature of things are not ascertainable. The fact, however, that in many cases of oophorectomy it is necessary to leave a small segment of ovarian tissue in situ for the purpose of main- taining the ligature in position, and the fact that a similar segment is frequently left through carelessness in excising the ligatured ap- pendages, will probably explain the majority of continuances of men- struation. It is known that in many cases in which more or less ovarian tissue is left designedly, the menstrual function persists. Bantock, Eeed, and numerous other operators have reported cases of the long persistence of menstruation after both ovaries were known to have been completely removed. Gonzalez, of Diriamba, Nicaragua, reports (N^ew TorJc Medical Journal) an interesting case of persistent menstruation following, not only the complete removal of both ovaries, but of the uterus also. The sexual function as influenced by oophorectomy, should be discussed with reference to (a) genital sensation, and (h) reproduction. With reference to the genital sensation, including libido sexualis, it should be understood at the start, that neither is as uniformly existent among women as among men. Eelative to this question Lawson Tait observed, that Avhen it is " carefully inquired into, and without j)reju- dice, it is found that women have their sexual appetites far less de- veloped than men, a fact explained by the process, necessary in evolu- tion, that the male has always been the struggling and aggressive creature. When the child-bearing period of a woman's life jDasses away, there goes with it a certain amount of her sexual ajDpetite. In a few cases the appetite entirely disappears, but in an equally large number of instances it becomes exaggerated, sometimes grotesquely so. In the majority of women the appetite lessens, and even disappears, during the time of the climacteric disturbance, and then returns to its former condition, when the change has been effected." The sexual appetite in its relation to oophorectomy, conforms to this law, and can not, therefore, be said to be unhealthfully modified. This theoretical view of the case seems to be supported by an investigation of the actual facts. Pfister reports upon 99 women, in 19 of whom the desire remained normal; in 2-4 it seemed somewhat diminished; in 35, in many of whom it had never been strongly developed, it was extin- guished, while in 21 it had never been present. Women have con- ceived after the extirpation of both ovaries, and, for that matter, of both Fallopian tubes. Cases of this kind have been reported by Sippel (British Medical Journal), Sutton (Transactions of the American Gyne- cological Society) and Dunn (Annals of Gynecolor/y and Pediatry). These cases are distinctly exceptional, and point to the fact that an ovule pre- TREATMENT OF INFECTIONS OF THE OVARIES 589 viously evolved may remain for a considerable time and retain its vitality in the folds of either the uterine ostium of the tube, or of the endometrium. The menopause is generally precipitated with abruptness following the removal of the ovaries. The patients complain, from the very start, of hot flushes, and there is a constant sensation of temperature vacillat- ing between heat and cold. The face burns, even without a correspond- ing turgescence of the cutaneous capillaries, although there do occur, to a certain extent, repeated changes from florid to pale. Associated with these phenomena are the more or less evanescent, but none the less distressing, nerve storms incident to the climacterium. (See The Meno- pause.) It can not be said that these phenomena differ in quality from those of the natural menopause, although they generally occur with more precipitation and greater violence. In some patients, how- ever, they are but little noticed, and in all cases they disappear in from twelve to twenty-four months. It is the distressing character of these symptoms, in certain cases, that has prompted surgeons to attempt the mitigation of their severity by leaving in position a part or all of an ovary, even after the removal of the uterus and Fallopian tubes. Satisfactory reports have been offered by Bland Sutton and others, and it is probable that the practice will find increasing favour with operators. The general system is influenced within certain limits by removal of the ovaries. In these cases, there occurs to a certain extent an exemplification of the law of antagonism between growth and genesis. When growth is active, the reproductive function is in abeyance; when, in turn, the reproductive function ceases, growth again attains its normal limit. This is shown in the increasing rotundity of figure fol- lowing the normal menopause. The same tendency exists when the change of life is induced, artificially, by oophorectomy. In Pfister's table, 52 per cent of the collected cases showed a tendency to increase in flesh; in 30 per cent the weight remained the same; while nothing is said about the remaining 18 per cent. With regard to those who increased in flesh, it is to be remembered that they were reduced by disease preceding the operation, and that, in many instances observable in the j)ractice of all operators, the increase of flesh amounts to noth- ing but the resumption of the normal standard. Pfister by his inves- tigations collected accurate data by which to refute many prevailing notions about the constitutional effects of oophorectomy — notions the fallacy of which have been known to operators for decades. The vulgar idea that women who have lost their ovaries become gross and masculine, acquire bass voices and raise whiskers, is only an indica- tion of popular ignorance which occasionally finds expression by an asinine physician. The effect of removal of the ovaries upon general metabolism has been a subject of inquiry, which has been given a fresh impetus by the investigations of Curatullo and Tarulli (Annali di Osielricia e Oinecohgia), investigations obviously undertaken for the 590 ' -^ TEXT-BOOK OF GYNECOLOGY purpose of establishing the existence of what they designated an in- ternal secretion of the ovary. In a series of observations on previously castrated lower animals, they observed variations in the elimination of metabolic products; while in osteomalacia they assumed to find a clinical confirmation of the theory that the ovaries secreted something which could not be found, but which, nevertheless, exercised an im- portant influence over tissue change. They found, in brief, that ablation of the ovaries modified metabolism, increased phosphates in the urine, changed the nitrogen curve either up or down, diminished the elimination of carbonic acid and the absorption of oxygen, and increased the weight. In applying their doctrine to women they failed, however, to take into account that every fact which they had noted was consistent with a retvirn to the normal equilibrium of nutrition. They mentioned that the injection of ovarian juice caused an increased elimi- nation of phosphates, proportionate to the amount injected, but they failed to take into account the fact, that a similar elimination of phos- phates occurred following the similar injection of like foreign ele- ments into the circulation. They assumed that this element, whatever it was, favoured the oxidation of phosphates, and they called attention to the point that, after removal of the ovaries, or before or after puberty, there should be an increase of calcareous salts in the bones, the deposition of the latter being determined by the action of the ovarian juice. It is unfortunate for this theory that, in the natural course of events, ovarian quiescence before puberty is associated with a minimum, while ovarian quiescence after the menopause is asso- ciated with a maximum, of lime salts in the bones. If the position of these investigators were tenable, it would follow that the condi- tion of the bones before puberty and after the menopause would be the same. Eclating to this subject, it is interesting to note that Heyse (Archiv fiir Gynakologie), from a careful microscopic study of ovaries removed from osteomalacic subjects, decides that there is no reason to infer that there is any diminution in the number of primordial cells under these circumstances, and consequently that there is no ground upon which to predicate a variation in the so-called " internal secre- tion." Intrapelvic morbid conditions are always modified, if not always cured, by the ablation of the appendages. The restoration of other- wise hopeless invalids to symptomatic health, is the crowning triumph of this operation in the great majority of cases. Many women after passing through this operation, and through the neurotic disturb- ances of the artificial menopause, are freed from pelvic pain and are otherwise healthy. There are cases, however, and a number of them, in which the removal of the ovaries, whether for acute infection, chronic inflammation, or cystic degeneration, is not followed by com- plete cure, or even pronounced amelioration, of the pre-existing intra- pelvic pain. In some of these cases the painful symptoms subside only after the lapse of one or two years. The reason for this delay in TREATMENT OP INFECTIONS OP THE OVARIES 591 recovery, or failure to recover at all, as the case may be, is to be found in the inflammatory changes which have become established outside the adnexa. Subserous exudates causing pressure on filaments of the sacral plexus, and organized inflammatory products in the parenchyma of the uterus causing pressure on terminal nerve twigs in that organ, are, for the most part, accountable for this persistence of pain. In- flammatory changes of a more or less permanent character in the nerve sheaths themselves are to be taken into account in this connection. A well-established uterine sclerosis of inflammatory origin is a per- petually painful condition. It is for this reason that the French school inaugurated the practice of removing the uterus with the adnexa for the relief of otherwise incurable infectious inflammations. (See Doyen's Operation and Panhysterectomy under Treatment of Infec- tions of the Fallopian Tubes.) CHAPTER XXXIX TROPHIC DISEASES OF THE OVARIES Atrophy — Cirrhosis — Hypertrophy. Atrophy of the Ovaries. — Atrophy of the ovaries, a physiologic change at the climacteric, becomes pathologic when it occurs in women during the period of sexual activity. This variety is to be carefully distinguished from so-called cirrhosis, the result of disease. More- over, it should not be confounded with nondevelopment of the gland in women who have never menstruated. Causes. — In a well-recognised class of cases, Coe observes that the rapid development of obesity in young women is associated with scanty menstruation, which may eventually cease entirely. Since the uterus is normal in these subjects, there is little doubt that the ova- rian function ceases in consequence of follicular atrophy, though opportunities for studying this condition anatomically are rare. Coe has had a chance to verify his opinion at the operating table in a typical case. The intimate relation between the ovarian activity and the nutritive processes is illustrated by the fact that, on reducing their weight, such patients may again menstruate with a fair degree of regularity, the flow again disappearing as they return to their former state of obesity. Premature atrophy has resulted from alcoholism, syphilis, the acute exanthemata, rheumatism, and typhoid fever, though in the febrile diseases there is probably a previous inflamma- tory process in the ovary. Prolonged pressure upon an ovary, in con- nection with uterine fibroids and broad ligament cysts or disturbance of its vascular supply by dense adhesions and exudates, may lead to complete glandular atrophy in young subjects. So-called cirrhosis is often erroneously described as an inflammatory process. Fibrous de- generation would be a more accurate term. While it may represent the termination of a previous acute inflammation, it is usually a form of chronic hyperplasia in which the follicles are entirely destroyed and the ovary is transformed into a mass of firm connective tissue. Such ovaries are often associated with chronic salpingitis and pelvic exu- dates, leading to the inference that obstruction to the blood supply is mainly responsible for this form of atrophy. Atrophic changes may follow supravaginal amputation of the uterus when one or both ova- ries have been left in situ. 592 TROPHIC DISEASES OF THE OVARIES 593 Pathology. — An atrophied ovary differs in its microscopic appear- ance from the organ after the normal climacteric, not so much in size, as in its irregular, nodular shape, and dense, almost cartilaginous, consistence. The cortex is much thickened, often from accompanying perioophoritis. On section, the surface presents a uniformly firm, fibrous structure, with few or no traces of follicles. When these are present, they are either atrophied, or, rarely, dropsical, their walls being greatly thickened. The arteries are few and their lumina con- tracted, and there are no evidences of leucocytic foci. Symptoms. — There are no symptoms characteristic of atrophy, if we except amenorrhoea and sterility in cases in which both ovaries are affected and sexual appetite is in consequence diminished or absent. Previously to complete atrophy, menstruation is irregular and painful, especially when the glands are buried in adhesions. In fact, the symptoms are due rather to the accompanying condition. Prognosis. — Great circumspection is necessary in giving a progno- sis in these eases, or in promising certain definite results from treat- ment. It is idle to expect an anatomical cure or restoration of func- tion in an ovary in which the normal stroma and follicles have com- pletely disappeared. In the case of the young obese subjects before alluded to, in whom the uterus is still of normal size, rigid diet and exercise, baths, electricity, and massage (and especially a course at a for- eign spa, such as Marienbad) may stimulate the ovaries to renewed functional activity. The possibility of conception is doubtful, so that it is not right to encourage the patient with false hopes. Treatment. — When the atrophied organs are adherent and give rise to constant pain and dysmenorrhoea, little is to be expected except from operative intervention. In the case of young women who desire to preserve their ovaries it may be sufficient to separate adhesions, in fact, the writer once saw menstruation return and persist after this simple procedure; but when the flow has ceased entirely and the glands are transformed into mere fibrous nodules, there is no object in retain- ing them. Cirrhosis of the ovaries requires at least brief consideration. It has been, and is still, the custom to regard the condition of the ovaries known as cirrhosis, as a mere sequence of an acute oophoritis. But there is ample evidence that this condition may occur independently of inflammation. It is found fully developed without antecedent his- tory of infection in women under thirty years of age, and it may involve one or both ovaries. It gives rise to severe pain in the affected ovary, especially before menstruation. Its persistence may lead to neurasthenia or to some other form of neurosis. The ovary in these cases may or may not be prolapsed, is firm, unyielding, globular in form, sensitive to the touch, but usually not adherent. In the earlier stages of the disease, the ovary presents a relatively normal appear- ance, but as the morbid process progresses, as it usually does, the organ contracts at the expense of the vascular stroma or medullary 39 594 ' A TEXT-BOOK OP GYNECOLOGY substance until all true gland tissue has been destroyed. As a result of the fibrous contractions the surface of the ovary is made to resem- ble, in miniature, the convolutions of the brain. It will follow as a natural conclusion that the majority of women suffering from cir- rhotic ovaries, are sterile. The symptoms are not always constant. So true is this, that the patient can seldom state definitely when they began. The pain has been described as of a sharp, darting, sickening or throbbing char- acter, in one or both ovarian regions, but more frequent and severe in character in the left ovary. This pain has its greatest intensity from a few days to two weeks prior to the menstrual period, and is usually accompanied with nervous reflexes, such as hysterical mani- festations, backache, etc. In many of the cases, owing to the intimate nerve connection with the lumbar ganglia of the spinal nerves, pain will be referred to the front and inner side of the thigh and to the hip joint. Dyspareunia is absent in many cases, owing to the fact that the ovaries are small and are not prolapsed and tender. In the early stage of these cases they may be treated, with some relief of the pain, by electricity, but the results from this agent have not been at all satisfactory. All cirrhotic ovaries do not require re- moval. It is in cases where other means have failed, and where the woman has been rendered an invalid or her suffering has become almost intolerable, that the removal becomes imperative. Hypertrophy of the Ovaries. — This may be defined as an enlarge- ment of the ovary, the result of former inflammation or chronic con- gestion. It is cystic or fibrous, according as the change affects the follicles or stroma, though the two conditions are commonly associ- ated. Causes. — So-called chronic oophoritis leading to hypertrophy, ac- cording to Coe, is doubtless the termination of an acute inflammatory process, which does not terminate in abscess formation, hence it may be due to puerperal or gonorrhoeal infection associated with similar disease in the tube. But the most common cause is long-standing pelvic congestion, such as accompanies tubal disease, peritonitis, and uterine and ovarian tumours. A prolapsed ovary, especially when surrounded by exudate, is liable to undergo hypertrophy. Chronic constipation also is an exciting cause, which fact may account for the relatively greater frequency of hypertrophic changes in the left ovary, which is not only in close proximity to the sigmoid flexure but has a valveless vein. Primary hypertrophy is sometimes traceable to sex- ual excess, traumatism, or frequent pregnancy and abortion. Cystic degeneration may result from disease of the individual follicles which are prevented from reaching the surface of the ovary or, when situ- ated in the peripheral zone, can not rupture in consequence of patho- logic thickening of their walls or peri-oophoritic adhesions or exudates. Pathology. — The follicles become dropsical and few or many cysts develop. A hypertrophied ovary may be enlarged to several times TROPHIC DISEASES OP THE OVARIES 595 its normal size, and presents an irregular shape, with one or more cysts of variable size, sometimes as large as English walnuts, project- ing above its surface; on palpation, there is a more or less distinct sense of fluctuation. Or, if the fibrous element predominates, the ovary may be globular or oval in shape, with a smooth whitish appear- ance and firm consistence. Fibroid ovaries are usually prolapsed, from their increased weight, and are often freely movable, though if there is accompanying tubal disease they are apt to be buried in exu- date. On section, such an ovary shows marked thickening of the cortex, with general induration of the stroma due to proliferation of the fibrous tissue. A few small cysts with thickened walls are seen, or no traces of the follicles remain. The walls of the arteries are usually thickened, the lumina are dilated and hyaline degenera- tion is common. In cystic hypertrophy the walls of the dropsical fol- licles are thickened and they contain a clear fluid, normal, or, not infrequently, a single cyst may encroach upon the stroma to such an extent that only a narrow zone remains. Symptoms and Diagnosis. — The symptoms are often due princi- pally to coexisting conditions — adhesions, tubal disease, or neoplasms. In uncomplicated cases, the patient complains of severe pain in one or both groins or in the sacrum, which is increased a day or two before the menstrual flow, sometimes recurring in a paroxysmal form during the intermenstrual period. The pain may radiate down the thighs and is often accompanied by reflex neuralgige of the inter- costal nerves and pelvic organs. If the ovary is prolapsed in Doug- las's pouch, a peculiar sickening pain is felt during defecation and coitus. Locomotion is often attended with severe pain in the groins and sacrum, extending down the lower limbs; if the ovary is fixed by adhesions these symptoms are aggravated. Menstruation is apt to be irregular. Menorrhagia is common in connection with cystic hyper- trophy. Sterility results from the general disappearance of the nor- mal gland tissue, though conception is always possible so long as healthy follicles persist. The effect of the local disturbances upon the general health may be such that the patient becomes a nervous invalid. The various hystero-neuroses are frequently referable to the ovarian condition. Treatment. — The treatment is palliative or surgical according to the extent of the disease and the severity of the symptoms. Sexual intercourse must be controlled, and rest during menstruation insisted upon. Hot vaginal douches and regulation of the bowels are routine measures in every case. Ichthyol tampons often accomplish unex- pected results, especially in the case of tender ovaries which are adher- ent in the cul-de-sac. Local galvanism and the fine wire secondary faradic current often relieve pain to a marked degree. Pelvic mas- sage is useful in the absence of subacute inflammation, or accompany- ing pyosalpinx or hematosalpinx. The bromides are indicated to allay nervous manifestations. To relieve dysmenorrhoea, the coal-tar 596 ' A TEXT-BOOK OF GYNECOLOGY derivatives, viburnum compound, and apiol are useful. Opium should be used with caution, preferably in the form of codeine. Postural treatment during menstruation (raising the hips, or even the Tren- delenburg position) sensibly diminishes the throbbing pain due to excessive pelvic congestion. Before resorting to operative procedures, nonsurgical treatment should receive a fair trial, and an examination should be made under anesthesia in order to determine the extent of the disease. An ovary adherent in Douglas's pouch may be readily reached by vaginal section (preferably through the posterior fornix), freed from its adhesions, and examined with a view to the necessity of removal. The abdominal route doubtless enables the operator to study the con- ditions more intelligently and to separate thoroughly all adhesions. Conservative surgery should be practised whenever this is possible, especially in cases of cystic hypertrophy. An ovary which is merely prolapsed and is not generally diseased may be simply sutured in its normal position. There is no object in trying to save one which is the seat of general fibroid hypertrophy, with no trace of normal follicles. When both ovaries are similarly diseased and the tubes are also generally affected, it is better to remove the adnexa on both sides, especially if the woman has long been sterile. But her wishes must, of course, have considerable weight. No fixed rule can be formulated to fit every case, as the surgeon must decide for himself regarding the extent of the disease and whether the best interests of the patient will be served by a conservative or a radical operation. CHAPTER XL NEOPLASMS OF THE OVARIES Benign neoplasms: Small benign cysts; simple or follicular cysts, cysts of the corpus luteum, tubo-ovarian cysts: Neoplastic cysts; proliferating cysts and their varieties; dermoid cysts and their varieties: Solid tumours; fibroma, calcified tumours — Hematoma — Malignant neoplasms: Primary carcinoma; medullary carcinoma; adenocarcinoma; secondary carcinoma: Sarcoma: En- dothelioma. Neoplasms of the ovaries are of frequent occurrence, and of several varieties. There is probably no organ in the body that is so suscep- tible to neoplastic changes. These will be considered in the following order : Benign" jSTeoplasms: 1. Small benign cysts: (a) follicular cysts, (&) cysts of the corpus luteum, (c) tubo-ovarian cysts. 2. Neoplastic cysts: (a) proliferating cysts (pseudomucinous and serous), (&) dermoid cysts. 3. Solid Tumours: (a) fibroid tumours, (b) calcified tumours. 4. Hematoma. Malignant jSTeoplasms : 1. Carcinoma: (a) primary, (&) secondary. 2. Sarcoma. 3. Endothelioma. Benign JSTeoplasms Small Benign Cysts of the Ovary. — The ovary by reason of its peculiar anatomic structure is greatly predisposed to cyst formation, and perhaps this tendency is shared by no other organ of the body to the same extent. The smaller cyst formations have been variously named, as hydrops folliculi, hypertrophy of the follicle (Ziegler), small cystic degeneration (Hegar), and follicular cysts. Slightly dilated follicles and small follicular cysts are distin- guished by no essential difference in appearance; so that the clinician is often perplexed to determine what constitutes the degree of cyst formation to be designated pniliologic. 597 598 A TEXT-BOOK OF GYNECOLOGY Between the somewhat dilated follicles so frequently met with as an accompaniment of chronic oophoritis, and true cysts, no sharp dividing line can be drawn, so that frequently a careful histological study is necessary before each can be placed in its proper class. Mar- tin {KranMeiten der Eierstocke, S. 324) has proposed to regard as hydrops folliculi those dilated follicles which reach a size whose diam- eter is not greater than the thickness of the normal ovar}^, and to desig- nate as true cysts only those reaching a greater size. Winter {Gynakolo- gische DiagnosWk, page 174), on the other hand, reserves the term cystic, to be applied to those ovaries which reach the size of a hen's egg. Pathologic cyst formation of the ovary is primarily divided into two groups : 1. Simple or follicular cysts. 2. Neoplastic cysts. To the first group belong (a) follicular cysts; (b) cysts of the corpus luteum; (c) tubo-ovarian cysts; while under the second group are usually classed {a) proliferating cysts; (b) dermoid cysts. Simple or FoMcular Cysts. — Various theories have been advanced in explanation of the development of follicular cysts, but in the ma- jority of instances they are probably due to previous inflammatory changes in the ovary, the fibrous tunic of which has become thickened, thus preventing the rupture of the follicle, and are therefore reten- tion cysts. According to Olshausen, they frequently develop in the following manner: In the beginning, the ovary will contain several dilated follicles (Fig. 249), which mate- rially increase its size; sooner or later, one of the follicles takes on abnormal growth and expands on the surface of the ovary in the direction of least resistance. Pressure from the increasing contents produces atrophy of its wall which be- comes thin. When the cyst reaches some Fig 249 (Whitacbe).-"!!! the ^-^^ ^j.- ^50), it replaces the ovary, beginnmg, the ovary will con- i • i i ^ n j, n i? tain several dilated follicles."- which has now become flattened trom EoTHRocK. pressure, and appears as a mere thicken- ing of the basal wall of the cyst, while the peripheral wall of the cyst is thin. As a rule, they develop on the sur- face of the ovary, the walls of which are thick and consist largely of ovarian tissue. Follicular cysts may be freely movable and even pedun- culated or they may develop within the ligament. They vary in size from that of a pigeon's egg to that of an orange, though, exceptionally, much larger cysts have been met with, reaching the size of an adult's head. The wall of the cyst varies in thickness, and the external surface may be smooth and shining, or rough from adhesions. The inner sur- face of the cyst wall is as a rule smooth, shining, and fascialike. NEOPLASMS OF THE OVARIES 599 though occasionally a few small wartlike, papillary growths, are ob- served springing from the surface. Follicular cysts are usually unilocular, though sometimes two or more cysts may fuse, in which case the remains of partitions or trabeculalike forma- tions may be seen. In the early stages of development so soon as the follicle begins to dilate, the ovum dies and the membrana granulosa undergoes fatty de- generation and dis- appears. The cyst con- tents, which repre- sent the epithelial secretion with per- haps some transuda- tion from the blood vessels, consist of a thin clear straw-col- oured fluid with a specific gravity of from 1.005 to 1.026, and may at times be blood-tinged or turbid. As a rule, the sediment is small, and contains a few formed elements consisting chiefly of degenerated epithelial cells, fat drops, and at times a few blood corpuscles and cholesterin crystals. Histologically, the wall of the cyst is composed of connective tis- sue with occasionally some ovarian stroma. The internal surface is lined with low cylindrical or cuboidal cells, or it may be without epi- thelial lining. Cysts of the Corpus Luieum,. — The observations of IsTagel, Bulius and Frankel, prove beyond doubt that cysts may develop in the rup- tured as well as in the unruptured follicle. To liokitansky, however, belongs the credit of being the first to describe cysts of the corpus luteum. Like follicular cysts, they are of slow growth and rarely reach large size, usually not larger than a walnut, though in a few instances they have been observed as large as a foetal head, and, rarely, as large as a man's head. They are usually solitary, but two have been observed in the same ovary. In the beginning, they are usually situated in one or the other pole of the ovary (Fig. 351), but as they increase in size they gradually replace the ovary, which appears as a flattened mass on the cyst wall. Like follicular cysts, they are unilocular, but differ very materially in Fig. 250 (Pfannen>tii:i. i. ■ W li. n ihc cyst reaches some size it replaces the ovary." — Kotiieock (page 598}. 600 A TEXT-BOOK OF GYNECOLOGY Fig. 251 (Whitacre).—" Cysts of the corpus luteum . . . are usu- ally situated in one or the other pole of the ovary." — Kothrock (page 599). laries. In a few instances having thick walls made up of two layers, which may be easily sepa- rated from each other. The inner stratum, which is called the lutein layer, is arranged in folds, and is further characterized by being of a yellow orange or brown colour. The outer layer represents the tunica fibrosa of the normal corpus luteum. The cyst contents consist, in most instances, of a clear serous fluid, which is probably the product of transudation from the very vascular lutein layer of the cyst. Microscopically, they differ widely in appearance. In some cysts, the inner stratum is of typical corpus-luteum struc- ture, consisting of large epithelioid cells lying thickly in a scant network of fibril- lary connective tissue very rich in capil- the innermost layer has been found to con- sist wholly of connective tissue (L. Frankel, Archiv filr Gynakologie, Bd. Ivi, H. 2). The recent observations of Orthmann and L. Frankel leave no doubt that occasionally cysts of the corpus luteum may be lined by epithelium. The character of the epithelium is usually cylindrical, but may be cuboidal or approach the squamous type. The cells are not always regularly arranged, but may be here and there set diagonally to the surface. The etiology of these cysts is not known. The frequent coexistence, however, of chronic oophoritis suggests that the chronic hypergemia incident thereto, may have been the determining cause of the increased transudation which gave rise to cyst formation. Blood cysts constitute another variety of cysts of the corpus luteum, which are not so uncommonly met with, and are of much pathological interest and clinical significance. Attention has been called to these cysts by certain French writers, as Robin, Rollin, Doleris, Petit, and especially Pilliet. More recently, Orthmann {Verhandlwigen der deutschen Gesellschaft filr Gynakologie, 1897) has made a careful and exhaustive study' of these cysts, and concludes that they originate from hemorrhage into the corpus luteum. According to Orthmann, these cysts are usually superficial, and are most frequently found at one or other pole of the ovary. They are round or oval in shape, and vary in size from that of a walnut to that of the head of a newborn child. They are frequently firmly ad- herent to the surrounding structures and may be bilateral. According to Orthmann, it is not always possible to distinguish between these blood cysts and primary cysts of the broad ligament into which hemorrhage has taken place, and they may be confused with ovarian pregnancy. NEOPLASMS OF THE OVARIES 601 The cyst contents vary. In small cysts, the blood may be coagulated, while, in the larger ones, it is usually liquid and of a reddish, dark brown, or chocolate colour. On section, one finds the cyst wall composed of the characteristic structure of corpus-luteum cysts (Fig. 252). In small as well as in large cysts, the inner wall is uneven and more or less strongly folded, and is of a yellow or brown colour. The microscopic appearance of the wall of the cyst is, in many cases, similar to that of corpus-luteum cysts already described; while, in others, there are present many of the histological changes occurring in the various stages in the pro- cess of regeneration of the normal corpus luteum. Like corpus-lu- teum cysts, they may sometimes be lined with epithelium. Tubo-ovarian Cysts. — Cysts are occasionally encountered which involve both the ovary and the Fallopian tube. Various the- ories have been advanced in ex- planation of such cyst formation, but from the great variety which have been described, it is evident that no one theory will explain all cases. It is probable, however, that pelviperitonitis with result- ing adhesion of the pavilion of the tube to the ovary, is primarily an important factor in their for- mation. The exhaustive studies of Eosthorn have done much to eluci- date this subject. He concludes that tubo-ovarian cysts may develop from any one of the following conditions, which he divides into two groups: The first group includes: (a) Cases in which a pyosalpinx becomes adherent to the wall of a coexistent abscess of the ovary, with subsequent perforation of the wall separating them. (h) Adhesion of the pavilion of the tube to the wall of a suppu- rating ovarian cyst, with subsequent development of a hydrosalpinx and perforation of the cyst into the tube. (c) Adhesions of a hydrosalpinx to a papillomatous cyst, with sub- sequent perforation of the intervening wall by papillary growths. To the second group belong : (a) Cases in which a hydrosalpinx becomes adherent to the wall of a follicular cyst, with subsequent perforation of the septum. (h) Cases in which the fimbriae of a previously diseased tube be- come caught in the opening of a ruptured follicle at the moment of rupture, and become adherent to the wall of the follicle with the devolopmont of a tubo-corpus-liiteinn cyst. Fig. 252 (Whitacee). — " On section, one finds the cyst wall composed of the character- istic structure of corjDus-luteum cysts." — EOTHBOCK. 602 A TEXT-BOOK OF GYNECOLOGY While undoubted instances of each of these modes of origin have been observed, the classical tubo-ovarian cyst is of follicular origin, and only rarely are proliferating cysts communicating with a dilated Fallopian tube encountered. These cysts are usually unilateral, though they may be bilateral, and they vary in size from that of a pigeon's egg to that of a closed fist, and, exceptionally, larger ones have been observed. The junction of the tubal portion of the cyst with the cyst proper, is marked by a sharp flexion, giving it the peculiar and characteristic appearance of a retort (Fig. 213, p. 498). As a rule, the larger portion of the cyst is developed from the ovary, and is round or oval. The cyst wall is usually smooth, if not adherent, and in large cysts may be quite thin. In most instances, it is more or less adherent to the surrounding structures. Tubo-ovarian cysts are unilocular, and not infrequently they com- municate with the uterine cavity, through which the contents are periodically emptied. The opening between the ovarian and tubal portions of the cyst varies in size, and is frequently guarded by a valvelike formation, the remains of the septum (Fig. 253). The cyst contents consist usually of a clear serous fluid similar to that of follicular cysts. They may, however, be turbid, blood-tinged, or chocolate - colour from disorganized blood. Histologically, the wall of the cyst is com- posed of connective tis- sue, while, in the tubal portion, atrophied mus- cle fibres may be ob- served. The epithelial lining of the ovarian por- tion of the cyst con- sists of low cylindrical, cuboidal, or spindle-shaped cells, or may be without epithelial lining, while the tubal portion of the cyst is lined with cylindrical epithelium which is frequently ciliated. Neoplastic Cysts. — Proliferating cysts constitute by far the greater proportion of tumours of the ovary. They have been variously desig- nated as simple, compound, areolar, unilocular and multiloeular, colloid and myxomatous cysts, all of which are clinical distinctions depending upon their most striking features. Waldeyer divided pro- liferating cysts into two groups : Proliferating glandular, and prolif- erating papillary cysts, according as they contained papillary growths, or not; and this division has been generally followed by most writers Fig. 253 (Martin). — " The opening between the ova- rian and tubal portions of the cyst ... is frequently guarded by a valvelike formation." — Rotiirock. NEOPLASMS OP THE OVARIES 603 to the present time. It will be observed that this is a purely clinical, and rather vague and indefinite, ground for division, based entirely upon macroscopic appearance and admitting of no very sharp dis- tinction, since many cysts come under observation in which the char- acteristic features of both are present to an almost equal degree. The most satisfactory division yet made, and one founded on a chem- ical and anatomical basis, and at the same time admitting of marked clinical distinctions, is that recently proposed by Pfannenstiel. Leav- ing out of consideration mere clinical appearance, Pfannenstiel sought to distinguish ovarian cysts by the chemical constituents of their con- tents, and found that a large proportion of cysts contained a chemical substance long known and formerly called paralbumin and metalbu- min. Hammarsten, however, found that it was not an albumin, but a substance resembling mucin, which he termed pseudomucin. In a smaller, and at the same time clinically sharply differentiated class of cysts, Pfannenstiel found that this substance was not present in the contents. Carrying his investigation further, he discovered that they differed histologically in the character of their epithelial lining. In the first group, the cells were cylindrical and resembled mucous cells, while in the second group, the cysts were lined by ciliated co- lumnar epithelium. He further observed that the two groups differed greatly in the gross appearance of their contents. Those of the first group were more or less thick, turbid, and often colloid, in appearance, while in the other, they were thin, clear, and serous. He therefore divided all proliferating cysts into — (1) Pseudomucinous cysts. (2) Serous cysts. Pseudomucinous (Proliferating) Cysts. — To this group belong the greater proportion of ovarian cysts. They are usually unilateral, and they vary in size from a mere beginning cyst only sufficiently large to be recognised, to tumours of enormous dimensions, often filling the abdominal cavity, displacing other viscera, and encroaching seriously on the thoracic cavity. Cartledge has reported (Journal of the American Medical Associa- tion, 1897) the largest cyst of the ovary on record. The tumour had been growing for thirteen years, and for the last four years very rapidly, so that the patient had been unable to assume a reclining posture for more than a year and a half. The circumference at the umbilicus was 79 inches. The woman was 5 feet 4 inches in height and well formed, except that she was very much emaciated from carrying this enor- mous cyst. Twenty-four gallons of ovarian fluid were removed before she was placed in position to be anaesthetized. After that, she was placed on her back and 10 additional gallons of fluid withdrawn. The adhesions to the anterior parietal wall were terrific. Many ligatures were used, and the operation consumed about two hours under unfa- vourable circumstances. The woman survived the operation fairly well, leaving the table with a pulse of 114. On the fifth day she had a 604 A TEXT-BOOK OF GYNECOLOGY normal temperature and a pulse of 108. Beginning with the sixth day, symptoms of intestinal obstruction developed and she finally died. The fluid withdrawn weighed 240 pounds and the sac 5 pounds. Other very large tumours have been reported, one successfully re- moved by Gilliam, of Columbus, weighing 176 pounds. A. H. Cordier has reported a cyst which weighed 160 pounds (Fig. 254). Tumours of 100 pounds are occasionally encountered. It is no longer com- mon, however, to meet with such large cysts, inasmuch as surgical aid is usually sought before the tumour reaches a great size. They may occur at any period of life, from puberty to ad- vanced age, although they are most frequent- ly encountered during the childbearing period, especially from thirty to forty-five. Unmarried and sterile women seem to be especially predis- posed. Whether, as has been suggested, preg- nancy and lactation by temporarily interrupting the menstrual function afl^ord a protection against tumour formation we do not know. It is conceiv- able, however, that the periodical congestion in- cident to menstruation, may have a determining influence. The shape of the tu- mour is usually spherical, ovoid, or irregular in out- line. If small, it is usu- ally irregular in shape from partial fusion of two or more cysts pre- senting no uniformity of structure. Larger tumours, while generally assuming a spherical shape, are often uneven in outline, with here and Fig. 254.—" A. II. Cordier has reported a cyst which weighed 160 pounds." — Kothrock. NEOPLASMS OP THE OVARIES 605 there nodular prominences due to bulging caused by smaller cysts de- veloping in the cyst wall. Thp external appearance of the tumour is pearly white or bluish, often smooth and glistening, and at times it has a cartilaginous ap- pearance. Over the surface, blood vessels of varying size are fre- quently seen ramifying. Occasionally, bands of unstriped muscle fibre and the remains of ovarian stroma are to be seen spread out over the tumour, especially near the pedicle. On section, the tumour will be found to consist of a conglomera- tion of a greater or less number of cysts (Fig. 255). Usually, one cyst attains a considerable size and constitutes the main portion of the tumour, while, in its wall, are developed numerous smaller cysts which encroach on the lumen of the main cyst. Sometimes, the entire number may^ be composed of a conglomeration of innumerable small cysts, separated from each other by a more or less dense struc- ture giving it on sec- tion a honeycombed appearance. Usually, the individual cysts are separated from each other by walls of varying thickness composed of highly vascularized connec- tive tissue. These septa frequently be- come very thin from pressure atrophy, and may rupture, result- ing in fusion of several cysts with intermingling of their contents. Fre- quently, the remains of such septa may be seen in the main cyst forming trabeculalike processes on its internal surface. Gradually, these septa disappear from pressure, and in old or very large cysts, the entire tumour may consist of one large space, though usually smaller flattened cystic spaces will be found in its walls. The internal surface of the cyst is usually smooth, though it may be covered here and there with wart- like excrescences, dendritic, or caiiliflower growths. These may be few or quite abundant. As a rule, the larger the cyst, the smoother will be its wall, and the fewer papillary growths it will contain. These papillary growths differ much in appearance. They are usually of a gray colour, but may be pink or dark red if rich in blood vessels. Tbe cyst contents arc the product of cell secretion from the lining membrane. The contents of the individual cysts composing the Fig. 255 (Martin's Handbook).— " On section, the tumour will be found to consist of a conglomeration of a greater or less number of cysts." — Kothkock. 606 A TEXT-BOOK OF GYNECOLOGY tumour may present the greatest diversity of appearance and consist- ence; one obtained by Pfannenstiel contained a bright transparent body, probably a degenerated ovum (Fig. 356). In general, they consist of a fluid with a specific gravity of from 1.010 to 1.030, of the consist- ence of honey, though at times it ^SS3ftgg Fig. 25(3 ( X'eit's llaudbook ). — " One obtaiued by Pfannenstiel contained a bright trans- parent body, probably a degenerated ovum." — KOTHROCK. W^S^^'^^*:^S:Sii^^^ ■ .-'-^-r^If^--^ niay be thick, ropy, and gelatin- ous, especially in the smaller cysts. In colour it varies quite as much as in consistence. It is usually turbid, and often has the appearance of oily water; it may be gray, yellowish, greenish, or wine-colour, and sometimes it is dark brown from admixture of blood. Microscopically, it is usually poor in organized elements, being composed chiefly of a homogene- ous mass which may contain a few fat globules, degenerated epithelial cells, and, at times, a few red blood corpuscles, hematin and cholesterin crystals. The cell described by Drysdale and considered by him a pathog- nomonic diagnostic sign of ovarian cysts is no longer so regarded. The greatest interest attaches to the chemical constituents of the cyst contents. They usually consist of a highly albuminous fluid which contains in addition a peculiar substance named pseudomucin. This substance varies in amount in different cysts, sometimes consti- tuting almost the entire cyst contents, and again it is present only in small quantities. Small cysts with colloidlike contents are the richest in this susbstance. Pseudomucin is a glyeoproteid, and differs from mucin in not being precipitated by acetic acid. It is further character- ized by setting free a copper reducing substance when boiled in the presence of dilute mineral acid. Test for Pseudomucin. — The following is the test proposed by Pfannenstiel and is a modification of Hammarsten's test. To the cyst contents is added twice their volume of alcohol after which the mix- ture is well shaken. The precipitate is then filtered and well washed with alcohol, after which it is gently pressed between filter papers to remove the excess of alcohol. A portion of the precipitate is now boiled for half an hour in a lO-per-cent solution of hydrochloric acid. After cooling, it is treated with phosphorwolfram acid until the albu- min is entirely precipitated. The filtrate is filtered and tested with Trommer's or Fehling's test for sugar, and if reduction takes place, it may be concluded that pseudomucin is present. Histologically, the wall of the cyst is made up of three layers. The outer represents the tunica albuginea of the ovary, and is covered with NEOPLASMS OF THE OVARIES 607 germinal epithelium consisting of a single layer of low cylindrical cells. The middle layer consists of connective tissue and may contain ovarian stroma or smooth muscle fibres. This layer also contains the larger blood vessels. The inner layer consists of cyst epithelium and is covered by a single layer of peculiar mucuslike cells, cylindrical in type. According to Pfannenstiel, these cells show a special affinity for hematoxylon and eosin, and by this double stain, the nuclei, cell con- tents, and periphery, are clearly differentiated. When stained, they appear as high cylindrical cells with small basal nuclei, while the cell body consists of a clear transparent mass inclosed within the cell wall, which appears as a faint outline. Occasionally, the cyst wall contains small ductlike tubes or glands, which originate in a proliferation and invagination of the cyst epithelium into the wall of the cyst. Frequently, instead of ductlike invaginations, their mouths will have become occluded from constriction of the connective tissue of the cyst wall, which is also in a state of proliferation, when they will appear as small cysts. The constant repetition of this process of epithelial proliferation throughout the tumour, together with the increasing contents from increased area of epithelial secret- ing surface, is responsible for its growth (Fig. 257). Papillary cysts, according to Pfannenstiel, develop in the fol- lowing manner: First, a prolifera- tion of epithelium takes place which causes tilting and displace- ment from crowding of the cells, carrying with them a thin vinder- lying stratum of connective tis- sue; this, being rich in blood ves- sels, also takes on proliferation. In many instances, the connective- tissue proliferation appears to surpass the proliferation of the epithe- lium, which must, however, always be considered primary. Serous {Proliferating) Cysts. — Serous cysts are much less common than the pseudomucinous variety, occurring in the proportion of about 1 to 8 of the latter. As a rule, they are small, and never reach the enormous dimensions of pseudomucinous cysts, although cysts the size of a pregnant uterus at term have been observed. In external appearance, they resemble somewhat pseudomucinous cysts. In contrast with pseudomucinous cysts they frequently develop bilaterally. While they may lie free in the peritoneal cavity, attached by a well-formed pedicle, they frequently develop within the folds of the broad ligament, and show a special tendency to become attached to the neighbouring viscera by adhesive bands. Fig. 257 (Wiiitacee). — Epithelium of a pseudomucinous cyst. — Kothrock. 608 A TEXT-BOOK OF GYNECOLOGY On section, these cysts are also multilociilar, though, as a rule, they seldom contain so many cysts as the pseudomucinous variety. A cer- tain proportion of serous cysts, especially the larger ones, may appear macroscopically as unilocular cysts, but microscopic examination will invariably reveal the presence of small cysts within the walls of the tumour. As a rule, these cysts contain papillary growths, and they represent the type of proliferating papillary cysts of the old classifica- tion, just as the glandular type is represented by the pseudomucinous variety. Occasionally, however, serous cysts may be of the glandular type and contain no papillary growths. Papillary growths may be very abundant, and may completely fill smaller cyst cavities, and even cause rupture by pressure from in- creased contents, or they may grow through the wall of the cyst caus- ing perforation. Not in- frequently, serous cysts are encountered with papillary growths on their surface as well as in their interior (Fig. 258). These may grow direct from the germinal epi- thelium, or may repre- sent a continuation of intracystic papillary growths which have penetrated the wall of the cyst. Such cysts are al- most invariably accom- panied by ascites. The contents of se- rous cysts consist of a thin, clear, straw - col- oured or greenish fluid, rich in albumin but con- taining no pseudomucin. It is partly derived from cell secretion and partly from transudation from the blood vessels. Histologically, the wall of serous cysts, as of pseudomucinous cysts, is composed of three layers, differing only in the inner layer which is lined by columnar ciliated cells. The papillary growths often present on microscopical section the most picturesque forms, usually consist- ing of rather scant connective-tissue stalks with branching processes extending in every direction from the main trunk (Fig. 259). The epi- thelium covering the papillary growths is the same as that lining the cyst. Not infrequently, deposits of lime salts are to be seen in the papillomatous growths, often presenting a concentric layer arrange- ment; they are termed psammoma. Superficial Papilloma of the Ovary. — Occasionally, noncystic ovaries Fig. 258. — " Serous cysts are encountered with papillary growths on their surface." — Eothrock. NEOPLASMS OF THE OVARIES 609 are covered with papillomatous growths, which are similar in their gross appearances and anatomic structure to those found in cysts. Frequently, they completely cover the ovary, so that it appears as a papillomatous mass which may reach the size of an orange. These growths may originate from per- foration of small cysts which be- come filled with papillomatous growths and afterward spread over the surface of the ovary; or they may grow directly from the ger- minal epithelium, which is perhaps the more common mode of origin. They are frequently bilateral, or may occur in company with a papil- lomatous cyst of the other ovary. Histologically, their structure does not differ from that of papillary growths occurring in cysts. They are invariably covered with ciliated ei^ithelium. Histogenesis. — The origin of proliferating cysts of the ovary is still a matter of much controversy, although the investigations of many competent observers in re- cent years, have done much to throw light upon this obscure sub- ject. Formerly all ovarian cysts were believed to originate in the Graafian follicle. Virchow, after •a careful investigation of colloid cysts, concluded that they were of connective-tissue origin, the result of colloid degeneration of the stroma of the ovary, and that the colloid mass constituting the cyst contents was the product of degeneration. The excellent work of Klebs and Waldeyer in determining the epithelial origin of cysts, has placed the subject of histogenesis on a firm basis. They advanced the theory that proliferating cysts origi- nated from Pfliiger's tubes. More recent investigations have shown, however, that epithelial neoplasms have their origin, not in the em- bryonal Pfliiger's tubes, but in tube or glandlike formations occasioned by a tilting in, and subsequent invagination of, the germinal epi- thelium into the ovarian stroma, which from the beginning must be regarded as neoplasms. According to Pfannenstiel, this dipping in of the germinal opitholium is not to be considered in the same light with embryonal misplaced epithelium in the sense of Cohnbcim's theory, 40 Fig. 259 (Whitacee). — "The papillary- growths often present on microscopical section the most picturesque forms." — EoTHEOcK (page 608). ^IQ A TEXT-BOOK OF GYNECOLOGY but rather as the result of certain pathologic changes which the ger- minal epithelium undergoes. Until comparatively recently, the ger- minal epithelium was considered the sole source of proliferating cysts, but evidence begins to accumulate that they may, and often do, origi- nate in the Graaffian follicle. The careful researches of Flaischlen, Bulius, Steffeck, Frommel, Pfannenstiel, Williams and others, seem to prove beyond doubt, that under certain conditions the membrana granulosa of the follicle may undergo pathologic change and be replaced by cylindrical epithelium, from which cysts may develop in a manner analogous to those devel- oping from the germinal epithelium. Williams, after an exhaustive study of the histogenesis of papillary cysts, concludes: (1) that the Graafian follicle is probably the usual starting point of papillary cysts, and, according as the membrana granulosa is transformed into cili- ated epithelium or not, so will the cyst be lined with ciliated or non- ciliated epithelium. (2) That the germinal epithelium is perhaps the most frequent source of superficial and multilocular papillary cysts. On the other hand, Pfannenstiel has shown that serous or ciliated cysts may develop from the germinal epithelium, it having first under- gone pathologic change, becoming ciliated ; and he regards this as the usual orgin of such cysts, while von Velits entertains the view that most ciliated cysts have their origin in the Graafian follicle. According to Pfannenstiel, pseudomucinous cysts usually originate in the Graafian follicle. The theory advanced by Marchand, that ciliated cysts may origi- nate from tubal epithelium, still remains to be proved. To sum- marize, therefore, it may be said that both pseudomucinous and serous cysts may have their origin in the germinal epithelium or in the Graafian follicle. Metastasis. — Both varieties of proliferating cysts may give rise to metastasis. While pseudomucinous cysts are usually classed with be- nign tumours, occasionally metastases have been observed, especially occurring in the peritoneum, which must be regarded as implantation metastases. They have most frequently been noted in cysts with papillary growths, and they tend to develop underneath the peri- toneum in the form of cystic growths containing gelatinous masses, and have been termed pseudomyxoma peritonei (Werth). They most frequently follow spontaneous rupture of cysts, thus allowing the cyst contents to escape into the peritoneal cavity, though they have been observed to follow operation for the removal of cysts, when they must be regarded as implantations occurring at the time of operation. Various explanations have been advanced in explanation of im- plantation metastasis, but it is generally believed that it takes place at points where, from irritation, as from pressure or operative pro- cedures, the endothelial lining of the peritoneum has been destroyed. These metastases are possessed of no special degree of malignancy, but are particularly prone to recur after removal. NEOPLASMS OF THE OVARIES 611 Metastasis is much more frequently observed to follow serous cysts. The glandular form is benign and does not tend to recur after removal or to give rise to metastasis. The papillary form, however, is particu- larly characterized by the tendency to metastasis which occurs, accord- ing to Pfannenstiel, in the proportion of about 13.3 per cent. Metas- tases almost invariably occur in the peritoneum, and appear as superficial cauliflower growths. They are very persistent, and only complete and thorough removal by radical operation will effect a cure. Malignant Degeneration. — Both varieties of ovarian cysts may un- dergo malignant degeneration. From the epithelial elements, carci- noma may have its origin, while sarcoma may begin in the connective tissue of the wall of the cyst. A cyst can only be said to have under- gone carcinomatous degeneration when the carcinoma is localized in small areas while the remainder of the tumour presents no evidence of malignancy. In case the carcinomatous process is widespread, the tumour must be classed as primarily carcinoma. (See Carcinoma of the Ovary.) Sarcomatous degeneration of the wall of ovarian cysts has been only rarely observed. Cases have been reported by Pfannenstiel, E. Frankel and Kelly. It may occur in the form of a nodule or as a dif- fuse infiltration of a considerable area of the cyst wall. Dermoid cysts, as the name implies, are tumours containing struc- tures resembling skin. They are the least frequent of ovarian cysts, occurring, according to Olshausen, in the proportion of about 3.5 per cent. They are usually small, seldom reaching a size larger than a man's head. They are commonly unilateral, though bilateral tumours are by no means infrequent. Gebhard, among 107 cases, found 16 bilateral. In most instances, they present a smooth external surface, though they may be irregular in outline and be attached to the sur- rounding structures by adhesions. Generally they are attached by a well- formed pedicle, and only rarely do they develop within the folds of the broad ligament. In the majority of instances, they appear as simple cysts, though close examination will frequently reveal the remains of septa or small cysts within the tumour walls. The cyst contents vary in consistence. In pure dermoid cysts they consist of an oily fatty substance, frequently resembling vernix caseosa, which thickens on cooling. It often contains loose hair, which is usually rolled in balls, besides caseous masses that are accumulations of sebaceous matter (Fig. 260). On section, a typical dermoid cyst is unilocular. More frequently, however, dermoid cysts are combined with proliferating cysts in which one or more of the cyst cavities contain dermoid structures. Accord- ing to Pfannenstiel (Veit's Handbucli, vol. iii, p. 366), they are most frequently combined with pseudomucinous cysts, and very rarely with serous papillary cysts. The outer layer of the cyst wall is fibrous and usually thin, while the inner layer consists of a structure )-esembling skin, from which gl2 A TEXT-BOOK OP GYNECOLOGY are frequently found growing appendages of the skin, as hair, teeth, occasionally nails; and in them are developed sweat and sebaceous glands (Fig. 261). Between this layer and the outer cyst wall, is usually found a struc- ture resembling adipose tissue, which consists largely of fat and con- FiG. 260. — "It often contains loose hair . . . besides caseous masses." — Eotheock (page 611.) nective tissue; in it are often found bone, smooth muscle, more rarely nervous tissue, cartilage, and, in a few instances, glandular structures resembling the mammary and thyroid glands have been observed. Very rarely, structures corresponding to the intestinal or respiratory tract have been observed. In these structures, Wilms has recognised an attempt at reproduction of the three embryonal layers — namely, those growing from the ectoderm including skin and appendages; those from the mesoderm consisting of fat, connective tissue, bone, muscle and nervous tissue; and endodermal structures resembling intestines and respiratory tract. As a rule, dermoid structures are found only in a small area of the cyst wall appearing as a nodular raised prominence, which is covered with hair and may contain teeth or bone. The hair in der- moid cysts is as a rule short, though it may, rarely, reach a length of several feet. It is usually of a reddish brown or blonde colour, which is uniform throughout the cyst. Teeth are usually irregularly shaped, often rudimentary, and as a rule only a few are present, though as many as 300 have been reported. They are generally incisors or molars, and are set with their crowns pointing toward the axis of the body. ISTot infrequently, they are set in bone resembling rudimentary jaws. The bones found in dermoid cysts simulate those which lie in positions near hair-covered skin, as the maxillary bones, bones of the cranium. NEOPLASMS OF THE OVARIES 613 or pubic bones. Less frequently, bones resembling long bones have been observed, such as ribs, phalanges of fingers or toes, and even joint- like formations with cartilaginous covering have been described. Earely, brainlike formations have been observed, and in a few instances, also, structures simulating the eye, with retinal pigment. Histologically, dermoids are of the greatest interest from the won- derful variety of structures they contain. Almost every tissue or organ in the body may find its prototype in the structures of a dermoid cyst, though often, it is true, in a more or less rudimentary state. Until comparatively recently, the theory most generally accepted in explanation of the origin of dermoids, was that of inclusion. At the present time, the ovulogenous theory, proposed by Wilms, finds most adherents. In proof of its correctness, there has been advanced the finding of structures in dermoids, corresponding to the three em- FiG. 261 fGEBHARrj). — "In them are developed sweat and sebaceous glands." — Rothrock (page 612). bryonal layers, which is characteristic of ovarian dermoids alone, as compared with those occurring in other regions of the body. In further support of this theory, the fact that they are sometimes met with in the foetus makes it appear that they have their beginning in early life, and that the ovum possesses all the requisites necessary for the de- velopment of the many structures present in dermoid cysts. 614 A TEXT-BOOK OF GYNECOLOGY Malignant Degeneration. — Dermoid cysts may undergo sarcomatous or carcinomatous degeneration (Fig. 263). Sarcoma usually develops in the wall of the cyst. Well-authenticated carcinoma beginning in dermoids has been ob- served in a few instances. It was formerly believed that it was always epidermal in charac- ter. Eecently, how- ever, Yamigiva found a glandular carci- noma which he be- lieved to have origi- nated in a pseudo- mammary gland. Teratoma. — Tera- tomata are tumours closely related to der- moids in their his- togenesis, but differ- ing in their struc- ture and appearance. They are very rare, as comjDared with dermoids, and are solid tumours, or are at least made up largely of solid struc- tures. They are usu- ally unilateral and may reach enormous size. The tumour consists of a conglomeration of embryonal elements resting on a fibrous structure, or stroma, which is rich in blood vessels. They are inclosed in a fibrous capsule, in which may, at times, be found the remains of ovarian stroma. Histologically, they contain the same embryological elements as dermoids. Solid Tumours. — Fibroma of the Ovary. — Fibroma belongs to the rarer ovarian tumours, its frequency being, according to the estimate of Pfannenstiel, between 2 and 3 per cent. It is probable that a num- ber of tumours heretofore described as fibroma were in reality fibro- sarcoma. As a rule, their surface is smooth, though often irregular in outline, and they are usually attached by a pedicle, but may develop within the ligament (Fig. 263). They are usually unilateral, though they may be bilateral. In size, they vary from that of a walnut to that of a man's head, and may rarely weigh as much as 30 or 40 pounds. Usually no ovarian structure can be recognised. They vary in consistence. When the tumour consists of pure fibroma it is firm. Occasionally, the tumour may be cystic from the presence of dilated lymph or blood vessels, or cystic cavities may result from degeneration or necrosis. Fig. 262. — "Dermoid cysts may underoo . degeneration." — Kothkoc k carcinomatous NEOPLASMS OF THE OVARIES <;i5 Fibroid tumours of the ovary may undergo fatty or myxomatous de- generation, or contain calcareous deposits. Histologically, they are composed of fibrillary connective-tissue bundles which run in all directions, and smooth muscle fibres may be present, though as a rule they are scanty (Fig. 264). Earely, combinations with other tumours are observed, as with ade- noma and sarcoma, and the former may degener- ate into carcinoma or develop cystic cavities containing colloid sub- stance. When smooth muscle is present, the tumour is properly termed fibromyoma. A few cases of pure myoma of the ovary have been described, but they are very rare. Calcified tumours of the ovary have been ob- served from time to time; they have general- ly been regarded as oste- omata, but the careful investigations of Whit- ridge Williams have established the fact that they contain no bony tissue. Schlenker published a description of this condition about the middle of the eighteenth century, and was followed a few years later (1760) by Le Clerc de Beaucoudray, with a description of an ossified ovary. From that time until the present, numerous similar descriptions have appeared, all of them obviously based upon the original miscon- ception as to the true character of the growth. The process of calcifica- tion may (a) occur in the ovarian stroma; or (&) be restricted to the Graafian follicle. Calcareous Tumours of tlie Ovarian Stroma. — These growths, if such they may be called, are generally small, the ovary containing them rarely exceeding 7 centimetres in its longest diameter. In one case examined by Williams the ovary revealed many cicatrices, but no adhesions, upon its surface. On section, one end was found to be occu- pied by a hard roundish nodule 12, 16, and 18 millimetres in its various diameters (Fig. 265). This nodule occupied an apparent capsule with which it was connected by numerous connective-tissue bands. On Fig. 263 (Maetin). — " As a rule, their surface is smooth, though often irregular." — Kotheock (page 614). 616 A TEXT-BOOK OF GYNECOLOGY Fig. 264 (Whitacre). — " They are composed of fibrillary connective - tissue bundles which run in all directions." — Rotheock (page 615). sawing through the nodule^ which was of bony hardness, its cut sur- face presented a mottled appearance and the general colour of bone. At one side of the ovary were found the corrugated walls of an old corj)us luteum, about 13 millimetres in diameter. Here and there were seen several follicles with clotted contents. On the other side, the ovary revealed a hard large nod- ule measuring 7, 6, and 5 centi- metres in its various diameters. From the anterior and inner sur- face of the ovary there developed a number of small pedunculated fibromata, the largest being 6 millimetres in diameter. From the neighbourhood of these small fibromata, the ovarian tissue cov- ering the hard nodule began to decrease in thickness, soon be- coming as thin as a sheet of pa- per. This thin capsule was per- forated in a number of places, through which perforations the surface of the hard mass was visi- ble. This mass weighed 220 grammes, was extremely hard, and re- sembled ivory in its general consistence. When thrown upon a hard surface it rebounded like a billiard ball. On section, its surface was mottled, presenting an appearance similar to that of the smaller nodules of the other ovaries. Dry sections of both masses revealed no trace of bony struc- ture. Microscopical sections made after decalcification by a 10-per-cent solution of nitric acid, showed that both masses were iden- tical in structure. They were composed of typical fibrous tis- sue made up of bun- dles of dense connective tisuse, which interlaced in all directions, and possessed but few long nuclei. The tissue resembled that found in the hilum of the ovary, except that it was poorer in blood vessels, and con- tained more veins than arteries. Scattered all through it, were irregu- lar-shaped areas of various size, which stained deeply with hematoxylin. Fig. 265. — " On section, one end was found to be occupied by a hard roundish nodule."— Keed (page 615). NEOPLASMS OP THE OVARIES 617 They generally presented sharply marked contours, and, in their in- terior, revealed signs of striation, but no trace of nuclei could be found within them. Here and there, under a high power, could be seen individual cells which had lost their nuclei and presented the typical appearance of coagulation necrosis. Single cells, each containing a calcareous granule, and others which were entirely calcified, were ob- served. The general mass had manifestly developed by a process of cell coalescence. Calcareous tumours of the corpus luteum have been observed by Bland Sutton, Coe and others. Coe's case was examined and reported upon by Whitridge Williams substantially as follows: The ovary was 5 centimetres long and 2.5 centimetres deep; on its surface were numerous cicatrices but no adhesions; in its centre was a hard mass 13 millimetres in diameter, of bonelike consistence. When sawn through, it was seen to consist of two portions, a soft pinkish central portion, and a hard bonelike outer portion, 2 millimetres thick, and of a distinctly yellow colour. The central portion of the nodule re- sembled partially organized blood clot. The rest of the ovary presented a normal appearance. Microscopic examination after decalcification and section of the mass, revealed no signs of osseous structure. The decalcified sections stained poorly, but the hard exterior of the nodule stained readily with hematoxylin and presented a more or less homo- geneous granular appearance, in which it was impossible to distinguish nuclei. This tissue was surrounded by typical ovarian stroma, which also stained poorly. The central portion of the nodule was composed of dense fibrous tissue which was very poor in cells. Between this and the decalcified portion, were layers of small cells, possibly corresponding to the membrana granulosa, though it is impossible to state their origin with certainty. In the surrounding ovarian stroma were numerous round stellate crystals, which were thought to be the result of the decalcification. The specimen was looked upon by Williams as in all probability representing a calcification of the large cells which sur- round a ripe G-raafian follicle and form the yellow margin of the corpus luteum. The causes of calcification within the ovary probably do not differ in general from those producing that condition in other parts of the body. The deposit of calcareous salts, first, in foci which, coalescing, form the larger masses, is recognised b}^ Cohnheim, Litten, and Whit- ridge Williams, as following only certain varieties of necrosis, par- ticularly those characterized by coagulation. The calcification of ne- crotic areas is explained by the chemical affinity which exists between the necrotic tissue and the calcium salts circulating in the blood, prob- ably as a soluble albuminate. It is assumed that the soluble albumi- nate, by virtue of chemical affinity, mingles with the material of the dead cells forming an insoluble albuminate of lime which is deposited in them. That this general law of calcification is operative within the ovary, becomes apparent when it is remembered that that organ is liable QIS ' A TEXT-BOOK OF GYNECOLOGY to fibroid changes, to displacements, and to other mechanical interfer- ence with its circulation, all of them calculated to induce more or less cell necrosis. The symptoms of calcareous tumours of the ovary are in no sense characteristic. The diagnosis of this condition has probably never been made before operation. There is, therefore, no special treatment, other than that which applies to other solid tumours of the ovaries. When discovered they should be removed. (See Ovariotomy.) Hematoma of the Ovaries. — Follicular hemorrhage is of common occurrence, being due to the rupture of vessels in the wall of the ovisac. But the term hematoma is usually applied clinically to tumours above the size of a hazelnut. In the case of hemorrhage into a follicular cyst, they may reach the size of a small orange. While excessive hypergemia of the ovary may lead to interstitial hemorrhage, so-called apoplexy of the gland is probably always secondary to rup- ture of a follicular hematoma. Causes and Pathology. — Venous stasis leading to the rupture of veins in the walls of dropsical follicles may be due to pelvic conges- tion from any cause, such as sexual excitement or excess. Its occur- rence in connection with neoplasms, ectoiDic gestation, and abortion, is similarly explained. Hematoma is often associated with tubal dis- ease, especially when there are many adhesions or torsions of the pedicle. General follicular hemorrhage and apoplexy have been noted as the result of profound alteration of the blood in extensive burns, phosphorus poisoning, and in the acute exanthemata. An ovary which is the seat of general follicular hemorrhage, is enlarged to two or three times its normal size, dark red nodules as large as a pea or marble appearing on its surface. On section, these are seen to be cir- cumscribed collections of semifluid blood or coagula in various stages of absorption. Or a single tumour may include almost the entire ovary, only a small portion of the stroma remaining. The usual changes occur in the blood until only a clot or mass of fibrin is found. The cyst may become infected through its proximity to the gut or Fallopian tube. The internal pressure may become so great that it ruptures, and an intraperitoneal hematocele develops; but it is doubt- ful if sufficient blood ever escapes to endanger life. Symptoms and Diagnosis. — In spite of the statements in text- books, it is questionable if the symptoms of ovarian hematoma are suf- ficiently characteristic to warrant a positive diagnosis; in fact, the condition is usually found on opening the abdomen for supposed in- flammatory disease. The sudden occurrence of severe throbbing pain in the region of the ovary, with marked enlargement and tenderness, but without rise of temperature, in connection with conditions leading to excessive pelvic congestion, would point to a rapid effusion of blood into a follicle. The sudden enlargement of a pre-existing cystic ovary would be still more significant. Should the cyst rupture, the usual symptoms of intraperitoneal hemorrhage would develop, though it NEOPLASMS OP THE OVARIES 619 would be exceedingly difficult to diagnosticate it from early rupture of an ectopic sac. After the acute stage, or in cases of slow oozing, the symptoms are those common to ovarian disease, and are often masked by those of localized peritonitis. Treatment. — The treatment of acute hemorrhage consists in rest, ice-bags, low diet, regulation of the bowels, and the avoidance of any influences tending to increase pelvic .congestion. True hematoma of the ovary is a surgical condition, and calls for removal of the affected ovary, or of the blood sac alone if a portion of healthy stroma can be preserved. Malignant Neoplasms Primary carcinoma of the ovary is the most common form of ma- lignant disease of the ovary. While varying greatly in form and appearance, it admits of division into two groups, each of which is represented by a more or less distinct type. Group I. Medullary Carcinoma. — The first group consists of solid tumours. They are of more or less firm consistence, usually rounded or oval in shape, though often irregular in outline, and frequently present a nodular or lobulated appearance. They vary in size, rarely, however, exceeding that of the head of a newborn child. As a rule they form their attachment by a short thick pedicle, and usually they lie free in the abdominal cavity; only very rarely have tumours been observed which were partially intraligamentary. JSTot infrequently, they are bilateral though unilateral development is the rule. They are inclosed in a dense fibrous capsule, and, on section, pre- sent a more or less homogeneous surface of yellowish or gray white colour (Fig. 266). Frequently, in softer tumours, the appearance is brainlike. Occasionally, the tumour will have a mottled appearance from extravasa- tions of blood into the tumour substance, which, if recent, may be coagulated, or if of long standing, may appear as an extrav- asation cyst simulating those often foimd in cerebral hemorrhage. Degeneration changes are of common occurrence, espe- cially caseous and fatty changes, with re- sulting softening and the formation of cystlike cavities. The contents of such ■^ , , 1 -n IP m • 1 1 Fig. 266 (Gebhard).—" They are cysts are turbid and of a yellowish colour, .^^^j^^^^ -^ ^ ^^^^^^^ ^^^^^^ ^^p. while their walls present an irregular and suie."— Eothrock. uneven outline. Histologically, they are composed of a more or less diffuse infiltration of a fibrous stroma with carcinomatous cells. In some instances, the fibrous stroma predomi- nates, forming alveoli which are filled with carcinomatous cells. More frequently, however, the microscopic appearance is that of a diffuse* infiltration of the rather sparse fibrous stroma, so that the cellular ele- 620 A TEXT-BOOK OF GYNECOLOGY nient constitutes the greater part of the tumour, in which case it is termed medullary carcinoma. Group II. Adenocarcinoma. — The second group consists of cystic tumours which bear a striking resemblance in their external appear- ance to serous cysts. They are rounded or oval tumours, and rarely exceed in size an adult's head, being usually smaller. They are gen- erally attached by a short pedicle, though they may develop within the ligament, and are frequently adherent to the surrounding viscera. Like serous cysts, they are often bilateral and are usually multilocular, though they may at times appear unilocular. According to Pfannenstiel, papillary growths are observed on the external surface of the cyst in about half the cases. On section, the cyst wall is composed of connective tissue which is often quite friable. Frequently the wall of the cyst is very much thickened in spots from the development in it of carcinomatous nodules. Growing from the internal surface, may usually be seen papillary and cauliflower growths at times almost filling the cyst cavity. The cyst contents may be clear, but more frequently they are turbid from the presence of cellu- lar elements, or they may be blood-tinged from hemorrhage into the Fig. 267. — " Cystic carcinoma of the ovary is almost invariably papillary." — Kotheock. cyst. Cystic carcinoma of the ovary is almost invariably papillary (Fig. 267). The papillary growths are often similar in appearance to those of the papillary cysts, still, on section, their carcinomatous nature may often be recognised by the naked eye. Histologically, they belong to the adenocarcinomata, and often the same tumour presents a great variety of structure. The solid masses, NEOPLASMS OF THE OVARIES 621 which are found in the wall of the cyst, may consist of a diffuse infil- tration of a medullary character. More frequently, however, such nodules and cauliflower growths are not really solid but are made up of papilla and glandhke formations, the lumen of which is still plainly visible. Everywhere an atypical proliferation of epithehal cells is present, and in papillary growths, instead of being covered with a single layer of cells as in cystadenoma, the epi- thelium will be replaced by several layers of cells asymmetrically arranged (Pig. 268). The same peculiarity is observed in the glandlike formations in which, instead of be- ing lined with a single layer of cells, the lumen will frequently be filled with a iDroliferation of cells giving it an alve- olar appearance. Not infrequently, lime salts become depos- ited, especially in the papillary growths, with the formation of psam- moma. Between cystad- enoma (Fig. 269) and this type of primary carcinoma, every gTadation exists, and so gradual is the transition that it is not always possible to distinguish between them. Ziegler {Pathologisclie Anatomie, page 335) admits that no sharp dividing line can be drawn between adenomata which are benign and those which are malignant. Pfannenstiel estimates that fully one half of all papillary tumours of the ovary belong to the carcinomata, but, according to his view, almost all cases which ultimately become carcinomatous should be classed as primary carcinoma. The adenoma from which the carci- noma develops, he regards as representing an intermediary stage, but at the same time he admits that there is no means of distinguishing it from benign adenoma. Most authors, however, take a middle ground, and regard a considerable number of such tumours as carcino- matous degeneration of primary benign tumours. The microscopic evidence of malignant change consists in a pro- liferation of the epithelial cells with atypical arrangement, as, for example, instead of the uniform single layer of epithelium are to be seen masses of cells, asymmetrical in their arrangement, and tending to form several layers (Fig. 270). Metastasis is of frequent occurrence, tending to involve first of Fig. 268 (Whitacee). — " Every where an atypical prolif- eration of epithelial cells is present." — Eothbock. 622 A TEXT-BOOK OP GYNECOLOGY all the peritoneum, next the omentum, liver, stomach, intestine, and occasionally, the pleura. Where the disease is unilateral, the ovary on the opposite side is frequently the seat of metastasis, and Steffeck has often found it to contain metastatic deposits, when macroscopically it Fig. 269 (Whitacre). — Cystadenoma. — Kothrock (page 621). appeared normal. Heinrichs observes, also, that bilateral develop- ment is commonly the result of metastatic involvement from one ovary to the other. Secondary carcinoma of the ovary is rare, and usually follows car- cinoma of the uterus, especially of the body. It has, however, been observed to follow carcinoma of the stomach and mammary gland, the- result of metastasis. Like other epithelial neoplasms of the ovary,, primary carcinoma may have its origin in the Graafian follicle or in the germinal epithelium. Sarcoma of the ovary is of much less common occurrence than car- cinoma. Cohn estimates the frequency as compared with ovarian. cysts at 1 per cent, and as constituting 10 per cent of malignant tumours of the ovary. On the other hand, Pfannenstiel, in 400 ovari- otomies, found sarcoma of the ovary in the proportion of 5.38 per cent. With these, however, he included endothelioma. Primary sarcoma of the ovary may occur at any period of life, in childhood as well as in advanced age, and Doran has observed it in- NEOPLASMS OP THE OVARIES 623 volving both ovaries of a seven months' foetus. It appears to be more frequently met with, however, between the ages of twenty and thirty. It is frequently bilateral, though, as Heinrichs observes, this may sometimes be the result of metastasis, only one ovary having been pri- marily involved. Sarcoma belongs to the solid tumours of the ovary, and is usually rounded or cylindrical in shape with a smooth sur- face, though it may be irregular in contour, pre- senting a nodular appear- ance. The size of the tumour varies and may sometimes reach a weight of 20 to 30 pounds or more, if left to run its course without surgical intervention. Usually, however, the presence of the tumour is manifested by symptoms before it attains a great size. The consistence of the tumour depends upon its histologic structure. If made up largely of spindle cells, it will be firm, resembling fibroma, whereas, if composed chiefly of rovmd cells, it will be soft, and often of brainlike consistence. Frequently, these tumours contain much fibrous tissue, when they are called fibrosar- coma. Usually, the entire ovary is replaced by the tumour mass, though, occasionally, the remains of ovarian tissue may still be seen on its surface. The tumour is commonly surrounded by an outer wall, which is in many instances so thin and delicate that the fingers may be thrust through it. These timiours are usually attached by a short pedicle, and are seldom adherent to the neighbouring viscera, but are frequently accompanied by ascites. On section, they represent a yel- lowish white, gray, or pink surface, the colour depending on their structure and blood supply. Cyst formations are by no means infre- quent, and are usually the result of hemorrhagic infarcts or extrava- sations of blood into the tumour substance with subsequent soften- ing, or of fatty degeneration of the tumour cells. Histologically, sarcoma consists of a diffuse infiltration of the ovarian stroma by sar- coma cells, the variety most commonly found being round or spindle cells (Fig. 271). Frequently both round and spindle cells are present in the same tumour. Fig. 270 ( Whitacee). — " The microscopic evidence of malignant change consists in a proliferation of the epithelial cells with atypical arrangement." — Eoth- BOCK (page 621). 624 A TEXT-BOOK OF GYNECOLOGY Fig. 271 (Whitacee). — ''Sarcoma consists of a ditfuse infiltration of the ovarian stroma by sarcoma cells." — Kothrock (page 623). In the order of malignancy, the small round-celled variety stands first, while fibrosarcoma appears in many instances to be relatively benign. Eothrock has observed a case of spindle-celled sarcoma involving both ovaries, in which the patient died of metastasis to the perito- neum six months after operation for their removal. Metastasis to other organs of the body occurs, acording to Te- mesvary, in the following order of frequency: peritoneum, omentum, stomach, pleura, lungs, uterus, liv- er, diaphragm, kidney. Sarcoma of the ovary frequently undergoes de- generative changes, the most com- mon of which, are myxomatous and fatty degenerations. Endothelioma of the Ovary. — Occupying an intermediate place between carcinoma and sarcoma, there is a group of malignant tu- mours of the ovary possessing many of the clinical features of both, but differing from them in anatomic structure. Leopold, first, in 1874, de- scribed a case under the name of lymphangeioma cystomatosum. Tu- mours of similar structure had, previously to this, been frequently ob- served occurring in other regions of the body, and were called angio- sarcoma and lymphangeiosarcoma. Marchand, in 1879, was the first to give a detailed description of these tumours and to distinguish them from both carcinoma and sar- coma, in spite of the great similarity in many respects to the struc- ture of both. He named them endothelioma, thus denoting their origin from the endothelium of the blood or lymph vessels. Since then, tumours of the same kind have been described by different au- thors, so that we may now form some conclusions concerning the most important features of these growths. Endothelioma of the ovary is, in most instances, a solid tumour (Fig. 272). It has been met with most frequently in middle age or beyond it, though Leopold has observed it in an eight-year-old girl, and Olshausen in a girl seventeen years of age. These tumours vary in size from that of a closed fist to that of a man's head, and are usually unilateral, though bilateral tumours have been observed. In shape, they are commonly rounded, or they may be multinodular or lobulated. The surface of the tumour may be smooth or rough, and its consistence firm or soft. Usually the tumour is attached by a short pedicle, and it frequently forms adhe- sions to the surrounding structures. NEOPLASMS OF THE OVARIES 625 Fig. 272. — "Endothelioma of the ovary is in most instances a solid tumour." — Eoth- EOCK (page 624). On section, the cut surface is of a yellow, gray, or white colour, often brainlike in appearance and consistence, and easily torn by the finger. Frequently, it is made up largely of fibrous structure in which are present nodular areas of softer consistence. Again the tumour may be composed of numerous small cysts in a rather dense stroma, thus giving it a honey- combed or worm-eaten appear- ance (Pick). In other instances, the tumour appears cavernous, or may be laminated in struc- ture. Cyst formation occurs ■chiefly in the lymphatic variety. Earely, papillary formations have been observed within the cyst, the histologic structure of which is fibrous. These tumours have their origin in the endothelium of the blood and lymph vessels, and, histo- logically, they present the greatest variety of structure (Fig. 273). Pick has distinguished three types: (1) A rosarylike form, consisting of chains of cells arranged in rows, lying in narrow spaces or clefts in the stroma; their borders run parallel, and they frequently anastomose with each other or send off branches. (2) The second con- sists of glandlike forma- tions which, on trans- verse section, furnish a picture often difficult to distinguish from adeno- carcinoma, as the lumen of these glandlike spaces is often encroached upon by several lay- ers of polymorphous cells. (3) The third form consists of a histologic formation resembling alveolar sarcoma, and appears as groups of roiirifled epithelioid cell Ijodies filling alveolalike spaces in the rather dense fibrous stroma. Not infrequently, all three types may be found in the same tumour. 41 Fig. 273 (Whitaoke). — " Histologically they present the greatest variety of structure." — Rotiirock. 626 ^ TEXT-BOOK OF GYNECOLOGY Endothelioma is frequently found in combination with other tumours of the ovary. The cases of Eckhard, Flaischlen, and Po- morski, were cystic, and contained dermoid structures, while Pfannen- stiel has observed a combination of endothelioma with true epithelial cystadenoma. They are very prone to undergo degenerative changes,, the most common being hyaline and myxomatous degeneration, while colloid and fatty degeneration have also been observed. Clinically, they are malignant. In a case of Leopold's, which was unsuited to operation, the patient died of cachexia within six months. As regards recurrence following operation, there are only scanty data available upon which to base an opinion. Of 7 cases tabulated by von Yelits, only 3 recovered from the operation. In 2 cases, metastasis was observed, while 4 had pronounced cachexia. Billroth regarded, these tumours as in the same order of malignancy as carcinoma. CHAPTEE XLI NEOPLASMS OF THE OVARIES (Continued) Complications— Symptomatology — Diagnosis — Treatment — Ovariotomy : History, technique, results — Incomplete ovariotomy — Ovariotomy during pregnancy. The complications of ovarian tumours are various as there is no rea- son why an ovarian tumour should not develop in the presence of any other visceral lesion. These growths occur, therefore, coincidently with neoplasms of the uterus, cysts of the mesentery, nephrydrosis, hypertrophies of the spleen, enormous distentions of the gall bladder, cysts of the urachus, etc. Among the more important complications, however, are (a) pregnancy, (b) torsion of the pedicle, (c) ascites, (d) albuminuria, (e) adhesions, (/) rupture of the tumour. Pregnancy as a complication of ovarian tumour is not an infre- quent occurrence in practice. Sir Spencer Wells, after an experience in ovariotomy greater than any which had then fallen to the lot of any other man, observed that, " certainly the most common mistakes in the diagnosis occur when the tumour is enlarged from some cause, and pregnancy is the most common of all causes of enlargement of the uterus. When a patient has no reason for deceiving her adviser, doubt or difficulty will often arise; and in cases of pregnancy, real or sus- pected, the patient may mislead the surgeon intentionally, or from her own hopes or fears biasing her judgment." This complication is always a condition of serious import. Pregnancy is liable to give a fresh impetus to the growth of a tumour, while the tumour, in turn, may exercise a deleterious influence upon the gravid uterus. Abortion is not an infrequent sequence. If the case goes to term, rupture of a thin-walled cyst is liable to occur as the result of the muscular con- traction of the abdominal wall. Inflammation resulting in adhesions between the cyst and either the intestines or abdominal wall, or both, may be induced. Twisting of the pedicle may occur as the result of the changed position of the cyst following the collapse of the parturient uterus. Gottschalk (Frauenarzt) has reported a case of infection of the cyst by the colon bacillus, and Zetter has reported 21 cases of cyst infection occurring during the puerperium. The mortality, both maternal and foetal, is very high in these cases when left to themselves. Heiberg found that 25 per cent of mothers, and 75 per cent of children, died in 271 cases in which pregnancy, coexisting with ovarian tumour, was permitted to go to term. Zetter 627 628 A TEXT-BOOK OP GYNECOLOGY gives the maternal death-rate at about 30 per cent, while Litzmann places it at 43 per cent. Torsion of the pedicle, as the result of axial rotation of the tumour, occurs with sufficient frequency, and is a complication of such gravity, as to entitle it to consideration in this connection. Knowsley Thorn- ton found a twisted pedicle 57 times in 600 cases of ovariotomy. It is a complication to which Eokitansky first called attention in 1865. He described 13 cases, 8 of them having been encountered in post- mortem examinations made in 58 cases of ovarian disease. Sir Spencer Wells, Kolb, Peaslee, and Barnes, were among the early observers of this complication. The causes of axial rotation of ovarian tumours have been the sub- ject of repeated speculation. Tait advanced the theory that descending masses of faecal matter caused the tumour to turn. Doran believes {Tumours of the Ovary) that the twisting of a pedicle is to be explained by the simpler doctrine that the tumour, pressed upon by the viscera, and even by the costal cartilages above and the pelvic structures below, but comparatively free laterally and anteriorly, rotates on its own axis every time the patient after walking or lying on her back turns round and rests on her side. Accidents, direct violence, sudden strain, and sudden change of position, were the determining causes of the attack in 8 of Thornton's cases. Pregnancy seems to bear a causal rela- tion to the complication. The pathologic changes are dependent upon the mechanical obstruction to the efferent circulation. The compara- tively firm and relatively noncompressible arteries continue to pump blood into the tumour, while the obstructed veins can not carry it out. As a result, there is an enormous increase in the volume of the growth, accompanied by acute pain which is referred chiefly to the pedicle, a fact which Thornton considers due to the pressure to which the nerves are subjected at that point. In extreme cases, the pain extends over the entire area of the tumour. Coincidently with this turgescence of the tissues, there occurs a transudation of sanguiferous elements upon the surface of the tumour. In some cases, the blood vessels rupture either into the peritoneal cavity or into the cavity of the tumour. Secondary rupture of the hemorrhagic tumour, the blood and pseudo- mucinous contents escaping into the peritoneum, has been noted. The incised wall of a tumour the pedicle of which has been twisted, reveals numerous hemorrhages, varying from punctate clots to large hematomata. While, as a rule, these tumours perish by the necrosis induced by strangulation, there are exceptional instances in which they have survived by virtue of nutrition derived from the newly formed peripheral adhesions. These are a distinct feature of the patho- logic changes observed in the majority of cases. Eeed has had a case in which there was a distinct history of rotation of the tumour, but in which operation was denied because the patient was in extremis. After several days her symptoms began to improve, and six months later she was in good health with a tumour of diminished volume. NEOPLASMS OF THE OVAEIES 629 The symptoms of twisted pedicle are^, sudden pain in the ovarian region, which may extend rapidly over the area of the tumour, and rapid increase in volume of the tumour, the patient manifesting signs of shock, associated sooner or later with evidences of systemic toxaemia. Vomiting may or may not be present. The diagnosis is not difficult if an ovarian tumour is known to exist. There is frequent extensive peritoneal tenderness. The treatment of this condition is by immediate ovariotomy. The changes observable in a cyst with a twisted pedicle are, first, oedema of the cyst wall, and, next, distention of the sac. Serous exu- dation from the circulation, following in the direction of least resist- ance, takes place as a rule into the cyst cavity rather than upon its surface. A certain amount of transudation is, however, observable on the surface, a condition which favours the speedy development of ad- hesions. The blood pressure becomes so great that hemorrhages fre- quently occur, as a rule into the cavity of the cyst, but occasionally upon the surface. It is rare that the cystic fluid in these cases is not discoloured by blood elements. The blood pressure may become so great as to induce cell necrosis. The treatment of twisted pedicle is incontestably by operation; " the only question admitting of discussion," says Eichardson {Virginia Medical Semimonthly), " is that of the most advantageous time. The conditions in one case demanding operation, in another justifying it, are not unlike those seen in appendicitis and in extrauterine preg- nancy. Under some circumstances intervention should be delayed for a more favourable moment; under others it can not be too prompt. " It can not be too prompt when the lesion is recognised before shock has become profound, and before sepsis has become pronounced. Nor can it be too early when the symptoms are increasing, even if shock and sepsis are grave enough seriously to compromise the imme- diate success of intervention. When, however, the patient is improv- ing, when the immediate effects of hemorrhage, of sepsis, or of both, are being recovered from, then the wisdom of intervention must be questioned. The patient must be carefully watched and a time awaited when she can safely withstand the added shock of operation. In the lesion under consideration the pulse is the most valuable guide. What- ever the other signs may be, whether the temperature be high or low, whether there be tenderness or not, whether there be distention, rigid- ity, vomiting, obstipation — in a word, whether there be general peri- tonitis or not, the tumour should be removed immediately if the pulse is good. More than this, it must be removed if it is getting worse. On the other hand, a pulse that from being bad is rapidly improving, justifies p short delay, even if other signs are bad. When all signs, from being grave, are improving, a reasonable delay is but common sense. To wait for improvement when there is no sign of improvement seems to mo unjustifiable; for too often, especially in hemorrhage, there will be no improvement. The risk of intervention must be taken. 630 ' ^ TEXT-BOOK OF GYNECOLOGY When bleeding is suspected, and when the pulse is poor or impercep- tible, intravenous injections of salt solution should be made, and the utmost speed of enucleation used. In the profound shock of general peritoneal infection without hemorrhage, salt solutions may also be used, but here one must not be disappointed by failure. In hemor- rhage, an infusion of salt solution into the veins adds the circulating medium needed by the flagging heart; in sepsis it simply dilutes an abundant supply of vitiated blood — in the one case it tides the patient successfully over a grave crisis; in the other it merely postpones the fatal event. " Whether delay be practised or not, every efl^ort should be made to add to the j^atient's strength. In addition to intravenous injections, stimulating enemata of hot salt solution and brandy and coffee should be given. If not vomiting, the patient should be given stimulants by mouth. Hypodermic injections of strychnine, brandy, ether, and other cardiac stimulants may be given. The whole body should be kept warm by means of hot-water bottles and hot blankets, and the foot of the bed should be elevated. While the strength is being re- stored in this manner, preparations for operation should be made. It is important, especially if free blood is in the abdominal cavity, that the operation be extremely aseptic, because infection is so apt to take place after hasty preparations of the operative field. Yet in advancing shock and hemorrhage it may not be possible to sterilize thoroughly the field, lest the patient die before the operation can be begun. The risk of infection from hasty and incomplete preparation must there- fore be taken. " It must not be inferred, however, that so hasty an intervention is always demanded. In all but one of the cases here reported the operation was performed after due consideration; the patient recovered fully from the initial shock, and was operated upon some time later. In but one was immediate operation performed, and in that case there was already a fatal gangrene. Hemorrhage was an important factor in but one instance." Ascites is sometimes caused by an ovarian tumour vidth which it may then coexist as a complication. It is to be remembered, however, that in many of these cases, the intraperitoneal accumulation of fluid may be the result of cardiac, renal, oi' hepatic disease. Care should be exercised to ascertain as nearly as possible the exact condition of these organs, and their possible causal relation to the ascites. If any of them present diseased conditions they should be subjected to appro- priate treatment. It is true that this treatment may sometimes need to begin Avith ovariotomy, for renal, hepatic, and intestinal complica- tions may be caused in the first instance, either by direct pressure from a large ovarian tumour, or by the mechanical interference of that tumour with the portal circulation. As a rule, however, such condi- tions may be found amenable to treatment before ovariotomy is per- formed, and when this can be accomplished it should be done. Douglas NEOPLASMS OP THE OVARIES 631 says that a small tumour, with ascites appearing early, is strongly pre- sumptive of malignancy. If the ascites is from obstructed circulation, the liquid will be a limpid fluid resembling water, perhaps slightly coloured, containing a little albumin but no fibrin, and giving no sediment. If the ascites is from peritoneal inflammation, the liquid will be thinner but never transparent, always cloudy, looking like but- termilk, and smelling like decayed cheese. If the effusion is from simple serous irritation, the liquid will be albuminous, rather clear, though sometimes coloured like bile. In the sediment will be found ele- ments of great importance. Large irregular cells may be seen, having a central nucleus surrounded by a quantity of granulations. The presence of these cells is usually taken as a sign of malignant growth. Albuminuria is of frequent occurrence in connection with the larger cysts of the ovary. When the growth attains such a size that it exerts pressure upon the kidneys, albumin is almost s^ire to appear in the urine, the condition being practically analogous to that which is frequently found in pregnancy. If the disease has been of long standing, the changes thereby induced in the kidney may have reached the destructive degree. It is highly important, as a matter of routine, that the urine be investigated in all these cases before operation. The facts thereby elicited will have an important bearing upon the selec- tion of an anaesthetic and upon the prognosis of the case. Adhesions are liable to occur as the result of mechanical hypergemia, traumatism, or infection of the tumour. Adhesions may be single or multiple, firm or friable, local or general, and may bind the tumour to either the visceral or the parietal peritoneum. Adhesions between the tumour and the intestines, the abdominal wall, or the omentum, ^re naturally the more frequent. While it is true that peritonitis ordi- narily results in the formation of adhesions, yet, Douglas and others have reported cases in which such a result did not follow distinct in- flammatory attacks. Persistent, definitely localized pain, of the trac- tion variety, at some point of the surface of the tumour is suggestive of adhesion, but the condition can not be said to present a definite ■symptomatology. Rupture of the tumour, when cystic, may be induced by overdis- tention, papillomatous degeneration, infection, or violence. It fre- quently happens that, in cysts of the pseudomucinous variety, the secondary peripheral growths have very thin walls, and are, conse- quently, more liable to rupture from any of the preceding causes. The larger sacs, however, have been known to empty their entire contents into the peritoneal cavity. This is an accident which may or may not produce profound symptoms. If the rupture is slight, the sac small, and the fluid bland, the accident may be almost symptomless; whereas, if the rupture is extensive, the sac voluminous, and the fluid irritating or septic, the symptoms may be those of profound shock, followed by acute peritonitis and septicaemia. There is no means of determining in ad- vance of exploration the exact character of the fluid of any ovarian 632 A TEXT-BOOK OF GYNECOLOGY tumour. Pure pseudomucin is not irritating, nor is it septic, but if the tumour has become the seat of infection, however slight, this ma- terial serves as a convenient culture medium, and may thus become the source of contamination. When there are grounds for suspecting rup- ture of the sac, the indication is for inunediate operation by abdominal section. The symptomatology of ovarian neoplasms is sometimes very ob- scure. In certain forms of ovarian growth, notably in dermoids, there is pain from a very early period. In a majority of cases, however, there is nothing more than a vague sense of discomfort in the pelvis, due to the weight and tension exercised by the developing tumour. In many cases, there are no symptoms whatever to attract attention to the pelvis until the patient by accident discovers that she has an en^ largement in either one or the other lower quadrant of the abdomen. There may or may not be disturbance of the menstruation, and, even in ovarian tumours of large development, the menstrual function seems to be but slightly modified. This modification of function may tend in the direction of either increase or diminution of the flow. In those cases in which the flow has increased, there will generally be found an antecedent history of pelvic disturbance — probably of an endo- metritis. In cases of amenorrhoea due to developing ovarian cystoma,, the disappearance of menstruation, coincidently with abdominal dis- tention, may lead to a suspicion of pregnanc3^ Cases of this kind are of frequent occurrence. While the tumour is yet relatively small, it occupies a position within the true pelvis, but as it grows larger it ascends into the abdominal cavity just as does a pregnant uterus. When the tumour is yet within the pelvis, its weight generally causes. it to fall into the cul-de-sac of Douglas, usually either to one side or the other of the uterus. At this stage of its develo23ment, bimanual examination will enable the surgeon to outline the growth, and per- haps to determine from which side it develops. It is generally felt as a hard, or semi-fluctuating globular mass, its spherical outline being readily detected by palpation through the abdominal wall. To deter- mine the side from which it develops and the location of its pedicle, Hegar advises drawing down the uterus with a tenaculum, employing the rectal touch or bimanual manipulation to outline the attachment. The mobility of the tumour depends upon the length and size of its pedicle, which is sometimes long enough to permit the growth to be carried far up to the pelvic brim, while in other cases it is so short that the tumour feels more like an abscess than a neoplasm. In some eases, the tumours are bilateral, a circumstance which may readily be confused with a multiloeular or a multinodular growth. The uterus is very liable to be displaced to either one side or the other — or, as occasionally happens, the growth may be poised above and behind the womb, forcing the latter forward into a state of extreme ante version. As the tumour grows larger, however, and descends into the abdominal cavity, its spherical outline becomes more and more apparent by NEOPLASMS OP THE OVARIES (533 abdominal palpation. Irregular bosses or protuberances upon the surface of the growth indicate that it is multilocular. On percussion, the tumour will yield dulness over its entire area. One of the essential diagnostic signs relied upon by Dunlap, who was one of the very earliest of the world's ovariotomists, was the position of the intestines. As the tumour develops from one side or the other of the pelvis, the bowels are pushed upward and toward the opposite side. Abdominal reso- nance is restricted to the area occupied by the intestines. This position should be more or less constant. If a patient with fluctuating disten- tion of the abdomen yields an area of dulness in the lower two quad- rants of the abdomen, with a resonant note above, and if she mani- fests these signs both when sitting and lying, it may be safely assumed that she is either pregnant or is the victim of an ovarian tumour. If, however, upon lying down, the area of resonance descends toward the pubes, a suspicion of ascites, rather than of either of the fore- going, is justifiable. As the cyst increases in size and weight, it exer- cises increasing pressure upon the neighbouring viscera; this is the frequent cause of vesical irritation, constipation, and occasional pro- found disturbance of the kidneys. The urine, under such circum- stances, becomes scanty, is loaded with albumin, and, if the pressure is long sustained, oedema of the extremity is the result. Hemorrhoids are another annoying result of pressure. Areas of pelvic tenderness are sometimes complained of when the tumour has attained consider- able size. These are generally the results of either pressure or slight traumatisms, and depend upon the fact that the tumour, after attaining considerable size, may lose areas of protective epithelium and form adhesions to either the visceral or the parietal peritoneum. The diagnosis of ovarian neoplasms is of importance, not only to establish their existence and whether they are ovarian in origin, but also to determine whether or not they are malignant. The effort to distinguish with accuracy between the different varieties of benign neoplasms is to be looked upon, from the practical standpoint, largely as a useless expenditure of energy and a waste of valviable time. It may be stated as a rule to which there are no exceptions, that ovarian growths, either by virtue of their primary characteristics, or in con- sequence of secondary changes, tend to the death of the patient. It follows from this fact that all ovarian growths should be sub- jected sooner or later to extirpation. The tendency to malignant degeneration, already noted, renders it important that even the so- called benign growths should be removed without unnecessary de- lay. This being true, it is not necessary to subject the patient to punchings, pommelings, and punctures, to establish the exact vari- ety of the growth; for, after it has all been done, and the guessing is all over, precisely the same thing remains to be done. It is, how- ever, frequently important for various reasons personal to the patient to indulge in delay; and it is, therefore, important to know with approximate accuracy, whether a given tumour is malignant or ^34 ' A TEXT-BOOK OF GYNECOLOGY benign. This fact, unfortunately, is not one that can be easily deter- mined. It may be accepted as a rule, however, that the more rapid the growth, the more liable is it to be of a malignant character. The solid tumours are of the slowest growth, while jDroliferating cysts grow with more rapidity than any other of the benign neoplasms. When a grow^th which has been increasing at a certain rate manifests sudden acceleration in development, it should become an object of suspicion; the sudden increase may depend upon a change of type from benign to malignant, or, it may mean that the efferent circulation of the tumour has been interfered with, either by pressure of the growth itself, by torsion of the pedicle, or by other causes. The increase in the volume of a tumour due to sudden twisting of the pedicle is very sudden, and is associated with pain, followed in the course of a few days by toxEemic symptoms due to the absorption of necrotic products from the tumour itself. Increase of size due to a twisted pedicle may become spontaneously arrested, the tumour itself surviving by virtue of nutrition derived from extensive j)eripheral adhesions. The diagnosis of small ovarian tumours is relatively difficult, although Davenport {Boston Medical and Surgical Journal) insists that they are usually accompanied by well-marked symptoms. He states, however, that pain, while usually present, does not bear any constant relation in its location, to either the situation or the variety of the tumour. Menstrual disturbances are the rule, the variation tending in the direction of excessive rather than of diminished flow. There seems to be a direct causal connection between severe uterine hemorrhages and cystic ovaries when the latter are closely adherent to the uterus. Uterine hemorrhage, associated with a pelvic tumour which is unin- fluenced by intrauterine treatment, is more likely to be due to an ovarian tumour than to a fibroid. Eeflex symptoms are comparatively rare, and, according to Davenport, occur chiefly in the later stages of the disease. The diagnosis of even large cystomata of the ovary is not always easy. A number of the most distinguished operators have mistaken pregnancy for an ovarian cyst. It may be stated that there are but few distinguished operators in the world who have not at one time or another made an exploratory incision, with the result of finding a pregnant uterus instead of the suspected cyst. (See Pregnancy as a Complication of Ovarian Tumours.) In extenuation of this accident, it should be remembered that an ovarian tumour may occupy such a position as to interfere with the detection of pregnancy by either vaginal or bimanual manipulation, and it must be remembered, further- more, that among the occasional erratic symptoms of ovarian cystoma, are reflex vomiting and mammary development, with enlargement, softening, and blue coloration, of the cervix. In view of these facts, occasional mistakes are to be expected. In the great majority of in- stances of pregnancy, however, the placental bruit may be heard, while, later, ballottement may be practised; and, after the period of quicken- NEOPLASMS OF THE OVARIES 635 ing, the foetal heart may generally be detected. It must be remembered, however, that even these signs may be obscured. This is particularly true of the placental bruit, which may be completely masked by the more pronounced bruit of the almost cavernous veins that develop in certain of these tumours. Ballottement may be defeated by the ascent of the uterus and the relatively low position of the tumour; while the foetal heart may be situated so remotely that its pulsations can not be heard. Ascites is not infrequently mistaken for a unilocular ovarian cyst. This is jiarticularly true in cases of encysted ascites, where the induced area of dulness remains inconstant, even when the patient assumes different positions. The ascites of tuberculous peritonitis frequently occurs in connection with tuberculous involvement of the mesenteries, or, at least, of the meso-enteron. The result of tuber- culous infection in this locality is a contraction of the peritoneal fold, which prevents the intestines, even when laden with gas, from floating upon the surface of the ascitic fluid. In these cases, however, the morphology of the growth may be taken as a reasonably safe index of its character. A tumour fluctuating and spherical in the upright pos- ture will maintain its outlines with but trifling variation when the patient lies down, whereas, if the distention depends upon free fluid in the peritoneal cavity, the abdomen will flatten to a certain degree, while there will be a corresponding distention of the ilio-costal interval. It rarely hapjoens that a tumour so develops as to distend the abdominal wall between the crest of the ilium and the ribs. Large cysts of the mesentery and nephrydrosis have been mistaken for ovarian cysts. To distinguish between an ovarian cyst and nephrydrosis it is important to remember that, in the former, the tumour develops from below upward, and in the latter from above downward. In the former, the upper, and in the latter, the lower margin of the growth is free. This sign is, of course, absent when the cyst is large enough to fill the abdominal cavity. If the tumour is of congenital origin, the jDresumption of nephrydrosis is strengthened, although Alban Doran has reported a case of congenital ovarian tumour. The position of the colon relatively to the cysts is important in distinguishing between these two conditions. In many cases, the bowel can not be palpated or percussed; under which circumstances Simon introduced an effervescing enema to distend the bowel. Exploratory puncture has been practised as a diagnostic means in cases of suspected nephrydrosis, but it is not to be recommended, not only for the reasons already enumerated, but because, according to Pozzi, the fluid from nephrydrosis is no more characteristic than is that from the proliferating serous cyst of the ovary or of the parovarium. Urea and uric acid may be absent from nephrydrosis and present in an ovarian cyst, a circumstance which will only tend to increase the pre-existing confusion. Urethral catheteriza- tion, as practised by Pawlick and Kelly, may be of value in distinguish- ing between these two frequently confusing conditions. E (^hinococcous cysts of the peritoneal cavity may be mistaken for 636 ' A TEXT-BOOK OF GYNECOLOGY ovarian tumours. They acquire great volume and give rise to corre- sponding distention of the abdominal walls. The}- may displace vis- cera, encroach upon the diaphragm, and occasion interference with the action of the heart and lungs, just as occurs in cases of advanced or neglected ovarian tumours. The facts, however, that the growth started in one of the upper quadrants of the abdomen, generally the right, extending thence toward the pelvis, and that the growth is more rapid than is ordinarily the case in pelvic tumours, Avill place the practitioner upon his guard. The fluctuation in hydatids is remote and circumscribed. The hydatid fremitus is considered characteristic and decisive. It is presumed that, in the majority of these cases, the origin of the parasitic infection is in the liver, and that the con- tamination of the peritoneum is consecutive to rupture of a lymphatic cyst and the consequent escape of the echinococci into the peritoneal cavity. When once implanted in the peritoneum, however, these para- sites may go on multiplying in any one cavity. They may vmdergo retrogressive changes and may, themselves, become the seat of bacterial infection. Sir Spencer Wells has recorded a case in which the degenera- tion of the hydatid cysts was associated Avith the formation of gas, due^ in all iDrobability, to the action of the Bacillus aerogenes capsulatus. Large malignant neoplasms of the lynipJiatics may occasion confu- sion in making a diagnosis of a seeming ovarian tumour. These growths may originate from the lymphatic glands within the broad ligament, or beneath the pelvic peritoneum, or even higher up. Dr. Mary Almira Smith, of Boston, has reported an interesting case in which a large malignant growth had developed from a lumbar lym- phatic gland. It was the size of a child's head and presented all the physical characteristics of an ovarian tumour. Phantom tumour yields a resonant note on percussion and entirely disappears under anaesthesia. A distended Madder has been mistaken by very capable physicians for an ovarian cyst. When the fluctuating tumour occupies a median position and extends to the symphysis pubis, and when it can not be moved from this position, a catheter should always be inserted as a precautionary measure. The indication for catheterization is positive when the patient complains of slight incontinence. Fiirocystoma of the uterus may present many physical signs in com- mon with an ovarian tumour. Eishmiller, in this connection, calls attention to the fact that fibrocystoma of the uterus is relatively infrequent and occurs usually in women over thirty years of age.' Its growth is slow at first, but rapid after attaining a certain size. Menorrhagia is seldom present. In fibrocystoma we have a lobulated condition which can be felt through the abdominal parietes, umbilicus not prominent, uterus moving with the tumour and the uterine cavity generally elongated; while, in ovarian cyst, we have no lobulation except in poly cysts, the umbilicus is prominent, the uterus moves independently of the tumour and its cavity is not elongated. The de- NEOPLASMS OF THE OVARIES 037 tection of hard nodules would be significant, but hard and tense cysts may impart the same sensation. Fluctuation is very hard to detect for the reason that the tumour gives rather an elastic feel. These confusing conditions occurring with relative frequency in the hands of the most distinguished and experienced operators, be- came so apparent to Lawson Tait that he proclaimed, not only the expediency, but the importance of exploratory incision as a diagnostitial measure. This decree has been ratified by the universal acquiescence of the medical profession. The presence of an abdominal tumour of "undetermined character and showing a constant tendency to increase in size, is of itself, not only a justification, but an imperative indica- tion for an exploratory abdominal section. The time has long since passed when surgeons felt justified in pronouncing an unequivocal diagnosis of the exact character of intra-abdominal growth upon evidence furnished by external examination alone. Puncture of the cyst through the abdominal wall, or through the vagina, is never a justifiable diagnostitial measure. The fact that puncture is sometimes practised without incident, does not in the least demonstrate that the operation is without danger, or that the operator is without responsibility. The possibility of wounding im- portant blood vessels, the location and development of which under these circumstances is always anomalous ; the possibility of punctur- ing a loop of intestine ; the probabilit}^ of inducing a possibly septic seepage into the peritoneum; and the certainty of inducing adhe- sions, are all cogent reasons against a manoeuvre which, under the most favourable circumstances, can only be looked upon as groping in the dark. The demonstrated utility and innoeuousness of explora- tory incision, u^ndertaken with reference to the completion of the operation should it be found justifiable, renders preliminary puncture of the cyst neither necessary nor defensible. It is a matter of scientific interest, however, to know that a clear and noncoagulable fluid from an abdominal cyst probably indicates the parovarian origin of the latter, although proliferating serous cysts of true ovarian origin may yield a fluid of similar reaction; whereas, the demonstrated presence of pseudomucin (see Test for Pseudomucin) indicates that the cyst is of true ovarian origin. If it were true, which it is not, that the fluid obtained by tapping- would enable the surgeon always to recognise the exact character of the cyst the manoeuvre would still be without practical value, because precisely the same treatment, namely ovariotomy, would be indicated, whether the fluid yielded pseudomucin or not. The treatment of neoplasms of the ovaries is necessarily surgical. All attempts to cure these growths or to arrest their progress and development by medicines, manipulations, or electricity, have proved, not only futile, but in many instances directly damaging to the pa- tient. It should be accoptod as a rule, that all cases of ovarian tumours should be operated upon as soon after the diagnosis has 638 " ^ TEXT-BOOK OF GYNECOLOGY been made as the conditions will judiciously permit. Delay may be indulged in temporarilj^, to improve the general condition of the patient and to place her in a better condition for operation. But it should never be prol nged beyond the time necessary to put her in the best condition for ovariotomy. Ovariotomy. — History. — Ovariotomy was first performed by Dr. Ephraim McDowell, who lived in the town of Danville, in what was then known as the backwoods of Kentucky. He had been a student in Edinburgh of John Bell, who had suggested in his lectures both the possibility and the advisability of removing ovarian tumours, though he himself had never operated for this purpose. The seed sown in the mind of j^oung McDowell brought forth its first fruit in 1809, when he removed a large ovarian tumour from Mrs. Marion Crawford, who not only recovered from the operation, but lived thirty-eight years afterward. Although McDowell did not pub- lish the report of this case and of two other similar operations until 1816, his claim to be the first ovariotomist in the world is now every- where admitted without dispute. McDowell performed, altogether, 13 ovariotomies, with 6 deaths. The principal operators in America to follow in the footsteps of McDowell within the next twenty-five years, were Dunlap, of Ohio, Nathan Smith, of Connecticut, Peaslee, of New York, and the Atlees of Pennsylvania. Lizars operated in Edinburgh in 1824 and 1825, but with such poor success that the operation did not gain much headway in Great Britain until 1812, when Charles Clay, of Man- chester, scored a success greater than any operator up to that date. Baker Brown, between 1852 and 1856, performed 9 ovariotomies with 7 deaths. He operated no more for four years, when he began a most successful career which was suddenly cut off by his untimely death. In 1858, Spencer Wells, of London, commenced his remarkable record, which, at the time of his death, had gone well up toward 2,000 cases. He reduced the mortality of this operation to 25 per cent but never got much below that figure. In 1862 Thomas Keith, of Edinburgh, performed his first operation and soon became the most successful living ovariotomist. Lawson Tait, of Birmingham, in the course of his extraordinary and startling career reported a series of 139 ovariot- omies without a death. Bantock and Thornton, of London, following in the footsteps of Spencer Wells, in the Samaritan Free Hospital of that city, greatly improved upon the teachings of their master, and reported long series of ovariotomies with much smaller mor- tality than Wells had ever been able to secure. In France the opera- tion did not make equally rapid headway until Pean and his followers began to do very successful work. On the Continent, Koeberle, Schroder, Billroth, Martin, Leopold, Sanger, and many others, began and carried on the good work, until now, in all parts of the world, ovariotomy is one of the most successful of modern surgical opera- tions. Thousands of women have had their lives saved, and have lived NEOPLASMS OF THE OVARIES 63^ long years of usefulness and happiness as a final result of McDowell's glorious effort in 1809. Indications. — Ovarian tumours should be removed as soon as prep- aration can be conveniently made after tneir diagnosis. There is no wisdom whatever in delay. Nothing can be gained and everything may be lost by putting off the operation. No medicine, or outward application or treatment of any kind whatsoever, is likely to cure an ovarian tumour. As ovariotomy is the only source of relief, the sooner it is resorted to the better. The life of a woman with an ova- rian tumour, as a rule, is not greater than three years from the time of its discovery. She is likely never to be in a better condition for the operation than at the time of diagnosis. The chief indication, then for ovariotomy is a clear and unmistakable diagnosis. Technique. — While a full description of the technique of ovarioto- my would require a statement in regard to the preparation of the patient, of the operating room, of the surgeon, his assistants and nurses, the instruments, sponges and dressings, etc., the limited space allotted to this chapter will not permit of these otherwise necessary details, especially as the general subject of operative technique is fully described in another part of this work. Readers are referred, there- fore, to the chapter on general technique for a descrip- tion of the arrangement of the sterilized instruments and towels, and of the nurses with their sponges and their basins of hot and cold water, their sterilized solu- tions, etc., while we proceed at once with a description of the technique of the " operation itself," which, for the sake of convenience and brevity, may be described under the following heads: 1. Instruments required. 2. The angesthetic and the ansesthetizer. 3. The incision of the abdominal wall. 4. Tapping and removing the contents of the cyst. 5. The treatment of adhesions and the ligation of the pedicle. 6. The toilet of the peritoneum. 7. Irrigation and drainage. 8. Accidents and complications. 9. Closure of the wound. 10. Dressings. 11. After-treatment. Instruments. — The instruments necessary for an un- complicated ovariotomy might readily be carried in the surgeon's overcoat pocket, but as we so often come upon the unexpected in the abdominal cavity, an experienced ovariotornist will have sterilized at the same time everything which he might require in case he should meet with complications and con- ditions which he had not suspected when he made his diagnosis. Fig. 274.— Dis- secting forceps- (page 640). 640 A TEXT-BOOK OP GYNECOLOaY The instruments most frequently required are: one or two sharp scalpels; a dozen hemostatic forceps; half a dozen prepared sponges or gauze pads; three pairs of scissors, one long and straight, one curved on the flat and blunt pointed, and one short, thick, strong, and curved Fig. 275. — Curved trocar, at right angles; two dissecting forceps (Fig. 374) for picking up the peritoneum; Tait's or Spencer Wells's trocar with long rubber tubing attached, to conduct the fluid into a bucket under the table (Fig. 275); two large cyst forceps, to grasp and withdraw the empty sac; two long aneurism needles, threaded at the point, for transfixing and ligating the pedicle; a good, free-working irrigation apparatus; needles long, straight, and curved, to close the abdominal in- cision; an assortment of sterilized silk, silkworm gut, and catgut; long perforated glass tubes and sterilized gauze, to be used, if necessary, in drainage. The following, also, may be needed: An as- sortment of large and small pressure forceps (Fig. 276), a catheter, retractors, rubber cord or tubing, fine curved and straight needles, a port- able electric light, an electro-cautery, and Mon- sel's solution. All these instruments, sutures, etc., should be carefully assorted and placed in approj^riate trays upon a table near by, and cov- ered with sterilized hot water by the assistant who is to hand them to the operator as needed, during the various stages of the operation. A basin of hot water should be placed upon a small table near the surgeon in which he can immedi- ately cleanse his hands should they become soiled with pus or fluid from the tumour. This water will need to be frequently changed as the opera- tion proceeds. T^Hiile these and all other ^^reparations by the surgeon are going on, his assistants, and nurses, to insure an aseptic environment and operation, the patient, who has also been properly prepared, may be anaesthetized in an adjoining room, thus preventing the fright and shock of being brought into the ojDerating room and Fig. 276. — Pressure forceps. NEOPLASMS OF THE OVARIES 641 placed upon the table in plain sight of the instruments, the operator, and his assistants, in their operating costumes. The Ancesthetic and the Ancesthetizer. — (See Anaesthesia.) The Abdominal Incision. — Although specially described elsewhere in this work, it may be well to say here that it need not be longer than 3 inches at first, and should be carefully and deliberately made. Ueckless oiDening of the abdominal cavity with one stroke of the knife is as unwise as it is dangerous. Large unilocular ovarian tumours have been frequently removed by Joseph Taber Johnson and others through a 3-inch incision. Should occasion require, the opening can be easily enlarged with the scissors, when necessary, to deal with adhesions or to deliver partly solid tumours without bruising the tissues. While advocating the short incision, one as long as is necessary is always made as we proceed. It is not needful to spend valuable time in searching for the linea alba. Many surgeons think that a stronger cicatrix is secured by the union of the cut muscles. Before opening the peritoneum, all bleeding should be arrested. That membrane may now be caught up between two forceps and nicked with a knife or scissors. In order to avoid the possibility of injuring the intestines, it is safer to roll the peritoneum between the thumb and finger before opening it. The intestines, if not adherent, will immediately drop back out of harm's way as soon as air rushes in through the opening. The incision is now enlarged with the scissors upon the index finger, which acts at the same time as a guide and a protection to the intestines against injury (Fig. 35, p. 108). All bleeding having been arrested, two fingers of the left hand should be passed over the face of the tumour in all directions to ascertain the nature and extent of adhesions. The Emptying of the Cyst. — The pearly-gray cyst wall can be readily seen through the gaping edges of the wound, and a large-sized Tait or Wells trocar can be passed into the tumour at the upper angle of the wound and the fluid drawn off through a tube at the end of the trocar, which conducts it into a sanitary bucket underneath the table. The relapsing walls of the emptying cyst, unless prevented by adhesions, may now be drawn out of the wound with the fingers, or with large cyst forceps. The assistant should press together the abdominal walls, which will aid in the expulsion of the cyst contents and at the same time prevent the escape of intestines, the soiling of the edges of the abdominal wound by the fluid contents of the cyst, or their entering the abdominal cavity. If it should be a multilocular cyst, its various compartments may be emptied by passing the trocar in different direc- tions. If this does not succeed in reducing the size of the tumour sufficiently, the hand may be passed into an enlarged opening and these various compartments ruptured with the fingers. The hand, upon withdrawal, may bring the collapsed tumour sac along with it. It is wise to keep tiio opening in the cyst wall always outside the abdom- 42 642 A TEXT-BOOK OF GYNECOLOGY iual cavity in order to prevent the soiling and infection of the peri- toneum by any colloid^, dermoid, or other infecting material which it would be exceedingly difficult to wash out. Adhesions of the Cyst and Ligation of the Pedicle. — Any adhesions, which may exist will come into view as the empty sac is withdrawn. Those wliich are recent and the result of inflammation can be easily pressed off with a sjjonge, or separated with the fingers. Older and firmer adhesions, which are likely to contain blood vessels, should be ligated in two places with fine silk or catgut, and cut between the ligatures with the scissors. ■ Adhesions of the omentum are generally vascular, and bleeding- surfaces which are not controlled by exposure to the air or sponge pressure, may require ligation. When the cyst wall is adherent to- the intestine, or can not be readily peeled off, a portion of it may be left attached, rather than to run the risk of laceration by its forced sepa- ration. Should an opening be made in the intestine, it should be immediately closed with fine silk. There are fewer incomplete opera- tions now than formerly. It is generally estimated that the mortality is greater where circumstances seem to require that the operation be left uncompleted, than where we are able to make a thorough re- moval of the tumour and toilet of the peritoneum, even in our worst cases. The ancient custom of Sir Spencer Wells, and many other distin- guished ovariotomists, in their day, of clamping the ovarian pedicle upon the outside of the abdomen is no longer practised. Clamps have been superseded by the ligature, the cautery, or the angeiotribe, according to the preference of the operator. (See Hemostasis.) In each case, the constricted or seared stump is dropped back into the peritoneal cavity, and, in all cases where drainage is not required, the abdominal wound is completely closed. While an assistant holds up the empty sac or delivered tumour, the operator transfixes the pedicle as near as possible to the uterus with a long-handled, dull-pointed needle, threaded at the point with pure Chinese silk or catgut, according to his preference, and thus securely constricts the vessels. and tissues in the pedicle. When doubt exists as to perfectly safe constriction, the ligature is brought around the entire mass and se- curely tied again, thus shutting olf any possibility of subsequent hem- orrhage. A figure-of-eight or a Staffordshire knot, when properly applied is equally safe. Taber Johnson still retains his preference for pure Chinese silk ligatures for the pedicle. They very rarely become infected or make any trouble. Many more accidents have resulted from the relaxing, untying, or slipping off, of catgut ligatures, and from sepsis caused by imperfectly prepared catgut, than from silk. Some surgeons, however, are very enthusiastic in regard to the use of catgut when sterilized in solutions of cumol or formalin. Eecently, Skene, of Brooklyn, has recommended an electro-cauterization of the pedicle instead of ligatures, and still more recently the angeiotribe NEOPLASMS OP THE OVARIES 643 has been recommended as a safe and proper substitute for all other means of treating the pedicle. If we meet with a pedicle especially broad and thick, it may require ligation in several places, making what is called a chain ligature. In cutting off a tumour above the point of constriction, a button of tissue should be left, sufficiently large to prevent the possibility of the slipping off of whatever ligature is used. Minor, of New York, has described a variety of tumour in the broad ligament, which has no pedicle whatever, and has taught us Iioav to enucleate it with safety from the tissue in which it lies embedded, ligating separately any bleeding vessels which are discovered. After the removal of an ovarian tumour, the other ovary should be examined also; if found healthy, it should be let alone. If the ovary is found somewhat diseased, every " conservative " effort should be made to preserve whatever portion of it can be properly left to perform its usual function. The subsequent condition of the patient will be much more nearly normal if sufficient ovarian tissue is pre- served to keep up the menstrual molimen, and thus to prevent a premature occurrence of the change of life, with all that that implies. The Toilet of the Peritoneum. — In those cases in which a simple ovarian tumour has been removed without rupture or spilling its con- tents into the abdominal cavity, very little in the way of a " toilet " is required; the less manipulation of the intestines and exposure of the abdominal contents the better. Even the small sponge, held in the grasp of a long-handled forceps, which is usually passed down into the pelvic cavity in search of blood or other fluids, may frequently be omitted, and the omentum carefully drawn down over the intestines and the wound closed. In those cases where the omentum has been lacerated or torn in separating adhesions, if there is any evidence of bleeding, it should be carefully drawn out of the wound, spread over hot sterilized towels, and the bleeding points sought out and ligated. In most cases, simple oozing can be arrested by hot water or hot sponge pressure. If some portion of the omentum is considerably lacerated, a ligature may be applied behind the leaking surfaces and the omentum tissue boldly cut away. In those cases where there has been much hemorrhage from tissues lacerated by the separation of adhesions, or the abdominal cavity has been soiled and possibly in- fected by fluids from malignant tumours, or by pus from infected abscesses, the cavity should be thoroughly irrigated with hot normal salt solution. In that class of cases which have heretofore required transfusion, large quantities of the normal salt solution may be poured into the abdominal cavity and left there to float the intestines, to prevent the immediate occurrence of adhesions, and to perform the office of transfusion Ijy being absorbed into the circulation. The great thirst which usually follows ovariotomy, as well as all other abdominal operations, is much alleviated by the salt solution. ISTo germicide of siifllcient strength to be of any service in destroying 6M A TEXT-BOOK OF GYNECOLOGY germs is ever permissible inside the abdominal cavity. If it were suf- ficiently powerful to kill the germs, it would at the same time kill the patient. General irrigation of the abdominal cavity is not employed at the present day as frequently as it was formerly. A localized collection of infectious fluid, readily absorbed by a sponge, might be carried to remote parts of the cavity by general irrigation and set up an incur- able septic peritonitis. The abdominal wound may be closed by what have been described as through-and-through sutures, or the tissues may be brought together by from three to six tiers of sutures according to the preference of the operator. When the through-and-through sutures are used, four to the inch should be emplo^'ed. The object of the more thorough suturing is the more sure prevention of ventral hernia. Taber Johnson doubts whether half a dozen layers of sutures accomplish this purj)ose more thoroughly than well-applied through-and-through su- tures. From the investigations which he has been able to make, about the same number of cases of ventral hernia occur with one method as with another. As ventral hernia will be prevented by per- fect union of the fascia, after the application of the through-and- through sutures Taber Johnson is in the habit of inserting one silk- worm gut to the inch through the edges of the fascia, and thus secur- ing permanent approximation of its edges when tied. If union fails to occur, these nonabsorbable, buried sutures will hold it together for- ever. Some operators prefer silver wire for this j)urpose. If a fixed rule, alwa^-s to close the abdominal wound with five or six layers of sutures, is adopted, the operator will not infrequently find himself spending more time over the closing of the abdominal wound than over all the other steps of the operation together. Drainage. — The present practice of ovariotomists is, so far as possible, to avoid drainage. I^^ot a few gynecological surgeons have recently reported that they have not drained the abdomen after ovari- otomy for a number of years, even in their worst cases, and that they find no increase in their mortality. In those cases where drainage is considered absolutety necessary on account of the soiling of the peritoneum with infectious fluid, gauze drainage is used much more frequently than the glass tubes. jSTeither the glass tube, nor gauze drainage, is likely to be of much service after twenty-four hours; for the glass tube does not drain any greater area than the little pocket at its distal extremity, on account of its being shut off from the abdominal cavity by lymph which has been poured out around it ; while gauze, after it has once become wet, ceases to absorb more fluid, and only drains by lying in contact with dry gauze which may absorb from it. Dressings. — The dressings applied to an ovarian wound need hardly differ from those applied after any up-to-date aseptic operation. The practice of dusting iodoform powder over the edges of the wound has been abandoned. The wound should be thoroughly dried and NEOPLASMS OF THE OVARIES 645 cleansed, and pads of gauze placed on each side of the row of sutures, and another, thicker gauze pad laid over them both. A combined dressing is then applied over the abdomen from hip to hip and secured by broad strips of adhesive plaster. A thin flannel or many-tailed bandage may now be applied, securely holding the dressings perma- nently in position. These do not require to be changed for seven days, if all goes well. If the tumour has been very large and the abdom- inal walls have sunk in considerably, the depressed spaces should be filled out by sterilized absorbent cotton. After-treatment. — The after-treatment of a simple case of ovari- otomy amounts to little more than keeping the patient clean and let- ting her alone. Give her a cheerful nurse, protect her from visitors, and encourage her to get well. Little medicine is required beyond what is necessary to move the bowels, quiet restlessness, and produce sleep. As soon as the patient has had a good operation from the bowels she is considered convalescent. This is usually produced by small doses of calomel, followed by teaspoonful doses of Eochelle salts every two hours until the bowels move. It was formerly the custom to withhold all food or drink for twenty-four hours. The piteous appeals of the patient for water to quench her thirst were stubbornly resisted, but we find by increasing experience that patients may, with- out injury and greatly to their comfort and happiness, take frequent sips of hot water or tea a few hours after their recovery from the ansesthetic, unless tormented by the ether nausea. Patients, it is found, may also take with benefit small draughts of beef essences or concentrated forms of liquid nourishment after the first twelve hours. If this disagrees with them, it should be withheld for a while. It is best to adhere to the rule that patients should not see visitors for a week after their operation. Exceptions will occur where a discreet mother or husband may see the patient a few days after her opera- tion with great benefit. The patient should be urged to pass her water in a bedpan. The use of the catheter in the hands of the most skilful nurse has often produced urethral or vesical irritation. Its routine use for several days after all ovariotomies should be aban- doned. The use of opium should be avoided when possible, as the patient's pain, nervousness, and restlessness, are generally increased and pro- longed by the unwise use of this drug. There will occur, now and then, a ease where a hypodermic of morphine or codeine will quiet restlessness and produce the greatest amount of comfort, with no harm whatever following its use ; but the routine employment of opi- ates after ovariotomy is full of mischief and trouble. If the bowels are painfully distended by collections of gas, the introduction of a rectal tube gives much relief. If, upon removal of the dressing on the seventh day, the wound is found well united, the sutures may be all gently removed. If union is not perfect, or if stitch-hole abscesses have occurred, a few of the stitches can be left 646 A TEXT-BOOK OF GYNECOLOGY for two or three days longer. If the wound is perfectly dry, no treat- ment is necessary, but narrow strips of rubber plaster may be placed across the wound to hold it securely while a firmer union is taking place. The gauze dressings should be changed and held in position by a firm clean binder. It is better for the patient to remain in bed three weeks. Young, vigorous patients, who have had an uninterrupted recovery, have gone home from the hospital at the end of two weeks without harm, but this is not a safe practice. If no pus is present, the wound may not require dressing oftener than once a week. At the end of the fourth week, the patient may safely be allowed to return to her home, but should be provided with an abdominal bandage, which she should be advised to wear for six months or a year, and to abstain, so far as pos- sible, from overwork, lifting heavy weights, or any straining occupa- tion which might have a tendency to produce ventral hernia. Accidents. — Accidents may occur during ovariotomy from the ad- ministration of the anaesthetic, or from the stripping ofE of the peri- toneum from the abdominal walls or the intestines. The cyst wall may be accidentally ruptured while separating adhesions. Bleeding points may be overlooked, and the patient's life lost from hemor- rhage after the closure of the incision. Ligatures have slipped off the pedicle, catgut has become untied; intestines, omentum, or bladder, have been injured when opening the abdominal cavity, or torn while separating adhesions. None of these accidents should occur in the hands of the average conscientious operator. Sponges, forceps, scissors, rings, and eyeglasses, have all been lost in the abdominal cavity during an operation, and have been searched for subsequently or found during a post-mortem. Obstruction of the bowels may be caused by paralysis of, or kinks or twists in, the intestines. Fistulas may follow the use of infected ligatures, and ventral hernia may occur to torment the patient in some cases to such an extent, that her sufferings are greater after her operation than they were from the condition which made the opera- tion necessary. Mortality. — The average mortality at the hands of all operators the world over, is probably about 10 per cent. Experts in the prin- cipal cities of the world will often report a series of 100 cases, how- ever, with no mortality whatever. Leaving out the cases of malig- nancy and the unexpected accidents, the mortality of ovariotomy in the hands of experienced operators will probably not range above 3 or 5 per cent, while during the first half of the present century the mor- tality lingered very closely around 50 per cent. We are proud and happy to state that as fhe new century is dawning the mortality is reduced to less than 5 per cent. Incomplete Ovariotomy. — This is sometimes made necessary by the character of the growth, and by the extent and density of its adhe- sions. Proliferating cysts, the pedicles of which have been subjected NEOPLASMS OF THE OVARIES 647 to even temporary torsion, exposed to traumatism or infection, or have become the seat of secondary malignant changes, may become so intimately involved with the intestines that they can not be removed without irreparable, if not fatal, injury to the latter. Under such circumstances, it may be found expedient to remove a part of the cyst wall, stitching the remainder to the margins of the intestinal incision, an operation which Pozzi designates as the marsupialization of the patient. It is always a matter of great importance to determine when this step should be taken. As a rule exemplified in the reported cases of Vander Veer {New YorJc Medical Journal, 1893), it should be done in the presence of the foregoing complications, particularly when the operation has already been so long or so difficult that, if still further prolonged, the patient will die from hemorrhage or shock. In fixing the edges of the sac to the edges of the abdominal wound, it is impor- tant to see that all bleeding points in the former are brought under control. This can be accomplished, as a rule, by means of ligatures; but in exceptional cases, the cyst walls will be found to be of such an embryonic character that they wilj not sustain a ligature, when it will become necessary to resort to the cautery, to styptics, or to sponge packing, to control the bleeding. Cases have been reported in which the remnant of tumour tissue has sloughed away through the opening left by this operation, the patient making an eventual recovery. For- tunately, complications rendering this course necessary are now of relatively rare occurrence. Ovariotomy during Pregnancy. — This is frequently an operation of expediency. The mortality from this operation, if done during the first five or six months of pregnancy, is not higher than when done in a nonpregnant state. Olshausen has performed the operation 26 times without a single death. The danger to both mother and child increases with the progress of gestation. The results are most fa- vourable for the mother in the second, third, and fourth months, and for the child in the third and fourth months — although favourable results are obtained even in the last month of gestation. The liability to rupture renders ovariotomy the desirable alternative at any stage of pregnancy. " Palliative " treatment by puncture of the cyst does not palliate; on the contrary the cyst rapidly refills, with an increased tendency to adhesion and rupture. Successful cases of double ovariotomy during pregnancy have been reported by Vander Veer, Knowsley Thornton, Gardner, Montgomery, Munde, Potter, Bovee and others. Potter's case, reported to the American Association of Obstetricians and Gynecologists (vide Trans- actions, 1888), was probably the first case in America in which a woman went to full term after a double ovariotomy done during the course of gestation. In this case. Potter operated in the latter part of the fourth month; there was a tendency to rhythmic uterine con- tractions on the seventh day, but these speedily subsided, after which she wont to full tortn without incident. These cases must be accepted 648 A TEXT-BOOK OF GYNECOLOGY as establishing the safety of the operation — although the liability of a double ovariotomy to induce abortion must be considered as greater than that which pertains to the operation upon one side only. The results of ovariotomy during pregnancy are favourable. Dsirne reports 135 cases with 8 deaths, being a mortality of 5.9 per cent. Subsequent reports from individual operators do not tend to- increase the mortality. The influence of ovariotomy, under these cir- cumstances, upon pregnancy, has been ascertained with approximate accuracy. Olshausen found pregnancy interrupted in about 20 per cent of his cases. While Dsirne (Archiv fur Gynakologie) found that it was interrupted in 22 per cent of 114 cases which he collected. This seemed to vary somewhat according to the stage of gestation, as indi- cated by the following table by Dsirne : At Months. No. cases. Interruptions of pregnancy. Percentage. 2 11 28 21 10 11 5 5 1 5 4 2 4 4 3 3 1 45.5 3 14.3 4. . 9.5 5 6 40.0 36.4 7 60.0 8 40.0 9 100.0 Bovee {American Journal of Obstetrics) has tabulated 23 cases in which extirpation of the uterine appendages has been practised in the presence of pregnancy. Ten of the cases were for ovarian cyst, while in. 8 out of the 10, the cysts were double; all the patients recovered. CHAPTEli XLII ECTOPIC PREGNANCY Historical resume — Definition — Etiology — Classification — Course and termination — Histology — Symptomatology — Diagnosis — Treatment. Historical Resume.^ — The term ectopic pregnacy, from e/croTros (Ik, out of, and tottos, a place), was suggested by Dr. Robert Barnes in lieu of the familiar term extrauterine pregnancy, to designate a mal- position of the fertilized ovum. It has been very generally accepted into gynecological nomenclature as more accurately designating the pathology of this most interesting condition. Since the fertilized ovum may be arrested and may develop in that portion of the tube passing through the uterine walls, it is ap|)arent that such a pregnancy would not be extrauterine but ivould be ectopic. This pathologic condition until recently constituted a dark chapter in gynecological surgery. It was altogether misunderstood in its etiology and pathology, its symptoms were misinterpreted, and hun- dreds of deaths occurred annually which would now be prevented by timely surgical intervention. Following the possibilities of aseptic surgery, this great achievement was accomplished by one man, Lawson Tait, whose genius illumined the entire subject and established meth- ods of cure that approach perfection. The first correct interpretation of the pathology of this abnormity, which has such heavy mortality, was attained by Bernutz and Goupil, two able French observers who have made an exhaustive study of the disease by post-mortem exami- nation. The work of these eminent students of pathology was trans- lated into English in 1866 and widely circulated under the auspices of the New Sydenham Society by Alfred Meadows. The work was ably reviewed in America at great length by Parvin, yet no surgeon adopted the true pathology of extrauterine pregnancy as therein set forth. John S. Parry, of Philadelphia, made a valuable contribution to the subject in a book published in 1876, but did not elucidate the pathology or recognise the surgical aspects involved when, through the advance of aseptic surgery, it became practicable to open the abdo- men with safety for the relief of grave and obscure intra-abdominal disease. Tait dealt with the subject in a masterly way. Utilizing the post-mortem researches of Bornutz and Goupil and the clinical obser- vations of Parry, he eluciflatod the entire subject, classified its various types and pliases, and fonniilaicd iind dcnionstrated with the mind 649 650 A TEXT-BOOK OP GYNECOLOGY of a genius and the hand of a master, therapeutic resources which have placed his name forever among the benefactors of science and humanit}'. Definition. — The term ectopic, or extrauterine, pregnancy is, as already stated, applied to a malposition and abnormal development of the fertilized ovum. After fertilization the ovum may establish its habitat within the ovary (ovarian pregnancy), within any part of the free Fallopian tube (tubal pregnancy), or witliin that portion of the tube which passes through the uterine wall at the cornu (interstitial pregnancy). Primarily, ectopic pregnancy is almost invariably situ- ated in the Fallopian tube, and ovarian pregnancy is so very rare that its existence has been denied both by pathologists and surgeons. However, specimens have been studied carefully by competent observ- ers, which establish the fact that this anomaly actually does occur; but the instances are so few as to render ovarian pregnancy an ex- treme rarity in clinical experience. Ectopic pregnancy, as a rule, is tubal. Etiology. — In considering the etiology of ectopic, or, preferably, tubal pregnancy, it is necessary to review to some extent the physiology of the Fallopian tube and the impregnation of the ovum. The tubes are the ducts through which the ovum, when discharged from the ovary, travels into the uterine cavity; hence their name, oviducts. From observations and experiments made on the lower animals, it appears probable that the transport of the ovum is effected mainly, if not ex- clusively, through the action of the ciliated columnar epithelium lining the tubal mucous membrane. It is quite probable that peristaltic movements of the tubes, if they take any part at all in the transport of the ovum, play a minor role only. We have every reason to believe that in the human being, as is the case in some of the lower animals, judg- ing from observations actually made, the fertilization of the ovum by the spermatozoa occurs in the outer half or outer third of the tube. Normally, an ovum fertilized in the tube will, in a few days, travel jnto the uterine cavit}^ and will there become implanted for further development. The question arises. What cause or causes are respon- sible for an impregnated ovum remaining and becoming implanted in the tube, instead of passing into the uterus? Certain alleged causes, formerly frequentl}'' cited as responsible for tubal pregnancy, such as inflammatory diseases of the uterus and tubes, must be absolutely discarded. We know now that these very conditions, instead of being the cause of tubal pregnancy, make a woman sterile for the time being, and therefore exclude tubal, as well as normal uterine preg- nancy. It is impossible here to go into a discussion of all the alleged causes of tubal pregnancy, since most of them really deserve detailed consideration. Herzog, who has carefully studied the gross and fine anatomy of over 30 cases of tubal pregnancy, believes that, in a con- siderable proportion, congenital anomalies of the tubes must be held responsible for the establishment of an ectopic gestation. Herzog has ECTOPIC PREGNANCY 651 certainly twice, and possibly three times, seen tubal pregnancy in a diverticulum of the main canal (Fig. 277), and once in an accessory blind fimbriated extremity. (Henrotin and Herzog. Anomalies du Canal de Miiller, comme cause de grossesse ectopique. Revue de chirurgie abdominale, 1898. — Henrotin and Herzog. Very Early Eupture in an Ectopic Pregnancy in a Diverticulum, New York Med- ical Journal, 1899.) Several times he noticed that the tubal canal in Fig. 277. — " A diverticulum of the main canal." — Heuzog. which the pregnancy occurred was unusually tortuous, so that the road from the fimbriated extremity to the ostium internum of the tube, which the ovum would have to traverse, was an unusually long one. The theory that congenital anomalies are the cause of tubal pregnancy is supported by facts. Another cause assumed by Herzog can not yet be supported by direct, actual observations. He is of the opinion that the tubal mu- cosa takes part to a certain extent in menstruation. ISTormally, the menstrual changes of the tubal mucosa are insignificant, compared with those of the uterine mucosa. Occasionally, however, the tubal mucous membrane shows intense menstrual changes, which may be so pronounced as to lead to the formation of a hematosalpinx. We can hardly doubt that the menstrual changes of the uterine mucosa pre- pare the latter for the reception of an impregnated ovum, which, as appears most probable from the latest contributions upon the sub- ject, eats or corrodes its way into the substance of the uterine mucosa by the aid of a phagocytic trophoblast (see page 657). Whenever the tubal mucous membrane undergoes extensive menstrual changes, it must become a soil into which an impregnated ovum can easily implant itself. It therefore appears very probable to Herzog that such well-marked menstrual changes in the tubal mucosa frequently become the cause of an ectopic implantation of a fertilized ovum. So far as our exact knowledge goes to-day, we must, however, con- fess that we are unable in most cases of ectopic gestation definitely to give the exact causes of this occurrence, often so very grave in its conseqnoTices. That our knowledge as to the etiology of most cases of ectopic gestation is yot so very deficient, lies in the very circum- 652 A TEXT-BOOK OF GYNECOLOGY stances surrounding this occurrence. In addition, we must not forget that when we obtain a specimen for examination post operationem or post mortem, hemorrliages and secondary changes have often so mutilated the parts that exact anatomical studies frequently become utterly impossible. Classification. — The varieties of tubal pregnancy, which are distin- guished according to the anatomical seat of the developing ovum, are as follows : If the ovum is in the part of the tubal canal which per- forates the uterine wall, we speak of it as an interstitial pregnancy. This variety is not very frequently seen. There have been reported erroneously as interstitial pregnancies, cases which were cornual or where the ovum was located in a blind prolongation of Gartner's duct, which sometimes extends down into the cervix. In interstitial tubal pregnancy, the developing ovum frequently pushes its way into the uterine cavity, and we then have the condition known as tuho-uterine gravidity. In it, the gestation sac may be of fair thickness, and the pregnancy may go on to full term and terminate fairly normally. The second vari- ety of tubal preg- nancy is present when the ovum is found in the middle part of the tube; in Avhich case we are dealing Avith an istJi- niic tubal pregnancy, or tubal pregnancy par excellence {gravi- ditas tubaria pro- pria). The placenta in these cases gener- ally has its seat in the lower or poste- rior part of the tube wall. The gestation sac in this variety is generally very thin and the danger of rupture very great. Here we also some- times find peduncu- lated gestation sacs. Probably the most frequent variety is that of a development of the ovum in the outer third of the tube or am- pulla. This kind of ectopic gestation is known as ampullar pregnancy. The widest part of the Fallopian tube, the ampulla, naturally offers the Fig. 27£ -The case [of ectopic pregnancy] of Joseph Price. — PlERzoa (page 653). ECTOPIC PREGN^AXCY 653 most favourable conditions for an undisturbed development of an im- planted ovum. So we frequently find ampullar pregnancy develop much beyond the earlier months of gestation. On the other hand, the funnel- shaped amjDulla favours abortion of the ovum. The latter sometimes partly protrudes out of the ampulla into the general peritoneal cavity, and then we have the condition known as tuho-abdominal pregnancy. This is, however, not the rule, but the excep- tion in ampullar pregnancy, because there exists already in the earlier months a tendency of the fimbriated extremity to become closed by aggluti- nation of the plicae. It also occurs that the ovum in ampullar pregnancy protrudes into, and partly develops in, cystic j^ortions of the ovary. This condition can probably supervene only when, early in the course of or prior to ectopic gestation, the fimbri- ated extremity becomes adherent to the ovary and forms what is called a tubo-ovarian cyst. The form of ecoptic gestation then established is called tubo-ovarian pregnancy. That primary true ovarian pregnancy occurs as a matter of fact, is demonstrated by well-authenticated cases, notable among which is an advanced case by Price (Figs. 378, 279) in which the child went to term, projecting on either side from the enlarged ovary; and an early case by Withrow (Fig. 280), the fact of impregnation in the latter having been established by careful microscopi- cal studies by Whitacre. Abdominal and in- traligamentous pregnancies are developed from primary tubal gestation. Intraligamen- tous pregnancy may be brought about in a va- riety of ways. There may be a rupture of the lower part of the tube wall with more or less hemorrhage and the escape of the ovum be- tween the folds of the broad ligament. The growing ovum may so stretch the lower segment of the tube that it becomes entirely membranaceous, and the sac so formed may unfohl the two leaves of the broad ligament. This splitting apart of the layers may also be brought about in such a manner that the ovum completely rarefies the wall of the Fallopian tube at some point, and Fro. •J.'~i'.). — " Thu chilli went to tuna projecting on either side from tlie enlarged ovary." — Heezog. Fig. 280. — "An early case by Withrow." — IIekzog. 654 A TEXT-BOOK OF GYNECOLOGY produces a slit through which it escapes to a spot between the folds of the broad ligament where further development takes place. Abdominal pregnane}^ can be brought about in a variety of ways. An ovum located in the tube may be aborted through the ostium abdominale into the general peritoneal cavity. If its placenta is not too seriously damaged, the embryo may, after tubal abortion, go on developing. Rupture of the tube may send the ovum into the general abdominal cavity. The embryo may continue to develop not only when, after primary rupture, its membranes are intact, but even after rupture of the foetal membranes has taken place. Course and Termination of Ectopic Gestation. — While almost every variety of ectopic gestation may go on to full term, most cases ter- minate in the earlier months of development by rupture or abortion. Rupture, in the majority of cases, is brought about by preceding larger or smaller hemorrhages. The latter are of two kinds: small hemorrhages from enlarged tubal vessels into the cedematous and in- flamed tube wall, and hemorrhages from the utero-placental sinuses into the intervillous space. The utero-placental sinuses in tubal preg- nancy are opened in a more irregular and more extensive manner by the syncytium than is the case in normal uterine pregnancy, and the stretching of the tube wall by the enlarging ovum early establishes a tendency to extensive hemorrhages from the utero-placental sinuses into the intervillous space. These hemorrhages frequently dissect the ovum loose from the gesta- tion sac, and rupture is often initi- ated in this manner. But even if a rupture does not occur, the embryo may be killed and the ovum arrested in further develop- ment in consequence of the in- tervillous or interplacental hemor- rhages. Herzog examined 2 cases of tubal pregnancy operated on before rupture had occurred. In 1 case, the embryo, about five weeks old, was badly macerated. In the other, the embryo, from seven to eight weeks old, looked per- fectly fresh and normal (Fig. 281). It was found, however, in both cases that extensive interplacental hemorrhages had taken place, and that the villi in both cases were badly crushed and in an advanced stage of degeneration. If this is the case, the embryo de- pending for its nutrition upon the villi must, of course, perish in a short time. Herzog thinks that interplacental hemorrhage very fre- quently precedes rupture for quite an interval of time, because often, even when operation is performed shortly after the symptoms of rup- ture become manifest, one finds the villi in an advanced state of de- FiG. 281. — "The embryo, from seven to eight weeks old, looked perfectly fresh and normal." — Herzog. ECTOPIC PREGNANCY 655 generation. When more or less extensive hemorrhage occurs, either into the tissues of the tube wall or into the intervillous space, rup- ture generally takes place in consequence of pressure. The hemor- rhage after rupture increases as a rule very much, and it may become fatal. The rupture generally occurs at the place where the placenta has been attached. Here, the tissues of the tube wall are often thinned out very much. The cellular elements, particularly the mus- cle bundles, have been pushed apart, the interstices created are filled out by a serous exudate (oedematous infiltration), and almost the whole thickness of the sac is undermined by the phagocytic action of the syncytium. What becomes of the ovum after rupture, has been indicated already in discussing intraligamentous and abdominal preg- nancies. Tubal abortion is brought about by either of two causes or by a combination of the two. These causes are hemorrhages and contrac- tions of the tube wall. The latter will, however, be impossible when the muscular coat of the tube has been weakened very much by rare- faction and oedematous infiltration. The embryo in ectopic gestation, as a rule, no matter what occurs, is arrested in its development and dies. Even if it goes on to full development, it must perish unless relieved artificially from its ectopic position. But interstitial tubal pregnancy, when leading to tubo- uterine gestation, may terminate in a natural manner without artificial aid. If the development of the embryo in ectopic pregnancy is arrested early in consequence of rupture or abortion, and if the foetus gets into the general peritoneal cavity, it is speedily absorbed, so that after a few days there is no trace left of it. Older embryos, arrested in devel- opment, become the subject of either mummification and litliopcedion formation or of maceration. The latter process usually takes place if the embryo Has been deprived of its protecting foetal membranes. Maceration brings with it the danger of septic infection or putrid changes. The process of calcification of an ectopic ovum may assume one of three forms. If only the foetal membranes become infiltrated with lime salts, we speak of a lithokelyphos; if the foetal membranes and the superficial tissues of the foetus are incrusted, we speak of litho- TcelypJiopcedion, while litliopcedion proper signifies the condition when the embryo alone presents as a calcareous mass. Lithopfedion formation is not infrequently found after the death of a fully de- veloped foetus has been brought about by spurious labour. A litho- pjcdion may often remain for years in the abdominal cavity v^ithout giving rise to trouble, yet may ultimately bring trouble about after having been harmless for a long period of time. Tubal gestation may be a twin pregnancy, and cases of bilateral tubal pregnancy have been observed. Repeated tubal pregnancies have likewise been recorded. Ilenrotin (he. oil., p. 380) saw an abdominal pregnancy brought about by an attempt of the patient to produce an abortion in the seventh week of normal uterine gestation. A sharp instrument inserted into the 656 A TEXT-BOOK OF GYNECOLOGY uterine cavity perforated the fundus. The ovum escaped into the general peritoneal cavity and kept on developing, the placenta spread- ing from the uterine cavity to the peritoneal coat of the womb. This pregnancy had to be terminated by an operation during the fifth month of gestation. The uterus in ectopic pregnancy undergoes hypertrophy. The latter is of course mostly confined to the muscular coat. The uterine mucous membrane is changed into a decidvia. That this is the case was maintained years ago by Langhans and others. There have been those, however, again and again, who assert that there is no uterine decidua formed in tubal pregnancy. Herzog, who has studied uterine scrapings from a number of cases of tubal pregnancy, finds that a decidua is formed. It is not materially different from the decidua vera as formed in normal uterine jDregnancy. This decidua is frequently shed at the time of rupture, abortion, or when the embryo dies from any cause. This accounts for the fact that a number of observers, making an examination at an improper time, have not found any uterine decidua and have been misled into the belief that none is formed in tubal pregnancy. The uterus as a whole in ectopic preg- nancy enlarges to the size of a womb in the third or fourth month of normal pregnancy. Beyond this stage it rarely, if ever, hyper- trophies; it then either remains stationary or frequently even be- comes gradually smaller. This is always the case as soon as the embryo is arrested in its development by rupture, abortion, or otherwise. The Histology of Tubal Pregnancy. — The study of the microscopic anatomy of tubal pregnancy is by no means an easy matter. By far the greater number of cases are only operated upon after primary or even secondary hemorrhages have occurred, and the material obtained under such conditions is often eminently unsuited to draw trustworthy, valuable conclusions from, as to histogenetic details. Even in cases operated on before any rupture has taken place, there may have oc- curred intervillous hemorrhages, which will greatly disturb the normal relation of the component parts of the placenta. Of a large number of cases of ectopic gestation, only a comparatively small percentage can be relied upon to furnish valuable material for microscopic examina- tion, and even this can only be properlj interpreted by one who has been a faithful, patient student of the histogenesis of the normal uterine placenta, a subject itself offering considerable difficulties. These, of course, become greatly augmented when we deal with an ectopic implantation of the ovum. The following short description of the histology of tubal pregnancy, Herzog bases upon the microscopic examination of over 30 cases. In a book of this kind it Avould, of course, be very much out of place to discuss in detail all the contested points, of which there are quite a number, in regard to the histogenesis of the normal placenta as well as of that of tubal pregnancy. It will be necessary to be brief and somewhat dogmatic. ECTOPIC PREGNANCY 657 Fig. 282. — " A dilFereiitiatiori into a decidua compac- ta and a decidua spongiosa." — Heezog (page 658). From observations recently made by Van Heukelom and Peters upon very young hmnan ova obtained in situ in the uterus, it appears that the human ovum, like that of other mammals, is surrounded, soon after fecundation, by a layer of solid ectoblast, called " trophoblast." In this, many nuclei but no individual cell boundaries are distinguish- able. The trophoblast, as it appears, has phagocytic properties and enables the ovum to corrode its way into the uterine mucosa, which at this early time has already as- sumed the character of the decidua. If this is the normal modus operandi, and the ob- servations cited very strongly suggest that it is so, it is easy to understand how an im- pregnated ovum may implant itself into the tubal mucosa. The mode of implantation would be exactly the same as in the uterus, because it depends chiefly, if not exclusively, upon structures and prop- erties of the fertilized ovum itself. From the trophoblast are later on developed the villi with their two ectodermal layers, viz., the inner cell layer of Lang- hans and the outer, nucle- ated Plasmodium, the syn- cytium. The very first stages of placental formation have never been observed in ectopic pregnancy. If we turn to what has been observed, the following outlines may be given: The early placenta foetalis in tubal pregnancy is in no way different from the same structure in normal uterine development of the ovum. The villi possess a meso- dermal core with foetal blood vessels and a double ecto- dermal lining, the cell layer of Langhans and the syncytium. The placenta materna presents a decidua serotina not so well de- 43 Fig. 283. — "The pseudo-gland spaces . . . have been formed by the deeper recesses between the origi- nal plicae." — Heezog (page 658). 658 A TEXT-BOOK OF GYNECOLOGY velojjed as in normal uterine pregnancy, but sliowing large typical decidual cells and a division into a decidua compacta and a decidua spongiosa (Fig. 382). The open spaces in the spongiosa are fre- quently lined by high columnar epithelium. This may also, how- ever, be more or less flattened, or it may have degenerated entirely and be found to have dropped off into the lumen of the pseudo-gland spaces. The latter have been formed by the deeper recesses between the original plicse of the tubal mucous membrane (Fig. 283). The changes which the plica? undergo in tubal pregnancy consist in a club-shaped thickening and a transformation of the fine connective tissue spindle cells into elements of the character of decidual cells. The plical blood vessels become enormously dilated to form the tubo-placental blood si- nuses. Neighbouring plica become confluent at their higher parts, and this gives rise to the formation of the ui^per .compact layer of the de- cidua, while the deeper recesses between the plica? give rise, as already stated, to the pseudo-gland spaces, forming in this manner the lower spongy layer of the decidua. The formation of the decidua vera is simi- lar to that of the serotina, but the vera as a rule does not extend very much beyond the place of insertion of the ovum. The formation of a decidua reflexa, or capsularis, in tubal pregnancy has been denied. Her- zog has, however, reported an instance that is beyond doubt. If the above-described mode of implantation of the human ovum is correct, as it most probably is, then the formation of a capsularis, or decidua re- flexa, in tubal pregnancy is very easily explained. Herzog has previously insisted upon the fact that a decidua reflexa must always be formed in tubal pregnancy. He says in connection with this subject {The Practice of Ohstetrics by American Authors, 1899, p. 362): "At an early period in uterine gestation an intervillous space filled with maternal blood, bounded on the outside throughout most of its extent by the decidua reflexa, surrounds the whole chorion. In tubal pregnancy, therefore, there must also always be formed a decidua reflexa, because an intervil- lous space capable of maintaining the maternal blood can be formed only by a decidua reflexa, unless we assume that the tube very easily be- comes obliterated on both sides of the ovum. Since we have no proof at all of such a very improbable occurrence, a decidua reflexa becomes an absolute necessity for the establishment of the intervillous space." This was written before the observations of Peters on a very young human ovum were published. These have since furnished some much- desired elucidation about the establishment of the intervillous space and the formation of the decidua reflexa. This brings us to the ques- tion of the intervillous space in ectopic pregnancy. How a recent writer (Kuehne, Beitrdge zur Anatomic der Tuharschwangerschaft, Mar- burg, 1899) can state with all seriousness that an intervillous space with maternal blood is never formed in tubal pregnancy, is a matter difficult to understand. If we consider that tubal pregnancies have gone to full term and have been terminated by the delivery of a living child, we must insist from merely theoretical reasoning upon the estab- ECTOPIC PREaNANCY 659 Fig. 284. — " An intervillous space." — Herzog. lishment of an intervillous space with maternal blood. But aside from any theoretical reasoning, we find favourable cases enough which per- mit us to recognise an inter- villous space (Fig. 284). The changes going on in the muscularis of the tube consist in a hypertrophy of the muscle cells. As in the uterus, their number does not seem to be increased, but each individual fibre be- comes enlarged. The num- ber of muscle cells normally found in the tube is, of course, very small compared with the number found in the muscularis of the uterus. The gestation sac formed in tubal pregnancy consequent- ly must soon be very inade- quate in thickness, and oedematous infiltration and inflammatory changes must take place (Fig. 285). This, of course, as is seen in every single case, always comes to pass. Microscopic examination of the gestation sac shows that the bundles of muscle fibres become separated by interstices. These are often filled out with fibrous connective tissue, but fre- quently we only find an oedematous or serous mate- rial between the muscle bun- dles. The whole tube wall, including the decidua, is in- filtrated with cellular ele- ments of an inflammatory type, such as polynuclear leucocytes and lymphocytes; plasma cells are likewise found. This inflammatory reaction is brought about by coagulation necrosis, in con- sequence of pressure and pulling and smaller and larger apoplectic insults from enormously enlarged tubal vessels. But all of these changes, which as a rule only become pronounced when the ovum has reached a certain size, do not seem, to be sufficient to explain very early ruptures. It appears to Ilerzog that one of the most important, if Fig. 285. — " fEdeinatous infiltration and inflamma- tory chan^e.s must take place." — Heezog. 660 A TEXT-BOOK OF GYNECOLOGY not the most important^ factor in the production of early rupture in tubal pregnancy, is furnished by the behaviour of the syncytium The latter in tubal pregnancy displays greater phagocytic properties or greater penetrating powers than in normal uterine gestation. In the latter we see the syncytium often penetrate deeply into the de- cidua. But it appears that the uterine muscularis offers to the fur- ther progress of the syncytium an obstacle as a rule unsurmountable. It is different in tubal pregnancy. Here there is no strong, solid, dense muscularis. We have on the contrary a rarefied, cedematous tissue, and in it one can frequently see that the syncytium pene- trates through almost the entire thickness of the gestation sac. It is this circumstance which appears to Herzog as of the greatest importance in bringing about the conditions which lead to early rupture in tubal pregnancy at a time when the pressure of an en- larging ovum can not yet be held as adequately responsible for the accident. The extensive penetration of the syncytium, as found in specimens of tubal preg- nancy, reminds one forcibly of the syncytial proliferation as found in placentoma ma- lignum. Decidualike cells are also found in the outer layers of the gestation sac, and one occasionally meets decidual masses on the peri- toneal covering of the tube. Here these decidualike struc- tures are furnished by pro- liferating peritoneal endo- thelium. Operations for ectopic pregnancy furnish excellent material for the study of the histology of the corpus lutem verum (Fig. 286). One is surprised to find occasionally that the ovary of the side on which the tubal pregnancy occurred does not show a corpus luteum verum but that the ovary of the opposite side contains this structure. This observation, not infrequently made by a number of workers on the subject, has given rise to the probably correct notion that tubal pregnancy is occasionally the result of an impregnated ovum wandering from one side to the opposite tube. Here the ovum becomes implanted before it can reach the uterus and gives rise in this manner to an ectopic gestation. Symptomatology. — The symptoms of ectopic pregnancy of course vary with its progress, according to the integrity of the sac, and to whether the foetus is living or dead. In the early period the ordi- nary signs of pregnancy are to be observed. Among these, cessation of Fig. 286. — " The corpus luteum verum." — Herzog. ECTOPIC PREGNANCY QQl menstruation, nausea, and changes in the breasts are to be mentioned, though any and all of these symptoms may be absent, or modified by individual peculiarities. As a rule, however, menstruation is delayed or missed; and the patient exhibits sufficient of the classical symptoms of pregnancy to direct attention to the probability of such a condition. The recurrence of menstruation, which is usually irregular and pro- fuse, is a part of the early history of this condition; and the shedding of the decidua in the form of shreddy discharges, constitutes a valuable diagnostic symptom of the early period. The objective symptoms consist of an enlarged uterus with softened cervix simulating normal pregnancy, and with a soft and movable tu- mour upon one side of the uterus. A microscopic examination of the ex- pelled decidua will often disclose the character of that membrane posi- tively and thereby facilitate diagnosis. Prior to the rupture of the tube, the symptoms are obscure and uncertain and the physical signs are for the most part those of normal pregnancy. AVhen rujDture oc- curs (Fig. 387), which invariably happens by the end of the twelfth or fourteenth week, the symptoms are marked and often most alarming. The pain is sharp and agonizing, and is referred to the pelvis. There is also a bloody flow from the uterus at this time. The pa- tient will usually exhibit the symptoms of profound shock and internal hemorrhage. It is not uncommon for the pa- tient to fall to the floor and suft'er profound shock, and, in a large proportion of cases, fatal collapse from pain and hemorrhage will supervene Fig. 287.—" When rupture occurs ... the symp- within a few hours. In other toms are marked."— McMuetet. cases the symptoms will not be so severe and extreme. The rupture may be only partial and the hemor- rhage slight, when the symptoms will be correspondingly light and tran- sient. After a brief interval varying from a few hours to several days, the rupture will extend with renewed pain and pronounced symptoms of intra-abdominal hemorrhage. Associated with this condition will be gen- eral abdominal tenderness; followed later, if left alone, by symptoms of peritonitis. With primary intraperitoneal rupture there is hemorrhage, but the detection of efl'used blood inside the peritoneum is difficult and uncertain; hence in this condition bimanual examination will avail but little at first in detecting the effusion. Later, when the blood has gravi- tated and coagulated, the physical signs elicited by bimanual examina- tions will show the pelvis to be filled with a semisolid mass. When tubal abortion occurs, the symptoms may be of such limited severity as to deceive the patient and physician as to the nature of the illness. The ovum is detached from its bed in the ampullar extremity 662 A TEXT-BOOK OF GYNECOLOGY of the tube and, with the accumulated blood of successive hemorrhages, forms a mass to become absorbed or to be walled off by adhesions. The general symptoms will be those of a tender, boggy mass and localized peritonitis, readily confounded with other forms of tubal disease. When rupture occurs with cleavage of the folds of the broad ligament, but without rupture into the general peritoneum, the symptoms are very obscure. The pain is paroxysmal, is prone to recur, and varies as to its severity. The symptoms of collapse are not so severe as when intraperitoneal rupture occurs, due to the limited hemorrhage — limited because of the resistance of the inclosing layers of the broad ligament. This is the form of ectopic pregnancy which permits continued vitality and development of the fcetus. Secondary rupture takes place later into the peritoneal cavity, and may occur so soon after primary rupture that they can scarcely be distinguished. Few foetuses survive the fourth month, and the symptoms during these months result from the ruptures of the investing tissues, and the hemorrhages associated inevi- tably with these changes. After the fourth month, if the foetus sur- vives, the symptoms are those of intrauterine pregnancy with the modi- fications which would reasonably obtain under the altered environment of the growing foetus. Diagnosis. — From the above exposition of the symptoms of ectopic pregnancy, diagnosis will be approximately made in most cases before bimanual examination is utilized. When the history and symptoms are considered in conjunction with careful bimanual examination, the diag- nosis will, as a rule, be readily established. Diagnosis during the first week and prior to rupture is rarely practicable, not only on account of the vague and obscure character of the symptoms, but also from the fact that the symptoms are rarely sufficiently active to impel the patient to seek medical advice. Menstruation is absent or retarded during this stage, and hemorrhage coming on later marks the shedding of the de- cidua. Physical examination is of doubtful significance, as the unrup- tured tube may be displaced posteriorly or may recede from the exam- ining fingers as does a cystic ovary or hydrosalpinx. Under these cir- cumstances, the general symptoms of nausea and changes in the breasts and uterus will afford those presumptive indications upon which a tentative diagnosis will be made. When the primary intraperitoneal rupture takes place, the symptoms of severe localized pain, varying in degree with the extent of rupture, together with the indubitable signs of intraperitoneal hemorrhage, readily establish the diagnosis. This generally occurs about the seventh week and is usually the first positive symptom that impels the patient to seek advice. Ectopic pregnancy is most frequently observed in women with pre-existing pelvic disease, which fact renders slight menstrual disturbances of minor significance. A vaginal examination at the time of rupture is often negative on account of the presence of pain and muscular contraction. After the paroxysm of pain has passed, a mass on one side of the uterus will be apparent to the bimanual touch. The diagnosis, however, is deter- ECTOPIC PREGNANCY 663 mined more by the distinct indications of hemorrhage than by the de- tection of a tumour. General abdominal tenderness is usually present with the symptoms of shock and collapse. When the rupture is into the fold of the broad ligament, the pain is more variable as to its severity and is usually paroxysmal. The shock is correspondingly less marked and the volume of effused blood is limited by the resistance of the peritoneal folds composing the broad ligament. When the rupture occurs into the broad ligament very early in the period of pregnancy, the pain and hemorrhage may be very slight and may pass unrecognised as if the condition was one of ordinary menstrual pain or colic. Such cases often recover entirely without treatment, the ovum, secundines, and effused blood being ab- sorbed. When secondary rupture into the general peritoneal cavity occurs in this form of tubal pregnancy, there is a recurrence of pain, with the symptoms of hemorrhage and shock very similar in character and severity to primary intraperitoneal rupture. If the ovum survives after secondary rupture by retaining sufficient vascular attachment to the tubal mucous membrane for its support, an altogether different and more marked series of diagnostic indications makes its appearance. These advanced symptoms are marked after the fourth month and are both general and local. The general diagnostic symptoms are those characteristic of advanced pregnancy, and consist in absence of menstruation, changes in the breasts, vulva, and uterus, abdominal enlargement, movements of the foetus, placental souffle, and ballottement. Palpation of the foetus is easily made on account of the thinness of the abdominal walls. As a means of diagnosis, palpation is an untrustworthy resource in ectopic pregnancy, since the same impres- sions may be derived through the walls of an attenuated uterus. Mc- Murtry has had frequent cases of attenuation of the uterus (American Practitioner and News) in which repeated examination by several skilled observers gave the impression, in the face of a doubtful his- tory, of ectopic pregnancy nearing full term. Normal delivery demon- strated the true condition to be that of attenuated uterus. In such cases the uterine walls are so thin that the foetal head, body, and limbs, may be followed by the hands, as if subcutaneous. In the diagnosis of all stages of ectopic pregnancy, the fact that intrauterine pregnancy may coexist should never be forgotten. When the term of pregnancy is completed (Fig. 288) and spurious labour supervenes, the diagnosis, if not previously made, will be estab- lished without special difficulty. The pains are well defined, contrac- tile, gradually increasing in duration and severity, recurring at inter- vals, and gradually subsiding. After spurious labour, and the conse- quent death of the fcetus, marked changes are observed in the foetal and maternal structures. The placental circulation continues for some time after the death of the foetus. The abdomen is usually decreased in size, fcjetal movements cease, and the uterus undergoes involution. In a certain proportion of cases, the gestation sac and foetus undergo 664 A TEXT-BOOK OF GYNECOLOGY necrotic changes and break down into a gangrenous, suppurative mass. Hectic fever and general septic symptoms of severe type at once appear. After a severe and protracted illness, pus may find outlets, single or multiple, through the abdominal wall, rectum, vagina, or bladder, to be followed by the debris of the macerated foetus. In some instances, the foetus un- dergoes mummification, cal- cification, or is converted into a lithopsedion, so that the septic symptoms men- tioned may be modified or be altogether absent, in accord- ance with these varied meth- ods by which the foetus and secundines are managed by the digestive activity of the peritoneum. Treatment. — In the pre- antiseptic era of surgery, many methods of treatment were devised to arrest the de- velopment of the misplaced ovum and to promote its ab- sorption. Among these may be mentioned the administra- tion of strychnine to a toxic degree, hypodermic injections of ergot, and puncture of the cyst. More recently, the in- jection of morjDhine into the sac, and later the apj)lication of electricity, have been in vogue to destroy the foetus and to facilitate innocuous ab- sorption. All these methods of treatment are now obsolete, and proper surgical treatment is the only method deserving confidence. In no field of surgery have the results been more brilliant than in the treat- ment of ectopic pregnancy. A certain proportion of the cases of ectopic pregnancy in which rupture occurs during the early stages, recover without operation. Some present themselves to the gynecologist weeks or months after rupture, with the symptoms of pelvic inflannnation of tubal origin. Abdominal section will reveal an old and infected blood clot, the removal of which will be followed by prompt recovery. These cases were formerly classified under the head of suppurating hemato- cele (Fig. 289). While recovery may eventually take place under ex- pectant methods of treatment, the larger proportion will be saved by prompt abdominal section and removal of the affected tube and its con- tents. In the following classes of cases, viz. — 1. Unruptured tubal pregnancy; 2. Cases of rupture without severe symptoms; 3. Cases of Fig. 288. — " When the term ... is completed . . . the diagnosis . . . will be established without special difficulty." — McMurtkt (page 663). ECTOPIC PREGNANCY 665 rupture with developing infection, Schauta has shown that the mor- tality of ectopic pregnancy, when uninterfered with, is over 65 per cent, while the mortality in cases treated by prompt surgical interven- tion is less than 6 per cent; from which it is apparent that the patient is exposed to greater peril by expectant treatment than by early resort to surgery. As heretofore stated, few cases of ectopic pregnancy will present themselves for treatment prior to the time of rupture, con- sequently it is exceptional that an opportunity is found for the simple and safe operation prac- ticable at this stage. The operation consists of ab- dominal section and re- moval of the involved tube in a patient free from shock or hemorrhage, and where the condition is un- complicated by inflamma- tory lesions. When rupture has oc- curred, esj^ecially if with extensive lesions directly into the general perito- neum, immediate opera- tion is a necessity to save life. The case is one of hemorrhage, and to arrest the bleeding is as impera- tive here as to secure the severed ends of a wounded blood vessel in other lo- calities. The operation in these cases is one of emergency, oftentimes to be done immediately upon seeing the i)atient and recognising the condi- tion, with all the haste that is compatible with due regard to reasonable aseptic operative precautions. When the peri- toneum is incised through an abdominal incision, blood clots will present themselves through the incision. These must be rapidly turned out, the ruptured tube sought with the exploring fingers, and secured with a clamp. The hemorrhage having been arrested by this manoeuvre, the operator can deliberately ligate tlie ruptured tube at the uterine cornu, and cleanse the peritoneum of all fresh blood and clots. When primary rripturo has preceded operation for a sufficient time, old and disintegrated blood clots will be found. Irrigation with hot saline solu- FiG. 289. — >■'■ These cases were formerly classified under the head of suppurating hematocele." — McMuetby (page 664). QQQ A TEXT-BOOK OP GYNECOLOGY tion will subserve a double purpose in removing these clots, and, by rapid absorption through the peritoneum, in overcoming the associated shock and anaemia. During the progress of the operation in these cases, as well as prior and subsequently to that procedure, hypodermic medication and saline infusion should be applied to maintain the circu- lation. McMurtry has had the gratifying experience of witnessing the return of the pulse at the wrist under this treatment, when the patient seemed beyond surgical aid from the severity of the hemorrhage. The anaesthetic should be given barely to the point necessary for permitting the operation without pain, and should be laid aside at the earliest possible moment in order to avoid adding anything to the profound shock already existing. Ether is to be preferred in these cases on account of its stinuilating effect. The question of drainage must be determined by the indications of individual cases. Where irrigation has been required, drainage for twenty-four hours by means of a glass tube will usually prove advantageous, and will also give assurance as to hemostasis. When the patient is placed in bed, dry heat should be applied and the foot of the bed elevated. When a patient has passed safely the immediate danger from rupture, with the pelvis filled with blood clots and membranes undergoing septic changes and suppuration, it may be best, if she has become feeble from sepsis, to incise the fornix vaginte and remove disorganized clots and septic foci, thereby pro- viding an outlet and securing drainage. In all other conditions, the surgical requirements of ectopic pregnancy will be best subserved by abdominal section rather than by vaginal incision. The operative treatment in advanced ectopic pregnancy will vary as the foetus is living or dead, and according to the consequent state of the placental circulation. The placental site varies in these cases, and may be on the abdominal wall, in the uterus, or spread out most frequently over the broad ligament and uterus; in some cases it is also attached to intestinal and bladder surfaces. After spurious labour and the death of the foetus, the placental circulation remains active for some time. Hence, under these circumstances it is best to defer operation for several weeks in order that the placental thrombi may be- come organized. Then the placenta can be enucleated without serious danger from uncontrollable haemorrhage. The danger to life in those cases where the pregnancy has advanced beyond the fifth month, and especially in those that have gone beyond full term, is extreme. The difficulty centres about the removal of the placenta. When the placenta is spread out over the uterus and intestines and the circulation through it is active, a fatal hemorrhage will usually follow any attempt at its re- moval. If this condition is found to exist, the cord is tied and cut short after removal of the foetus, and the sac is stitched to the edges of the incision after packing it with gauze which is allowed to protrude from the lower angle of the incision. The danger here, too, is great; for the large mass is readily infected, and secondary hemorrhage will often ensue as the placenta breaks down. When the foetus is alive ECTOPIC PREGNANCY 667 and viable, operation should be done without waiting for the comple- tion of the full term of pregnancy and spurious labour. In opening the abdomen, the sac should be avoided carefully by diverting the line h'ui. 290.—". . . A patient who had t^ono two inonths beyond term, -maceration of the foetus having conitnenced." — McMubtky (page 668). of incision. When tbe sac is opened, the child is extracted and handed to an assistant. If tbe plactrnta is favourably situated, it may be rapidly enucleated and the hemorrhage controlled by firm gauze pack- 668 A TEXT-BOOK OP GYNECOLOGY ing. Otherwise, it may be best to leave the placenta as already de- scribed. When the foetus has been dead for several weeks, the dangers of operation are much lessened. In these cases it will often be practicable to remove the placenta at once without severe hemorrhage. When the foetus has been long dead and has undergone mummification, adi- pocere change, or calcification, the operative procedure for its removal Fig. 201. The child was removed bv abdominal section." — McMurtet. will present no additional difficulties, and can be conducted in accord- ance with the principle already set forth in this chapter. Eeed operated on a patient at the Cincinnati Hospital who had gone two months be- yond term, maceration of the foetus having commenced (Fig. 290). The child was removed by abdominal section (Fig. 291) and the sac sutured to the margins of the wound and packed with gauze, as the slightest traction on the placenta induced hgemorrhage. The placenta was sub- sequently removed, and the patient made a complete recovery. CHAPTEE XLIII NEOPLASMS OF THE BROAD LIGAMENT The broad ligament — Varieties of neoplasms — Cysts (parovarian), origin, causes, symptoms, complications, diagnosis, treatment — Hydrocele of the round liga- ment — Fibroma, myoma, and lipoma; symptoms, diagnosis, treatment — Der- moids — Solid tumours of the round ligament — Pelvic varicocele — Aneurismal varix and phleboliths — Malignant neoplasms : Carcinoma ; sarcoma. The broad ligaments consist of folds of peritoneum, extending from the uterus to the bony wall upon either side of the pelvis. On the upper margin of each of these peritoneal folds, and extending lengthwise with it, is the Fallopian tube, the fold beneath it being fre- quently designated the mesosalpinx. Attached to the posterior fold of the broad ligament, near its outer extremity, is the ovary. There are various structures contained within and beneath the folds of the broad ligament. It is necessary in this connection to consider only (a) the round ligament, which extends from the uterus to the inguinal ring, and over which there drops a sort of duplication of the peri- toneum, usually designated the anterior fold of the broad ligament; (b) the parovarium, or the rudimentary survivor of the Wolffian body; (c) the blood vessels; (d) the lymphatics; and (e) unstriped muscular fibres. Each of these several structures may present patho- logic changes demanding consideration. Neoplasms developing within the broad ligament may originate from any of the structures therein contained. They may be consid- ered under the two classes of (a) benign, and (b) malignant. Benign enlargements, some of which are not, strictly speaking, of neoplastic character, but which, for convenience, are grouped together in this chapter, are : 1. Cysts arising from the inner tubules of the parovarium. 2. Fibromata arising from the fibrous connective tissue. 3. Myomata arising from the unstriped muscular fibres. 4. Fibromyomata arising from the two preceding. 5. Lipomata arising from the areolar tissue. 6. Dermoids arising from the connective tissue. 7. Varicocele arising from the dilated veins. 8. Aneurismal varix arising from the increased number and en- largement of blood vessels. 660 670 ■ ^ TEXT-BOOK OF GYKECOLOGY 9. Phleboliths arising from the calcareous infiltration of thrombi. 10. Hydrocele arising from the round ligament. Malignant Neoplasms: 1. Carcinomata / -,-, n i •. „ <-i ± r are generally secondary deposits. 2. Sarcomata j o ^ j r Cysts developing in the broad ligament may arise from (a) the epoophoron (parovarium), (h) the paroophoron, (c) the round liga- ment (hydrocele). It is important as a preliminary step in this con- nection to consider more in detail these various structiires — particu- larly the two former. Notwithstanding that M. Sanger, W. Fischel and Werth (Archiv fiir Gyndkologie, Bd. xv, xvi) wrote in 1880 extensively, clearly, and correctl}^, upon the tumours of the broad ligament and of the struc- tures lying between its folds, Doran {Tumours of the Ovary and Broad Ligament, 1885) expressed regret that the gynecologists manifested so little interest in the parovarium. Since then, however, most of the writers on gynecology, and the text-books on this subject, speak more or less extensively of this organ and its relation to certain pathologic conditions. While, clinically, the diseases of the parovarium and the mesosalpinx can not, or should not, be considered separate or distinct from those of the ovary, they are, nevertheless, peculiar to organs that are as different from the ovary as is the Fallopian tube; and just as the tubes, and the affections characteristic of them, are dealt with by themselves, so should the diseases of the parovarium and its peritoneal coverings be treated distinctively and form a chapter of their own. Parovarium is the term first used by Kobelt. Waldeyer called it epooplioron, in contradistinction to the paroophoron (which lies closer to the uterus and represents the vestiges of the corpus Geraldes of the male, the parepididymis). The organ was formerly, and still is, quite generally known also as the corpus Eosenmiiller because Eosenmiiller gave the first description of it. The mesosalpinx is merely a part of the hroad ligament. The two terms should not be used synonymously. Briefly defined, the parovarium is that portion of the female inter- nal genitalia which represents the atrophic or rudimentary remnant of that part of the Wolffian body that would have become the epididymis in the male. Anatomy (Embryology). — The parovarium (Fig. 207) resides be- tween the two folds of the broad ligament, and consists of a number of small, " closed " tubules running transversely in a fan-shaped ar- rangement from the ovary toward the Fallopian tube. These tubules can be easily detected by the unaided eye, if the normal meso- salpinx is spread out and held up against the light (Quain). The number of tubules varies, as a rule, from 10 to 15, though there may be only half a dozen, or as many as 25 or 30 (H. C. Coe). It is said that they have no openings ; that they measure from a little less than 0.5 millimetre to 1 millimetre in diameter; ^elling with up- ward, downward, anterior, posterior, or lateral, displacement of the uterus and some of its appendages. Here, too, there will be noticed a steady augmentation of the symptoms. The bladder will become dis- turbed in its position and this may cause frequent, painful micturi- tion or even incontinence of urine. The rectum may be affected in the same way. The symptoms, then, in all uncomplicated cases, will vary according to the size, age and locality, of cysts. As they are of very slow growth and sometimes stationary, other conditions may give NEOPLASMS OP THE BROAD LIGAMENT 675 rise to complications, as, for instance, pregnancy, rupture of the cyst, torsion of the pedicle, diseases of the uterus and its appendages, etc. The physician may be consulted for any one of these or for several of them, and may discover the presence of a parovarian tumour by accident rather than otherwise, either by his examination, or while operating in the abdominal cavity for other diseases or injuries. It is evident, therefore, that the diagnosis is not always easy, and that errors may be made; but let it be remembered that fluctuation is nearly always very distinct and superficial, as in ascites, and that, if the cyst wall is flaccid, the percussion note may change slightly with the change in posture of the patient. If a spontaneous rupture takes place, there may be no symptoms. This, it is said, may happen re- peatedly, without even a suspicion on the part of the patient, and may be eventually followed by recovery. Rupture of the cyst, spontane- ously or accidentally, is always followed by diuresis; often, it is also followed by pain, in the absence of complications ; and always by pain, sometimes by shock, and occasionally by sepsis and death, if this acci- dent occurs in the presence of acute or chronic inflammatory suppura- tive complications. That there are cases in which a diagnosis can be made, can not be doubted. When we find a flaccid abdominal tumour, with distinct fluctuation and devoid of hard nodules, which is of slow growth, accompanied by a hstory of the absence of pain, and, possibly, of repeated rupture without serious consequences, it seems safe to conclude that we are dealing with a broad-ligament cyst. But it may be wise not to be too positive even then. At the present high stage of devel- opment of abdominal and pelvic surgery, puncture of any cystic growth for diagnostitial purposes must be mentioned only to be condemned. To distinguish between a papillary parovarian cystoma and a mul- tilocular cyst of the ovary, we need only remember that the former is mostly, if not always, bilateral; that it is always intraligamentary, and that the inner surface of the cyst is lined by ciliated epithelium. Treatment. — The treatment of parovarian and other cysts of the broad ligament is very much like that of the solid tumours of this structure. Formerly, puncture of the cyst was earnestly advised, and is still held out, by some, as worthy of trial now. Zinke can not sub- scribe to this view. It may be true, though he is inclined to doubt it, that some patients have been cured by this means. He does not doubt that hundreds of women afflicted with these growths have each been successfully tapped many times, and, in some instances, hun- dreds of times ; but he knows, also, from personal experience and the experience of others, that in the great majority of all the cases so treated, nearly all were but temporarily relieved and eventually died of exhaustion. In some, adhesions were caused that subsequently complicated the extirpation of the growth; and in others, conditions were established that resulted in the death of the patient, as the result either of carelessness or of errors in diagnosis. There is no class of cases that, when U'cc U-om complicntions, recover more promptly from 676 A TEXT-BOOK OP GYNECOLOGY radical operative procedures when done under strictly aseptic precau- tions than these. The pedunculated variety, especially, admits of easy removal of even very large tumours and through a very small incision. Those cases which develop within the broad ligament with- out a pedicle, are often shelled out with ease, and not unfrequently a pedicle ma}' be made of a part of the base of the broad ligament not taken up by the cyst, and of a part which is stripped from the lat- ter during its enucleation. In the class of cases that are entirely sub- serous or extraperitoneal, as in the solid tumours of the broad liga- ment, enucleation of the entire cyst may be accomplished and the cavity left treated in the same way as recommended under Treatment of Solid Intraligamentary Tumours. Should the removal or enucleation of a cyst seem, for any reason, impossible, or, on account of existing complications, inadvisable, then the plan of removing part of the cyst and stitching the edge of the remaining portion to the abdominal wound for the purpose of packing and drainage, as first advised by Spencer Wells, and practised by 01s- hausen, Winckel, Sanger and others, may be resorted to, and complete recover}^ confidently expected. Some of our German confreres, also, state that, in the absence of complications, the sewing of the remain- ing portion of the sac, as just described, is really unnecessary ; because its contents and what may be subsequently secreted, will be readily absorbed by the peritoneum; the sac eventually shrivels up, atro- phies, and the patients recover perfectly and permanently. An important innovation in the technique of operations for intra- ligamentary cysts, was devised almost coincidently, and with equal originalit}', by Hall of Cincinnati and Hawkins of Denver. The method, which is essentially a supravaginal hysterectomy, is described by Hall as follows: " Open the abdominal cavity in the usual manner. Then, tap the cyst and empty it. Xext, ligate the ovarian artery on the tumour side at the pelvic border. legate the ovarian artery on the opposite side, outside the ovary if that organ is to be removed, inside it, if it is to be left. Divide the peritoneum crosswise above the top of the bladder and push the bladder down. Ligate the uterine artery on the healthy side. Cut across the cervix, and clamp or ligate the uterine artery on the tumour side. The blood supply is then cut off and the patient has not lost a drachm of blood. The capsule of the tumour can now be divided at a suitable point behind and in front, and the tumour can be enucleated from below upward with much greater ease than from above downward, and with corresponding safety to the ureter, the rectum, and the iliac vessels. Close the peritoneum over the pelvic floor with running sutures of catgut. Every part of the field of operation is in view of the operator." The drawing (Fig. 294) from a specimen of Hall's, shows the extent of the operation. This operation, which certainly offers the maximum of safety to the patient, is one that necessarily involves the loss of the reproductive NEOPLASMS OF THE BROAD LIGAMENT 677 Fig. 294. — " A specimen of Hall's " (intraligamentary cyst). — Eeed (page 676). power. This may be a matter of serious moment in certain cases, and should not, therefore, be done, except after the menopause, or when fecundity has been destroyed by disease; or as a matter of emergency, and even then as a matter of policy it is better to have the consent of the patient. Intraligamentary cysts may be removed by enucleation without damage or conse- quence to the reproduc- tive apparatus, although this is manifestly more hazardous to the patient than is the Hall-Hawkins operation. Hydrocele of the round ligament may de- velop precisely as does hydrocele of the sper- matic cord in the male. The pathology is essen- tially the same in the two conditions, with the ex- ception that, in women, the dropsical accumula- tion is much more re- stricted, being as a rule limited to the canal of Xuck; the sac may present at the inguinal ring, or even protrude beyond it, as a fluctuating tumour, suggestive of a hernia with a fusion. It is not ordinarily a painful affec- tion, although it may occasion enough disturbance to attract atten- tion to it, when the exact character of the difficulty may be ascertained. Treatment may consist of (a) puncture, followed by different varieties of injections; (6) free incision of the sac, followed by sterilized tam- ponade; or, (c) extirpation of the sac. The two former methods are painful, tedious, and uncertain — ^the last-named, alone, being entitled to the designation of radical. Yolbrecht operates upon hydrocele of the round ligament, when the sac is large and located high up, by making a section of the inguinal canal in its entire length. The sac is then isolated and cut away, a ligature being placed upon the pedicle; the canal is then sutured, layer to layer, as in the Bacini operation. Fibroma, Myoma, and Lipoma of the Broad Ligament. — Fibroma and myoma may develop in the broad ligament as such pure and simple, or combined (fihromyoma). They are subject to cystic degeneration in this as well as in other regions of the body (cystofiiroma or cysto- myorna). The myoma of the broad ligament is the leiomyoma of Ziegler, because it is made up principally of newly developed, un- striped muscular fibres. Prior to 1880, the primary development of these tumours in the bioad ligament was almost universally denied. To M. Sanger (Archiv fiir nyiinj-ohif/ie, Bd. xvi, 1880, s. 258) be- 678 A TEXT-BOOK OF GYNECOLOGY longs the credit of establishing a definite clinical autonomy for this variety of intraligamentary neoplasms. He states that Klob, in 186-i, questioned the possibility of the independent development of the same; though Kivisch, in 1849, admitted the primary formation of small fibroids, but when he saw large ones, they, in his opinion, could only arise from the uterus. Scanzoni (1875) was of the same opinion; he attributed their origin to small blood extravasations. Even Schroder (1879) denies that fibroma and myoma have their genesis in the broad ligament, notwithstanding that Virchow recognised their primary development in this locality, and Schetelig (Arcliiv fur Gynd- hologie, Bd. i, s. 459) had described a large " cystomyoma teleangeiectodes cavernosum of the right broad ligament," which showed its genuine developmental origin to be from the unstriped muscular fibres of the same. Sanger then quotes the cases of Schmidt {Prager medicinische Wocliensclirift, 1878, s. 35) and Mikulicz {^Yietm' medizinisclie Wochen- schrift, 1878, s. 19-21). That of the former was a case of fibrosarcoma weighing 8 kilogrammes (17.60 pounds); it sprang from the right broad ligament, had a long, tolerably thick pedicle, and occurred in a patient thirty-three years old. The latter was an oedematous fibro- myoma weighing 5 kilogrammes (11 pounds), and developed in the left broad ligament of a nullipara aged twenty-two years, and single. The latter tumour was of slow growth, was complicated with ascites, and had a very thin pedicle. Both patients recovered. It is interesting to note that even Professor Winckel, so late as 1887, still clung to the idea that myomata of the broad ligament were at first, probably, subserous or intraparietal, and grew from the uterus into the broad ligament; he admits, however, that primary gro^vi;hs have been observed. There is no reference at all to intra- ligamentary fibroma and myoma in Mann's American System of Gyne- cology, 1888. The same must be said of Thomas and Munde's Prac- tical Treatise on the Diseases of Women, 1891. Senn, in his book on the Pathology and Surgical Treatment of Tumours, 1895, p. 511, speaks of the primary formation of myofibromata within the broad ligament, but still maintains that " not infrequently " they originate from the uterus. Kelly {Operative Gynecology, 1898) no longer discusses the question, and describes and illustrates a variety of cases. A beautiful representation of a cystic myoma can be found on p. 394, vol. ii, of his work. Baldy {American Text-hook of Gynecology) devotes not quite one page to the consideration of intraligamentary fibroids, and calls them " ex- ceedingly puzzling." Zinke states that Edwin Eicketts presented 3 cases of intraligamentary fibroids to the Academy of Medicine of Cin- cinnati, Ohio, weighing severally 16, 8, and 65 pounds. They were re- moved from patients aged forty-four, fifty-one, and forty-eight years respectively. The last died; the two former recovered. Zinke also maintains that at this time it is simply impossible to estimate the frequency of these growths. They are rare; but they do occur sufficiently often to demand the full attention of every gyne- NEOPLASMS OF THE BROAD LIGAMENT 679 cologist and abdominal surgeon. According to Rosenwasser (Annals of Gynecology and Paidiatry, vol. iv, No. 6, 1891) — Olshauseu found among 280 ovariotomies 20 intraligamentary Wylie " " 500 " 6 Munde " " 154 '• 18 Rosenwasser " " 12 " 6 " or " 946 '^ 50 " = 18.85 per cent. Sanger (1880) remarks: " I have the conviction that our experi- ence with solid tumours of the broad ligament will be like that with parovarian cysts. At one time believed to be great rarities and prac- tically unimportant, they have been observed so frequently that every laparotomist must take them into account." The only references Zinke can find to lipomata of the broad liga- ment are contained in Pozzi's Treatise on Gynecology, p. 187; in Senn's Pathology and Treatment of Tumours, p. 407, which is merely a quota- tion of the former; and in Winckel's Diseases of Women, p. 598. Pozzi saw one case that had been mistaken for an ovarian cyst. An explora- tory puncture was made, and the patient died of embolus three days later. Terrillon is cited by Pozzi as removing a lipoma springing from the mesentery and weighing 60 pounds. Winckel quotes Pernice, who extirpated one weighing 30 pounds from the right broad ligament; his patient, aged sixty-four years, recovered. Winckel also gives credit to Klob and Orth as having seen similar cases. After quoting Rokitan- sky, who observed a lipoma the size of a walnut on the lower border of the tube in a woman aged forty-seven years, Winckel dismisses the subject by saying that " lipomata have no practical significance be- cause of their small size." The clinical character, symptoms and diagnosis of solid tumours of the broad ligament are much the same as those produced by the cysto- mata of this region. They are of slow growth, not tender to the touch, and are with or without pedicle. When pedunculated, as in Dr. Schmid's case, they extend freely into the general peritoneal cavity and admit of comparatively easy removal; when there is no pedicle, the tumour develops subperitoneally, spreading the folds of the broad ligament apart and forcing the uterus to one or the other side. Like some of the parovarian cysts, these tumours may dissect up the parietal peritoneum anteriorly or posteriorly or both, and thus present great difficulties during efforts at their removal. The diagnosis is by no means easily made, and, so far as Zinke is able to determine, in the great majority of the cases observed, it is arrived at only after the abdomen has been opened. This, too, is his own individual experience with these cases. The treatment of the solid but benign tumours of the broad ligament may be conveniently divided into palliative and curative. Both methofls of procedure are much the same as those in vogue for uterine fibroma and myoma, and the reader is referred for the details of descrip- 680 ^ TEXT-BOOK OF GYNECOLOGY tion to the chapter on this subject in this work. Suffice it to state here, that the use of ergot, hydrastis canadensis, and electricity, have been well tried by good, earnest, well-trained men. The results are anything but satisfactory so far as a cure or decided relief is concerned. Apostoli, Keith, Engelmann, and many other able and painstaking investigators of the value of electricity in these cases, have been disappointed in the results obtained, and it is pretty generally believed that the so- called " cures " accomplished, about 2 A per cent of many hundreds of cases, represent the possible percentage of errors in diagnosis {American Text-booh of Gynecology, p. 401). Unfortunately, the result obtained with ergot, hydrastis canadensis, and iodide of potassium, hypoder- matically or per os, is not much better. Zinke, for a number of years, has given these remedies a faithful and extensive trial, even after spending a month with Apostoli in Paris and many years of association as pupil and assistant to C. D. Palmer, who was, and to some extent still is, a firm believer in and ardent advocate of these methods of treatment. If there is any doubt as to the value of any of these means in the treatment of uterine fibroma and myoma, it would seem that the outlook is not very encouraging with the same measures in the treatment of intraligamentary fibromyomata. There appears to be no record of the application of the above treatment in lipomata of the broad ligament. The only true remedy is removal of the tumour or tumours by enucleation through the abdomen; although Pean, and a few others who have followed his method of morcellement, have done so success- fully, by accident rather than otherwise, by the vaginal route. According to Olshausen the credit of first presenting and recom- mending the essential features of the present mode of enucleating these growths belongs to Miner, of Boston (1869). The operation of enuclea- tion is not a very difficult one if the tumour is not large, and has grown toward the abdominal cavity rather than into the pelvis; but when excessive in size, both the abdominal and pelvic cavities will be occupied by the tumour. Again a tumour or tumours of but moderate dimensions may be so situated in the pelvis as to fill it out completely, thus displacing the pelvic viscera upward in every direction; in addi- tion to this, there may be numerous adhesions and other complicating diseases, which will make the operation very difficult and formidable. Martin, Hegar, Kaltenbach, Olshausen, Kelly, Baldy, and many others, have clearly described how to proceed under the various con- ditions that may present themselves. The principal object to be at- tained is to avoid hemorrhage and injury to other structures as much as possible. The ureters, bladder, and the large blood vessels within the pelvis, are especially endangered when the growth is very large or confined to the pelvis, and the adhesions numerous and firm. Pe- dunculated, solid, intraligamentary tumours, are very rare. Their removal is simple enough. The stitching up of the cavity left by the peritoneal folds after enucleation of the tumour is no longer prac- NEOPLASMS OF THE BROAD LIGAMENT ggl tised. Where the folds fall into apposition^ there is no need for sewing; where they remain separate, experience has shown that recovery is much more prompt when, after arrest of hemorrhage, the cavity is simply cleaned and the abdominal wound closed without drainage. Martin, Hegar, and Kaltenbach recommended drainage into the vagina. Greig Smith, Goodell, and Skene were the first to abandon it. At present, drainage in these cases is, with most operators, a thing of the past. We doubt whether Senn, who recommended vaginal drainage in his book on tumours (1895), still practises what he then taught. 01s- hausen (1886) does not approve of supravaginal hysterectomy in all these cases, as has been advocated by Reuss, Goffe, Schenk, Braun, Kelly, Hall, and others. Olshausen believes that this procedure simply complicates and prolongs the operation, and should not be resorted to unless there is an absolute necessity for it. (See Treatment of Par- ovarian Cysts.) Dermoid tumours of the broad ligament may develop from the underlying connective tissue. Quervain (ArcMv filr Minische CM- rurgie, Bd. Ivii, H. 1), in mentioning this fact, alludes to 15 cases of dermoid tumours developing from the pelvic connective tissue. The symptoms in such cases are due to pressure. Dermoids in front of the rectum may simulate tumours of the cul-de-sac, those behind it cold abscesses or serous or hydatid cysts. Exploratory puncture, though not free from danger, may be necessary for diagnosis, but when that is established it is better to operate as soon as possible. The method of operation depends on the situation of the dermoid; peri- neotomy is indicated if the tumour extends downward, the juxtasacral incision if it is high up, and either of these methods may, if necessary, be combined with the extraperitoneal abdominal. If discovered during labour, the tumour may be incised and drained, but should be extirpated as soon as possible after delivery. Solid tumours of the round ligament are occasionally encountered. They are rarely very large, and may develop either from the outer extremity of the ligament, when the neoplasm becomes extraperi- toneal, or, more properly, properitoneal; or they may develop within the peritoneal cavity, when they may be properly designated intra- pelvic. Weber {Societe d' Ohstetrique et de gynecologie de 8t. Petershourg) has reported 3 interesting cases of tumours of the round ligament. In one, the tumour extended from the inguinal canal into the labium majus. The growth was solid in character, containing a few small cavities filled with fluid; and was pronounced to be a lymphangeiectoid fibroma. In another of his cases, a myoma originating in the round ligament had developed within the abdominal wall. In his third case, a fibromyoma was discovered inside the peritoneal cavity, in the course of an operation for hernia. The treatment of these cases is necessarily by operation. In the properitoneal variety, the tumour is exposed by a long vertical inci- 682 A TEXT-BOOK OF GYNECOLOGY sion, crossing obliquely the crural arcli. Care is then taken to search for the portion of the tumour which lies in contact with, and occupies, the inguinal canal. If necessary, the inguinal canal itself should be opened by free incision, the dissection being carried far enough upward to enable the operator to enucleate the tumour, precisely as if it were a growth of the abdominal wall. When the tumour is intrapelvic, it is liable to be mistaken for one of ovarian origin. The operation, under such circumstances, is precisely like an ovariotomy, with the exception that the pedicle should be differently treated. It is to be remembered that, in cutting away the tumour, a segment of the round ligament is likewise being removed. This deprives the uterus of one of its anterior guy ropes, a defect which, if possible, should be remedied at the time. This may be accomplished by transfixing the two cut ends of the round ligament by means of a ligature and bringing them together, the ap- proximation being strengthened by a fold of the peritoneum, held in position by another transfixing but continuous suture. When these tumours are large, they sometimes cause backward displacement of the uterus, which should be remedied at the time of operation. Fibj'omyomatous tumours of the round ligament are very rare. They generally develop in the extraperitoneal segment. Delbet and Heresco {Revue de cJiirurgie), in 16 cases of these tumours, found but 4 devel- oping from the intra-abdominal portion of the ligament. Claisse ac- counts for their relatively greater extraperitoneal development on the theory that that segment of the cord is more liable than the intra- abdominal portion to repeated, although probably slight, traumatisms. They grow to various sizes. Kleinwachter had a case in which the tumour developed 2.5 centimetres from the uterus and weighed 1,750 grammes. Matthews Duncan reported one the size of a hen's egg; Winckel, one the size of a bean. In Delbet's case, the tumour weighed 5 kilogrammes. In Segond's case, the growth in the ligament was associated with numerous similar growths in the uterus itself. Like the latter, they occur for the most part in women of middle or ad- vanced life, and are as liable to develop upon one side as upon the other. In their structural origin and evolution, they are analogous to fibromyomata of the uterus, although their manner of growth seems to be by perivascular inflammatory proliferation. Pelvic varicocele, aneurismal varix, and phleboliths, may be con- sidered under one head. Varicocele of the broad ligament is probably not as uncommon as is supposed. There are but few operators of long and extensive experience who do not come, accidentall}^, across cases of this kind in their abdominal and gynecological work; yet we find the literature upon this subject exceedingly meagre. The first case reported in this country was that of Dr. Dwight, of Boston, in 1877, quoted by A. P. Dudley, who, so far as Zinke is able to determine, wrote first in this country exhaustively on Varicocele in the Female and reported 4 cases (Neiv Yortc Medical Journal, 1888, p. 147). Winckel found dilatation of the utero-ovarian veins not less than 10 NEOPLASMS OF THE BROAD LIGAMENT 683 times out of 300 autopsies. He also found thrombi. Both Klob and Bandl have found phleboliths (Pozzi). Dudley also quotes Brandt as having often seen stones, the size of peas, in the veins of the broad ligament. Rousan {These de Paris, 1892; Bagot, Denver Medical Times) states that pelvic varicocele is of frequent occurrence. Ed- ward Malins, of Birmingham (American Journal of the Medical Sci- ences, 1889, p. 340), writes interestingly upon Varicose Veins of the Broad Ligaments, and reports 2 cases. To this, Zinke adds 2 cases: one, an aneurismal varix of the right, and the other a phlebolith with- in the left, broad ligament. In the former case, an abdominal section was successfully performed for the relief of uterine hemorrhage in- duced by varicose conditions in the right broad ligament. This condi- tion was in turn brought on by previous labours and was aggravated by a laterally flexed uterus in the fourth month of gestation. In the second case a bilateral salpingo-oophorectomy and myomec- tomy resulted in the discovery of a phlebolith 4.5 centimetres long, 1 centimetre thick in the centre, and tapering off toward each end, in the left broad ligament quite close to the uterus. The causes of varicocele and aneurismal varix of the broad liga- ment are, to say the least, quite obscure. Dudley in this country, Malins in England, and Winckel in Germany are about the only authors who have essayed to ascertain the etiological factors of this affection. Dudley divides the causes into, (a) constitutional, and (&) mechanical. Malins into general and local, which is practically the same. (a) Constitutional or general: Arrest of involution of the uter- ine and ovarian vessels, keeping up pelvic engorgement long after con- finement. A relaxed condition of the tissues from a low state of gen- eral health. An unhealthy condition of the vessel walls. An absence of valves in the veins. (&) Mechanical or local: The anatomical relations of the veins themselves; the spermatic and ovarian vessels being of such great length that the weight of such a column of blood has a tendency to weaken the vessels. Habitual constipation. Uterine displacement. As a reason why the left broad ligament is the more frequently af- fected, Dudley states: The emptying of the venous blood from the left broad ligament into the left renal vein is at right angles to the blood current from the kidney, and it obstructs the free flow of the blood from the ligament into the general circulation. Janni (Congress of Italian Surgeons, October, 1898) asserts that varicocele is not due to the retrogressive changes of the venous walls, conditional upon their expansion; but, frequently, to neoplasms of the elastic connective tissue of the intiraa, which assumes the form of an actual endophlobitis in knots or plaques, and is often accompanied by neoplasms of the connective tissue of the median vein. These neo- plasms have not the compensatory character ascribed to them by Eckstein (Cincinnati Lancet-Clinic, April 1, 1899). 684 A TEXT-BOOK OF GYNECOLOGY Zinke believes the causes just cited to be without objection; but thinks that intra-abdominal pressure from any cause should be added to the list, and that for the formation of an aneurismal varix in this region, direct or indirect travunatism is necessary, as, for in- stance, external violence, frequent application of the forceps during labour, repeated abortion, operations ujDon the cervix, and diseases of pelvic organs. Phleboliths result from calcareous degeneration of thrombi. The history and symptoms of these cases, as Dudley correctly re- marks, are those of varicocele in the male. The pain is of a heavy, dull, aching character, most marked and much increased when the subject remains long in the erect posture; and correspondingly less- ened, and even followed by almost complete relief, when she is in the recumbent position for a long time. There may be a history of traumatism, malaise, nervousness, general indisposition, and even of melancholia. Frequent and profuse menstruation, or even metror- rhagia, in women past the menopause may be observed (Zinke). The diagnosis of varicocele must of necessity be very difficult and uncertain, if at all possible, even in well-marked cases. Varicosities and vein stones are, as a rule, recognised only when the abdomen is opened on account of other pathologic processes. The same may be said of aneurismal varix when not very large; otherwise it may give rise, as in Zinke's case, not only to a palpable, pulsating tumour, but to serious hemorrhages from the uterus, especially when complicated with pregnancy. Under certain favourable conditions, however, a diagnosis does not seem impossible in connection with the symptoms given. When limited to the broad ligament and free from thrombi, the knotted swelling felt with the patient in the upright posture, will be absent when the patient lies down, and only a doughy, thickened condition, will present itself to the finger in the vagina or rectum. If thrombi are present, the knotted condition will continue to exist, more or less. At all events, we must never be too sure of our diag- nosis. But little can be said as to the course and treatment of these cases. One or all of the three conditions may exist to some extent for a considerable period, and, perhaps, for a lifetime, and not give rise to any symptom whatever; or complications may be present obscuring the varix entirely. If discovered during an operation, the operator must determine as to what should be done for the relief or cure of the patient. Up to the present time, the experience of all writers and operators is very limited. Zinke has occasionally removed vari- cosities together with diseased ovaries and tubes; and when, as hap- pened in one of his cases, the varix existed in the broad ligament alone and uncomplicated, he did not interfere, which he now believes was a mistake. Nor did it appear wise to him to attempt the removal of the aneurismal varix mentioned above, because of the existing preg- nancy and the injury done to the uterus by the sac forceps. It is. NEOPLASMS OP THE BROAD LIGAMENT 685 however, more than likely that, should another or similar case present itself to him in the future, he would dispose of the evil in the man- ner pursued by Dudley, of New York, who operated upon 4 cases. In case No. 1, he was able to remove the varix with the ovary and tube, just as Zinke did in his three instances. In eases No. 2 and 3, Dud- ley quilted both broad ligaments close to the pelvic floor. All his cases recovered promptly, perfectly, and permanently, and he advo- cates radical treatment as the only means to do good. Bleeding by leeching or puncturing the cervix; the daily use of irrigation with hot water; the tampon, a well-adjusted Hodge's pessary, and other local applications as recommended by Malins before removal of the vari- cocele is resorted to, will always remain palliative, not curative treat- ment. It is also doubtful whether the mere removal of the ovaries and tubes will invariably produce good results. Eeed operates upon varicocele of the pampiniform plexus by inter- rupted ligatures inserted at short intervals by means of a long-han- dled, curved needle (Fig. 395), and incision of the veins between Fio. 295. — " Interrupted ligatures inserted at short intervals curved needle." )y means of a long-handled the ligatures. This operation is applicable only when there exists no indication for the extirpation of the uterine appendages. Under the latter circumstances, the hemostatic ligatures should be made carefully to embrace the veins as well as the arteries, the veins being divided between the ligatures. Division of the veins is essential to the permanent success of the operation, as shown in Fig. 296, in which one section of the ligated veins has not yet been incised. The influence of the varix in the broad ligament upon the ovary manifests itself, according to the histological researches of Paul Petit, in two distinct y)hasos ; one of engorgement, which renders the ovary (edematous and, later, hypertrophied; and one of sclerosis, ter- minating in atrophy. 686 A TEXT-BOOK OF GYNECOLOGY Malignant Neoplasms: Carcinoma and Sarcoma of the Broad Liga- jnent. — When the broad ligament becomes the site of malignant dis- ease it is, so far as we now know, of secondary origin ; in other words, it is the result of a primary affection of the uterus, vagina, ovary, or peritoneum. According to Pozzi, " Bandl has seen some cases where they came from the pelvic ganglia." To what extent the broad liga- ment may become involved, is best illustrated in a case related by Fig. 'Jti. — "Division of tlie veins is essential to the permanent success of the operation" (page 685). Howard A. Kelly in his work on Operative Gynecology, vol. ii, p. 331, wherein he says he found it " impossible to extirpate the disease in the broad ligaments and to check the free oozing from the diseased tissue which was cut ; in order, therefore, to control the entire blood supply going to the part, I ligated both internal iliac arteries at a point 1 centimetre below the bifurcation of the common iliacs." Winckel refers to Chenieux, Duplay, Gortier and Hages, who have reported operations upon sarcomata of the broad ligament. An involvement of the broad ligament in cancerous diseases of the uterus and ovary is not rare; it is not so frequent when the bladder or vagina is the site of the primary growth. Zinke is of opinion that when the disease springs from the uterus and involves the vagina and broad ligament to but a limited extent, the total ablation of the dis- eased organs, glands, and tissues, through the abdomen will, in some cases, insure permanent relief. Zinke has 2 cases on record in both of which he performed total hysterectomy per vaginam eight years ago. Both patients are still living and in excellent health. One was fifty years old, and the victim of an epithelioma starting in the cervix and implicating by extension the corpus uteri, vaginal roof, and both broad ligaments. The operation was performed at the German Hospital, March 28, 1892. The other patient, aged forty-six years, had a sar- coma of the body of the uterus extending into both ligaments to a marked degree, but not sufficiently to cause uterine fixation. The NEOPLASMS OF THE BROAD LIGAMENT 687 operation was performed on February 22, 1892, at the patient's home. Zinke now prefers the abdominal route in all cases showing involve- ment of the uterine ligaments. Though both the foregoing cases were attended by excellent results, he feels that the operation can be done with much more ease and thoroughness by going in from above. CHAPTEE XLIV INFECTIONS OF THE BROAD LIGAMENT AND OF THE PELVIC PERITONEUM Infections of the broad ligament— Pyogenic — Pelvic abscess ; treatment — Syphi- litic — Parasitic — Tuberculous — Tuberculous peritonitis, etiology, morbid anat- omy, miliary, caseous, fibroid, symptoms, diagnosis, prognosis, and treatment. Infections of the broad ligament may result from invasion by various micro-organisms, which may migrate thither from various points of entrance into the system, and through different highways of communication. Thus, the streptococci finding their original point of entrance in an infection atrium of the parturient uterus, reach the broad ligaments and the structures contained therein through the avenue of the lymphatics. The same may be said of the Bacillus aerogenes cap- sulatus, the staphylococci, and the toxine of syphilis, when the uterus is the site of the primary sore. On the other hand, it is exceedingly probable that the gonococcus, so fruitful of mischief upon the mucous surfaces, rarely if ever extends its ravages to the subperitoneal struc- tures, although it is a frequent cause of inflammation originating in the peritoneal side of the broad ligament. Echinococcous infection probably travels through the circulation, or else by direct invasion of cellular areas. It is probable that the colon bacillus reaches this locus by direct invasion of intervening structures. The pathology of infections of the broad ligament depends somewhat upon the micro-organism or other causative infectious element, and upon its avenue of ingress. Wlien the lymphatic system is the high- way of invasion, the resultant phenomena may be, in the case of less virulent bacteria or toxines, nothing more than an acute nonsuppura- tive lymphangeitis (pelvic lymphangeitis); or, in the presence of more virulent elements, suppuration may ensue; while, as the result of chronic infection of syphilitic origin, there may result that form of hyperplasia of the lymphatics, known as gummata. Pyogenic infections depend chiefly upon (a) the streptococcus, (b) Bacillus coli communis, (c) the staphylococcus, and (d) the Bacillus aerogenes capsulatus. As elsewhere intimated, gonococci seldom play a part in the production of suppuration in this locality. It is unnecessary in this connection to attempt to distinguish clinically between these various forms of infection. A conclusion on this point may be reached 688 INFECTIONS OP TPIE BROAD LIGAMENT QgQ by studying the general features of a given case, as, for instance, in puerperal fever; for, as a rule, infection within the broad ligament is only a part of the clinical and pathologic picture. Pelvic Abscess. — Suppuration in this locality may begin at multiple foci, or it may radiate from a common centre. It may be so circum- scribed as to defy detection by bimanual examination, or it may be so extensive as to lift up and separate the- folds of the broad ligament and of the parietal peritoneum; such an accumulation of pus constitutes a tumour, upon the surface of which may be seen the tensely stretched Fallopian tube and the ovary, both uninfected. These are cases of true pelvic abscess. The treatment of pelvic abscess is by evacuation and drainage. This may be accomplished in various ways, the method to be selected de- pending somewhat upon the location of the pus sac. If careful bi- manual examination indicates that the accumulation of pus has ex- tended forward and lifted up the anterior fold of the broad ligament, and has thus resolved itself into an essentially properitoneal abscess, an inguinal incision may be made. This should be done by making a careful dissection down to the upper margin of Poupart's ligament, after which the peritoneum can be lifted up and the abscess cavity be thus reached without opening the peritoneum. If desired, through-and- through drainage may be practised by making a counter opening in the fornix of the vagina and passing a tube through the external opening into and through the vagina. (See Fig. 231.) If the accumulation has burrowed far down along the vagina, vaginal puncture may be prac- tised, as elsewhere described (see Fig. 225), and permanent drainage may be established, either by the introduction of a self-retaining tube, or by the use of gauze. (See Infections of the Fallopian Tubes.) The operation formerly adopted by Tait, of making a median abdominal incision and stitching the wall of the abscess to the margins of the abdominal Avound and draining in that way, may still be an operation of choice in exceptional cases. It, however, uniformly results in the formation of peritoneal adhesions, which must necessarily be the source of subsequent pain, and is, therefore, not to be employed under ordi- nary circumstances. Zuckerkandl operated upon these cases by placing the patient upon the side and making an incision obliquely on the affected side in the sacrococcygeal region. This becomes an available expedient in those cases in which the suppuration has extended behind the rectum and presents a fluctuating point in the postrenal region. It liappens occasionally that pus burrows almost or quite to the vulva, under which circumstances an incision may be made vertically, a little to one side of the vulvoperineal region and about 4 centimetres long. The dissection should be carried up until the levator muscle is ex- posed, which should be pushed to one side, when the abscess cavity can be easily reached. This is the procedure adopted by Sanger, which has been modified l)y Zuckerkandl, who makes a transverse perineal incision in cases in uliich the purulent accumulation occu- 45 690 A TEXT-BOOK OF GYNECOLOGY pies both sides of the vagina. Eectal puncture has been practised by different operators^ but while it is a convenient method of reaching tlie pus cavity in certain of these cases, it is always liable to leave a sinus which is difficult to control. Syphilitic infection, manifesting itself in the structures beneath the broad ligaments, is necessarily secondary to a primary sore of the uterus, or the upper portion of the vagina. If the primary chancre is located in the lower portion of the vagina, or upon the vulvar struc- tures, the superficial lymphatics are the first to be involved, the second- ary disturbance manifesting itself in the inguinal glands. Lymphangei- itis of syphilitic origin may be manifested, although rarely, in the lymph channels themselves, or, as is most generally the case, in the lymphatic glands (lymphadenitis). The lymphatic vessels may become acutely in- flamed and subsequently indurated, exhibiting the characteristics of tense, sensitive cords, within the more or less diffusely infiltrated con- nective tissue. Inflammation of the intrapelvic lymphatics occurs after the first or second week of an initial infection. Invasion of these glands is associated with fever, and with tenderness and enlargement of the glands themselves. They may reach the size of a hazelnut or a walnut, and they may or may not become the seat of suppuration. As a rule, however, the tenderness subsides after a few days, leaving the glands enlarged and but slightly sensitive to the touch. This enlargement, asso- ciated with but slight sensitiveness on touch, may persist from a few weeks to several years. In the irritative stage, there are marked hyper- semia, increased flow of serum, and enlargement of cells. The enlarged follicles of the gland present the appearance of grayish- white dots; with the recession of the circulatory engorgement, there occurs con- nective-tissue proliferation, and newly proliferated tissue elements show a marked tendency to become definitely organized, a fact which accounts for the persistence of glandular enlargement in these locali- ties. In some instances, however, cell proliferation progresses to such a degree that the newly formed elements can not be sustained by the blood supply, and then retrogressive changes are inaugurated. This may take the form of either a cell necrosis eventuating in what Virchow designated caseous metamorphosis, or of suppuration. In still other cases enormous gummata the size of a man's fist, may develop. These may be mistaken for fibroids of the uterus, or other fibromyomatous growtlis of intrapelvic origin. Eeed has seen two cases of this kind, in which the exact character of the enlargement was demonstrated. The diagnosis of S3rphilitic infections of the broad ligament is based chiefly upon an antecedent syphilitic history. The treatment is by that course of medication which is conveniently designated under the title anti- syphilitic. In cases of large gummata, the latter may be removed, ac- cording to their exact location, by either abdominal or vaginal section. Parasitic infection of the broad ligaments is chiefly restricted to invasion by the echinococcus. It is well known that the echinococcous disease may attack any organ in the body, and it seems, according to INFECTIONS OF THE BROAD LIGAMENT 691 W. A. Freund, Wiener, and others, that the broad ligament constitutes no exception. It is asserted (Pozzi) that the echinococci " travel about in all the cellular interstices communicating with the superior pelvi- rectal space, which seems to be their point of entrance, and may thus reach the broad ligament, pass into the iliac fossa, and out of the pelvis either below or above the crural arch." Freund reported 18 cases of echinococcus within the pelvis to the gynecological section of the Fifty-first Meeting of German Naturalists and Physicians at Baden, 1880. In 10 of the cases the diagnosis was proved by section, and in the rest, by puncture and operation respectively. It was Freund, too, who determined the site of the echinococcus in the pelvis, the road it travels, how it grows, its relations to the intestines, its spontaneous existence if left to itself, how to make the diagnosis, and the treatment to be pursued (ArcJiiv filr Gyndkologie, Bd. xv, 1880). In addition to the symptoms of the presence of a pelvic tumour or tumours, we shall have the symptoms characteristic of echinococcus; if the patient's health is good, as it often is, vocation, association with dogs (especially shepherd dogs), and country, will aid us in our diag- nosis. The hydatids often cause inflammation of the pelvic organs and adhesions between them. The cysts which form vary considerably in size; some may grow so large as to demand removal through the abdom- inal wall. When the inflammation is extensive, the disease may be mistaken for cancer. The cysts are filled, as a rule, with a clear fluid, nonalbuminous in character, and containing chlorides and sometimes traces of sugar (Osier). Suppuration may occur, especially when hook- lets are found; when they are absent, it is believed that the fluid is sterile and the cyst becomes harmless. Medical treatment of these cases is not very satisfactory. The cysts, if they become troublesome, may be attacked through the vagina, perineum, juxtasacral region or the abdominal wall. All will depend upon the location and size of the cyst. The sac may be completely enucleated or stitched to the wound and then drained. Freund (Pozzi) says : " If we have to cut through the peritoneum we must, so soon as we reach the sac and before opening it, use a tamponade of iodoform gauze for twenty-four or forty-eight hours, in order to assure hema- temesis, and the formation of protective adhesions; at a second seance we can open the sac under antiseptic precautions." Tuberculous infection of the broad ligament may be manifested in either the peritoneum (tuberculous peritonitis) or, in the underlying lymphatics. Tuberculous infection of the pelvic lymphatics rarely exists as an independent manifestation of the disease, but, on the con- trary, is but a local manifestation of a general involvement of the lymphatic system. Lymph adenomata of tuberculous origin rarely attain the size of those due to syphilitic infection. They are equally chronic in their manifestations. Tuberculous infection of the peritoneal folds of the broad liga- ment probably never exists, except as a part of the general tuberculous 692 A TEXT-BOOK OP GYNECOLOGY infection of the peritoneum. In view of the fact, however, that the reverse proposition is equally true, there may be no impropriety in considering tuberculous peritonitis in this connection. Tuberculous Peritonitis. — Tuberculosis of the peritoneal cavity is one of the most important conditions that the gynecologist is called upon to treat. The disease is characterized by the development of minute miliary tubercles over limited or extensive areas of the peri- toneum, by ascites, by tumour formation, and by the development of caseous abscesses. Etiology. — The cause in all cases is the invasion of the peritoneal cavity by the tubercle bacillus. The method of this invasion is at times difficult to determine, and certainly varies in different cases. The infection may take place from the blood in a very few cases. An infection through the female genital tract has been found by Williams to occur in from 40 to 50 per cent of the cases, a fact which likewise has support in the greater frequency of tuberculous peritonitis in women than in men (Sippel). The female genital organs seem to afford an easy portal of entrance. Abbe has demonstrated that &Q> per cent of the cases are infected from tuberculous thoracic lymph nodes, and 16 per cent through the mesenteric lymph nodes. The alimentary canal, certainly, wvaj be the source of infection, since it has been well demonstrated that the tuberculous sputum or fragments of tuber- culous lung (as used in animal experimentation) may cause an intes- tinal or a peritoneal tuberculosis (Klebs, Mosler, Jans). A previously depressed state of health does not seem to be a predisposing factor, since the majority of these cases look well nour- ished in the early stages of the disease, and have previously been in good health. Pregnancy shows a definite causal relationship which has not been adequately noted (Kelly). The age of the patient likewise seems to be a predisposing factor, since the collected cases of Osier show that the greater number occur between the ages of twenty and thirty, and that the two extremes of age are relatively immune. In regard to race, it has been shown that the negro is more frequently affected than the white. Hereditary transmission of the disease has been observed to be an important etiological factor. Brunn has observed such transmission in 55 per cent of his cases, Brehmer in 40 per cent, Desplans in 71 per cent, and Fuller in 60 per cent. A peculiar feature of the disease is the uncommon occurrence of grave tuberculous lesions in other parts of the body. Schroder states that it is a local phenomenon in 70.8 per cent of cases. The presence of a tuberculous peritonitis would seem to afford an immunity to tuberculosis elsewhere (Kelly). Morbid Anatomy. — The lesions of tuberculous peritonitis show de- cided variation in their manifestation, and permit of an indistinct division into a miliary, a caseous, and a fibroid variety. The mil- iary form may appear and exist for a long time without giving the slightest symptoms. On opening the abdomen for other reasons, the INFECTIONS OP THE PELVIC PERITONEUM 693 peritoneum of the pelvis or the entire peritoneal cavity is found to be peppered with minute miliary tubercles. The other appearances will vary greatly with the acuteness of the attack, the formation of adhe- sions, etc. In an acute miliary tuberculosis, the peritoneum is notice- ably congested and thickened, has lost its normal lustre, and shows fresh lymph on the inflamed surfaces. The fluid in the peritoneal cavity is j^ellow or bloody, and may be encysted by adhesions or free in the general cavity. The adhesions of the intestines to each other, or of the omentum, are not usually extensive because of the tendency to effusion, and they are usually frail and bleed easily. The caseous variety is characterized by a much more profound anatomical disturbance, by tumour formation, caseous abscesses, and severe interference with the functions of the intestine. In the most severe eases, the peritoneum throughout is the seat of a caseous tuber- culosis, all structures are agglutinated by the tuberculous pseudo- membrane, and the entire mass of intestine may form a firm tumour which is retracted against the spinal column. A variable number of encysted accumulations of yellowish caseous or purulent fluid may be included in the tumour mass. It is the rule, however, to find the disease more localized in the region of the pelvis, the csecum, the omentum or the liver. Under these conditions, the intestines adhere lightly or firmly together and may wall off the exudates in a more or less distinct sac which repre- sents the entire lesion, or a general ascites may co- exist. Such a sac may be mistaken for a cyst. This error may be avoided by observing (1) the fine white lines which mark the point of agglutination of the intestine by lymph and run parallel to it, and (2) a faint vermicular mo- tion after a sharp blow with the finger. If such collections become puru- lent, they may lead to ul- ceration and intervisceral or external fistulge or they may burrow extensively. Wlien the disease is lo- cal ized in the omentum (Fig. 297), this organ be- comes greatly thickened, but at the same time puckered and rolled up to form a firm, elongated tumour lying transversely across the upper part of the abdomen. This tumour m;vy subsequently caseate and Fig. 297. — "When tlie disease is localized in the omen- tuin, this organ becomes greatly thickened." a, Typ- ical round-celled miliary tubercles. — Wiiitacre. 694 ' ^ TEXT-BOOK OF GYNECOLOGY ulcerate either externally or into the intestine, but such a termination is extremely rare. Pelvic tuberculous peritonitis is generally associated with tubal tuberculosis and in this type of the disease is generally represented by cystic formation and extensive binding down of all pelvic struc- tures into one hard mass. The cyst may extend well above the pubes, and the entire pelvis is covered in by a thick, friable, grayish, tuber- culous membrane, which is likewise adherent to the intestine above. The pelvic peritoneum is certainly the most frequent seat of tubercu- lous peritonitis, and this fact has been explained by Weigert, who has demonstrated that the tubercle bacilli always fall to the bottom of the peritoneal cavity. The -fibroid type of tuberculous peritonitis is in reality a terminal stage of the preceding varieties, more especially the first. The miliary tubercles are found in a quiescent stage with few cellular elements and very few bacilli, while old adhesions and tuberculous masses have almost entirely lost their tuberculous nature, and have been converted into firm fibrous tissue. Symptoms. — It will be seen from a study of the lesions of tuber- culous peritonitis that the symptoms may be entirely absent, or may possess all the severity of an extensive inflammation of the perito- neum, and be associated with those of intestinal obstruction. Certain indefinite prodromata, such as loss of appetite, loss of flesh, digestive disturbance, or an afternoon fever, may be present, but many cases begin as a sudden attack of acute peritonitis with a tem- perature as high as 103° F., acute abdominal pain, tenderness, and ascites. These symptoms subside after a few days and the patient continues with a persistent digestive disturbance, indefinite pains, an afternoon rise of temperature and some tenderness. The most con- stant symptom of the slower form of onset is pain referred to the lower abdomen and pelvic organs, and associated with menstrual dis- turbance. This pain varies all the way from a continuous ache to a most intense sufi'ering that confines the patient to bed (Kelly). It is described as a bearing-down pain, as shooting pains, or by the negro as a " misery." The pain is usually associated with tenderness over the lower abdomen. Swelling of the abdomen and a sense of " bloating," are also fairly constant features, dependent at first almost entirely upon tympanites, but, later, ascites adds to the swelling. This is usually associated with loss of appetite, dyspeptic symptoms and constipation. Fever is a marked symptom in the acute cases and fairly constant as an afternoon rise in the more chronic forms. In the latter it reaches 99° to 100° F. and the patient complains of having " malaria " or " chills and fever." Pain in urination is given by Kelly as the most characteristic of all the symptoms. Berggriin and Katz have found that an abundance of fat in the INFECTIONS OF THE PELVIC PERITONEUM 695 stools of infants is a valuable diagnostic point. They state that, while the bile is fully secreted and acts normally to prevent putrefaction, the vi^ork of fat digestion is imperfectly done. A striking peculiarity of the condition is the frequent occurrence of an abdominal tumour. These tumours are omental, the result of sacculated collections of fluid, are made up of adherent masses of intestine that have become thickened and retracted, or they are formed hy enlarged mesenteric glands, especially in children. They give the most confusing physical signs that are ever encountered in abdominal surgery, yet their very anomalous nature has come to be looked upon as one of the diagnostic features of peritoneal tuberculosis. An appar- ently solid tumour will give tympanitic resonance, the confines and the relations of the tumour will often change between two examina- tions, tympanitic resonance will persist in the flanks in the presence of a considerable effusion because of the encysted condition of the fluid, and, finally, such tumours of the uterine appendages or in the region of the caecum may simulate those of pyogenic origin. Diagnosis. — The diagnosis of this condition presents many difficul- ties, since the signs that are characteristic of tuberculosis in other parts of the body fail us here, and it is a well-established fact that many cases of tuberculous peritonitis are not diagnosticated before operation. Nevertheless, experience has taught us that a diagnosis may usually be made with certainty (a) when the abdominal condition is associated with extensive pulmonary disease; (h) when tubercle bacilli are found in the uterine secretions or curettings, and (c) when an anomalous mass of slow formation is found in the pelvis and is associated with an ill-defined fluctuating tumour of the lower abdo- men that changes its relations from time to time. Bulius has called attention to the diagnostic value of tuberculous nodules in the pelvic peritoneum. These vary in size from that of a mil- let seed to that of a bean, and may often be distinctly felt on the broad ligament, the Fallopian tube, the lateral wall of the pelvis or on the pos- terior surface of the uterus when this organ is pulled down by a vol- sella and examined per tectum,. The sensation is that of a grater. The other conditions in which such nodules may be encountered are metastatic carcinoma, papillary cystoma of the ovary, and the small blisters of certain forms of peritonitis. Edebohls has placed positive diagnostic value on a plaquelike thickening of the peritoneum. The exclusion of abortion or gonorrhoea in the presence of a lateral mass will make a diagnosis of tuberculosis probable (Morris), but it must be remembered that abortion sometimes acts as a predisposing factor in tuberculous peritonitis. The simultaneous occurrence of pleurisy with eff'usioii, especially when this fluid is bloody, is a very important diagnostic sign. A careful personal and family history of the case should never be omitted since heredity, the history of previous attacks of peritonitis, the history of "chills and fever," a gradual increase in the swelling, a more or less constant pain increased in walking, an (596 A TEXT-BOOK OF GYNECOLOGY uncertain percussion note, and loss of flesh, are among the most im- portant clinical diagnostic points. Finally, the diagnosis has been made absolutely certain, according to some authorities, by the use of tuberculin. If no reaction takes place, the tuberculous character of the peritonitis is excluded. It must be remembered that the tubercle bacilli are rarely found in the ascitic fluid. But they may be found in the uterine or vaginal secretions, or the ascitic fluid may be injected into the peritoneal cav- ity of guinea pigs. The acute cases may be distinguished from typhoid fever by a previous history of abdominal pain, the absence of rose spots, the absence of diarrhoea and continuous fever, a distinct induration in the region of the caecum, and the absence of the Widal reaction. Osier states that of 96 eases, 30 were diagnosticated as ovarian dis- ease. In the diagnosis between tuberculous peritonitis and ovarian cyst, we are guided by the history of antecedent disease of the append- ages, the rapid development of an effusion, the ill-defined nature of the fluid tumour, a coincident pleurisy, the bacteriological examina- tion of the uterine secretions, and by a most accurate bimanual ex- amination made per rectum when the uterus is drawn down. Prognosis. — The age of the patient, the advanced state of the dis- ease, and the character of the operative treatment, will all determine the prognosis in tuberculous peritonitis. The cases that do well are those in patients of middle age who have a considerable effusion of fluid either free or sacculated; while the dry forms and those cases with extensive adhesions of the intestines are likely to do badly. Treatment. — Osier has justly stated that a great many cases of tuberculous peritonitis recover spontaneously, but it must be remem- bered that errors of diagnosis form a constant factor in such cases, and that a diagnosis often can not be made without an abdominal sec- tion. Furthermore, the nontuberculous type of peritonitis described by Gusserow, and also by Henoch, as " peritonitis nodosa," which is identical in appearance with miliary tuberculosis of the peritoneum, must form a constant source of error in medical cases. The treatment of tuberculous peritonitis is invariably by laparot- omy, and no case should be abandoned as hopeless unless actually dying or in such feeble condition that the operation itself would be fatal. Simple incision and immediate closure of the wound without touching a single viscus, or the evacuation of the fluid, has resulted in a cure of the condition, but the indications of the individual case must be met and certain principles adhered to in the performance of these operations. The oj)eration should have for its object the removal, if possible, of the focus of the disease, the removal of serous or purulent exudate, and the release of dangerous or painful adhesions. The length of the incision will vary with the amount of manipula- tion that is necessary within the abdominal cavity. The uterine ap- INFECTIONS OF TPIE PELVIC PERITONEUM 697 pendages should be removed whenever they are involved, and the diflflculties of the operation in the advanced type of the disease are certainly very great. All structures below the brim of the pelvis are bound together in one rigid, friable mass; enucleation of the tumour without rupture of the intestine requires the most painstaking care; and nothing short of a raw, uncovered condition of the pelvis can be left behind. The fluid in the peritoneal cavity is either free and requiring no special effort for its removal, or it may be sacculated and require a careful tearing of adhesions for its relief. Single adhesions should be released, but when the intestines are bound together in one mass they should not be touched. Certain operators advise flushing the peritoneal cavity in every case and the thorough mopping out of every part of the fluid, while others would irrigate only the pus cavities. The question of drainage in these cases has been rather definitely set- tled in favour of the immediate closure of the abdomen, unless there are distinct pus sacs which demand drainage. Many theories have been advanced with considerable sagacity to explain the manner of the healing after abdominal section, but we are still without a positive explanation. It was first thought that the cures were accounted for by the presence of a " nodular peritonitis " instead of the true tuberculous peritonitis, but a great number of cases are on record in which the diagnosis has been made from the tissues or fluid removed at operation, and a disappearance of the tuber- culous process has been demonstrated at a later date by autopsy or by subsequent operation. The removal of the exudate was supposed to im- prove the peritoneal vitality and resorptive power by relieving the em- barrassment to the blood and lymphatic circulation (Bumm); but this is inadequate, since the dry forms are also healed by operation and mere tapping does not often result in healing. The use of ayitisep- tics (iodoform, mercuric bichloride, etc.), can not explain the good results, because the improvement is much more satisfactory when none are used. The modern surgeon has suggested that certain bacteria which develop a toxine that is antagonistic to the tubercle bacillus must gain entrance at the time of operation. The germicidal action of air and sunlight on the tubercle bacillus was suggested by Koch as an ex- planation, but it is apparent that such action is only momentary, that it can not possibly reach the deeper pouches of the peritoneum, and that lupus of the face would not exist in the presence of such an action. Warnecke first suggested hypercemia of the peritoneum fol- lowing handling, sponging, flushing, or the contact of air, as the heal- ing factor, and others insist upon the antibacterial action of the exudate that is immediately poured out (Sippel, Satti). Hildebrandt has dem- onstrated on animals that a laparotomy can only have its full efl'ect when, in the natural life history of the tuberculosis, the retrograde process has already set in; and he believes that the assistance to healing given by laf)arotorny is the result of a persistent venous liypenemia. 698 A TEXT-BOOK OF GYNECOLOGY The injection of sterile air by Nolen can have no value, while the explanation of Biimm and Buchner, of a healing by phagocytosis and alexine formation, may have some importance. It is probable that the combined action of a number of these agencies will explain the healing that takes place. The percentage of cures following operation is placed by Parker Syms at about 30 per cent as a result of a comparison of statistics varying from 2J: to 80 per cent. Konig reports 131 cases in which 24 per cent were healed for over two years, 65 per cent under two years, and 3 per cent died after operation. At any rate, laparotomy must be looked upon as a life-saving measure that will be necessary in a majority of cases and having only the very low mortality of 3 per cent. The operation is not contraindicated in slight involvement of the lung, but should not be done when an acute miliary tuberculosis is present. CHAPTEE XLV MENSTRUATION Normal menstruation — Time of appearance — Menstrual cycle — Quantity of dis- charge — Character of the discharge — The inducing cause of menstruation — The role of the uterus — The role of the Fallopian tubes — The role of the ovaries — The hygiene of menstruation. Normal Menstruation. — If we say that menstr-uation is a sanguineous flotv from the genitals of woman, lasting four days at each recurrence, and appearing at regular intervals of twenty-eight days from the dawn of puberty until the child-bearing period has passed, we have made a very- fair definition; but every separate statement contained in it is sub- ject to many exceptions. For, in the first place, menstruation is not peculiar to woman. In her, to be sure, the function has risen to its highest; but, none the less, it is an inheritance, and she, in menstruating, is not unique. In a number of our domestic animals at the time of maximum sexual ex- citement, there is a very notable flow of mucus from the vulva, and this mucus is oftentimes loaded with anatomical elements, young cells, and a small amount of blood. Millikin has observed this tinge in the case of the cow and the mare, and it has been reported as present in the female dog and in a number of apes and monkeys. Walter Heape {Proceedings of the Royal Society, iSTo. 361) has given an excellent account of Macacus rhesus, an Indian monkey, which has a definite breeding season but menstruates with regularity through the whole year. At the menstrual period, macacus displays a certain congestion of the skin upon the abdomen, legs, and tail, and to these simian symptoms adds the strictly ladylike features of swelling and congestion of the nipples and vulva, and flushing of the face. At the same time, there is a discharge of viscid menstrual fluid, mostly white, but containing red corpuscles, uterine debris, stroma and epithelium. Menstruation in Semnopithecus, as observed by Mr. Heape, corre- sponds very closely to that in macacus. Curiously comparable to this is menstruation among the lowest savages of southern Africa. James Stirton, in the Glasgoiv Medical Journal, supporting a contention that menstruation is a product of civilization, says that in the lowest tribes accessible to him he found menstruation to be very scanty and irregular, and always inaugurated l)y a prolonged mucous flow wliich never became highly sanguineous. 699 700 ^ TEXT-BOOK OF GYNECOLOGY There appears to be a gradation leading us from dry mammalian rut to the rutting with discharge of the highly artificialized domestic animals, thence to the menstrual rut of the quadrumana, and thence to the highly sanguineous flux of the human female. It is a biologic fact that the higher mammals menstruate Avhen in heat; it is no slan- der to say that woman is in heat when she menstruates. Confirmatory of this is the fact, often obscured by the self-control belonging to women of the highest and most refined type, that the beginning of a menstrual flow tallies with an acme of sexual desire, insomuch that considerations of modesty and convenience will not always deter them from absolute solicitation at the menstrual time. Against the identity of menstruation and rutting it has been urged that menstruation continues with regularity through the year, whereas rutting is a phenomenon of some particular time of the year; and the fittest answer is that the females of those animals which have been most artificialized by domestication, tend to come in heat at regular intervals through the whole year, after the manner of women. The mare, for example, tends to come in heat every three weeks, and the female dog who escapes pregnancy will also develop a regular period. That is to say that, when li^nng under human conditions, they tend to human menstruation. It should be noted that the heat of wild animals is determined b}^ two causes, the arrival of spring and the greater food supply which comes after a time of relative scarcity in most climates. Human fore- thouglit and ingenuity have practically annulled the influence of the seasons and have made the supply of food constant over the greater part of all the earth. But where degraded tribes exist in primitive con- ditions, virtually in a feral state, we find that women return to the animal type of menstruation. In the long, bright days of the Arctic summer, the Eskimo men and women pass into a state of ecstatic sexual excitement which is terminated only by satiety and exhaustion. It is at that season that the women become pregnant, for the most part. The comparatively refined women of Greenland often cease to menstruate during the long dark winters, and similar observations have been made in the high mountain regions of France and Switzerland. Barnes says flatly that some women menstruate only in warm weather. The inmiigrants who came to our shores forty years ago, after long voyages on short rations, came, as was often observed, in excellent health, but in a condition of amenorrhoea. In our north temperate zone, it can be shown that women of the robust type who nurse their children and do not limit their fecundity, have a tendency to bear children every second year in midwinter. So frequently does this occur that it leaves room to question whether there may not be still a breeding season for the human female, a faint fossil relic of primeval times. In a comparative study, it must ever be remembered that perturbing influences tend to induce a more prolonged and uniform sexuality in MENSTRUATION YOl the human female. Her purely animal lust is complicated with spir- itual affection for her mate, and this is in conformity to high poetic ideals; it is fused with aesthetic ideals, also; it finds its ethical restraints; and all of these human complications are only faintly prefigured in the psychology of the lower animals at the breeding age and the breed- ing season. With woman, primeval sexual instincts are continually cooled by prudence, modesty, conventional prudishness, and high intel- lectuality; it is inevitable that advancing refinement, and even in- creased comfort in life, should cause the phenomena of rutting to take on a less furious character and, as a corollary, a more uniform character through the year. And so the cycle of human rutting be- comes much shortened. It may well be that the function of menstruation will disappear in the course of ages, but in its last waning recurrences it will still be cyclical in its manifestations. It is a law of life and of all activity. The respiratory movements are rhythmic, and by a deeper breath at every seventh or eighth respiration we graft rhythm upon rhytlim. There is a recurrence of hunger and of the propensity to sleep which is not in exact correspondence with the needs of the organism. In healthy persons of both sexes there is a diurnal tide in the pulse rate, the respiration, the arterial tension and the temperature. More than one competent observer has come close to a demonstration of that which is inherently probable — a tidal movement in the adult male of the human species during which all vital processes and the sexual appetite reach a climax and then decline to a minimum, so that the question has been seriously raised whether it is not true that men menstruate as well as women. And if we make the easy step from the physiological to the pathological, we find the same inexorable law of rhythm in the periodi- cal recurrence of malarial paroxysms which the plasmodium has not fully explained, of epileptic seizures, of maniacal crises, and in the characteristic fever curve of the acute infectious diseases. Even in the highest intellectual activity we find the same law, for the creative power of genius has its ebb and flow. The Time of Appearance. — That menstiiiation usually comes with pubert}' is a matter of common knowledge. In the United States that age may be put at fourteen years and six months, with wide individual variance from this average. Very frequently the function announces itself and is heard of no more for months; irregularity for the first year is too common to excite the alarm of most mothers. Precocious menstruation may appear even in infancy. Hungry for marvels, women will often bring the baby's first diaper with a red stain upon it, and this is presented for blood in the case of a boy, and for menstrual fluid in the case of a girl. In almost every case the red patcb will be founrl to be gritty under tbe finger, and its free solubility in warm water will confirm the diagnosis of rod urates. Sometimes, however, in the case of girls, a small aniount ol' blood will be found to come from a vul vo-vagiiiilis, wil li or \\i1lioiii ^oiiococci. Even 702 A TEXT-BOOK OF GYNECOLOGY more rarely, granulations exist about the urethral opening sufficiently- large and weak to produce a stain of blood. Millikin recalls a very puzzling case of a little girl who did not cease to " menstruate " until after a course of antisyphilitic medicine. The mother's many abor- tions furnished the clew to a diagnosis, confirmed after years by the child's dentition and the development of periosteal nodes. But a menstrual fioAv from the uterus of a healthy child is not to be denied. It may appear under the stimulus of disease, as in a case reported by Gemmell {British Medical Journal, vol. i, 1892), where a healthy girl of nine years, not hemophilic, had a flow of blood, squamous epithelium, and debris, which continued five days following the height of the erup- tion of measles. There are many cases reported showing the menstrual tendency so strong that no stimulus of acute disease is needed to bring on the flow precociously. Millikin knows a case of two girls in whom puberty came, by gradual and symmetrical development, at the ages of eight and eight and a half years, respectively. Here, menstruation was a mere incident to perfect womanhood, for, though these little women had not attained their full stature, they had acquired rich voices, they cared little for children of their own ages, one of them suddenly be- came very averse to school, and the other attended to household matters with womanly enthusiasm. More extreme cases may be cited, but here we trench upon the mon- strous or the pathologic. Plumb (Neiv York Medical Journal, June 5, 1897) reports the case of a child that weighed 9 pounds at birth, had genitalia similar to those of a girl of seven years, had pubic hair, but none in the axilla, and had a clitoris an inch and a quarter in length and of a diameter of half an inch. The mammae were an inch in thickness and an inch and a half in diameter. Bathing the breasts caused erection of the clitoris; contact of clothing with the clitoris caused a complete orgasm. Amputation of the clitoris relieved her of reflex nervous disturbance. At six weeks she began to menstru- ate, and so continued until the age of si^ months when the report was made. Irion {op. cit., August 15, 1896) gives account of a girl of 9 pounds' weight at birth, with breasts and mons veneris well developed. She menstruated at the age of seven days, the flow continuing four days. A month later there was no flow, but from that time until the child was ten months old she was reported " regular." Wladimiroff {Arcliiv fitr KinderlieiTkunde, 1897) reports the case of a rhachitic girl, six and a half years old, 4 feet high, weighing 50 pounds. Her breasts, pubic hair, voice and modesty, all proclaimed her a little woman. She had menstruated once. Klein {Deutsche medicinische Wochenschrift, 1899, 'No. 3) gives an account of a girl of ten months who had been separated from her parents up to that age. She was then found to be menstruating. She menstruated regularly for nine months. Then she had amenorrhcea MENSTRUATION 703 for four months, and then menstruated for seven months. At that time she had an attack of measles and ceased to menstruate for many months up to the time of the report. She was a delicate child of good mental development. Her breasts were of womanly shape and her genitals were large, with pubic hair. Howie {Year Book, Gould, 1898) reports the case of a girl who men- struated from the age of three years and fourteen days. At each period she was languid and suffered malaise. She had pubic hair and promi- nent breasts. Morse {op. cit.) reports the case of a girl who began to menstruate at the age of nine months. Price {op. cit.) gives a case in which the child menstruated from the age of four years. Pubic and axillary hair appeared at eighteen months. Her breasts and bodily contour were womanly. Lopez {Revista de la Sociedad Medica Argentina) reports the case of a child of five years which menstruated from the age of eighteen months. Each flux was of from three to five days' duration. The ex- ternal appearances were those of maturity. The little creature was cursed with ardent sexual passions. Eein exhibited before the Kieff Obstetrical Society a girl of six years who had menstruated regularly for a year. The breasts and ex- ternal genitalia were appropriate to a girl of thirteen or fourteen years. The abdomen was enlarged^, and a fluctuating, thick-walled cyst was diagnosticated. Sometimes the ripe femininity of these little creatures is attested by maternity. Thus, McLaury, of New York city {American Jouryial of Obstetrics, 1887), sent a girl of thirteen years to a lying-in hospital. Prom her earliest recollection she had cohabited with men and boys. It is an interesting fact that she was one of four children born to an unmarried woman. In 1858 there was a young mother, not quite eleven years old, living at the public charge at Taunton, Mass. Dr. Gleaves, of Virginia, has reported the case of a girl who at the age of ten years and two months was delivered of a child of five pounds. She had menstruated from the age of five years. She had no mammary development, and her baby, during its short life of one week, was suckled by its grandmother, who had a child of only a few months. These last cases might hardly be called exceptional in warm coun- tries where men and women are so soon ripe and so soon rotten. In Ceylon a youth attains his majority at sixteen years and one may find the girls mature at from eight to fourteen years. Even in Mexico it is not uncommon to meet with grandmothers who are but little be- yond the age of twenty years, and some cases fall much witliin this limit. One author, representing no extreme views, has stated that the average age of first menstruation is twelve years at the tropics, and sixteen years at the coldest civilized regions. 704 A TEXT-BOOK OF GYNECOLOGY The Menstrual Cycle. — The menstrual month is a myth which has no other basis than the obscure moon-worship, latent in our race. For each woman, a definite and precise cycle is usually established, early in her menstrual life, but that cycle is seldom measured by precisely twenty-eight days. Vast numbers of women menstruate scantily every two weeks and enjoy perfect health. Upon inquiry, it will be found that man}^ women menstruate every three weeks. A very large number of women are delighted to know that they conform to the classic period of twenty-eight days, but make their reckoning from the end of one period to the beginning of the next, so that they really have a cycle of about thirty-three days. In the same group are those who compla- cently declare that they are regular as the clock because they men- struate always on the same day of the calendar month. Millikin knows a case of two sisters who were in excellent health, but much dis- turbed because of menstrual irregularity, and it took much patient investigation to determine the fact that they had periods of thirty- seven and forty-nine days, respectively. There is, in truth, no normal period of menstruation except in the sense that there is an average period of about twenty-eight days, from which most women depart widely. Exact conformity to this period brings no added grace, health, or fecundity; and contrary to the com- mon belief among women, departure from it brings no peril. As a general rule, women highly refined and of delicate tissues will men- struate more frequently, while coarser, more robust women will men- struate less frequently. The Quantity of the Dischargee. — At each menstrual period, the human female loses from 2 to l-f ounces of fluid. As the estimate must be made from the collection of a few hours, it is not surprising that tlie range of variation should be so great. Individual dift'erences are known to be very great, for, while one healthy woman will have merely enough discharge to stain her clothing, another, equally healthy, with like fixity of habit, will soak her cloths for two or three days. No other mammalian female loses so much blood as woman. This we explain, first, by the fact that the reproductive apparatus of the lower animals has no other purpose than reproduction, whereas, in the highest of mammals it ministers to complex loves and likings and lusts which are only incidentally or accidentally reproductive. If the stimulus brought to bear upon the genitalia of the human female were ten thousand times less than it is, it Avould still suffice for the perpetua- tion of the species. There is therefore an abnormally high functional activity of the human uterus and all that pertains to it, if we allow the lower animals to fix the norm, and with this goes abnormal conges- tion and a tendency to increased leakage. In the second place, it may be observed that the erect posture of the human female distinctly invites a free supply of blood to the pelvic organs and hinders its return to the heart. Such indeed is the law of all parts of the body lower than the heart. Man, the monarch of all MENSTRUATION 705 living things, erects himself in appropriate attitude and pays the pen- alty of his arrogance by suffering from varices, hemorrhoids and pre- carious nutrition of his hinder legs: his poor mate, to these lesser plagues, adds her characteristically profuse menstrual flow. We may add, as a third consideration, that the delicate tissues of the highly civilized woman are poorly able to resist the influences which tend to leakage of blood at the menstrual time. In temperate zones the average duration of menstruation is about four days and a half. In any locality may be found great numbers of women who habitually menstruate two days, and as many who men- struate seven days. Character of the Discharge. — There are occasional cases which fur- nish what has been well called white menstruation. The subjects usu- ally announce themselves as suffering from a leucorrhoea which is " very weakening." Investigation, after excluding gushes of fluid from diseased tubes, and after establishing the periodic character of the discharge, will properly refer it to an attempt at menstruation which goes no farther than engorgement and superseeretion of the uterine glands. White menstruation is not pathologic and certainly does not demand surgical treatment. The ordinary menstrual fluid is composed of mucus which comes at first from the uterus alone; at a later stage, the vaginal glands are also active and pour out their share of mucus. At an early stage, blood is mixed with this mucus, and the fluid takes on the tint of venous blood, or, by rapid decomposition of corpuscles, it becomes brown or black. Ciliated epithelium from the uterus is abundant, and a small quantity of epithelium from the vagina is also present. Eemains of the endometrium are to be found abundantly. Fatty acids are present to give to the fluid its characteristic odour, and to prevent the coagulation of the menstrual blood. When the blood is present in high proportion, possibly because of a low amount of mucus and acids, clots form, to the dismay of the subject. Of all the compo- nents of the menstrual fluid, the blood is probably the least impor- tant. The hemorrhage is merely an untoward accident occurring in the course of important significant changes within the uterus. That menstruation is an excretory process during which " bad blood " and nameless poisons are excreted, is an error possessed of notable vitality, for it has lived long and it dies hard. No one has suggested a mode or an avenue of elimination for this poison in men, boys, old women, pregnant women, little girls or women in whom sur- gery has brought on an artificial menopause; no one has detected it in the discharges; no one has pointed out any essential difference between women wlio menstruate freely and those who menstruate scantily. Nevertheless the fancied peccant substances will remain in literature for another century. Millikin knows of courtesans enjoying excellent health who, with more knowledge of thnir trade tban of transcendental pathology, have 40 706 A TEXT-BOOK OF GYNECOLOGY learned the trick of suppressing the menses at will by the use of tightly packed sponges. A. W. Parsons, of Northampton, Mass., has taught many patients to tampon the vagina, partly for the comfort and neat- ness secured, and partly to limit the amount of discharge as might be thought good. In 1888 Gehrung recommended {American Journal of Obstetrics) the use of an alum-soaked tampon to be retained for forty-eight hours unless there should be leaking through or around it. He uses this tampon boldly to abbreviate or lessen the flow at his pleasure or to hasten the menopause. It was his deliberate purpose to reduce the flow to a limit of from 2 to -1 ounces, and this was ac- complished in his therapy without a hint of harm. Loewenthal, in June, 1888, advocated the restraint of menstruation by intrauterine injections of hot water, or, occasionally, of iced water. He had greatly benefited 18 cases of chlorosis by suppressing menstruation for from three to five months. The Inducing Cause of Menstruation. — Then, throwing aside the notion that the menstrual fluid is cast out by an active effort of the system to rid itself of a poison or a group of poisons, we inquire fur- ther into the inducing causes. From the very beginnings of medical literature, there is a hint that the blood of the human female was rich enough to force an overflow every four weeks, this capacity for plethora being born and bred in her for the benefit of her pos- sible offspring. Without a fact to support it, this teleologic theory was unchallenged until late in the present century. More recently a very popular theory was, that Nature prepared a decidua for the coming ovum and that, when impregnation failed, for any cause, she entered upon a house-cleaning process which involved the cast- ing off of the decidua, and, as Christopher Martin said, poured out a flood of blood from the turgid capillaries to wash away the use- less debris. Of late, some have been strangely impressed with the fact that the uterus has a rich nervous supply, its sympathetic fibres re-en- forced by spinal filaments given off from the abdominal splanchnics, which send filaments to the uterus by way of the hypogastric plexus, and re-enforced also by fibres from the pelvic splanchnics which also pass through the hypogastric plexus on their way to the generative organs, the bladder, and the rectum. It has caused admiration, also, that the uterus has its own ganglia, giving it independent movement,, even when dissevered from the body, and it has been announced that the uterus has anabolic nerves to retard, and katabolic nerves to accel- erate, its metabolism. But in all this, the uterus is not singular; its nervous organiza- tion is in every way comparable to that of other important viscera, for we believe that they all have motor, sensory, vasomotor, and trophic nerves. That the function of menstruation involves nervous apparatus is true, by all analogies, but that it is in any special sense a nervous phenomenon, is not true. MENSTRUATION 70Y Ott (Wiener medizinische Presse; Archiv fiir Gyndhologie) has shown, as have man}' other observers, that there 'are slight changes in temperature, pulse, blood pressure, and respiration through the men- strual cycle, and that, carefully followed, these indicate that vital activity is at a maximum just before, or during, menstruation. Gath- ering up the large array of facts that show these trivial changes in vital processes, and show, also, that the daily excretion of urea and of carbonic acid is subject to slight variations through the menstrual cycle, Stephenson has held that the wave of rising vitality is influ- enced by a menstrual centre, wholly hypothetical as yet, which is, or ought to be, situated somewhere in the lumbar portion of the spinal cord, and which acts rhythmically to bring on Stephenson's wave and the accompanying menstrual flow. No explanation has yet been offered for the rhythmic action of the supposed centre. The advo- cates of this theory of menstruation are troubled little by the fact that similar waves are to be detected in the lower animals and in the males of our own species, and the doctrine may well be dismissed in the words of Stephenson, himself, who reduces the whole theory ad absurdum by his comment on the varying intensity of vital phe- nomena in the male : " it is therefore evident that the phenomena belong, not to the function of menstruation, but to a general law of vital energy." A case of Eushton Parker's may here be quoted with profit. He was consulted by a couple who had been married eight months and had never accomplished coitus. The husband was twenty-four years old, and nothing could be seen amiss with him save that he had " a cowed look." He denied any practice of masturbation and also denied any sexual feeling. All organs were normal, save that the testes were small and soft. His wife had observed that he had a sanguineous discharge for three days out of every month. He readily agreed to a separation and a division of income. {British Medical Journal, March, 1899.) Napier has suggested that the pressure of the enlarged utricular glands of the endometrial mucous membrane may be the stimulus, acting upon the terminal nerve filaments, to induce menstruation, and he has pointed out the fact that the time required for such growth in the constantly renewed mucous membrane, would correspond rudely, with the intermenstrual period. But we need not look for any accurate, mechanical explanation of this function. We can do no better in the present state of our knowkidge than accept menstruation as a habit which has been nailed upon our race by heredity, and which is for us an ultimate biologic fact. This hypothesis meets all cases of menstruation without ovula- tion, all cases of menstruation after the removal of the pelvic geni- talia and the destruction of their nervous apparatus, all cases of menstruation in infants and in withered old women, all cases of mcn- stnuition in men, and all cases of vicarious menstruation. 708 A TEXT-BOOK OF GYNECOLOGY The Role of the Uterus. — It is often said, with essential truth, that " menstruation marks tlie destruction of the endometrial mucous membrane." If it does not do all this, it certainly marks the destruc- tion of its highly organized, thickened superficial part, the decidua menstrualis. The endometrium is a mucous membrane highly special- ized, to be sure, but not more so than the mucous membranes of the intestines and the stomach, and it certainly does not depart from the type so far as does the conjunctiva. It is distinguished anatomically by its delicate stroma and by its abundant glandular elements; it is distinguished physiologically by its power of self-renewal which recalls continually the fcetal tissues, the cells of malignant growths, and the tissues of the crustacea and lowlier forms of animal life. Delicate as it is, it is not thinner, but thicker, than most mucous membranes during the greater part of the menstrual month. It is essentially a uterine lining, for it does not extend downward into the cervix, or into the Fallopian tubes. At, or before, the menstrual time, it under- goes fatty and granular degeneration and is cast off in great part, and when discarded, it leaves the blood vessels in its basal substance unsupported. That the whole mucous membrane is discarded, is not believed; regeneration is accomplished by the remaining glands in the deeper layers, and is complete in about ten days after the general wreck has been effected. These facts have been derived from the studies of many observers, but unfortunately they have been somewhat vitiated by the post- mortem delay in preparation of specimens, or by the impress of lethal accident or disease. For this reason we turn to our quadrumanous sisters and follow the admirable epitome of Walter Heape's labours, prepared by Lawrence for the Ohio State Medical Society in 1897. It will be understood that the researches cover studies made upon the lowly Cynomorpha, but mostly upon the higher group of Antliropomor- pha which includes the lemurs, chimpanzees, orangs, and the gorilla. Heape divides the menstrual cycle into four stages: 1. Eest; 2. Growth; 3. Degeneration; 4. Eecuperation. During rest there is only one layer of cubical columnar cells, with round nuclei. The protoplasm of cells is continuous with the proto- plasm of the stroma network beneath. This epithelium is continu- ous with that of the glands beneath. The stroma has round nuclei embedded in a continuous network of protoplasm. During growth the stroma nuclei are much increased by amitotic division and by fragmentation ; this causes swelling of the superficial portion of the mucosa. Nuclei now become fusiform. Deep portions of stroma are not changed. Interglandular tissue swells, but the glands are not much altered. The epithelium, lifted by the dense layer of nuclei, becomes less dense. The blood vessels below the epi- thelium undergo hyperplasia. The more superficial layers of the stroma swell. Glands are widened. Many stroma nuclei are re- duced in size, but the mucosa as a whole is increased in thickness. MENSTRUATION 70^ During degeneration there appears hypertrophy of the epithelium, the stroma, and tlie walls of the blood vessels. Afterward, there is amyloid degeneration of the superficial layers of the mucosa. In this layer, congested capillaries break down with extravasation. At each point of rupture, red and white cells are swept into the stroma. The extravasated blood collects in lacunaj in the stroma, and these lacunas, extending and dissecting, lift the epithelium. At this time, the deep portions of the mucosa are not infiltrated, and neither red nor white cells are found free. Leucocytes and stroma cells degenerate; the epithelium shrivels; lacunae grow larger; degenerated epithelium is ruptured; blood is free in the uterine cavity. If, in any case, the lacuna surround a gland, the gland is washed away. In this later stage of degeneration, leucocytes increase the number of their nuclei but are not seen to divide. Denudation is now complete ; all the epi- thelium, portions of glands and sometimes whole glands, and even small portions of the stroma, are lost in the flood. The inner surface of the uterus appears ragged, with layers of masses of blood here and there. The deep layers of the stroma are wholly intact. In regeneration, the epithelium is formed anew by extension from the torn edges or by the transformation of the stroma cells. N'ew capillaries are formed and new blood vessels. New glands are formed by the infolding of epithelium. Extravasated blood is absorbed. Re- pair is complete ; rest is at hand. The Role of the Fallopian Tubes. — It is positively known by the dissection of women who have died by violence at different stages of menstruation, that the Fallopian tubes are much congested during menstruation and that, in most cases, at least, they are filled with fluid that contains blood corpuscles and epithelial cells. Robinson, of Chicago, after a study of 800 tubes from operative and post-mor- tem cases (American Journal of Obstetrics, September, 1891), confirms this, and expresses his belief that the ovum is more easily preserved and wafted through the tube while thus filled with fluid. Besides what is known, it is certainly very probable that the con- gestion and contraction of the tube leads to its erection, and that, during some part of menstruation, it has a gross movement of peri- stalsis, while the cilia of its epithelium become active. That the tubes have much to do with the excitation which precipitates men- struation, might well he supposed from the fact that they are con- tinuous with the uterus, and the additional fact that they have a nerve supply identical with that of the fundus. Tait says that 90 per cent of cases will not even menstruate once, after the removal of the tubes. The Role of the Ovaries.— Some have admitted the theory, wholly fanciful in the present state of our knowledge, that the ovary is, in part, a ductless gland and that its secretion, having accumulated in the tissues of the body to a certain saturation becomes the proper stimulus for menstruaiion. 710 A TEXT-BOOK OP GYNECOLOGY Waiving this doctrine, which is capable neither of proof nor dis- proof, we may say that the ovary has but one function, viz., ovula- tion, the production of ovules whose highest destiny is to be fructi- fied in the Fallopian tube and developed in the uterus. It is a matter of regret that the term ovulation is a vague one. It is used, commonly, to comprise processes which cover much time, possibly months. We have reason to believe that it takes long for the young Graafian follicle to assert itself, deep in the stroma of the ovary, and still more time before it appears on the surface of the ovary as a mass of vascular loops, and yet more time before the wall becomes nonvascular, fatty and friable, for the escape of the ovule. And even then, according to the notions of some, ovulation is not accomplished until the Fallopian tube receives the ovule and sends it to the uterus. Making the term cover only the latter part of this long process, however, we put upon it a time limit of days rather than weeks, and come upon a wilderness of doctrines as to the relation of ovulation and menstruation. It is held by Pfliiger and his followers that menstruation is a result of a nervous discharge caused by the bursting of a Graafian follicle and the liberation of an ovule. Eaciborsky found rij)e or rup- tured follicles in healthy and menstruating women who had met with sudden death, as did Leopold, also, and their opportunities for inves- tigation were ample. Unfortunately for the theory, they also found many ripe follicles unruptured. Walter Heape puzzles us by a state- ment that in Macacus rhesus the breeding season is strictly limited, but that menstruation continues regularly all the year round. Out of 16 cases he has found a recently discharged follicle in only 1 case. He has not seen a clot in a follicle in any case. His researches on Semno- pithecus agree with these observations, and lead to a conclusion that ovulation and menstruation have no relation in these species. Leo- pold's studies were made upon twenty pairs of ovaries of women whose menstruation was recorded, and he could only say that rupture took place most frequently at menstrual periods, but might occur at any time. It is held also, by some, that the passage of the ovule through the Fallopian tube is the immediate stimulus for menstruation. This is not inherently impossible, for, as we have remarked, the nervous and muscular anatomy of the tubes makes them almost one with the menstruating organ, the uterus. But we are barred from dogma- tism here by our ignorance of the duration of the transit of the ovule through the tube, for the authorities vary in their estimate from one day to eight days. We do not even know whether the escape of an ovule from the ovary and its journey to the uterus precede or follow menstruation. ISTaegele taught that the ovum could live in the newly prepared uterus for some time after menstruation was completed, and that, failing to MENSTEUATION 711 be fertilized, it was cast off with the decidua at the next menstrua- tion. Loewenthal's doctrine is not far from this, for he teaches that the ovule always embeds itself in the endometrium and stimulates the formation of the decidua menstrualis; at a later date, if still unfer- tilized, its death brings about that congestion which ends in menstru- ation, though he holds all hemorrhage to be accidental and pathologic. (Archiv fur Gynakologie, Bd. xxiv, p. 2.) Barnes also taught that the un- fertilized ovum, of some considerable age, is cast off with the decidua menstrualis, but he conceived the plausible idea that there was habit- ually another ovule on the road to the uterus at the time of men- struation. This jungle of theories will not be cleared until we master funda- mental facts which at present are beyond us. We need, first, to col- lect all the ovules which pass from a woman, but their fragility and their microscopical dimensions will forever forbid such investigation. We need, secondly, to be able to read the record of ovulation which is left in the corpus luteum ; but Cohnstein is not alone when he de- clares that we have no means of estimating definitely the age of one of these bodies. We are therefore obliged to return to the principle enunciated in a former section, and to say that menstruation is a habit of the female organism, inherited and fixed beyond her present needs, and to that we add that ovulation may occur at any part of the menstrual period cycle. Avoiding any more definite creed, we are not dismayed by the following anomalous cases which are entirely inexplicable on other theories of menstruation and ovulation. In girlhood, and even in childhood, ovulation is active without menstruation, and is sometimes attested by pregnancy before the menses have appeared. Eobinson, of Chicago (AmeTican Journal of Obstetrics, September, 1891), says that an examination of 800 ovaries convinces him that ovulation begins before birth and continues into old age. Conception, implying ovulation, occurs in many nursing women who do not menstruate. Menstruation occurs in some exceptional women only during preg- nancy. Menstruation occurs exceptionally after the removal of the ovaries. Girls and other young mammals have ovules even at birth, long before the period of menstruation. De Sinety found a fresh corpus luteum in a young woman who had died of phthisis, though she had not menstruated for many months. Vermeil and others have reported similar cases. It is known that some women who have long passed the meno- pause, ovulate. In rare cases women who have ceased to menstruate become preg- nant. 712 A TEXT-BOOK OF GYNECOLOGY The Hygiene of Menstruation. — The primitive man looked upon his genitalia and those of his mate with worshipful regard, first, as a fetish, and later, as an incarnation of the creative principle in Nature. Most women, and even some men with microscopes, have failed to out- grow this savage theology, and upon small knowledge of the genitalia have grafted an incredible mass of barbaric superstition and crude folk- lore. More or less vaguely, women hold to the belief that menstruation is a season of peril, and the general drift of the best teaching is to the erroneous opinion that menstruation is a pathologic process which must be skilfully guided to an end by the craft of the physician. It would be well if this had definite form, for then it would become vul- nerable and absurd ; as a matter of fact it survives in misty form in the subliminal consciousness of the race, beyond the reach of logic or persuasion. Menstruation being a perfectly innocuous, physiologic process, it may be said that the hygiene of menstruation is the hygiene of all the year round. The woman who conserves her general health and main- tains herself in the highest possible vigour has done all that can be done to make menstruation safe and easy. In negation, we will say that there is no need for putting the young girl to bed during her first few periods, and still less excuse for putting a poultice on her, as a distinguished author has recommended. Clothing should be changed at need, in spite of the protests of old women; and there is never so much need of a daily sponge bath as during the menstrual time. The salutary truth, that filth and health do not agree, should be pressed upon the young girl and upon the older woman who complains of an ill-smelling menstrual discharge when, in fact, she is offensive from the rancidity and putrescence of axillary secretions. The fishermen's wives in Europe, the bathing attendants at the seashore, and the patients at water-cure establish- ments are not, in general, permitted to abstain from contact with water at the menstrual time, and they are not aware of any great harm resulting from the exposure. In the early stages of Eaynaud's disease, Basedow's disease, phthi- sis, chlorosis, and a number of forms of anaemia, amenorrhoea is an early symptom. In the late stages of disease, the wretched female patient often looks back over her career and recalls to memory some one of the traditional causes of suppression — a bath, a drenching, or what not — and with poor logic she connects the exposure, the sup- pression and her ruined health in a causal chain. Experience, the fruitful mother of all error, has its preconceived theory; it marks the hits ; it forgets the misses ; it perpetually confirms the error with which it began. And so it happens that the greater number of women are, at the menstrual time, fearful of harm when they make a toilet for the skin, or put the hands in cold water, or walk, or ride, or dance, or do a thousand things which are considered proper and safe during the intermenstrual period. MENSTRUATION 7I3 The list of complications which are said to go with menstruation is one which might be safely attributed to a group of men. It in- cludes constipation or diarrhoea, subjective sensations of heat or cold, increase or diminution of urine, anorexia or craving appetite, in- creased activity of the sudoriparous glands, pigmentation of the skin, yawning, cramping, hiccough, meteorism, palpitation, and irritable temper ! For a short period at the very height of menstruation, the bodily temperature is elevated about half a degree. In very impressionable persons, this causes a slight feehng of lassitude. A certain slight dragging sensation, a feeling of weight in the legs, and a definite though slight pain in the sacrum, groins, and thighs, often cause menstruating women to take more than their usual repose. It would not be wise to induce such women to exercise violently; neither, on the other hand, is it wise to coddle them and cultivate valetudi- narianism. CHAPTER XLVI THE DISORDERS OF MENSTRTJATION Menorrhagia, general systemic causes, local causative diseases above the pelvis, pelvic causes ; treatment — Metrorrhagia — Amenorrhcea ; treatment — Retention of menses, symptoms and diagnosis ; treatment — Dysmenorrhoea ; treatment — Membranous dysmenorrhoea — Intermenstrual pain — Vicarious menstruation — The menopause. Menorrhagia. — j\Ienorrhagia is an excessive flow from the uterus at the menstrual time. Only its periodicity distinguishes it from metrorrhagia. We can hardly conceive of hemophilia as a cause of menorrhagia. Women transmit this defect of constitution, but the disease is so mani- festly incompatible with menstruation that Nature has long since stamped out the tendency to hemophilia in the female. General Systemic Causes. — (a) In purpuric conditions we have a strong tendency toward menorrhagia, for in this disease the blood is altered in such wise that it has a manifest tendency to transudation, and a loss of its normal coagulability. Menstruation opens the door and the flow is excessive, (b) In all forms of anwmia we have a relatively great amount of water in the blood, a relatively diminished amount of albuminoid substances, and diminished coagulability. Chlorosis, in this regard as in many others, stands apart from the anaemias, for it tends to scant}^ flow, if any. (c) In plethora the increased flow is due to high arterial tension rather than to a morbid condition of the blood. {d) In the different chronic forms of nephritis we have an altered condi- tion first, of the blood, and, later, of the blood vessels, both disposing to hemorrhage, (e) In malarial poisoning we have the bleeding tendency well marked, not alone in the uterus, but also in the rectum, bladder, and nose. (/) In any form of debility, menstruation is apt to run into excessive hemorrhage from inability to promptly repair the endome- trium, (g) In the specific infectious diseases we have reason to believe that hemorrhage is often excessive by a combination of depraved blood, altered blood vessels, and the debility of an organism that is too busy with the disease to make repairs in the uterus. Local Diseases above the Pelvis, causing Menorrhagia. — (a) Violent emotion has often been known to increase the menstrual flow, even to the danger point. We are obliged to assume that it causes vasomotor 714 THE DISORDERS OF MENSTRUATION 715 paralysis, (b) In cardiac disease with venous stasis, extravasation is invited. Stagnant blood, dammed back in the veins by an inefficient heart, seeks a place of least resistance even in the male patient. In the female the place is indicated plainly, once a month, (c) Pulmonary disease may run such a course as to obstruct the pulmonary circulation early, thus wearing out the right heart and leading to venous stasis. Ordinarily, the early course of the disease is toward amenorrhoea, or scanty menstruation, and the blood is rich in the coagulating prin- ciple, (d) In hepatic disease, the return of blood from the uterus is impeded, and there exists in jaundice the hemorrhagic tendency which is the plague of the surgeons, (e) In splenic disease, also, there is some obscure alteration of blood or of blood vessels disposing to hemor- rhage as in urtemia. All these causes of menorrhagia are rare, how- ever, (f) In a given number of cases of abdominal tumour we shall find a great number of cases of menorrhagia due to pressure of the great venous avenues of return of blood and to the perturbing influence of pressure on the uterus, {g) Yet, the commonest cause of menor- rhagia, after all, is the f cecal tumour so often present in the female patient. It, like any other abdominal tumour of its size, operates viciously by compressing venous trunks; it presses upon the uterus and directly irritates the organ; it is liable, through the sympathetic system, to irritate the nervous apparatus of the uterus and increase its arterial supply; by its downward pressure it aggravates every flexion and version; it slowly establishes a condition of stercorsemia and hydrgemia; it breeds a tympanitic tumour in addition to the solid fgecal mass, and thus still more increases pressure. Pelvic Causes of Menorrhagia. — But for the etiology of menor- rhagia, we look most to the bleeding organ itself and to its neighbours in the pelvis. The uterus and tubes are anatomically continuous and virtually inseparable by dissection. These organs and the ovaries have a common nervous supply. The whole trio is fed by only two pairs of arteries, and their veins are few and simple. It is, therefore, in- herently probable, and it is clinically proved, that irritation or inflam- mation of one of these organs must lead to exalted function of the other two. Passing to the uterus itself, we note that one of the most com- mon causes of menorrhagia may be found in the subinvolution of the uterus after abortion. Subinvolution may also occur after delivery at full term, especially if it is not followed by lactation. In the condition known as areolar hyperplasia, sometimes reck- oned a true chronic corporeal metritis, we have a flabby, atonic state of the uterus with enough inflammation to determine much blood to tlie uterus and to limit its power of repair after the menstrual wreck. Inflamrrialion involving the endom.elrium, tends to produce menor- rhagia, and this tendency is especially well marked in the cases where large granulations ai'o pi-odueod on tli(! interioi- surnice. 716 A TEXT-BOOK OF GYNECOLOGY Healed lacerations of the cervix and deep ulcerations at the same site sometimes seem to be starting-points for an irritation that disposes to an increase of menstrual blood. In malpositions of the uterus we have often the greatest irritation leading to increased blood supply. In some of the malpositions, the veins of the broad ligament become varicose from distortion and long- continued pressure. The blood returning from the small vessels of the endometrium passes into the uterine sinuses and thence toward the heart by way of the veins in the pampiniform plexus, and it is evident that any limitation of the carrying power of the veins of this plexus will produce some degree of stasis in the uterus. Uterine tumours also act in this double manner to cause menor- rhagia; they vastly increase the normal irritation of the uterus, and they act in a mechanical manner, by pressure or by dragging, to block the veins of the broad ligament. Subperitoneal tumours do less harm than those which lie in the wall of, or under, the endometrium. After incomplete abortion, when some portion of placental tissue remains rooted in the endometrium, the menstrual flow is sometimes enormous. The irritation is out of all proportion to the size of the offending body. Malignant disease of the uterus often leads to menorrhagia at an early stage. Sometimes the menorrhagia has no provoking cause that can be detected. The theory of congestion is then invoked to cover our ignorance. Reinecke and others have, of late years, devel- oped the fact that in some cases of menorrhagia the uterine arteries are sclerosed, prematurely old, prominent, and incapable of contraction. They carry a maximum of blood and necessarily tend to menorrhagia. Treatment of Menorrhagia, — When menorrhagia is due to plethora, the tendency is toward automatic palliation. Later, the volume of the blood may be diminished by purgatives, exercise, and restricted diet. In all forms of hydrsemia, the treatment must look to restoring to the blood its nutrient principles and especially its saving power of coagulation. In the very time of menstruation, every means of limiting the discharge should be used; for each hemorrhage, by impoverishing the blood, invites a more profuse and prolonged hemorrhage. The bowels should be kept open without violent purgation. The subject should lie rather than sit. The feet should be warm, day and night. In urgent cases the tampon should be applied in such a manner as to correct any malposition of the uterus, and it should make firm pressure on the cervical tissues. Since it is not the object to coagulate the blood in the vagina, no styptic substance should be used. The tampon should rather be treated with some antiseptic substance like boric acid which is only slightly toxic, is inofi^ensive, and has a faint acid reaction, to avoid neutralizing the normal acids of the vagina. In extreme emergencies the uterus might well be flushed with hot water at 110° to 115° F., under asepsis and with free return of fluid secured. The emergency passed, the attempt should be made to improve general nu- trition and to enrich the blood. The milder, scale preparations of THE DISORDERS OP MENSTRUATION Yl7 iron have great value for prolonged use. In the presence of a brisk hemorrhage, the tincture of the chloride of iron is of most value. The common impression that iron increases an existing hemorrhage has no basis in fact. Arsenic is of great value in anaemia, and may well be alternated with iron. The debility which leads to menorrhagia is often based on some hemic defect. It will often demand a blood count and estimate of hemoglobin with a study of excreta for a comprehension of its causes. Meno]'rhagia complicating the acute infectious diseases is seldom severe or long continued. In the exanthemata, it usually declines with the develoj)ment of the cutaneous eruption. In scorbutus, treatment must be addressed chiefly to the imderlying disease, and that treat- ment is dietetic. In menorrhagia resulting from nephritis, the treatment must reach the underlying disease, also. In malarial cases, treatment for the toxsemia will accomplish brilliant results even in an emergency. The chief danger in menorrhagia is that the physician will, with mind prepossessed, seek for a cause in the pelvic organs and overlook some profound disease or dyscrasia. Menorrhagia caused by great disturbance of the emotions should be treated by palliative meas- ures at first. The menorrhagia, curiously enough, tends to repeat itself for a few months. When this affection is a result of cardiac or of pul- monary disease, it needs virtually no treatment save that which is directed to the relief of venous stasis. In pulmonary disease, the ulti- mate tendency to amenorrhcea will be an aid. When menorrhagia com- plicates hepatic, splenic, or renal disease, the treatment is mostly pal- liative, while the fight is made upon the causal disease. In advanced stages, when a cachexia has been established, menorrhagia is rarely a complication. The treatment of abdominal tumours is a matter of sur- gery, not to be considered in this chapter. The treatment of fsecal tumours is of the greatest importance and may be here discussed. They should be swept out by repeated doses of purgatives. In severe cases, it may be necessary to aid purgatives by enemata or by tunnelling through hard masses in the rectum. If it is known that there is no obstruction, calomel may be given in an efficient dose combined with podophyllin, or any of the more powerful vegetable purgatives. For initial purging, the salines may suffice. They have a special value in their power to cause a free osmosis into the intestinal tube, reducing incipient inflammation and putting an end to the absorption of poisons from the intestine into the blood. Eepeated enemata, each measuring half a pint, of a saturated solution of magnesium sulphate, retained as long as possible, will often produce great results and save the patient the annoyance of large and repeated doses of medicine per os. When the bowel is well emptied, it is important to keep it empty to the physio- logical limit. liadical and abrupt changes in diet will have some effect, but very little, in tlie average woman of constipated habit. The laxa- tive power of fruit is a fiction from Paradise. So long as it is a novelty, oatmeal is sometimes an (ifficient laxative, but the system is 718 A TEXT-BOOK OP GYNECOLOGY soon habituated to it. Mustard seed or flaxseed, swallowed without mastication, is oftentimes very efficient. Senna, the basis of most of the secret purgative and laxative teas and syrups, is to be commended in small doses for a limited time. As an alternate medicine, cascara sagrada is most excellent. The intestines rarely become habituated to this medicine. Atropine and strychnine seem to have some effect in breaking up constipation. It has long been taught that a sharp purgative, preferably a mer- curial, given a short time before menstruation, has a distinctly cura- tive effect in some cases. The treatment should be kept up for some months. It may be conceived that the benefit is accomplished by de- pleting pelvic viscera, diminishing a mild metritis, and exercising a tonic nervous action on the uterine blood vessels. Supposing the bowels to be in good order, one may resort to ergot and its allies, ustilago and gossypium, with a hope of permanently con- tracting the fibres of the uterus and the muscular fibres of uterine and ovarian arteries. The liquid preparations of these drugs are so bulky and offensive that tablets of ergotin are to be preferred. The treatment is of no avail in emergencies, but under ordinary circumstances should be maintained for one or two months at least. Excellent results will sometimes be attained by giving potassium iodide for ten or twelve days previous to the menstrual time. The dose should rise, as rapidly as tolerance will permit, from 10 to 40 grains per diem, and be there maintained until the second day of menstruation. Apart from any obscure " alterant " action, the drug produces its benefits through known channels. It has a power of dilating systemic arteries and lowering arterial tension; it improves the nutrition of the heart, in many eases, by its direct action on heart muscle and by its action on the coronary arteries; it cures bron- chitis and bronchitic asthma and moderates the complications of em- physema, thereby lightening the labours of the right side of the heart and diminishing venous stasis; it palliates concealed syphilis. For prompt and evanescent action as artery dilators, alcohol and the nitrites may be used. Digitalis has no place in the routine treatment of menor- rhagia. It is only indicated in cases where the hemorrhage is caused by some cardiac disease demanding the drug. The use of styptic substances per os has no other justification than a credulous hope that the stomach may be induced to take up so much of the drug that the blood will be saturated to a degree sufficient to check undue hemorrhage at a distant point. Quinine, strychnine, and atropine, have no direct effect upon the hemorrhage, but have great value when it is desired to whip up circulatory or respiratory centres, or the lumbar centres which send fibres through the hypogastric plexus to the uterus and its appendages. In rare cases, supposed to be caused by ovarian irritation, the bro- mides will diminish the menstrual flow. They certainly tend in the main to diminish the flow, and, as Ernst, of Vienna, has pointed out. THE DISORDERS OP MENSTRUATION 71<> to increase the interval between menstrual periods. Whether, for the benefit reached, it is well to blanket the whole nervous system with a depressant drug, is a question. Electricity has doubtless a place in the treatment of menorrhagia, though it will be the resource of the few. The positive pole in the uterus, carrying a galvanic current has an admitted hemostatic effect, the current being cautiously raised to from 30 to 50 milliamperes. Later, in the absence of hemorrhage or inflammation, the current may be much increased. In any case, a cure can not be expected under a treatment extending over months. In emergencies, the current used in the interior for hemostasis may be raised to 150 milliamperes, and it must be understood that it is then positively cauterant. Strict anti- septic technique must accompany this treatment. (Goelet, New York Medical Record, March 28, 1891.) Desperate cases of menorrhagia may require the induction of the artificial menopause by the aid of the surgeon. Metrorrhagia. — Metrorrhagia is a hemorrhage from the uterus in the intermenstrual period. Time was when menorrhagia and metror- rhagia were a long way apart, but it is now perceived that all red fluxes from the uterus are essentially hemorrhages, and all akin. When we meet with a metrorrhagia which begins in an intermenstrual period, continues with increased volume through a menstrual period, and so runs on for weeks, we perceive small difference between the two affec- tions; or, if we encounter a case of sharp menorrhagia which each month lingers longer through the intermenstrual period to become at last an unbroken flow, we must admit that our classification is artificial and a matter of mere words. The reader is, therefore, referred to the preceding section for the causes of metrorrhagia in general, since these uterine hemorrhages are not sharply distinguished in their etiology. Metrorrhagia in early life almost always points to anaemia, and particularly that anaemia which is very properly referred to sterco- rsemia. In young married women, metrorrhagia should excite suspicion of incomplete abortion. In such cases curettage should be done after the technique laid down in another part of this work. The mechanical removal of the wreckage of an incomplete abortion has the added ad- vantage that it gives opportunity to remove the dilated follicles that maintain uterine hemorrhage in low grades of endometritis, whether the endometritis is a result of abortion, or not. The operation also clears the diagnosis by giving information of intrauterine tumours. In mature life, metrorrhagia, much more than menorrhagia, should excite suspicion of uterine cancer. Such subjects, approaching the menopause, look complacently upon an intercurrent flow as a sign of vigour or of plethora. They know that pain and fu3tor belonp; to can- cer, and, having no knowledge; beyond this, they pass, still in good gen- eral health, beyond all possibility of surgical aid. In the present state 720 A TEXT-BOOK OF GYNECOLOGY of our knowledge, it would be well if every case of metrorrhagia in women past thirty-five j^ears were held to be a case of cancer until the contrary was proved. In the absence of a visible and tangible mass of malignant growth, the physician should still hold doubts as to small adenomata of mucous glands of the endometrium. In 2,200 cases of metrorrhagia, Baer found 41 who had malignant disease of the uterus. Only 3 of these were younger than thirty-five years; only 5 were older than fifty-five years; 26 of them fell in a group in the years between forty and fifty-five years of age. Metrorrhagia is sometimes maintained by a sclerosis of arteries, as in the case of menorrhagia. Leopold, in 1896, made 4 extirpations of the uterus in women who had borne from 4 to 12 children, and found the uterine arteries large, tortuous, thick, and gaping. The vessels projected above a cut section. The thickening was of the median layers, the intima not being afllected. The extirpations were made for suspected malignant neoplasm. Curetting had been of no avail and ergot had appeared to increase the hemorrhage. When the floor of the pelvis has been broken down, with great damage to the levatores ani and to the recto-vesical fascia, metror- rhagia is likely to follow in the course of years, and to be so intractable that surgical treatment only will avail. The general principles of treatment laid down for menorrhagia apply here. In metrorrhagia, intrauterine applications will work a cure in a larger proportion of cases than in menorrhagia. The cervix being sufficiently dilated, iodine in solution; phenol, pure, diluted, or combined with iodine; creosote in solution; or tannic acid, may be carried up to treat the entire endometrium with the hope of diminishing succulence or atony, or of reducing inflammation. The solution of these and other styptic and cauterant substances is often made in glycerine, and that solvent, by virtue of its great avidity for water, is able to deplete the endometrial tissues and new growths. Amenorrhoea. — Amenorrhoea is not a definite disease or even, in all cases, a symptom of disease. By the term is indicated merely an ab- sence of menstruation. Amenorrhoea may be physiologic, as in nursing women and in pregnant women, or it may be symptomatic of some wasting disease. An interesting group of women appear to be perfect in their devel- opment and yet never menstruate. Not all such women are sterile, though conception is excessively rare among them. Millikin has knowl- edge of one such case, a woman who has been happily married for twenty years. Hubbard Winslow Mitchell {Neiv York Medical Record, March, 1892) reports an Irish immigrant, well developed as to geni- talia and breasts, who had never menstruated. Withrow, of Cin- cinnati, has reported the cases of two sisters, and the daughter of another sister, who had never menstruated. All three of them had en- joyed the sexual relation and all were sterile. Two of them had profuse periodical epistaxis. THE DISORDERS OF MENSTRUATION 721 It would appear that this condition of amenorrhoea may be acquired, ■as in the notable case reported by Petit {Annales de gynecologie, 1883), in which the woman of twenty-one years was found with a child be- tween her thighs, an inverted uterus and an adherent placenta. Eeduc- tion was accomplished, and, after a tedious convalescence, she was restored to health in the course of eighteen months. Although she bore a child after two years and a half, another in sixteen months, and her fourth child after six years, she never menstruated and never had leucorrhoea. In most cases of lifelong amenorrhoea something teratological ap- pears. Thus, Walter B. Chase (American Journal of Obstetrics, Ko. 4, 1898) records the case of a woman of good physical development who had the menstrual molimina every twenty-eight days from the age of eighteen; she married at twenty-two years and came under his notice at twenty-four years of age. She had been sterile through two years of married life. Her periodical pain was unbearable, and insanity was feared. Her abdomen was very fat but tumour was diagnosticated. 'Operation revealed a thin-walled sac subdivided into cavities of which some were, and some were not, infected, and a teratoma containing .sebaceous matter in emulsion, hair plates, and bone. Ko Fallopian tubes were found. A small amount of ovarian tissue was flattened on the wall of the multilocular cyst, with an imperfect corpus luteum. Manton reports (American Gynecological Journal, March, 1891) a woman of twenty-two, married three years, who had never menstruated, but for four or five years had suffered, periodically, with abdominal cramps, severe headache, and, occasionally, tender and swollen breasts. ,She had no vagina, but the husband's perseverance had made, at the fossa navicularis, a pouch 3^ inches deep, leading nowhere. Eectal examination with a sound in the bladder showed the ovaries in proper position, but no uterus could be found. Manton has seen a girl in a similar condition. She seemed to enjoy such " intercourse " as was possible to one who, in lieu of a vagina, had a cul-de-sac of a depth of only 2 inches. Herbert C. Jones, of Decatur, 111., gives an account of a woman of size and stature above the average, who consulted him as to a vaginal discharge. She had never menstruated. He found that she had a capacious vagina, a large, hooded clitoris, a uterus three quar- ters of an inch in depth, and no ovaries to be distinctly palpated. She had no mammae, and her nipples were rudimentary. Her statement that sexual intercourse gave great pleasure was confirmed in a day or two when it was determined that her discharge was from gonorrhoea contracted the second year after marriage through illicit intercourse. In young girls, there is often a period of amenorrhoea following hard upon the first one, two, or three, menstrual periods. In most ■cases this failure is due to anemia. Treatment of Amenorrhoea. — Since amenorrhoea is only a symptom, it can not in strictness be said to require any treatment. The treatment should be addressed to the diseases or dyscrasia; of which it is sympto- 47 722 ^ TEXT-BOOK OF GYNECOLOGY matic. The amenorrhoea which comes to many young girls soon after menstruation announces itself, should not be meddled with. It is a confession that Nature^s first attempts were premature. The amenor- rhoea of some young girls is, however, a danger signal hung out to give warning of the earliest stage of phthisis. The treatment of the symptom is wholly included in the appropriate treatment of the disease. Aneemia should also be suspected in well-grown girls who have passed the usual age of menstruation. Most cases will be found to have dyspepsia as the underlying condition, and the dyspepsia will gener- ally depend upon physical inaction, incessant nibbling without real meals, addiction to sugar, which, valuable as it is, will destroy the appetite and lead to fermentative dj^spepsia as girls use it and abuse it. Cofi^ee toping is a common cause of dyspepsia at this age. Whim- sical appetites for ice, uncooked rice, laundry starch, uncooked prunes,, and miscellaneous rubbish may often be detected by adroit questioning, and it will be found that these substances in many cases, not only dis- place the regular meals, but lead to a positive gastritis, the pains whereof are interpreted as an all-day hunger to be satisfied only by the trash that bred it. The subjects of these whims are often fine, strong girls, who will do well if they can be brought to take no food save at regular meals with limitations as to cofi^ee, sweets, and raw fruits. An astonishing number of girls are ignorant of the fact that the human stomach needs long periods of profound rest; the truth once presented to them by authority, they will often take the reform in their own hands with honesty and enthusiasm. Constipation, or coprostasis, which in the older woman is some- times the source of uterine hemorrhage, in the young girl very fre- quently produces such a degree of anamia as to suppress the menses. Many young girls are so loaded with faecal products that the breath has the odour of a night-cart. Here again, ignorance combines with lazi- ness or modesty to aggravate the condition. It is very easy to convince the average girl that it is a filthy and degrading deed to go about loaded with some pounds of excrement, and when that is done the case is half cured. Purgatives are not indicated in these cases. The formation of the syringe habit and the absolute annihilation of the rectal con- science is most deplorable. A course of laxatives, of which cascara is usually the best, combined with deep massage, rational physical exer- cise, and an immediate response to the rectal call, will not only get the bowel empty, but will go far to establish the habit of a daily evacuation of the bowels. Until the stercorsemia has been corrected, one need not attempt to correct other causes of anasmia; when the bowels have been unloaded, and when the digestion has been amended, one should settle the question of the existence of albuminuria, malaria, syphilis, saturnism, splenic disease, or whatever dyscrasia may pro- duce angsmia in young subjects. Wlien all cases have been sifted, there will remain a residue of girls, and boys are not exempt, who, with- out apparent cause, develop the " anaemia of adolescence." THE DISORDERS OP MENSTRUATION Y23 For the medical treatment of this anaemia, the whole range of hematinic drugs may be invoked. Iron and arsenic are the chief of them. Manganese has acquired a reputation probably far beyond its deserts. Apiol, an amber fluid obtained from parsley seeds, has been highly extolled by the French as being able to produce the menstrual flow. It is given in doses of from half a gramme to a gramme and is said to be wholly innocuous. The use of oxalic acid in half-grain doses, given every four hours to three doses, is said to be very efficient as an emmenagogue, but it is admitted that toxic effects have followed such treatment. All emmenagogues are open to an objection that they merely solicit a flow which ought not to be directly solicited, and which is sure to appear when the physiologic conditions of men- struation are present. This objection applies to the old and popular terebinthinate emmenagogues, and to those composed chiefly of essen- tial oils. It should, indeed, be a general principle of treatment that it is not worth while to bring on the menses, but rather to annul, if possible, the morbid conditions under which they disappeared. We have already noted the fact that there is a tendency toward amenorrhoea in the presence of any notable hardship, and we shall be consulted, perhaps, when that hardship has passed away. Even a mere change that does not involve hardship, will sometimes produce amenorrhoea, as when a girl leaves the country and enters a factory, or vice versa. Curious cases are sometimes observed in which amenorrhoea develops after marriage and persists for some months without pregnancy; and precisely reverse cases are observed in which amenorrhoea comes with widowhood. These cases are inexplicable in the present state of our knowledge, and should not be rashly meddled with. The same principle applies to amenorrhoea developing in the course of exophthalmic goitre, Kaynaud's disease, myxoedema, and in connec- tion with the sudden and grave development of fat. If we can amend the disease, we are likely to cure the amenorrhoea; if not, the amenor- rhoea can do no harm. Retention of Menses. — In amenorrhoea no menstrual fluid is pro- duced. In retention, the fluid is formed but does not manifest itself externally. For this seclusion there can be but one cause, viz., occlusion of the genital canal at some point. (See Malformation of the External Genital Organs.) The occlusion may be at the os internum, or at the hymen, or at any intermediate point, or at all points at once. When the stenosis or occlusion is congenital it may be charged to an arrest of development. Acquired stenosis of the vagina may be produced by severe inflam- mation after parturition, as in Battey's famous case in which the entire utero-vaginal canal was obliterated. It has also been produced by severe croupous or diplitlieriiic inflammation witb destruction of epi- Y24 A TEXT-BOOK OP GYNECOLOGY thelium, and by Nature's blundering repair after burns or destruction of tissue by escharotics. Clumsy surgery has produced stenosis by amputation of the cervix, especially when the amputation has been done by cautery. The opera- tion of trachelorrhaphy has been so done as to cause stenosis of the cervical canal. One third of all cases are due to an imperforate hymen, and, as a rule, the obstruction is external and vaginal rather than cervical or uterine. Symptoms and Diagnosis. — Apparent amenorrhcea, with the men- strual molimen recurring regularly, should excite suspicion of reten- tion. The ordinary pains of menstruation may be much exaggerated by the retention, so that the pelvic dragging, aching thighs, legs, and sacrum, the flushed face, headache, nausea and malaise, will become almost unendurable. The general symptoms of sepsis must be added after a time. Peritonitis may arise, either as a part of the septic process or as a result of expression of fluid from the Fallopian tubes. Eupture of the tube has occurred in rare cases. Bulging of the hymen will lead to a diagnosis if the obstruction is due to an imperforate condition of that structure. From the first, the confined fluid forms a tumour which, growing monthly, sooner or later attains palpable dimensions. If the fluid is confined to the uterus, the mass will be round; if a tube is involved, the mass will be asymmetrical. Pregnancy is not absolutely excluded when the hymen seems im- perforate or when the vagina is closed. But in retention, by using the bimanual method, the uterus may be found central, mobile, and too small for a pregnancy which has lasted as long as the amenor- rhcea; this, of course, tends to exclude pregnancy. When the vagina is not available, a finger should be introduced into the rectum and a sound into the bladder, and in difficult cases of diag- nosis a finger has been introduced into the bladder also, through a dilated urethra. Solid and cystic tumours arising from the genitalia are diagnosti- cated by the passage of the uterine sound and by the history of the case. Hematocele is diagnosticated by a history of rapid development, often with pain and shock, and the diagnosis is confirmed by the passage of a sound. Abdominal tumours must be considered and carefully excluded by their location and their appropriate symptoms. The mass of retained fluid sometimes reaches a bulk of 4 or 5 quarts, and by its great mass is puzzling. Treatment of Retention. — The only treatment is the evacuation of the fluid by surgical means. To leave the patient alone, invites rup- ture. If the rupture is through the hymen it invites sepsis. Eup- ture through a Fallopian tube or rupture of the uterus would be dis- THE DISORDERS OF MENSTRUATION 725 astrous. Emmet is singular in saying that in this affection the uterus becomes thickened as in pregnancy; most reporters have found its walls thinned. The patient to whom relief is not given surgically ;, suffers from pres- sure on pelvic viscera. The disturbance of the general health is very great. The fluid can not be absorbed, but, on the contrary, its mass continually grows greater. The question of how much fluid should be drawn off, has agitated the surgeons for a long time. Emmet, following Dupuytren, drew it all off at once, and flushed all accessible genitalia Vi^ith hot water until they were cleansed. It must be remembered that the fluid has only the colour of blood and lacks its antiseptic qualities, and that fact alone seems to justify the bold and complete operation. Puncture of the protruding hymen is a trifling operation, but the surgical tech- nique should be as perfectly aseptic, and possibly antiseptic, as in the most formidable operations. One or more points of occlusion in the vagina may need to be torn open. Extreme care will be demanded in such a dissection, to avoid opening the bladder, rectum, or peri- toneal cavity. Natural lines must be followed, not only to avoid these accidents, but to leave the greatest possible amount of epi- thelium on the raw surfaces. It has been found possible to make a vagina where there had been absolute atresia, the lumen being main- tained by the prolonged wearing of a glass or rubber plug, and preg- nancy and parturition have ensued. Puncture or incision of the external os, the cervical canal, or the region of the inner os, should be done upon the same guiding prin- ciples. In rare cases in which there was no uterus, but where fluid had accumulated from tubal menstruation, Braxton-Hicks and Haffner removed tubes and ovaries at a single operation by abdominal section. Dysmenorrhoea. — Some rare cases of dysmenorrhoea, or painful men- struation, appear to be a manifestation of a general neuralgic tend- ency due to general neurasthenia. The very wide distribution of the pain — abdominal, sacral, and crural — suggests to the mind the theory of a general nerve storm, and it is upon this theory we rest when we can find no deformity or disease in the uterus or its appendages. We recall the anatomic facts that the nerve supply of the pelvic genitalia of woman is from the second, third, and fourth, sacral nerves ; that the sympathetic fibres come from plexuses which are virtually branches of the aortic plexus, and that the aortic plexus is virtually a derivative from the semilunar ganglion and renal plexus on each side. The genitalia are therefore connected by no remote strands with the cere- bro-spinal system and with all abdominal viscera, so that no great perturbation of the nervous system can occur without a disturbance of tlie genitalia. For pelvic pain at a menstrual time, bred by starving or irritated nerves in some remote part of the nervous system, the tenn dysmcnorrhcr'a is inappropriate* for it does not appear that the Y26 ^ TEXT-BOOK OF GYNECOLOGY pain is clue to menstruation. Menorrhalgia, proposed by Massey, is commendable in that it asserts pain, and nothing more. By far the greater number of cases are due to some morbid condi- tion of the generative organs. Turning to the uterus, we note, first, that the infantile uterus, with a depth of 2 inches or less, a conical cervix, and a pinhole os, is often a jDainful uterus at the menstrual time. The only explanation offered for dysmenorrhoea associated witli the infantile uterus is, that the filaments of spinal nerves im- prisoned in the embryonic stroma of the imperfect endometrium are compressed during the menstrual congestion and subsequent changes. After pregnancy, when the uterus normally shrinks from pounds to ounces, the involution sometimes passes all bounds and leaves the patient with what is, to all intents and purposes, essentially an infan- tile uterus, by superinvolution. Here, again, we have dysmenorrhoea, and are again tempted to theorize as to the replacement of muscle by fibrous tissue and the incarceration of nerve endings. There has long been a tendency to ascribe menstrual pain to the pressure of fluid which, by reason of partial stenosis at the inner or outer OS, or at some point of flexure of the uterus, has an imperfect exit from the uterus and induces pain by hydraulic pressure. The old masters had high controversy on this head. Hewitt said, " The large majority of cases are really cases of retention." Sims said, " There can be no dysmenorrhoea, properly speaking, if the cervical canal be straight and large enough to permit a free passage of men- strual blood." The curative effects of cutting and stretching opera- tions and the similar effect of parturition were held to confirm this doctrine. But, per contra, MattheAvs Duncan was prompt to contend that dysmenorrhoea was always neurotic in its origin; he pointed out that the pin-point os was large enough, as could be demonstrated on thousands of women ; he urged that, in the absolute retention of menses, the pain was no greater than it was in many eases of dysmen- orrhoea with free exit; he held it to be significant that girls in their first menstruation did not usually suffer much; he showed that the women who suffered most had less flow than others ; he demanded an explanation of the fact that there was no distention or sacculation above the alleged stenosis. Others re-enforced him, declaiming that dilatation of the cervical regions cured dysmenorrhoea, only because the irritable fibres at that point were destroyed or paralyzed inci- dentally during the operation or during parturition. It was also shown that the uterine sound passed easily into the cavity during menstruation; that autopsies never showed stenosis at the site of a flexion; that the anguish was not extreme when in membranoiis dys- menorrhoea the membrane acted as a valve, temporarily, and arrested the flow. Confirming this negative argument came JHandfield-Jones who declared that the os was normally open during menstruation, that it slowly closed in the next week and was tightly closed in the week before menstruation. He ascribed dysmenorrhoea to fibroid thicken- THE DISORDERS OP MENSTRUATION 727 ing, liypersesthesia, and muscular spasm at the inner os. Williams, of CarditI' {British Medical Journal, October M, 1897), extended these views in part to the higher regions of the uterus and suggested that the pain of dysmenorrhea might be caused by abnormal contractions set up by diseased mucous membrane at the site of flexure. Those who hold out for the obstruction theory admit that in flex- ion of the uterus there may be no stenosis demonstrable in the post- mortem specimen, but hold that, with the ante-mortem thickening and congestion, there may be a decided obstruction in life which no au- topsy can reveal. The observation of Da Costa {Obstetrical Society of Philadelphia, December 5, 1889), that a flexion with a regular curve rarely causes obstruction, whereas a sharp bend does produce obstruc- tion, is important in this connection. Waiving all questions of the causal relation of obstruction, it must be admitted that a vast majority of cases of dysmenorrhoea are asso- ciated with anteflexion. It is very probable that this deformity is caused chiefly by an arrest of development in the anterior wall of the uterus, and a portion of the pain of menstruation may be due to causes which jDroduce dysmenorrhcea in the infantile, or undeveloped, uterus. Displacements of the uterus are associated with dysmenorrhoea, but not so frequently as flexions. It is a question whether the pain is produced by direct dragging on nerves or by an interference with the circulation at a critical time, or by setting up inflammation in the uterus or its appendages with adhesions. Uterine tumours produce dysmenorrhoea. The general rule is that the more peripheral tumours, as subperitoneal fibroids, set up less disturbance than those which lie nearer the endometrium. Metritis and endometritis are common causes of dysmenorrhoea. In its normal condition, the endometrium is almost, if not quite, as insensible as the cartilages and serous membranes, but, like these structures, it becomes exquisitely sensitive when inflamed. There is, in health, a certain sensitiveness at the internal os, giving the patient, usually, some uneasiness, or exciting strong reflexes when the sound is passed over this region; in inflammation, this sen- sitiveness is exalted into a capacity for excruciating agony at a touch. Metritis and endometritis interfere with every step in men- struation; from the beginning they cause pressure on pelvic vessels and nerves; the capillaries in the deep stroma become excessively congested and prematurely tear the epithelium away; the inflamed glands crowd and compress each other and retard amyloid or hyaline flegeneration ; and hyperplasia welds the deep and superficial stroma beyond tbe possibility of normal degeneration or regeneration. With all this irritation, we can not doubt that the uterine ganglia will become irritated, setting up contractions of muscular fibre which shall be either wholly abnormal or preternatural as to intensity. TTandficld-.Toncs aiifl oiliors have shown the probability that there is 728 A TEXT-BOOK OF GYNECOLOGY in all cases of menstruation a certain initial dilatation of the inner os, as at the beginning of labour before pressure or active dilatation has begun; if we grant this, we shall doubtless have the intermittent pains of the softening process aggravated many fold by the metritis or endometritis. The connection of tubal disease or deformity with dysnienorrhoea is based upon very strong probabilities. The evidence is chiefly that the tubes are muscular; that they have motor ganglia capable of causing rhythmic motion in the tubes even after their severance from the body; that dysmenorrhoea is common among women who have sal- pingitis; that it is intense when a tube is obstructed at the uterine junction; that the tubes are continuous with the uterus and have the same nervous and vascular supply; and that they participate actively in normal menstruation. Dysmenorrhoea from oophoritis is wholly denied by some who say that the pain is merely referred to the ovary by the sufferer, when, in fact, it originates elsewhere. Nevertheless, there are very competent observers who have blamed certain severe cases of dysmenorrhoea on the ovary by a process of exclusion. Dysmenorrhoea is sometimes found to be associated with large, painful, easily palpated ovaries,, so irritable that pressure upon them causes pain and nausea. The study of chronic alcoholism in the female is sometimes con- firmatory of the doctrine that inflammation of the ovaries may pro- duce dysmenorrhoea; for dysmenorrhoea is often set up in heavy drinkers as a new symptom about the time the ovaries become large and tender. Treatment . — No hope of relief for dysmenorrhoea caused by an infantile uterus could be extended if the uterus were not unique among the adult tissues in its marvellous degeneration and regenera- tion. It has happened repeatedly that that which has been correctly diagnosticated as a shallow, imperfect, undeveloped uterus, has be- come gravid and, mayhap, after repeated abortions, has been able to carry a foetus to full term, and thereafter, reconstructed by normal invo- lution, has maintained its proper adult condition. Only a few cases have this fortunate termination, and the prognosis is more gloomy in cases of superinvolution occurring in women of somewhat mature years. The surgical treatment of uterine flexions is so treated in an appropriate part of this work, that its discussion as curative of dys- menorrhoea may be omitted here. But assuming that the flexions of the uterus are caused by defective development, one might well look to the hygiene of the adolescent girl as a prophylactic against the deformity. It is not going too far to say that the conventionalities of refined European and American life directly tend to undeveloped genitals in the young girl. The contrast between what is decent and proper among girls of our time and tribe, and girls living under sav- age conditions, is very great. The little children in many tribes of THE DISORDERS OF MENSTRUATION 729 savages are encouraged to attempt and to practise copulation until puberty, when, except among the most degraded, the girls are with- drawn from such possibilities. In many Oriental countries the girls are not only pledged in marriage in babyhood, but they are actually delivered over to their spouses before puberty. This is a very wide usage, also, among savages ; it has been a source of horror and dismay to our red men that the girls sent to Government schools menstruated while at school, and the basis of this rage and astonishment is the Indian's conviction that menstruation at school is a sure sign that his little children have been debauched ; for, so early do Indian girls enter into the marriage relation, that, as a rule, they do not menstruate until some time after they have found a place in the husband's lodge. Practices so repugnant to our notions of decency and morality seem most unnatural, and yet they belong to a state of Nature, and, what- ever may be the decrees of fashion and civilization, there can be no doubt that the early sexual life, arousing rather than dwarfing the prophetic sexual instincts of girls, tends to develop the uterus. The free and licentious conversation of pastoral life, and even of agricul- tural life, in some countries, is doubtless a stimulant in the same direction, and these stimulants are forever withdrawn from our girls in the name of decency. This must be so; but the mischief wrought by the young girl's dress is remediable. When her breasts begin to bud, the young Amer- ican girFs shame of them is made a virtue by her mother, and while she cramps them up with a long and stiff corset, she jams all abdom- inal viscera down toward the pelvis by the same apparatus. Most girls say, and say truly, that the corset is not very tight ; the mischief is done even by moderate pressure at the wrong place and in the wrong direction. A short and flexible corset, loosely worn, might be a beneficent thing by distributing the pressure of waistbands, while a long corset, stiff in front if not elsewhere, is a positive injury by transmitting pressure downward, by increasing constipation, and by interfering with the circulation in the uterus and its appendages. The circulation in the uterus seems to be directly related to, and connected with, that of the lower extremities. It is the misfortune of the American girl that her legs are going into a state of disuse by reason of perfected artificial locomotion and elevators. As a mat- ter of uterine hygiene, and as a provocative of uterine growth, she should walk much. Lawn tennis should be cultivated, and other games of the sort. Since it involves walking, one might even say a good word for golf. The bicycle used without excess is admirable. Housework, with its infinite variety of posturing, is to be com- mended. Horticulture, with its carrying and stooping and rising, is an ideal pursuit. Gymnastics might be scientifically prescribed for the legs and the whole body, but there was never yet a girl who, in dreary solitude, would practise bodily movements for the sake of exemption from vague and half-guessed pains in the far future, and. ^30 A TEXT-BOOK OP GYNECOLOGY for that reason, girls' gymnastics must incline to games, witli some- thing of excitement and rivalry and the exhibition of personal prowess. Many girls have the feet habitually cold in summer, and in winter, so cold and numb as to be beyond the perception of suffering. It is very important that this state of arterial spasm should be broken up, for it is, as has been suggested, directly related to deficient blood supply to the pelvic organs. When there is a marked flexion with dysmenorrhcea, the flexion must be dealt with on surgical principles laid down elsewhere in this work. Stenosis, when it is believed to be a cause of severe dysmenorrhcea, should be dilated. The treatment is indicated whether it is held that mere obstruction is the cause of the menstrual pain or not, for in the latter case we have reason to believe that the stretching pro- cess interrupts unnatural and pain-producing channels of nerve con- duction. Extending his observations over 2,000 cases of marked dysmenor- rhcea, Emmet found that about 75 per cent of them were sterile, and in this fact we find another reason for dilatation, for it will often happen that, after that operation has been thoroughly done, preg- nancy ensues, and this, wbile a positive benefit incidentally, tends to the cure of dysmenorrhcea. The choice Avill lie between gradual dilatation, which requires no angesthesia and may be done at the consulting room, and rapid dilata- tion, which faces all risks of sepsis and inflammation once for all. In 1893, Goodell reported 400 cases of rapid dilatation with hot, antisep- tic irrigation and gauze packing, and no untoward results, and, while others have not so enthusiastically advocated the operation, it is con- ceded that it is not a grave one. In the gradual dilatation of tough strictures, electricity is of much assistance. A sound is insulated to within 2^ inches of its tip and is passed into the cervix. When resistance is met with, a current of 10 milliamperes will often cause the resistance to disappear in a few min- utes. The treatment is completed by a current of from 20 to 50 milli- amperes for five minutes only. The sound will drop out easily and should be replaced by a larger one at the next sitting. The sound is, of course, connected with the negative pole and a clay electrode with the positive. For the treatment of flexions and strictures by the cutting opera- tions of Simpson, Sims, Dudley and Schroder, and for the modifica- tion of those operations the reader is referred to the appropriate chapters. The treatment in all cases seeks to amend any possible stricture and to interrupt the channels of painful nervous reflexes. Eeference to other parts of this work is also made for the proper treatment of displacements of the uterus by tampon, pessary, or oper- ation on the ligaments or upon the floor of the pelvis ; for these surgi- cal devices may need to be invoked for the relief of dysmenorrhcea. THE DISORDERS OF MENSTRUATION Y31 Like reference must be made also for the appropriate treatment of metritis and endometritis. The pain of dysmenorrhoea is much relieved by drugs which are not strictly anodyne, but rather antispasmodic. Chloral and croton chloral hydrate will control many cases. Some of the milder cases of pure neuralgic type will yield to a single sound sleep induced by trional or sulphonal. Sulphonal has a specially powerful sedative action on the lower portion of the spinal cord whence the uterus and its appendages receive their spinal supply. Atropine will relieve a certain number of cases, and seems to benefit those women most who never have warm feet or a blush of pink upon the general surface of the body. To be of use, the drug should be given in increasing doses for five days before menstruation, and it should be so managed that the face shall be flushed for one or two evenings. Most unfor- tunately, alcohol has a similar effect in like cases. As it breeds an indifference to small discomforts it is very seductive and should not be used. Amyl nitrite may be used with good effect in cases where the pain comes and goes in waves. A few drops may be poured on cotton in a wide-mouthed bottle and the patient permitted to inhale the volatilized drug from time to time as the pain demands. Cannabis indica will mitigate the pain. Unfortunately, its anodyne effect is rarely produced until the patient is about to experience some disagree- able confusion as to time and space. Gelsemium is a drug much more available, yielding anodjTie effects long before it produces diplopia. The dejDressant effects of the lyromides, affecting the whole nervous sys- tem, should be borne in mind. In ordinary cases, the relief from pain under the bromides is too dearly purchased. Camphor yields surpris- ing results occasionally, but is worthless in most cases. Brisk eliminant treatment, with the administration of salicylates of sodium, a^nmonium and lithium, will so signally relieve certain cases as to reveal the gouty or rhemnatic diathesis. In all cases, and especially in these last, acetanilide will relieve the pain of menstruation. It is as valuable as any of the high-priced, licensed and patented " coal-tar derivatives." There is no good reason for combining it with alkalies or with caffeine, as in the popular secret mixtures. Like its chemical cousins, it is directly depressant and ulti- mately destructive to the most important elements of the blood or probably to the tissues, and its anodyne effect is produced by paralysis of nerve-endings. That it is a poison in all doses should be remembered, and it should only be used as a makeshift, or as antagonizing the rheu- matic poisons. It is distinctly contraindicated in anemic or debilitated patients. Cyanosis, sweating, and dark urine, show overdosing. As an anodyne, an antispasmodic, and remotely as a hypnotic, morphine is an ideal drug in the treatment of dysmenorrhoea. Its deleterious effects upon the digestive tube are such that it should be reserved for emergencies. Xine out of ten female morphine habitues i6 ?,9 A TEXT-BOOK OF GYNECOLOGY have learned to use this seductive poison from its emplojanent originally in the treatment of dysmenorrhoea. The physician who uses it should never name the drug in the presence of the patient, and the possibility of having a prescription refilled should be wholly forestalled. The active treatment of anemia and chlorosis in the intermenstrual period ■will be the best treatment for dysmenorrhcea in many cases which have no pelvic disease or defect. Fermentative dyspepsia is relatively common among dysmenor- rhoeics. It is sometimes necessary to treat this complication most actively. Active purgation just before menstruation has more than a palliative effect on dysmenorrhoea in some cases: it reduces pelvic con- gestion, and possibly assists in ridding the system of poisons which tend to neuralgia. Heat is an admirable palliative. Patients will usually suffer less when rolled up in a superfluity of blankets. Hot footbaths and sitz baths give an amount of relief which freshly shows the patient that congestion and pelvic pain are linked together. Great comfort is oftentimes obtained by chasing the sharpest pain from the sacrum to the abdomen, and back again, by the application of a bag of hot water. Membranous Dysmenorrhoea. — In some cases of dysmenorrhcea the pain seems to be intimately associated with the appearance of a mem- brane in the form of a three-cornered pocket (Fig. 298), or of shreds and patches. In a very few cases the membrane gives a copy of the cervical canal. Some authors have held the membrane to be the re- sult of a slight exaggeration of the normal process of shedding of epithelium ; others hold it to be an ex- foliation of the entire mu- cous membrane instead of its superficial layer; others see in it the ^^lastic lymph of metritis organized; others, with less charity for unmarried patients, hold it to be the decidua vera of a pregnancy which has come to an early termination. And there is a similar disagreement as to the im- mediate cause of the pro- duction of this membrane. Literature shows that it may be due respectively to flexions, versions, an OS too small or too large, a constricted cervical canal, a constricted internal os, congestion of the mucous membrane, hypertrophy of the Fig. 298. — " A membrane in the form of a three- cornered pocket." — MiLLiKix. THE DISORDERS OF MENSTRUATION 733 mucous membrane, hypertrophy of the uterus, metrorrhagia, disease of the ovary, anaemia, chlorosis, syphilis, and hysteria. Nevertheless many of the subjects of the affection are exceedingly healthy women and some of them menstruate with so little pain as to make the term dysmenorrhoea inapplicable. In the present state of our knowledge, it is safe to say that the characteristic exuviae are the product of an endometritis of low grade. The membrane does not differ in any appreciable degree from that which is sometimes thrown oft' in cases of acute phosphorus poisoning, in typhus fever, and in cholera. It has been precisely imitated by severely cauterizing the interior of the uterus, for, following that pro- cedure, there has sometimes appeared a three-cornered sac consisting of fibrous tissue " faced with a mosaic of cylinder epithelium." Schonheimer has had the opportunity of studying the membranes cast oft' by a woman who was sterile and had one thick tube, and he found nothing notable except fibrinous deposit full of leucocytes and uterine epithelium. In this case dilatation and curettage brought away normal endometrium. Membranous dysmenorrhoea usually appears in early menstrual life. It may, however, appear later, to the dismay of the patient. Cook {Chicago Medical Observer, February, 1898) reports the case of a single woman, thirty-five years of age, who had often passed shreds of mem- brane, but who came under suspicion of pregnancy by passing a com- plete cast of the interior of the uterus while visiting. Under his ob- servation she passed similar casts for two successive months. In Schonheimer's second case, the woman had borne six children without anything anomalous in her menstruation. After bearing these children she began to pass a uterine cast without pain at every third period. The affection sometimes disappears as abruptly. Coughlin {New Yorlc Medical Journal, December 9, 1899) records the case of a virgin, thirty-one years of age, who passed the characteristic membrane with great suffering. She was under observation afterward for some time and had no recurrence. The affection is exceedingly rare. Kleinwaechter made a collection of all accessible reports of cases and could only find 80 cases recorded {Wiener Klinilc, February, 1885). The membrane is seldom passed at a first menstruation. It is most common between twenty and thirty years of age. Nearly 80 per cent of cases recorded occur in married women. Relative sterility belongs to the disease; only 9.5 per cent of the cases in married women become pregnant. Pregnancy does not appear to be curative in any degree. The symptomatology of membranous dysmenorrhoea is simply pain and the appearance of the membrane. The pain is not always severe, nor is it always promptly relieved by the appearance of the membrane. The flow is preternatural ly great, though there are exceptions to this rule. The increased flow is explained by the facts, that there is a large surface suddenly denuded, and that the membrane, as soon as it 734 A TEXT-BOOK OF GYNECOLOGY becomes a foreign body, acts as a stimulant and irritant to the uterus. Wlien membranous dysmenorrhcea lias no history it will require a microscopic investigation to exclude abortion from the possibilities. After the affection has continued for some months, abortion is certainly excluded. IvTevertheless there are some sterile Avomen who, between shame and hope, will tell of 12 and 13 abortions in a year. The treatment of membranous dysmenorrhcea by divulsion has not been satisfactory. Here and there, a nulliparous patient who passes large membranes, has received benefit. The curette usually brings away normal endometrium, and makes no impression on the next men- struation. Strong applications of phenol, iodine, nitrate of silver, caustic potash and nitric acid have been used with a vague hope of reconstitut- ing the endometrium for the better; but it has been altered not a whit. Cauterant applications of electricity have not succeeded better. Gun- ning {American Journal of Obstetrics, April, 1891) reports a softening and disintegration of the membrane after a series of treatments by mild currents of galvanic electricity. He places the negative pole at the fundus and the positive pole Just within the external os. His first current is as light as 5 milliamperes. After a few seances the current is raised to 10 milliamperes continued for five minutes and repeated every three days. Intermenstrual Pain. — Intermenstrual pain is here considered be- cause it has its relations to the menstrual period. Coming between the periods it certainly can not, in strictness, be allied to dysmenor- rhcea. Intermenstrual pain is referred almost invariably to one ovarian region or the other. In some patients, the pain changes from one side to the other from month to month. If there is an overfloAV of pain from the ovarian region, the iliac fossa, groin, and thigh, are affected. Sacral pain is not characteristic of this affection. No change of pos- ture will alter the character or amount of the pain. The pain is dis- tinctly paroxysmal and intermittent in character. The attacks are brief, lasting two, three, or four days, in most cases. Fever is not observed. As to the time of attack, each case is a law unto itself. Palmer (American Journal of Obstetrics, 1892) reports a case in which the pain came on four days and a half after the cessation of menstruation, but this is unusual. In his second case, the pain appeared about eight days after the cessation, and in his third case, about eleven days after. Wil- liam 0. Priestley gives two cases in which the pain came on fourteen days before menstruation. Thomas and Munde give cases in which the pain appeared at nine, ten, and seven, days after menstruation ceased. Some reporters vaguely speak of attacks covering four or five days in the middle of the intermenstrual period. One of Palmer's patients began to have the intermenstrual pain after confinement. She suffered ten years, then had an abortion followed by severe pelvic inflammation. THE DISORDERS OP MENSTRUATION 735 then, after a slow recovery, experienced some relief, the attacks becom- ing milder, shorter, and less frequent. No pathology has been suggested for this curious affection other than that which attributes the pain to an ovary which, by the slow changes of inflammation, has become so dense as to make the passage of the ovule from the deeper layers a very difficult one. By hypothesis, there is some definite date for each woman, at which, measured from the close of menstruation, active preparation for the ripening and ex- trusion of an egg begins. This hypothesis involves the doctrine that pain is produced by tension about the growing follicle, and that the pain ceases abruptly when the follicle finally fights its way to the surface of the ovary and is free to ripen and rupture. The doctrine harmonizes the facts, that the cases do not present much uterine dis- ease, that several of them at autopsy have shown dense ovaries, and that the patients are relatively, though not absolutely, sterile. An- other and more tenable theory is that the pain is caused by ovarian adhesions which are placed upon tension by the periodical recession of the menstrual blood pressure, a recession which reaches its climax about the middle of the intermenstrual period. Treatment is as inefficient as this pathology would indicate. Some have held that benefit was given by tampons of ichthyol and boro- glyceride, and the great " alteratives," iodine, arsenic, and mercury, given for a long time. During the paroxysms, anodynes must be used. Vicarious Menstruation. — If menstruation implies the casting ofl! of endometrial elements, then the term vicarious menstruation can only be justified on the plea that it is convenient, for it certainly is inaccurate. The term vicarious hemorrhage has been proposed, but this is equally inexact in that it carries the implication that hemor- rhage is an essential part of menstruation instead of a mere incident. We therefore use the older term, vicarious menstruation, arbitrarily, as indicating no more than hemorrhage which appears from some part of the body other than the uterus and in response to the menstrual molimen. Though the cervix uteri has no part in ordinary menstruation, it is such a near neighbour to the uterus that we might expect it to be the source of vicarious discharges. Few cases are recorded. Ash- ton (PhiladelpJiia Medical Bulletin, November, 1898) gives an account of a woman from whom he removed cancerous ovaries, whereupon she began to menstruate at the rate of four or five days every two weeks. He soon had occasion to remove the uterus close to the vaginal junction and closed the wound with peritoneum, whereupon she began to men- struate scantily from the cervix, every four or five weeks. The tubes have occasionally presented at fistulse in the abdominal wall, and in a large proportion of cases yield a red discharge at the time of menstrual molimen. In ventro-fixation of any part of the pelvic organs after operation, vicarious h(;morr]iage has occurred. Thus, in 1884, Rein showed a 736 A TEXT-BOOK OF GYNECOLOGY woman from whom he had removed an ovarian cyst and had fixed the pedicle in the abdominal wound. Healing had taken place promptly, but at one point there occurred a small slough just before menstruation, and from that sloughing point came blood during the whole catamenial period. This had occurred for three years. The flow does not necessarily come from mutilated genitalia, but may come from other parts of the body, particularly from the mucous membranes. The nose is the most prone to vicarious menstruation. Macnaughton Jones reported {Edinburgh Medical Times, October, 1897) a case in which there was no epistaxis but in which a baffling nasal ulcer was conquered only after eleven months' treatment, and during the greater part of this time it was much worse at the menstrual periods. Withrow has reported 2 cases, already cited in these pages under Amenorrhoea, in which there was lifelong amenorrhoea and periodical ej)istaxis. Periodical hemorrhage from the stomach has been diagnosticated as symptomatic of an ulcer at its onset. Charles T. Parks, of Chicago, reports a curious case of a woman who was sick for eighteen months, and for four months had defecated at intervals of from one to four weeks. For two months after coming under observation she failed to menstruate, and at the proper menstrual times she vomited torrents of blood. Her mental and physical condition became so bad that when faecal vomiting came on, an exploratory incision was made. Enlarged ovaries were removed. Scybala in enormous quantity were expelled. The urine, which for four months had been reduced to one ounce per diem, rose to normal amount and recovery ensued. Hemoptysis is sometimes due to the menstrual excitement. Nor- ton {American Journal of Ohsletrics, February, 1892) tells of a woman who menstruated from the age of fourteen, with much pain and cramps. At the very first menstruation she had a smothered or choking sensa- tion followed by a coughing paroxysm during which she spat blood freely. This was repeated after a few hours and so continued until the fourth day, when the vaginal discharge was growing pink. From this time the bloody expectoration diminished to the vanishing point on the fifth or sixth day. She had a small uterus, high in the pelvis, with a minute os. Nevertheless, she became pregnant after five years of married life and, during her pregnancy, she continued to menstruate after her fashion, with vaginal discharge and bloody expectoration. The last menstruation was about ten days before delivery. During all the years that she was under observation she was a hysteric. Chad- bourne {Journal of the American Medical Association, January 22, 1898) has made the important observation that many girls who have periodic hemoptysis, either synchronous with menstruation or replacing it, have incipient phthisis. Sometimes the hemorrhage is from the ear. Lermoyez {Societe medicale des hopitaux) reported the case of a girl who had a periodic discharge of noncoagulable blood from the right ear. After three years THE DISORDERS OP MENSTRUATION 73^ of this vicarious discharge, normal menstruation was established, whereupon the aural discliarge appeared only once in two or three months. Sometimes the weak point is found at a njevus. Bloom {Archives of Pediatrics, September, 1897) records the case of a girl, sixteen years of age, who bled from a nasvus of the face. The hemorrhage came always two days before menstruation and lasted until the end. After two weeks there was another slight bleeding. Two teatlike projections furnished the blood. One of these being ligated, another appeared at the same site. Many cases of bleeding cicatrices have been reported. Ker- ley presented to the New York Academy of Medicine, November 18, 1891, an Irish girl twenty-five years of age. At the beginning of her menstrual career at the age of fifteen, she developed an abscess at the level of the cricoid on the left side. From this point there had been a discharge of bloody pus four days out of every twenty-eight through the whole ten years. In each intermenstrual period the cicatrix healed. Vicarious hemorrhage is most common from the nose. Next in order of susceptibility come the stomach and intestines. The hemor- rhage has been observed to appear in the retina and under the con- junctiva. The vocal cords, the nipples, and the bladder, have also been the seat of vicarious bleeding. We have no philosophy for this remarkable phenomenon, save the doctrine repeatedly expressed in this chapter that the human organism has inherited, and has intensified, a strong tendency to hemorrhage at the menstrual time. So strong is the impulse that it is felt at remote points in rare cases. We can not rest upon mere increase of arterial tension, for though there is a slight increase of tension at the menstrual period, it is so slight that it be- comes as naught when compared with other variations of blood pres- sure. A case reported to the Indian Medical Record by J. E. Wallace is instructive in this connection, for it indicates that Nature sometimes blindly confuses two discharges under the stimulation of the menstrual molimen. The subject was an Anglo-Indian lady who menstruated at twelve years and was married at twenty-three. She proved to be sexu- ally impotent, incapable of orgasm, and, after enduring eight months of frigidity, her husband parted from her in disgust. Upon this ensued six years of amenorrhea, but during these years, at regular menstrual intervals, her breasts would become hard and painful, and milk would pour from them freely. She had good general health and no pelvic pain. She laid on an immense amount of fat, increasing her weight from 98 to 245 pounds. At the end of this period of six years, Wal- lace adjusted an intrauterine stem and a slight discharge of blood was noted for three days. Four weeks later she had high fever, turgid breasts and resumed normal menstruation, and, at the time of the re- port, she had so continued to menstruate for six months. During this last period the mammary engorgement had diminished, and she had lost 48 738 A TEXT-BOOK OF GYNECOLOGY 28 pounds. It would appear that the brief irritation of the uterine stem had determined the direction of overflow for this singular case. The Menopause. — The menopause, or the cessation of the menses, is an incident in the grand climacteric which comes to men and women alike, but comes to women earlier as a penalty for their earlier ma- turity. There need be no mystery as to its causes; when the geni- talia have reached an age approximating half a century, it is proper that they should be subject to senile changes. When we consider the profound changes in skin, hair, arteries, Peyer s patches, the intes- tinal villi, and crystalline lens, at this time of life we are prepared to admit that the ovaries may be developing fibrous tissue and may be losing the power of producing ovules, and that the uterus, with its diminishing possibilities of gravidity, is also undergoing atrophic changes which are truly senile. Making a mystery where there is none, some have assumed that during the menstrual years the ovaries secrete a certain substance which determines the menstrual flux and ministers to female health. Napier and Christopher Martin have held that this hypothetical sub- stance being lacking at the menopause, gives rise to some of the symptoms of the climacteric. But it should be remembered that shoals of men, women, and children, live in health without active ovaries, or with none at all, yet have good health, and that the cli- macteric is not a pathologic process or the menopause a symptom. The vulgar rule which gives to each woman thirty years of men- strual life allows her too little. The menstrual career is more than thirty-one years. Raciborski found that Parisian girls menstruated first at about the age of fourteen years and seven months, and that the women ceased menstruating at forty-six years and six months. Tilt, upon knowledge of more than a thousand cases, comes to almost identical figures. There is no doubt that, within the past two genera- tions, civilization has increased the menstrual period as it has length- ened life. When the menopause is accomplished early in life, it has some- times been foimd at necropsy that atrophy of ovaries had advanced, and in some cases hard, subperitoneal fibroids have been found. Tumours which have a mural or submucous situation tend, in gen- eral, to maintain the menstruation to the age of fifty, or beyond that. The uterus is said to become a trifle larger and heavier at the beginning of the menopause. Whether this is true or not, it is cer- tain that the tendency is presently toward atrophy. The walls be- come demonstrably thinner ; the cervix becomes shorter and thinner ;. the OS internum is sometimes obliterated ; the uterus is smaller in all dimensions; the endometrial glands become smaller, and their num- bers diminish. The rule is that the uterus atrophies later than the tubes and ovaries. A competent observer has found the ovaries of normal size THE DISORDERS OF. MENSTRUATION 739 three years after the menopause^, and it is known that ovulation is often prolonged for years after the uterus has ceased its functions. Changes in the ovaries at the time of the menopause have been studied by Otroschkevitch {Vratch), who has come to the following conclusion : " The lessening of both ovaries in old age arises in connection with increased growth of fibrous connective tissue and the predominance of this over the degenerating follicles. The disappearance of the epithelium covering the surface of the ovaries which occurs in old age can not always be put down to separation during preparation of microscopical specimens, but must rather be taken as one of the true changes in the senile ovaries. Desiccation of mature and wholesale degeneration of the primordial follicles forms one of the chief and most important changes in senile ovaries. Hyaline degeneration of the arteries and fibrous tissue progresses with age, and in very ad- vanced age striking examples of this degeneration are found. Fatty degeneration of the cellular skeleton occurs fairly often, and is evi- dently dependent upon the deficient nutrition of the ovary. A direct connection between degeneration of the vessels and diminution in function of the ovaries is not substantiated, for the ovary becomes limited in function when there are still but few vessels affected by degeneration and therefore at a time when its nutrition is but little altered. The nervous system plays the chief part in the complex process. ^^ At the menopause, women, like men at a corresponding age, suffer from a deposit of fat which is oftentimes a serious burden. The masses deposited in the abdominal wall and in the omentum are absorbed in great degree in later life, or, as some think, are simply redistributed. The mesentery, also, takes on a large amount of fat. About the heart, in the pericardium, and in the subpericardial con- nective tissue, the accumulation of fat becomes very embarrassing, leading to such serious symptoms as hurried respiration, cardiac asthma, cardiac palpitation, venous stasis, and, in the worst cases, to albuminuria and oedematous feet and legs. 1 About one woman in ten will be annoyed while at the menopause, by flashes of heat running over the face and neck, and sometimes sweeping over the whole body. The heat is a subjective sensation and is not real. The sensation is caused by a temporary vasomotor paral- ysis which permits the extreme dilatation of the small vessels. Some- times profuse sweating follows these waves. Metrorrhagia has no place among the normal phenomena of the menopause. It occurs rarely, though the folklore of the women keeps them dreaming of torrents of blood at the change of life. Scanzoni himself endeavoured to explain the profuse hemorrhages of the meno- pause by assuming a great friability of the blood vessels, and Kisch has taught that the softening and relaxation of the uterine substance is the cause. But, as a matter of fact, their theories are superfluous, 740 A TEXT-BOOK OF GYNECOLOGY for hemorrhage is not an incident pertaining to the menopause. Metrorrhagia^ when it does occur at that time of hfe, is usually in- duced by some one of the ordinary causes which we have enumerated elsewhere. Baer (American Journal of Obstetrics, May, 1884) has analyzed 2,200 cases of metrorrhagia, and shows that the profuse hemorrhage belongs to the early years of greatest fecundity and to any period of menstrual life rather than to the menopause. In five years following the age of twenty-nine there were 364 cases; in five years following the age of thirty-four, 333 cases; in five years fol- lowing the age of thirty-nine, 223 eases; in five years following forty-four years, 131 cases. In the years between twenty and forty there were 1,533 cases, and there were only 667 cases for all other ages. It is at the menopause that inhibition fails and lurking cancer advances by leaps. Any metrorrhagia at this time of life should excite suspicion of cancer. A serous discharge is sometimes the warning of cancer, and sometimes of senile endometritis. With the atrophy of the hypogastric plexus come some disturb- ances of the sympathetic nervous system, though the reflex disturb- ances of the stomach and intestines at the menopause have certainly been exaggerated in medical literature. The dyspepsia of this time of life is not iDeculiar to females. Many alert practitioners have worked through a lifetime without seeing the alleged diarrhoea of the change of life. The heart is more disturbed at this time than, perhaps, any other or- gan. By far the larger number of cases of tachycardia in women appear at the very first announcement of the menopause. It is a noticeable fact that tachycardia is most likely to afflict those who experience the menopause early in life. Few cases have come to autopsy, but those few have almost invariably confirmed the theory that the tachycardia belongs to the exceptional cases in which there is early shrivelling of the ovaries with hyperplasia of connective tissue, and it is a part of the theory that the nervous reflex, doubtless a stimulation of the accelerators, proceeds from the cirrhotic ovaries. Tachycardia is also common in eases in which the operations on pelvic organs have caused adhesions. Tachycardia should be carefully distinguished by the strong, full, regular pulse, the irritable disposition, the throbbing aorta, the constriction of the chest, and the high percentage of hemo- globin, from the weak heart, announced by a weak and fluttering, easily compressible pulse, and the low ratio of hemoglobin which accompanies this sort of debility. Glycosuria is sometimes present in the years about the menopause. The prognosis is not so grave in these cases as in glycosuria in gen- eral, for the theory of causation permits us to believe that the disease is produced by irritation of the sympathetic supply of the liver, and permits us to hope that when the immediate nervous irritation from ovaries and uterus shall have ceased by atrophy, there Mdll be a tend- THE DISORDERS OP MENSTRUATION 741 ency toward recovery. In many of these cases of glycosuria, vulvar pruritus is the danger signal. Early in the menopause there is sometimes noticed a curious men- tal exaltation. While it lasts the woman becomes inclined, perhaps, to meddle with business affairs which concerned her not in earlier life; she has large plans; she essays large tasks; she proposes for herself all that is difficult or impossible. It is a state of mind which does not last long. Far more frequently, the mental condition of the menopause is one marked by depression. The sane woman at the change of life is one who, as a rule, suffers depression rather than mental exalta- tion. If the perturbation of the time drifts into a positive mental alienation, it is likely to take the form of melancholia and hypochon- dria, and passive forms of hysteria. JSTot that more active forms of insanity are excluded. At this period may appear strong irrespon- sible impulses, active moral perversions, delirium and acute mania. Of these, and of all sorts of insanity, it may be said that the prognosis is good if there are not too many neurotic defects in the ancestry. At the menopause, that which seems to be an insanity or a radical change of character, newly acquired, is, upon close study, seen to be merely an exfoliation of mental habits formed in the best years of life. Thus stripped, the patient returns to her earlier mental condi- tion revealing traits which were suppressed through her young womanhood. In one woman we may see something of childlike trust- fulness and pliability appear; in another, disagreeable childish traits appear when the veneer has been peeled off; and she who was tidy is slovenly in her house or her person, becomes stubborn about small matters and is absolutely frivolous in conversation and in behaviour. Addiction to alcohol and other nerve-tickling drugs sometimes be- comes pronounced at this time, and the demand for these drugs seems to have no other basis than childish ennui and a babyish lack of self- control. The patient, no longer busy in life, no longer self-centred, can not abide solitude and relies wholly on company. She becomes exacting in small matters, and jealous, not of her husband alone, but of all upon whom she has claims. It is a curious fact, and fortunate, that many such cases, having fallen into this advanced senile state, will work out of it again and go through many years of later life sane and serene. jSTo doubt we pay too much attention to the physical changes ac- companying the menopause and too little to the tremendous mental change which comes to every woman at that period of life. A man grows old by merciful and gentle gradations, and so he slides, half willingly, and half unconsciously, into the afternoon of life, with regrets so soft that they can scarce provoke a sigh. But for a woman, man's twenty years of gentle change are compressed into two; she is rudely compelled to make an abrupt change of mental attitude as regards life and love, and the big world arid the groat future. It is Y42 A TEXT-BOOK OF GYNECOLOGY evolution for him; it is revolution for her. She is suddenly brought to perceive that her charms, her youth, her sex itself, are passing from her. She is invited, with cruel abruptness, to be to her hus- band merely an intellectual companion or a sexless helpmeet, when she has been of late the object of his embraces and the mother of his babes. One third of her adult life is still before her, full of promise of placid enjoyment and great usefulness, but to her, remembering the glory of conquest and surrender, the future stretches a dreary waste of empty years. It appears small wonder, therefore, that, with this sudden violence done to lust and love and pride and hope, the woman at the climac- teric, finding a sharp boundary set to her warm young life, beyond which she must walk into a gray and passionless old age, should be the victim of a sadness which may drift into a melancholy and so into a madness. The explanation of the psychoses and the neuroses of the menopause is not to be sought in absolute senility, nor in the accimmlation of menstrual poisons, nor in the lack of ovarian juices, so much as in the suddenly changed mental atmosphere of her who stands reluctantly between youth and age, bereft of all that she most valued in herself. Treatment. — The menopause, itself, needs no treatment. But since it is a season of nervous depression, and a time when the vital powers are failing, latent diseases and defects, hitherto well borne or suppressed, assert themselves. The gouty diathesis or the rheumatic taint may demand treatment by elimination, regulated diet, and prescribed muscle waste. A syphi- lis may need a course of treatment after it has been forgotten for years. Perineal and cervical lacerations, hemorrhoids and varices, may cry for attention, not merely because the menopause is at hand, but because the woman is no longer young, and repair is slow, resisting power is lessened, and inhibition by the higher centres over the irri- tated lower centres is withdrawn in some degree. Climacteric fat may become a burden so grievous that the inges- tion of hydrocarbons must be restricted, drink must be limited, and vapour baths and physical exercise must do the rest. Dyspepsia, diarrhoea and constipation may be so extreme as to be interpreted as manifestations of profound disturbance of the sym- pathetic supply of the intestines by an irritation proceeding from the genitalia. At this time, errors of diet and regimen will tax the patience of the physician who would detect and correct them. The circulatory disturbances of the menopause are mostly affec- tions showing stimulation of the accelerators. Digitalis is much abused in these cases. Veratrum viride is more indicated when a sound heart is to be dealt with. The heart is not involved in the curious flushes and subjective flashes of heat. The bromides, used with due regard to their depress- THE DISORDERS OF MENSTRUATION 743 ing effect, will yield very good results in these eases. Many women, when they are made to understand the nature of these sensations, do not care to have treatment for them. Insomnia is a very troublesome symptom of this time of life, and will demand careful treatment. The patient may take a certain amount of hypnotics, but always with the knowledge that they are great evils, introduced only for emergencies, and that the main re- medial agents must be open-air life, moderate fatigue at bedtime, a mind at rest and plain food. The attendant who is justified in the occasional use of hypnotic medicines will do well to keep his own counsel, and never permit the name of the drug to cross his lips, attributing each sound sleep to anything other than the drug he has used. If his wakeful patient becomes his confidante he will find him- self unable to bafSe her when she sets herself to use drugs for the induction of sleep at her own pleasure. Tachycardia, mild or severe, occurring at the menopause, will usu- ally end in recovery when the ovaries have had time to lose their nerve elements and have ceased to tease the sympathetic system. The cases in which there is a dilatation of the heart do not tend to recov- ery, though they usually improve after the patient has ceased to menstruate for some years. Plainly, the source of irritation is not always in the contracting ovaries; tachycardia has, in rare cases, come to an end after the removal of cicatricial tissue at a laceration of the cervix. In some few cases with great nervous fretting and poor nutrition, a period of rest and seclusion away from home may avert absolute insanity. This treatment, with high feeding, is indicated especially for women who have long been overworked. The beneficial effects upon the thoughtless or deliberately cruel home people is sometimes the chief justification for sanitarium treatment. There are many patients, on the other hand, who are in danger of grave psychoses because they have nothing to do, and it may be possible for the physi- cian to suggest some avenue through which the patient may find her way to useful work, renewed zest in life, and some promise of a mind at peace. Certain it is, that mere drug therapy can avail little for those who are overworked or for those who have no occupation. CHAPTEE XLA^I THE FEMALE URINARY APPARATUS Physical examination — Catheterization of the ureters : Pawlik-Kelly method ; use of the ureterocystoscope — Harris urine segregator — Anomalies of the kidneys in number, location, form — Movable kidney, etiology, patliologic anatomy, symp- tomatology, treatment — Anomalies of the ureters — Stricture of the ureters — Nephrocystosis : Nephrydrosis ; nephropyosis ; pathologic changes, symptoma- tology and diagnosis, treatment. Physical Examination. — In all examinations of the kidney, the abdomen should be thoroughl)' exposed by the removal of all cloth- ing. The examination may be made with the patient lying on the back, on the side, or standing. When on the back, the shoulders should be slightly raised and the limbs drawn up to relax as much as possible the abdominal muscles. With the palmar surface of the fingers of one hand, counter pressure is made posteriorly Just below the twelfth rib, while the other hand presses upward and backward beneath the costal arch external to the rectus muscle. The patient should now take a deep breath, and during the expiration, the anterior hand should follow the receding abdominal wall. The kidney, if it descends far enough, may be grasped between the hands and its surface easily palpated. In the side position, the patient lies on the side opposite the one to be examined. The body should be curved slightly forward and the limbs drawn up. In this position the kidney, if movable, drops to- ward the middle line and may be more easily felt. The standing position is to be preferred when examining for " pal- pable " kidneys, for " movable " kidneys of low degree, or when the superior pole tilts forward. The body should bend gently forward with the hands resting on a table or chair. The kidney can often be palpated in this position when it can not be felt lying down. The kidney is recognised as such by its shape, its range of motion, its rela- tion to the colon, and its return to the normal location by manipula- tion or position of the body. The shape can not be better expressed than by the well-understood expression " kidney-shaped." The range of motion of the mass is of considerable diagnostic value. In movable kidney, the range of motion is usually through an arc of a circle, the vessels forming the pedicle representing the radius, while the origin of the vessels corresponds to the fixed point or centre. The majority of 744 THE FEMALE URINARY APPARATUS 745 , movable kidneys pass below the transverse colon and behind and to the inner side of the longitudinal colon. When the superior pole tilts forward, the rounded end may be felt just below the edge of the liver and above the transverse colon. It may resemble very much an en- larged, distended gall bladder, and diagnosis is often difficult. The diagnostic points, aside from the history, are these : The kidney may usually be felt with the hand behind as well as in front, which is not often the case with the gall bladder. The kidney may be returned to its normal location by manipulation or when the patient lies down, the tumour disappearing; while though the gall bladder, if it has a long mesocyston, may be crowded back under the liver thus partially disappearing, it tends to return forward to its normal position so soon as the pressure is removed. A so-called " Schniirlobe " of the liver may closely simulate a movable kidney, but its connection with the liver can usually be made out. Very small tumours may rarely be detected in palpable kidneys by the slight irregularity or protuberance produced on the surface of the organ. Tumours of the kidney that are of sufficient size to form dis- tinct enlargements, can usually be outlined without much difficulty. One of the most important diagnostic points in connection with these tumours is the relation that they bear to the longitudinal colons. As the kidney lies in the retrocolonic space, enlargements of it from whatsoever cause displace the colon forward, forward and inward, or inward. Deviations from this rule are the exception, and occur usu- ally in enlargements of movable kidneys. The relation of the colon to the tumour can always be easily determined by having the bowel thoroughly emptied; then the tumour should be mapped out on the sur- face of the abdomen and the colon gently distended with air by means of an ordinary rubber hand bulb. Having decided that a tumour is con- nected with the kidney, it is next desirable to know if it is solid or cystic. This can often be determined by the sense of touch and the presence or absence of fluctuation. At times, however, fluctuation is so doubt- ful that one is unable to decide. In such a case, the aspirating needle may be used with the usual aseptic precautions. It should always be introduced posteriorly so that the peritoneal cavity may not be entered. Should fluid be withdrawn, its character will determine the nature of the enlargement, whether simple cyst, nephrydrosis, nephro- pyosis, echinococcus, etc. The surface of the tumour should be palpated to ascertain if it is smooth and uniform, or irregular and nodular. Of the former class, are the simple cystomata and usually the large rapidly growing " mixed tumours " of childhood. Of the latter, are congenital multi- ple cystic kidney, infected kidneys with multiple intranephric and perinephric abscesses, and some malignant growths. Tumours of the kidney are usually movable, particularly during their early stage. Later, they may become fixed by adhesions to sur- rounding parts. A careful examination of the urine is of great im- 746 A TEXT-BOOK OF GYNECOLOGY Fig. 299.— Urethral dilator. — Harris. $ portance in the diagnosis of renal diseases. In order to determine accurately the point of origin of pathologic products in the urine, it may, at times, be necessary to collect the urines directly from each kidney separately. This may be done by catheterizing the ureters or by the use of the Harris urine segre- gator. Catheterization of the Ureters. — There are two methods at present in use of catheterizing the ureters. These are the Pawlik-Kelly method and the use of the ureterocystoscope. In the Pawlik-Kelly method the instruments neces- sary, as given by Kelly, are the following: A conical urethral dilator (Fig. 299); several specula with ob- turators (Fig. 300), Nos. 8, 8^, 9, 9^, 10; a light; a head mirror; an evacuator; long recurved mouse- toothed forceps (Fig. 301); a ureteral searcher (Fig. 308); flex- ible ureteral and renal catheters; a metal ureteral catheter; hard- rubber bougies, and a series of dilating catheters. The bladder should be completely emptied of its urine and the patient placed in the knee-chest position on a table. The urethral orifice should be cleansed with a boric-acid solu- tion, the urethra dilated, if necessary, with the conical dilator, and a properly sterilized speculum, No. 8, 9, or 10, introduced into the bladder. Upon withdrawing the obturator the bladder immedi- ately distends with air. The vagina, likewise, usu- ally distends with air, but when it fails in this, as is likely in the vir- gin, it may be neces- sary to introduce into the vagina a very small cylindri- cal speculum or one ,. , t. „„. ^ , „ J , -^ ,11 V ..^^ ^^°- 300.— Speculum with of the urethral spec- >0^ obturator.-HARRis. ula, when the air will readily enter and the speculum may be withdrawn. The light is now reflected from the head mirror into the bladder, illuminating it so that its interior m.ay be readily examined. The speculum is withdrawn until the internal end of the urethra begins to fold over it. Now, by pushing it straight in for a distance of about 1 centimetre, and then deflecting it laterally about 25° or 30°, the ureteral orifice usually comes into view. This has THE FEMALE URINARY APPARATUS (47 the appearance of a small narrow slit, a slight elevation or papilla, or sometimes of a small fold in the mucous membrane. If the ure- teral orifice does not readily present itself after the end of the speculum has been directed to the location where it presumably ought to be, it may be sought for with the searcher. When found, it should be carefully wiped off with a piece of cotton wet in boric-acid solution, and the catheter gently introduced. If de- sired, the speculum may be withdrawn, the patient turned on the back and the catheter allowed to re- main until sufficient urine has been collected for analysis. The chief advantages of this method are that the instruments necessary are simple and inexpensive, and that it permits cleansing of the ureteral orifice by direct application before introducing the catheter. The method, however, is not so simple as it appears. Much practice and dexterity are necessary, and nu- merous failures will be recorded by the occasional user. Besides, an anesthetic is often necessary in order to secure perfect ballooning of the bladder, when two trained assistants or a special apparatus will be required to hold the patient in position. Catheterization by Means of the Cystoscope. — By this method the catheter is introduced into the ureter under the guidance of the eye by means of one of the ureterocystoscopes, such as Casper's, Mtze's, Albar- ran's, Brenner's, etc. (Fig. 303). The bladder is thor- oughly cleansed by irrigation, and about 100 to 150 cubic centimetres of clear boric-acid solution allowed to remain in the bladder. The cystoscope, prop- erly sterilized, is then introduced, and the interior of the bladder illuminated by the electric light. The ureteral orifice is sought for by inspection, and, when found, the catheter, passed along the small canal in the instrument, is directed toward, and made to enter, the ureter by the sense of sight. The Harris Urine Segregator (Fig. 30^ By this instrument the urines are collected separately from each kidney without the ureters being entered (Fig. 305). The patient is placed on the back in an easy lithotomy position with the hips on the same level as the shoulders. The blad- der, after being thoroughly cleansed by irrigation, is distended with about 150 cubic centimetres of sterile water. The double catheter, sterilized by boiling, is introduced mto Fig. 301. Mouse- toothed forcepf*. — HA1U4IS (page Y46). ureteral (page 74G). 748 A TEXT-BOOK OF GYNECOLOGY the bladder and the lever into the vagina. After these two pieces are locked by means of the small pin in the forked piece, the catheters are opened and fastened by means of the small spiral spring. The rubber tube connecting the curved tips of the catheters is now removed and Fig. 303. — "One of the ureterocystoscopes." — Harris (page 747). the water within the bladder allowed to escape. The vials are attached and, by means of the most gentle action of the bulb, the urine will be found to collect in the vials, right and left respectively, as fast as it escapes from the ureters. Each of these methods has its advantages. By means of the cystoscope, the interior of the bladder may be accu- rately inspected, and local conditions, such as inflammatory changes, ulcers, incrustations, new gTo\^i:hs, etc., recognised. By catheterization of the ureters the urine may be collected and the pelvis of the kidney drained and then treated by irrigation. The use of ureteral bougies will often enable one to recognise the ureter more readily in certain operations in the pel- vis, or to locate the divided ends of an in- jured ureter. One may be able to detect the presence and loca- tion of a stricture or obstruction of the ureter, possibly to dislodge a calculus from the ureter, and rarely to detect a cal- culus in the pelvis of the kidney. The great disadvantage of the ureteral catheter is the danger of infecting a healthy ureter and kid- ney. This danger is so real that, in the presence of a septic bladder, or in tuberculosis of the bladder or of one kidney, a healthy ureter should never be catheterized except under the most urgent necessity. The great advantage of the urine segregator is that it may be used without danger of infecting a healthy kidney, even if the bladder is septic, as the instrument does not enter the ureteral openings. Pig. 304. — The Harris urine segregator. — Harris (page 747). THE FEMALE URINARY APPARATUS 749 Anomalies of the kidneys may be considered under three heads: (a) Anomalies of number; (b) Anomalies of location; (c) Anomalies of form. Anomalies of Number. — Absence of both kidneys has been observed, but the condition is incompatible with prolonged post-natal existence. Fig. 305. — " By this instrument the urines are collected separately from each kidney without the ureters being entered." — Harris (page 747). Absence of one kidney, provided the other is normal, is perfectly compatible with health and existence to old age. This condition is found in one individual in about 3,000, and is thus of considerable surgical importance. The remaining kidney is called a " single " or " solitary " kidney. Ballowitz (Archiv filr pathologische Anatomic, Bd. cxli) has collected 213 cases of " single " kidney. The left kidney was absent 70 times, and the right, 42 times, in males; the left, 31 times, and the right, 34 times, in females. Eemainder unstated. "Wliile in men the absence of the left kidney distinctly predominates, in women, the two sides are about equally represented. With absence of a kidney is frequently found some developmental defect in the generative organs of the same side, such as absence of 750 A TEXT-BOOK OP GYNECOLOGY the ovary and tube, and uterus unicornis in women, or absence of the seminal vesicle, vas deferens, or testicle, or unilateral prostate, in men. In 71 women, such defect was found 41 times, while in 113 men, it appeared only 28 times. A " single " kidney is almost always larger than normal. In 116 cases, the kidney was distinctly hyper- trophied, while in only 5 cases was it found smaller than normal. Nephrydrosis, chronic inflammatory, or other pathologic changes, were found in nearly 13 per cent of Ballowitz's 213 cases. " Single " kid- ney has been unwittingly removed a number of times for disease, with the inevitable death of the patient as a result. In all cases, there- fore, in which nephrectomy is contemplated, the possibility of " sin- gle " kidney must first be excluded. In " single " kidney, almost always but one ureter is found opening into the bladder, and this is of great diagnostic importance, but in 4 cases, 2 ureters were found opening into the bladder at their normal locations, the one leading to the kidney, the other forming only a shorter or longer blind tube. " Single " kidney usually occupies the normal location on one or the other side, but may be displaced as described under anomalies of location. A few cases have been described in which three kidneys were said to be present. Most of them were probably cases in which one kidney had become subdivided into two portions by a deep furrow extending entirely through it, the two portions becoming somewhat displaced from each other, and the ureter from each soon uniting to form a common ureter. Cheyne {Lancet, 1899, vol. i, p. 215), however, de- scribes a case of a woman on whom he operated for a movable tumour situated to the right of the middle line. Upon opening the abdomen the tumour was found to be a movable third kidney with its own ureter and blood supply. It lay near the pelvic brim from 3 to 4 inches from the normal riglit kidney, which was present. A left kidney, some- what smaller than normal, was present in the usual location. Anomalies of Location. — The kidney may occupy any position from the normal above, to within the pelvis below. Both kidneys may oc- cupy the same side of the body, lying one above the other. The ureter of the misplaced kidney usually crosses over to its proper side where it enters the bladder at the normal place. The most common mis- placement is at, or near, the brim of the pelvis, over the sacro-iliac joint, or just within the pelvis. Of 76 collected cases of pelvic mis- placement, the right kidney was misplaced 12 times, and the left 64 times. The ureter is shorter than normal, according to the degree of misplacement, but enters the bladder at the usual point. The blood supply is derived from the aorta near its point of bifurcation, or from one or the other iliac arteries. The kidney is usually fixed, and some- what flattened from before backward. When in the pelvis, the kidney may be the cause of dystocia by preventing the engagement of the head. In such a case, Cragin did a vaginal nephrectomy under the supposition that it was a tumour causing the dystocia. Goulliund THE FEMALE URINARY APPARATUS 751 operated on a pelvic kidney under the mistaken diagnosis of in- terstitial salpingitis. Misplaced kidneys may be the seat of pathologic changes. Dartigues operated on what he supposed to be a cyst of the mesen- tery, but found a case of nephropyosis in a kidney misplaced in the mesentery of the small intestine. Such cases have only been diagnosti- cated at or after the operation, but in ail cases of unusual tumours in the pelvis or about the pelvic brim, the possibility of a misplaced kid- ney should be considered. In misplaced kidney, the adrenal does not usually accompany the kidney but remains in its normal location. Anomalies of Form. — The kidney may retain its foetal lobulated form, deep fissures, often extending to the pelvis, separating the lobules. The most important anomaly of form is the " fused "' kidney. In this condition the two organs are united, the degree of union, or fusion, varying from the simple horseshoe kidney to almost com- plete fusion into one organ. In the variety called " horseshoe " kidney, the two organs lie one on either side of the vertebrae, their lower j^oles being connected by a band of tissue called the isthmus, which extends across the vertebra in front of the aorta and vena cava. The isthmus may be composed simply of a band of connective tissue, or it may contain kidney tissue. It may be quite long, or the lower poles may be fused directly together, in which latter case a connective-tissue septum usually separates the kidney elements belonging to one organ from those belonging to the other. The pelves are usually directed more anteriorly than normally, and the ureters pass in front of the isthmus. Earely, the isthmus extends between the upper poles instead of the lower. The fused organs may both lie on the same side of the body, in which case the lower of the two is the misplaced organ. The lower pole of one fuses with the upper pole of the other, with the pelves looking in opposite directions or in the same direction. Almost all degrees of fusion may take place, but the pelves usually remain com- pletely separate and distinct, each having its own pyramids and tubules supplying it, and each having its own ureter. One half of a fused organ may be the seat of pathologic changes, while the other half remains normal, a fact of considerable surgical importance. Abnormities in the blood supply are almost always present. Fusion does not appear to predispose to disease. According to McMurrick (International Journal of Surgery, 1898, vol. xi, p. 335), 40 per cent of the fused organs were on the right side and 60 per cent on the left; 78 per cent occurred in men and 22 per cent in women. Under the anomalies of form, may be mentioned the " suppressed," or congenitally small kidney. In this case the kidney has been arrested in its growth so that often but a remnant of the organ is found. A " suppressed " kidney may secrete urine of normal composition, but in quantity insufficient to maintain life should the opposite organ re- quire removal. 752 ^ TEXT-BOOK OF GYNECOLOGY Movable Kidney. — The kidneys, although classed as fixed organs, move up and down with respiration, the normal range of motion vary- ing from 2 to 5 centimetres in a longitudinal direction. As a rule, the normal kidney can not be palpated through the intact body walls in men, but in women the right can be distinctly felt in a majority of the cases, and the left in a much smaller proportion. The extent to which the kidney may be felt, varies from the lower third to the major portion. It is best sought with the person standing, the body bent slightly forward so as to thoroughly relax the anterior abdominal muscles. The volar surfaces of the fingers of one hand should be pressed firmly against the loin beneath the twelfth rib, while those of the opposite hand are crowded upward and backward beneath the costal arch in front. While the person takes a deep breath, the kidney, if palpable, may be grasj)ed between the two hands. A kidney that can thus be felt is called a " palpable kidney." A kidney may be " pal- pable " without being movable. By the term " movable kidney," is meant one which is not onl}^ palpable, but which likewise possesses a degree or range of motion in excess of the normal. There are all degrees of mobility in " movable kidney." It may move up and down but slightly in excess of the normal, or it may descend as low as the true pelvis. It may move forward beneath the costal arch as far as the anterior abdominal wall, or it may be moved inward to considerably beyond the middle line. Most English writers divide this subject into " movable " and " floating " kidney, the former being considered an acquired, the latter a congenital condition. The " floating " kidney is described as possessed of a mesonephron of congenital origin which permits of a Avide range of motion. As yet no anatomic facts have been presented which demonstrate the congenital origin of a mesonephron, consequently the condition must be considered one of degree only, and the term "movable" kidney will here be used for all degrees of mobility. Movable kidney is a very common condition, but statistics based upon dead-house reports are very misleading. This unreliability of dead-house statistics is due mainly to two reasons: First, the condition rarely plays any direct part in the cause of death, and consequently is frequently overlooked; and, secondly, when the patient assumes the re- cumbent position, the kidney usually returns to its normal location, and the post-mortem solidification of the perirenal fat limits its degree of mobility. AYe therefore turn to clinical experience to determine the frequency of this condition. Klister examined in order 1,733 patients as they applied to him in private practice, and found 44 eases of mov- able kidney. There were 828 men with 4 cases, or 0.48 per cent, and 905 women with 40 cases, or 4.41 per cent. This is a good illustration of the general average in a surgical practice. In an exclusively gyneco- logical practice, the percentage is much higher, as not far from 20 per cent of such eases will be found to have " movable " kidney (Edebohls). In considering the etiology of movable kidney, two facts stand out so prominently that all etiological factors must be consistent therewith. THE FEMALE URINARY APPARATUS 753 These are: First, the proportion of women affected is greatly in excess of men; secondly, the right kidney is affected much more frequently than the left. In 667 cases collected by Kuttner {Berliner klinische Wochenschrift, 1890, Nos. 15-17) 584 subjects were women, and 83 men. The explanation of this marked predominance of women over men is found in the body form. The upper or cephalic portion of the abdom- inal cavity is relatively of much smaller capacity in women than in men. The cavity is not only contracted laterally, but from before back- ward as well. The effect of this is to displace and distort the organs occupying this zone of the abdomen. The stomach lies in a more longi- tudinal direction and the pylorus is depressed. The liver is compressed from before backward, thus depressing its anterior and posterior bor- ders. The depression of the posterior border crowds the right kidney lower and tends to displace or tilt the superior pole in an anterior direc- tion. The increased breadth of the female pelvis gives to the psoas muscles a more oblique direction than in the male. This condition produces an obliquity in the sagittal axis of the kidney so that the superior pole lies nearer the middle line than the inferior. The rela- tion between the body form and the location of the kidney is so con- stant, that by dividing the length of the body from the suprasternal notch to the upper border of the symphysis pubis by the least circum- ference of the body, an " index " will be found from which it may confidently be predicted in a given case whether the kidney will be found palpable or not. The formula of this index as expressed by Becker and Lennhoff {Deutsche medicinische Wochenschrift, 1898, Bd. xxiv, p. Kf^o^ ■ #11 distance jugulo-symphysis ^-,^^_- ^^^^ rpr,^ 508) IS as follows: .; — ^-i ■ — t — ■ ? X 100 — mcLex. ine least abdominal circumference greater the index, the smaller the upper zone of the abdomen, and vice versa. Therefore the greater the index, the lower the kidney will be found. With an index above 77, the kidney is almost always " pal- pable," while with an index below 75, it is the exception to find a " pal- pable " kidney. The body form must, therefore, be considered the predisposing factor in the cause of " movable " kidney, and explains the predominance of movable kidney in women over men. Etiology. — The chief determining cause is mechanical insult to the kidney. Mechanical influences may be divided into internal and exter- nal, the former being the more common and important. By internal mechanical influences are meant all sudden or severe muscular strains, such as heavy lifting, wrenching of the body by slipping or falling, straining at stool, coughing, twisting and turning of the body, in fact any muscular action that produces adduction of the lower movable ribs and thus a constriction of the upper zone of the abdominal cavity. In body forms with high indices, it will be found that the plane corre- sponding to the least abdominal circumferences cuts the distal portion of the floating ribs in women and passes above the centre of the kidney, particularly the right. The effoct, therefore, of adduction of the lower ribs by the internal mechanical influences above mentioned, is to bring 49 Y54 A TEXT-BOOK OP GYNECOLOGY pressure on the upper portion of the kidney and thus depress it. In men^ the before-described jDlane usually passes below the centre of the kidney, so that constriction at this level tends to elevate or compress the kidney. The truth of the above statements is well exemplified by the statis- tics of Kuster {Archiv filr Minisclie Chirurgie). He found that of 295 cases of traumatic subcutaneous rupture of the kidney, 93 per cent were in men and only 8 per cent in women, while of 84 cases of " mov- able " kidney the percentages were almost reversed — namely, 94 per cent in women and only 6 ])er cent in men. By external mechanical influences are meant injuries, such as falls, sudden jolts of the body, or blows about the region of the kidney. That an injury may directly produce a movable kidney, is certain. Harris has seen a movable kidney in a man, produced by his being thrown from a runaway carriage, and a case in a woman, produced by a fall on the buttocks. Cases, however, that are directly and solely attributable to a single injury are not common. Usually, the injury but directs atten- tion, or aggravates somewhat, a kidney already more or less movable. The principal reason why the right kidney is so much more fre- quently movable than the left is, unquestionably, the presence on the right side of the liver. This organ forms a firm, resisting body which transmits all force from above directly to the kidney, and prevents it from moving in any direction except downward and forward. The left kidney is not only somewhat more firmly fixed in its location, but has above it only the small spleen and the soft yielding stomach. What has brought about the body form of the female, which is so favourable to the occurrence of movable kidney? The broader hips, of course, are a sex peculiarity. The narrow contracted waist, however, is an acquired condition produced by artificial constriction which has been operative for innumerable generations. This constriction is due, not alone to the corset, but to the tight skirt bands as well, and the latter are often more harmful than the former, as is shown by the fact that movable kidney is not uncommon in labouring women who have never worn corsets but who constantly constrict their waists with tight skirt bands. According to Thomson {Ediiiburgli Medical Journal, De- cember, 1900), however, Trekaki, of Alexandria, finds that 42 per cent of Arab women, who wear no corset, girdle, or constriction of any kind, have a freely movable kidney.* There are other conditions that are considered by some authors as instrumental in the production of movable kidney. Foremost among these may be mentioned pregnancy. That the influence of pregnancy has been greatly overestimated is apparent when we learn that from 30 to 50 per cent of the cases occur in the unmarried, or in those who have never borne children. In 188 cases seen and collected by Harris, 89 were married, 83 were single, and in 6 the condition was not stated. Of the married, 4 are stated never to have borne children. Comby {British Medical Journal, 1898, vol. ii) mentions 18 cases in children. THE FEMALE URINARY APPARATUS 755 Two were aged, respectively, one and three months, 6 were between one and ten years, and 10 were over ten years of age. The same argument is applicable against the statement that laceration of the perineum, with prolapse and displacement of the uterus, is a material factor in the causation of movable kidney. The relaxation of the anterior abdominal wall and diminished intra- abdominal tension following the removal of large abdominal tumours and fluid accumulations, are supposed to favour the occurrence of movable kidney, but in large scrotal hernige in men and in umbilical hernias in women, where the intra-abdominal pressure is often very much reduced, movable kidney is not common. Absorption of the perirenal fat, as occurs in wasting diseases, has been emphasized par- ticularly by Landau as an etiological factor. As it is inconsistent with the two fundamental facts stated above, its influence must be consid- ered slight. The course of the ureters through the pelvis is too much of a curve and too much " slack " is present, as shown by the possi- bility of uretero-ureteral anastomosis, for the kidneys to be materially influenced by displacements of the uterus and tubal disease drawing on the ureters. The causes of movable kidney, then, may be summarized thus: The principal predisposing cause is the body form. Principal determining cause: repeated internal and ex- ternal mechanical influences as defined above. Of the minor in- fluences may be mentioned gen- eral relaxation of the abdomi- nal walls and kidney attach- ments following distention, wast- ing diseases, or enervating condi- tions. The pathologic anatomy of movable kidney varies some- what according to the degree of mobility. Three degrees of mo- bility may be described: 1. That in which the major portion of the kidney is palpable; 2. That in which the kidney descends so low that the hands may be brought together above it (Fig. p,e 306.—'- The kidney deseeDds so low that 306); 3. That in which the range the hands may be brought together above of motion is so great that the kid- it."-HARuis. ney may descend to the brim of the pelvis, move forward to the anterior abdominal wall, or be moved inward beyond the middle line (Fig. 307). In the first and second degrees, the kidney moves up and down in the connective-tissue .space formed anteriorly by the prerenal, and posteriorly by the retro- 756 A TEXT-BOOK OF GYNECOLOGY y Fig. 307. — " The kidney may descend to the briin of the pelvis." — Haekis (page 755). renal, fascia. The perirenal fat which varies much in quantity moves mostly with the kidney. As the renal fascia passes between the adrenal and the kidney, the former remains fixed and does not move with the latter. In the third degree, the perirenal fat is often much less in amount and may almost entirely disappear. As the kid- ney moves anteriorly, it carries with it the prerenal fascia and the peritoneum, so that these structures gradually surround the kidney more and more, forming with the vessels and ureter at the hilum a pedicle or, as it is some- times called, a mesonephron. The peritoneum is not firmly attached to the kidney as in normal intra- peritoneal organs, but loosely fixed thereto, being separated from it by the prerenal fascia and subperitoneal tissue. The renal vessels are often considerably lengthened. Legueu describes vessels that were 11 and 13 centi- metres long. The kidne}^ moves through an arc of a circle of which the vessels form the radius and their point of origin the centre. The range of motion is therefore limited by the length of the vessels. The large majority of mov- able kidneys belong to the first and second degrees. Those in which a so-called mesonephron is present are quite rare. At times the kidney, instead of moving up and down in a longi- tudinal direction, has its supe- rior pole tilted forward, the or- gan moving in an antero-poste- rior direction, and approaching the surface just below the edge of the liver between this and the transverse colon (Fig. 308). Again, the kidney may turn about an antero-posterior axis so that the hilum looks upward, and the superior pole may even occupy a lower level than the fig. 308.-" At times the kidney . . . has its inferior. More or less of the superior pole tilted forward." — Hakkis. THE FEMALE URINARY APPARATUS 757 upper portion of the ureter usually moves with the kidney, and there is often a marked tendency for the ureter to become sharply flexed or kinked at the junction of the movable with the fixed portion. This kinking of the ureter may interrupt temporarily the flow of urine pro- ducing distention of the pelvis and leading, eventually, to the for- mation of an intermittent nephrydrosis (Fig. 309). The renal vessels may also be sharply flexed so as to interfere with the blood supply to the kidney. A movable kidney may acquire new attachments to neighbouring organs, as, for instance, to the duodenum, the under surface of the liver, the colon, or the small intestine. Such attach- ments may limit its mobility or prevent its being returned to its normal location. Movable kidney is frequently associated with de- scent of other abdominal organs such as the stomach, liver, colon, or small intestine. By some au- thors, it is considered simply a part of a general visceral ptosis which is described under the name of G-lenard's disease. Such, however, is not the case, as mov- able kidney is often found unac- companied by marked displace- ment of any other abdominal ■organ. Dilatation of the stom- ach has been so frequently found in connection with movable kid- ney, that a dependent relation is claimed, based upon the fact that the kidney (right) in its move- ments may compress, drag upon, or so kink the duodenum, as to interfere with the proper emptying of the stomach, or through nervous action disturb stomachic digestion. Frank {British Medical Journal, 1895, vol. ii, p. 895) mentions a case of movable kidney so attached to the duodenum that the intestine would be kinked whenever the kidney moved out of place. The characteristic changes of dilatation and chronic catarrh are often found in the stomach. In left-sided movable kidney, the spleen may also be abnormally movable, but it usually retains its proper location. Symplomatolofiy . — In a systematic examination of patients, one fre- quently finds movable kidneys that have given rise to no symptoms whatever, and whose presence was unknown or unsuspected until dis- covered incidentally during the examination. On the other hand one sees patients whose lives are made miserable by a train of symptoms produced by a moval)le kidney. Pjetween these extreines all degrees Fig. 309. — " This kinking of the ureter may interrupt temporarily the flow of urine, . . . leading to the formation of an inter- mittent nephrydrosis." — Harris. 758 A TEXT-BOOK OF GYNECOLOGY will be found. The number and severity of the symptoms do not neces- sarily depend upon the degree of motion present, as there may be more suffering in one case with motion of the first degree than in another with motion of the third degree. It is, at times, difficult to state why one patient should suffer so much and another so little. In sudden dis- placement or acute dislocation of the kidney, the result of an injury, there is always pain in the side affected, and the patient often states that a feeling as if something had given way in the side was experi- enced. The pain may be quite severe, and be attended by nausea or vomiting. There may be a frequent desire to urinate and, at times, a little blood in the urine. That side will be tender to touch, and, on examination, the kidney may be felt in its dislocated position. The kidney may be found dislocated forward along the under surface of the liver, or downward behind the ceecum, or inward toward the middle line. It may return spontaneously to its normal location or appear somewhat fixed, requiring gentle manipulation to reduce it. After reduction, the symptoms quickly subside. After an acute dislocation, the kidney may regain its former fixed condition, or it may remain permanently more or less movable. The symptoms attributable to mov- able kidney may be arranged under four heads: Pain; disturbances of the urinary organs; disturbances of the gastro-intestinal tract; dis- turbances of the nervous system. The pain is located in the lumbar re- gion just below the twelfth rib, or anteriorly extending from the costal border down the side toward the inguinal region or the bladder. It may be located over the region of the appendix, and Edebohls has par- ticularly directed attention to the association of appendicitis with movable kidney. The pain may be quite acute, or, more commonly, a dull aching or a dragging feeling which is aggravated by standing, walking, or lifting. Of the urinary symptoms, frequent urination is the most common. It is most marked when standing, and usually disappears at night or when lying down. The desire to urinate frequently may be periodic. Harris had a case of a woman with a movable right kidney who, at irregular intervals, would have severe attacks of painful, frequent urination, lasting several hours. She was permanently relieved by fixing the kidney. Gastric symptoms are among the most common with which these patients are affected. They are the usual symptoms noted in gastric dilatation and chronic catarrhal gastritis, such as pain and distress after eating, eructations, nausea, and, at times, vomiting. There is tenderness on pressure in the epigastric region, and the abdominal aorta pulsates so markedly at times that one may be led to suspect an aneurism. Ffitterer calls attention to a bruit sometimes heard over the renal artery, which he considers due to a partial kinking of that vessel. Earely, jaundice has been noted, caused probably by the kidney draw- ing on the hepatico-duodenal ligament. Constipation is the rule and flatulence common. In connection with the nervous system, we find THE FEMALE URINARY APPARATUS 759 dizziness very common, headaches, frontal or occipital, and, at times, all the vague nervous disturbances of hysteria and neurasthenia. Sometimes, the mental state is one of depression or despondency amounting almost to melancholia. Patients with movable kidneys are liable to acute attacks, at irregular intervals, which are quite charac- teristic. They consist of acute pain in the region of the kidney often extending down the ureter to the bladder, with frequent, scanty urina- tion, and nausea or vomiting. These attacks may be very severe and may simulate renal colic due to calculus. They are called Dietl's crises and are probably due to a sudden twisting of the pedicle, causing a kinking of the renal vessels and ureter and a drawing on the renal nerves. They disappear on returning the kidney to its normal position. Many of the foregoing symptoms will be found aggravated during menstruation, and the kidney at this time is usually somewhat larger and more tender to pressure. It is not to be expected that all these symptoms will be present in any one case, but the cases may usually be grouped according to the prominence of particular symptoms. We thus find that in some cases the symptoms are referred principally to the urinary organs, in others to the gastro-intestinal tract, and that in yet a third group the nervous symptoms are the most prominent. It should also be remembered that movable kidney is frequently found associated with other conditions, such as lacerations of the pelvic floor, uterine displacements, tubal and ovarian diseases, chronic appendicitis, gastric disturbances due to other causes, visceral ptosis, anaemia, etc., so that, in individual cases, judicious discrimination is often necessary in assigning to each condition its proper influence in determining the symptoms present. Owing to the relations of the right kidney to the duodenum and bile tracts, gastric symptoms are usually more pro- nounced when the right kidney is involved than when the left alone is movable. The diagnosis of movable kidney must always rest on the findings of a physical examination. (See Physical Examination.) The treatment of movable kidney is palliative and operative. Pallia- tive treatment consists of the use of abdominal supports, pads and trusses, massage and symptomatic treatment. In patients with lax, dependent abdomens, with or without general visceral ptosis, the use of a well-fitting, firm, abdominal supporter is often followed by marked relief. In those cases in which the superior pole of the kidney tilts forward, and the kidney approaches the anterior wall below the edge of the liver, a properly applied pad may materially aid in retaining it in position, but, in the majority of cases, in which the kidney has a down- ward movement, it is practically impossible to retain it in place by pad or truss, and most observers are agreed that the use of mechanical appliances is here without material benefit. Massage has been recom- mended particularly by Kumpf with the idea that thereby a retraction of the peritoneum around the kidney may be brought about, thus fixing it again in place. Tliat such result is ever obtained is more than doubtful. 'IFowever, massage rnay be of benefit in restoring tone to a 760 ^ TEXT-BOOK OP GYNECOLOaY relaxed abdominal wall, in overcoming constipation, and in improving digestion, thus relieving many of the symptoms accompanying this con- dition. Symptomatic treatment should deal with the condition of the stomach, the constipation, the ansemia, the nervous symptoms, etc. In this manner, all associated or incidental conditions may be relieved, leaving such as are due directly to the movable kidney. A movable kidney can be permanently restored to its normal location by operation only. Not all cases, however, require operation. Operation is advis- able: 1. When distinct symptoms are present which are unrelieved by mechanical or symptomatic treatment; 2. Where secondary changes in the kidney are present, due to the mobility (nephrydrosis, nephritis). In those cases associated with general enteroptosis, an operation on the kidney should be followed by mechanical support of the abdominal wall. Those cases which are relieved by pads or trusses should be given the option of an operation with release from the annoyances of mechanical appliances. The gravity of the operation in uncomplicated cases is slight, the mortalit}^ being from 1 to 2 per cent — 374 cases with 4 deaths (Albarran). Relief from symptoms is most marked in those cases in which pain, and urinary and gastric disturbances, are most prominent. In such, the results are usually very gratifying. In the distinctly nervous type, much less can be promised, as such patients are frequently confirmed neurasthenics or hysterical, and such states are likely to persist. However, if it can be shown that the nervous state has its origin in the movable kidney, much good may result from the operation. The operation is that of nephropexy or fixation of the kidney. (See Opera- tion on the Kidney.) Anomalies of the Ureters. — The most common anomaly of the ureter is duplication. This may occur unilaterally or bilaterally. The second ureter may extend from the kidney to the bladder, open- ing into this organ usually a little above the normal opening, or the supernumerary ureter may join its fellow at any point along its course. It may terminate at the bladder in a blind tube which, as it becomes distended with urine, may project into the bladder as a cystic pouch. This pouch may even obstruct the opening of the nor- mal ureter and thus give rise to a nephrydrosis. The ureters may open abnormally into the bladder, both ureters opening on the same side. A ureter may open near the internal orifice of the urethra or even into the urethra or the vestibule alongside of the meatus uri- narius. In the latter two cases, permanent incontinence of urine will be present, as the urine will escape continuously from the open ureter, and a surgical operation, having for its object the implanta- tion of the ureter into the bladder, will be necessary to correct the condition. Stricture of the ureter may result from cicatricial contraction fol- lowing internal trauma due to the passage of a stone ; to laceration THE FEMALE URINARY APPARATUS 761 from overstretching of the body, and to injury from external vio- lence. The contraction leads to dilatation of the ureter (hydro-ureter) above the seat of the obstruction and to the development of a nephro- cystosis (g. v.). The latter condition usually first directs attention to the possi- bility of a stricture which may then, at times, be located by means of the ureteral bougie. Attempts have been made, and with some suc- cess, to dilate ureteral strictures by passing bougies as in urethral strictures. Should this not succeed, an operation may be necessary. The ureter may be reached through an extended oblique incision, the peritoneum being raised up and carried inward. The stricture, if it is a narrow one, may be divided longitudinally and stitched transversely after the manner of the Heineke-Mikulicz operation on the pylorus (Fenger) ; or the stricture may be resected, the upper end of the lower portion of the ureter ligated, a small slit made in the canal just below the ligature, and the lower end of the upper portion, which has been slit up slightly, invaginated into the lower portion through the slit in the side and retained by fine catgut stitches (Van Hook). Calculi may lodge in the ureter in their passage from the kidney. The points at which lodgment most frequently takes place are at the contracted portion just below the pelvis, at the point where the ureter curves to dip into the pelvic cavity, and just before it enters the blad- der. When a stone lodges, it interferes more or less with the free passage of the urine along the canal, and the usual changes take place above the seat of the obstruction. The stone may ulcerate through the walls of the canal and materially increase in size in the little pocket which it forms. Harris has seen such a stone lying at the brim of the pelvis and measuring over 3 centimetres in diameter. There are no characteristic symptoms of ureteral stone. A history of acute pain or "colic," incident to the passage of the stone from the kidney to its place of lodgment, might be elicited and the fact that, following such an attack, no stone had been passed might sug- gest the possibility of one remaining lodged in the ureter, particularly if symptoms of renal enlargement appeared soon after. Very rarely, a stone in the abdominal portion of the ureter has been palpated through the abdominal wall. Those lodged in the lower portion of the canal have frequently been felt through the vagina. Usually, the stone is discovered by passing ureteral bougies either from below or above, while endeavouring to discover the cause of obstruction in nephrocystosis. A stone lodged in the upper end of the ureter has been dislodged or pushed back into the kidney by the ureteral bougie. \¥hen lodged fartlier down, its passage into the bladder has been facilitated by injecting sterile oil through a ureteral catheter below the stone (Kolisher. From the lower, or vaginal, portion of the ureter, stones have boon removed through an incision from the vagina, and when in the bladder wall, by dilating the ureteral open- ing through the cystoscoy)e or a suprapubic opening. When situated 762 A TEXT-BOOK OF GYNECOLOGY in the abdominal portion, it may be removed through the extended oblique incision mentioned under Operations on the Kidney. The ureter should be incised, the stone removed, and the incision stitched with fine catgut. If unable to close the ureter, it may be left open, a packing of gauze in either case being placed down to the opening to guard against leakage. In case of injury to the ureter, such as accidental puncture or incision during operations within the pelvis, the unilateral wound should be closed at once by fine catgut stitches. If completely divided, an immediate anastomosis should be made after the method of Van Hook (see Strictures of the Ureter), or if near the bladder, the proximal end should be reimplanted in the bladder at the most con- venient point. In case neither of these procedures is possible, it may be necessary, as a last resort, to implant the ureter into the bowel and run the risk of an ascending infection of the kidney, or to bring the end to the surface at some point leaving a permanent fistula, or to remove the corresponding kidney. Fortunately, owing to the success of ureteral anastomosis, these latter alternatives will seldom be ne- cessary. Nephrocystosis. — If the escape of urine from the kidney is inter- rupted, completely or incompletely, for a sufficient length of time, by any cause acting upon the excretory channels, dilatation of the pelvis and calyces of the kidney results, producing the general condition of nephrocystosis (cystonephrosis). This condition may be subdivided into nephrydrosis (uronephrosis, hydronephrosis) when the fiuid con- tained in the dilated pelvis is urine or modified urine; and nephro- P3^osis (pyonephrosis) when the additional element of infection is present with the formation of pus. Nephrydrosis may be congenital or acquired. The congenital vari- ety may be unilateral or bilateral. When bilateral, the child is not viable, and hence is not a subject for surgical relief; when unilateral, the condition is perfectly compatible with life. The cause of the neijhrydrosis is usually some error of development such as double ureter, one or both of which may be imperforate or stenosed, or im- perforation of a single ureter. The ureter may open at some abnor- mal point such as the vestibule, vagina, urethra, uterus or tubes, in which case the orifice is apt to be small and contracted and the ureter dilated above it. The ureter may enter the pelvis of the kidney so obliquely, or in such an abnormal manner, as to lead to a valve forma- tion interrupting the free escape of urine from the pelvis into the ureter. The ureter may be sharply fiexed by a malposition of the kidney or compressed from without by an abnormal or anomalous renal artery. As a result of some of these abnormities the dilatation may be present at birth, thus being strictly congenital. In other conditions, as for instance valve formation at the uretero-pelvic junction, the nephrydrosis may not develop to a perceptible degree until many years THE FEMALE URINARY APPARATL'S 763 after birth or in adult life. While in these cases the cause of the dilatation is of congenital origin, their late development makes it bet- ter to classify them, at least clinically, under the head of acquired nephrydrosis. The most common cause of acquired dilatations is pressure on the ureter in its course through the small pelvis. This may be due to carcinoma of the uterus, particularly of the cervix, to intraligamentous fibromyomata or other tumours of the small pelvis, or to the pregnant uterus compressing the ureter at the pelvic brim. (Olshausen, Sammlung Jclmische Vortrdge, 1892.) Displacements or prolapse of the unenlarged uterns seldom pro- duce obstruction of the ureter. Epitheliomata or other tumours of the bladder, if located near the ureteral orifice, may be the cause of obstruction. Internal obstruction of the ureter may be due to the lodgment of a calculus; to cicatricial contraction, the result of an injury inflicted by the passage of a calculus or the uric-acid infarcts of early infancy (Bernard); or to strictures the result of external trauma or of tuberculosis of the ureter. An interesting and important cause of nephrydrosis is movable kidney (Landau). Harris has seen a t}^ical case of intermittent nephrydrosis of small size, due to a movable kidney kinking sharply the upper end of the ureter, also one due to a " Schniir "' lobe of the liver displacing the kidney and kinking the ureter. Both were com- pletely relieved by operative correction of the position of the kidney. Not all cases of intermittent nephrydrosis, however, are due to mov- able kidneys, as certain valvular formations about the uretero-pelvic orifice and other conditions, not always readily explainable, may per- mit the irregular or periodic evacuation of the sac. The fundamental factor in all cases of nephrydrosis is an obstruction to the escape of urine from the pelvis of the kidney. This obstruction, as has been shown, may vary much in its nature and location. The pailiologic changes begin at the point of obstruction and extend centrad. Thus, if the obstruction is located at the lower ureteral orifice or in the bladder, the entire ureter will be found dilated; if the obstruction is located along the course of the ureter, only that por- tion lying above or centrad of it will take part in the dilatation; while if the obstruction is at the uretero-pelvic junction the ureter will not be involved. There may be multiple points of obstrnction with sacciform dilatations between them. In enlarging, the ureter becomes thickened and elongated and assumes a curved or serpentine course. The upper part is particularly prone to assume an S-shaped curve (Albarran) which may become secondarily kinked or com- pressed by the enlarging pelvis. The dilatation of the pelvis soon extends to the calyces (Fig. 310). The pyramids gradually become compressed and smaller, and eventually are almost entirely effaced. Occasionally, the calyces, instead of forming a part of the general pelvic enlargement, present fingerlike prolongations. The secreting portion of the kidney becomes flattened and thinned out, resting as a 764 A TEXT-BOOK OF GYNECOLOGY cap on the enlarged sac. In acute obstructions, the kidney is at first markedly congested, and multiple hemorrhages may take place in the parenchyma or even in the mucosa of the pelvis. As the enlargement continues, the secreting portion of the kidney becomes thinner and thinner, the glomeruli are flattened out, the canals compressed, and their epithelial cells lost. Eventually, this portion of the kidney may be so thinned and spread out in the sac wall as to be no longer detect- able macroscopically, al- though at this stage a little thickening or ir- regularity on the inner surface of the sac often indicates the location of a former pyramid. The secreting function of the kidney is very rarely en- tirely destroyed, even when kidney tissue can no longer be detected macroscopically. Ayner found complete destruction of the kidney tissue only 11 times in 473 cases (Traite cle cliirurgie clinique et operatoire, tome viii). The enlargement may vary in size from a slight dilatation of the pelvis to an immense tumour filling the abdominal cavity and containing from 15 to 20 litres of fiuid. The sac wall is usually much thickened, but may be quite thin in places. Attachments by adhesions to surrounding organs are common, rendering the complete removal of large sacs at times very difiicult or impossible. Partial nephrydrosis, a condition wherein but a part of the kidney is involved in the process, may result when the anomaly of double ureter is present with imperforation or obstruction of one (Heller), or when one of the calyces becomes shut off from the pelvis, as has been described by Fenger, Israel, and others, and of which Harris has seen one example. The contents of the sac are always normal or modified urine. In the intermittent variety, the urine may show no changes from the normal, or it may contain blood due to the con- gestion induced by the retention as mentioned by Albarran {Annales des maladies des organes genito-iirin aires, 1898, p. 470). In the closed variety, the fluid gradually becomes more and more changed from normal urine. The specific gravity grows less, the quantity of chlorides, phosphates and urea is diminished, the latter often being present only in traces. The fluid becomes more serous in Fig. 310. — " The dilatation of the pelvis soon extends to the calyces." — Hakkis (page 763). THE FEMALE URINARY APPARATUS 765 character and contains a small amount of albumin with mucous and epithelial cells from the mucosa of the pelvis. Traces of uric acid and oxalates may sometimes be found, even when all urea has disap- peared. The fluid is usually more or less clear, but may be coloured by blood from old hemorrhages. Very rarely, the sac may contain a quantity of gas, mostly carbon-dioxide, which may give to the tumour a resonant sound on percussion. Symptomatology and Diagnosis. — The symptomatology, strictly speaking, of the ordinary closed nephrydrosis is practically nil. The first point which directs attention to the condition is usually the accidental discovery of a tumour in the lateral region of the abdo- men. The tumour develops so slowly and insidiously that no symp- toms, save perhaps a vague sense of uneasiness or fulness about the side, are experienced by the patient. There may be no changes what- ever in the quantity or quality of the urine passed, or symptoms of any kind referable to the urinary organs. As the tumour enlarges, symptoms resulting from pressure upon, and displacement of, neigh- bouring organs may develop. If the growth of the tumour is observed for a time, it will be found to develop from the upper and lateral re- gion of the abdomen in a direction downward and inward. If seen sufficiently early, the tumour is usually somewhat oval in outline, and occasionally in thin subjects with lax abdominal walls the de- marcation between the cystic portion and the kidney tissue may be detected by palpation. As it enlarges, it becomes globular in shape and the surface more uniform. The relations of the tumour to the longi- tudinal colon, ascending or descending, respectively, are of very great diagnostitial value. This portion of the colon will be found displaced forward, forward and inward, or inward. Very rarely, in a nephry- drosis developing in a movable kidney, the longitudinal colon will be found to the outer side of the growth. The dull area of the tumour should be outlined by percussion while the colon is empty. This por- tion of the intestine should then be distended with air and the rela- tions to the tumour observed. The so-called " renal ballottement " of Guyon is a valuable diagnostitial sign but not pathognomonic of a renal tumour. The fact that the tumour contains fluid, may usu- ally be determined by the sense of touch and by the presence of fluc- tuation. The use of the aspirating needle, as means of diagnosis, is seldom advisable. When a tumour is present which, owing to its location and relations to surrounding organs, may be referred to the region of the kidney, segregation of the urines (see Methods of Ex- amination) becomes an important factor in the diagnosis. If, by use of the urine segregator or the ureteral catheter, no urine is found to come from the side corresponding to the tumour and the urine from the opposite side represents the entire output, the tumour may, with almost alDsolute certainty, be referred to the kidney as its point of origin. In intermAtlent nephrydrosis, symptoms are frequently present which point directly to the kidney as the source of the trouble. Some "leG A TEXT-BOOK OF GYNECOLOGY of these are such as are commonly present in movable kidney, such as an aching or pain in the lumbar region or lateral portion of the abdomen, nausea, irregular attacks of frequent urination, etc. Har- ris had a typical case in a woman who, at irregular intervals, had attacks of frequent and painful urination amounting, at times, almost to strangury. These attacks usually lasted two or three hours. Dur- ing the intervals, there was no difficulty whatever in urinating and the urine was normal. In this case, a very movable kidney kinked the ureter at its upper portion, producing a mild degree of intermittent nephrydrosis. The tumour in these cases does not become so large as in the closed variety, and is often scarcely perceptible. In other cases, a tumour of moderate size has been noticed by the patient, which, at times, suddenly disappears, its disappearance being accom- panied by an unusual flow of urine. This rise and fall of the tumour is quite characteristic of an intermittent nephrydrosis. Intermittent hematuria has occasionally been noticed in these cases. The intro- duction of the ureteral catheter up to the pelvis of the kidney may drain away the fluid and cause the collapse or disappearance of the tumour. The diagnosis of nephrydrosis is never complete without taking into consideration the nature of the condition giving rise to the obstruction. This should always be carefully sought. The course and prognosis of these cases depend entirely upon the nature of the obstructing cause. A simple closed nephrydrosis may exist for years with little inconvenience to the patient, provided the opposite kidney is normal. When both sides are affected, the end in ursemia is seldom long delayed. When due to carcinoma of the bladder or uterus, death follows as a result of the primary trouble unless that admits of successful surgical removal. Intermittent nephrydrosis due to movable kidney, usually admits of relief by permanently restoring the kidney to its normal location and position. The greatest danger in these cases is that they may become infected, thus converting a nephrydrosis into a nephropyosis with all the serious accompaniments of a septic kidney. A nephrydrosis sac may be ruptured by trauma and the contents scattered throughout the peritoneal cavity. This is not necessarily serious, provided the contents are sterile, but when septic, a fatal peritonitis usually results. Treatment. — As nephrydrosis is a secondary condition, dependent upon some obstruction to the escape of the urine, the treatment should naturally be directed to the cause of the obstruction. We may divide the cases into two classes, namely: 1. Those in which the nature of the obstruction is known and remediable; and 2. Those in which the nature of the obstruction is unknown or irremediable. Under the first class we may mention the removal of a tumour of the bladder or a vesical calculus that is obstructing the ureteral orifice; removal of a uterine or pelvic tumoiir pressing on the ureter, and dislodgment of a calculus obstructing the ureter by means of the ureteral bougie or catheter; dilatation of a ureteral stricture with THE FEMALE URINARY APPARATUS 767 the bougie. The use of the ureteral catheter a demeure is recoin- mended by Pawlik and Albarran in some cases of open nephrydrosis due, probably, to valve formation or compression of the upper end of the ureter. The catheter has been retained for several days with per- manent relief. Nephropexy may be done for movable kidneys. This operation should not only fix the kidney, but should fix it in such a posi- tion by rotating it, if necessary, about its sagittal axis, that the ureter escapes from the most dependent part. In certain valve formations at the uretero-pelvic junction, plastic operations after the method of Klister and Fenger may be tried. Strictures of the ureter may be relieved or ureteral stones removed by open operation. All the above procedures have for their aim the conservation of the kidney and its function, and it will be seen how varied is the treatment of this class of cases. In the second class of cases, we have to deal with the sac or tumour itself, as the cause of the obstruction is unknown or can not be dealt with directly. We have to consider here. First : Aspiration or punc- ture ; secondly, nephrotomy ; thirdly, nephrectomy. While it can not be denied that the use of the aspirator has been followed occasionally by success, still, the relief afforded is usually so temporary, and the danger of infection so great, that it can not be recommended as a curative procedure. Occasionally, however, aspira- tion may be employed for the temporary relief which it affords where the patient is greatly oppressed by the enlargement, and her condi- tion contraindicates more radical measures; or in the later stages of pregnancy when the emptying of the uterus is expected soon to give relief to the pressure on the ureter. The needle should always be introduced posteriorly, so as not to traverse the peritoneal cavity or endanger the intestine. Nephrotomy should always be performed by the lumbar route. It is advisable to make the incision so as to be able to explore the ureter and locate, if possible, the source and nature of the obstruction. If this can not be done, the sac should be opened and drained. This will often be followed by permanent recovery but, in the majority of cases, a fistula remains that continues to discharge urine. Ordinarily, such a fistula is of considerable annoyance to the patient by its constant leakage, but, at times, a tight-fitting tube or rubber catheter may be adapted to the fistula and opened at regular intervals with little inconvenience. Nephrotomy should always be the operation of choice when the state of the opposite kidney is in doubt. However, when the opposite kidney is known to be healthy, and it has been found impossible to restore the normal course of the urine on the diseased side, nephrectomy should be performed. This may be done as a primary operation, if the patient's condition warrants it, or sec- ondary to a primary nephrotomy. The adhesions usually present, when the sac is large, make primary nephrectomy often a diificult operation. CHAPTER XL VIII THE FEMALE URINARY APPARATUS (Continued) Renal infections; pathologic changes, symptomatology and diagnosis, treatment — Tuberculosis of the kidney ; pathologic changes, symptomatology and diag- nosis, treatment — Renal calculi; pathologic changes, symptomatology and diagnosis, course and prognosis, treatment — Tumours of the kidneys; pathol- ogy, symptomatology and diagnosis, treatment — Operations on the kidney: Nephropexy; nephrotomy; nephrectomy. Ik renal infections, as in infections in other tissues of the body, the essential etiologic factor is the presence of pathogenic microbes. The kidneys, in the performance of their excretory function, are fre- quently called upon to eliminate bacteria from the blood current, and they may be eliminated in the living state with the urine without the kidneys becoming the seat of pathologic changes. In order that the kidneys may become the seat of the inflanmiatory conditions herein considered, it is necessary that the bacteria should lodge and develop there. There are certain antecedent conditions which favour this lodg- ment and development of the microbes. Among these may be men- tioned: The ingestion of certain medicaments which produce an active hypera?mia with exfoliation of cells of the kidney, such as turpentine, copaiba, cantharides, etc.; the presence of toxines, the result of bac- terial invasion elsewhere in the body; congestion of the kidneys due to obstruction to the return circulation or to chilling of the surface of the body; internal trauma, due to the presence of a renal calculus or other foreign body; external trauma, subcutaneous or direct; and, per- haps the most common, obstructions to or interference with the free escape of the urine at some point along the excretory channels. AVIiile, at times, the entire organ may appear to be involved, ordinarily the infection is sufficiently limited to warrant the use of certain descriptive terms. Thus we may have a circumscribed parenchymatous infection producing a kidney abscess. When the pelvis is more particularly in- volved, it is termed pyelitis. If the infection extends from the pelvis along the collecting tubes to the parenchyma, we have a nepliro pyelitis (pyelonephritis). If, in addition to the infection of the pelvis, we find this cavity dilated, it is called nepJiropyosis. It should be understood that these terms imply simply a difference in degree or extent of in- volvement, and that the kind of infection and nature of the process may 768 THE FEMALE URINARY APPARATUS 769 be the same in all. We may likewise find the different conditions coex- isting, as for instance, pyelitis, with multiple parenchymatous abscess, etc. The routes by which bacteria may reach the kidney are four, namely: 1. Through the blood; 3. Along the urinary tract; 3. Through the lymphatics by contiguity; 4. Directly from without by trauma. Infection through the blood is called hematogenous infection; or some- times descending infection, owing to the direction in which the infec- tion travels. This is perhaps the most common route in the female. The bacteria gain entrance to the blood current from some point of in- fection elsewhere in the body and are carried to the kidney, where, ■owing to the presence of some of the antecedent or predisposing condi- tions above mentioned, they find lodgment and develop. Hematogenous infection may occur in connection with the acute infectious diseases, isuch as typhoid fever, pneumonia, influenza, etc., or in septic conditions following confinement or miscarriages. Infection from without inward along the urinary tract is called ascending infection. The first step in the process is usually a cystitis. The changes may remain limited to the bladder for an indefinite time as the ureteral orifices offer a considerable barrier to the passage of any of the contents, bacteria included, of the bladder into the ureters. However, when the bladder becomes distended or contracts vigorously to expel its contents through an obstructed channel, or when inflamma- tory changes, ulceration, etc., involve directly the ureteral orifices, these may become incompetent and permit infection to ascend into the ureters. It is unnecessary that the ureter throughout its entire length should become involved in the inflammatory process, as it has been ■demonstrated experimentally that bacteria, as well as minute inanimate particles, may be carried along the ureter to the pelvis of the kidney by antiperistaltic action of the ureter or by propagation along the urinary column. Even in the presence of a cystitis, it is not always essential that the bacteria should reach the kidney through the ureter, as a hemato- genous infection may take place from such a local infection as well as any other. Propagation by contiguity may take place from the bowel in colitis, severe constipation, subcutaneous contusion of the bowel, etc., as, when the integrity of the bowel wall has been compro- mised in any manner, bacteria may escape through it. Infection may also occur as the result of a perirenal abscess due to an appendicitis, an infection from the gall bladder, or from a hepatic or subphrenic abscess. Direct infection is always due to a penetrating wound. A variety of bacteria have been found as the infecting agent in these cases. In 79 cases reported by Albarran, Schmidt and Aschkoff, Wumschein and Savor, the colon bacillus was found pure 48 times, 6 times associated with Bacillus proteus, and 5 times with the staphylo- coccus or streptococcus; with the Staphylococcus pyogenes aureus or the streptococcus, 11 times; the Bacillus typhosus, twice; and the Diplococcus r,n 770 A TEXT-BOOK OF GYNECOLOaY pneumonice, once. Although the gonococcus is unquestionably a com- mon cause of the urethritis and cystitis which so often precede the renal infection, it does not appear to have been frequently found alone in the kidney. From the foregoing, it will be seen that the colon bacil- lus is the organism most commonly found in these cases, and this fact indicates the frequency with which the infection proceeds from the intestine. In the etiology of nephropyosis, all those conditions which lead to dilatation of the pelvis, mentioned under nephrydrosis, are equally active, the only difference being the addition of an infection. The pathologic changes vary somewhat according to the manner of infection. In hematogenous infections, there may be one or more ab- scesses of varying size due to the lodgment of septic emboli, and pre- senting the same characteristics as pysemic abscesses in other organs of the body. Again, there may be a diffuse involvement of the kidney with masses of microbes found in the glomeruli and about the secret- ing tubes, which lead to swelling, coagulation necrosis, and exfoliation of the cells with peripheral leucocytic infiltration. When the infection extends from the pelvis, the microbes are found ascending the collect- ing tubes, often reaching as far as the secreting portion, producing the same destructive effect on the epithelial cells, and leading to in- creased interstitial connective-tissue formation. In pyelitis, the mucosa of the pelvis is thickened and reddish or grayish in colour. Circumscribed denudations or superficial ulcerations may, at times, be seen particularly about the tips of the pyramids. The mucous membrane is often covered by a thin layer composed of pus cells, exfoliated epithelia, microbes, mucus, etc., which gives to the membrane a vsmooth velvety feel to the touch. In nephropyosis, in addition to the changes in the mucosa already noted, the pelvis is found more or less dilated. The dilatation may be slight, or so great that the kidney tissue is compressed and flattened out so that the entire organ forms but a large pus sac. Usually, the dilata- tion is but moderate, and the calyces form pouches or pus sacs com- municating with the pelvis, the pyramids being so compressed as to present the appearance of trabecular extending through the cavity. Concretions are often found in the calyces or pelvis. A calyx may be- come shut off from the pelvis, thus forming a circumscribed abscess, and independent abscesses in the kidney tissue which do not communi- cate with the pelvis are common. When the infection has been an ascending one, the ureter often shows marked changes due to chronic inflammation. Its walls are much thickened, it becomes dilated, elongated, and tortuous, and reduplica- tions of the mucosa lead to the formation of valvelike strictures. Peri- nephritis with abscess formation is quite common, and, in nephropyosis, adhesions to surrounding parts the rule. Symptomatology and Diagnosis. — The symptoms may be arranged under three heads: 1. General; 3. Local; 3. Urinary Changes. The onset may be acute or slow and insidious. When renal abscesses THE FEMALE URINARY APPARATUS 771 occur in the course of a pyaemia, the condition is usually unrecognised owing to the severity of the general disorder, and the abscesses are found only at the autopsy. In an acute case following general ex- posure, or after confinement, or from a sudden extension of an infection from the bladder, the temperature will be found elevated, 101° to 103° F., with the usual symptoms accompanying fever. Locally, there will be pain in the lumbar region with distinct tenderness as the kidney is grasped between the two hands. In many cases of ascending infec- tion, the kidney becomes involved so insidiously that it is frequently impossible to tell just when this organ began to be affected. There will be an elevation of a degree or two in the temperature, particu- larly toward evening, with gradual loss of weight and deterioration of the general health. The kidney, if palpable, will usually be felt to be slightly enlarged and tender on pressure. There may be pain in the region of the kidney, at times simulating mild attacks of renal colic. Frequent urination is the rule, and it may be present even when there is no involvement of the bladder. Changes in the character of the urine are always present. It will be found to contain a variable amount of pus and albumin, numerous bacteria, and epithelial cells from the pelvis as well as from the tubules, should these be involved. Cylin- droids and casts will be present if the kidney substance is affected, but may be absent when the infection is limited to the pelvis. The reaction of the urine will depend upon the kind of microbe present. The urine may remain acid throughout when the infection is due to the colon bacillus as well as to some varieties of streptococcus, but the usual Staphylococcus pyogenes aureus and the proteus decompose urea, thus rendering the urine alkaline. It then often contains the common triple phosphate crystals. There is nothing characteristic about the pus or the epithelial cells to indicate their origin from the pelvis of the kidney. When the origin of these pathologic products is in doubt, it will be necessary to collect the urines directly from the kidneys by catheteriza- tion of the ureters, or by the use of the urine segregator. In nephropyosis the appearance of pus in the urine may be inter- mittent. If the affection is unilateral, the opposite kidney in the in- terval may furnish perfectly normal urine. The kidney is always more or less enlarged in nephropyosis, and, at times, the tumour reaches con- siderable dimensions. The diagnostic points which indicate the renal origin of the tumour have already been referred to under Methods of Examination. The course of these infections is variable. Many cases following confinement recover entirely. In other cases, the pus may disappear but the bacteria remain, leaving a condition of simple bacteriuria. If the affection is unilateral, it may persist in a mild way for several years without materially injuring the general health, but the opposite kidney is always liable to become affected, which adds materially to the serious- ness of the condition. When abscesses develop in the kidney substance or in the perirenal tissues, death may take place from sepsis, or from ^772 A TEXT-BOOK OF GYNECOLOGY ur£eiiiia when a considerable amount of the kidney tissue is destroyed. The prognosis is also somewhat influenced by the kind of infection present, a colon-bacillus infection, for instance, being more favourable than one due to the streptococcus. In the treatment, due consideration should be given to antecedent conditions, as cystitis, pelvic infections, primary perinephric abscesses, intestinal complications, etc. For the renal affection itself, the admin- istration of large quantities of distilled water to induce free flushing of the kidneys is of advantage. At the same time may be given some of the antiseptic agents which are eliminated with the urine, and of these the formalin compounds, such as urotropin and cystogen, appear to be the most useful. Salol, boric acid, and benzoic acid, are also, at times, of value. Direct treatment of the pelvis in pyelitis by irrigation through the ureteral catheter, as practised by Kelly, Casper, and others, has given good results in some cases. The solutions used are boric acid; dilute nitrate of silver 1 to 1,000; and bichloride of mercury 1 to 150,000 gradually increased to 1 to 16,000 (Kelly). They should be used warm and with great care. This treatment does not appear ad- visable in cases with fever (Casper), as chills with high temperature may follow. Should these means fail to give relief, nephrotomy with drainage through the lumbar region may be tried. At the same time, all complicating conditions should be relieved, if possible, such as removal of calculi, correction of strictures or obstructions of the ureter, fixation of movable kidney, etc. As a last resort, and only when it is positively known that the opposite kidney is normal, may nephrec- tomy be performed. Tuberculosis of the Kidney. — In acute miliary tuberculosis the kid- neys may be involved in connection with the other organs of the body, but as such cases have no special interest to the surgeon, they will not be further considered here. Surgical tuberculosis of the kidney may exist as a primary affection, or it may be secondary to tuberculosis of other portions of the urinary tract or of contiguous structures. In the primary variety, it is well understood that an infection atrium must have existed at some pre- vious time through which the tubercle bacillus gained entrance to the body, and, in many of these cases, a latent tuberculous focus is found in the shape of an old tuberculous bronchial or mesenteric lymph gland. The bacilli are carried to the kidneys by the blood and the process is therefore a pure hematogenous infection. Women are more commonly affected than men in the proportion of 29 women to 14 men (Tuffier); 148 women to 55 men (Albarran); and 73 women to 59 men (Bangs); a total of 378 cases, with 350 women, or 66 per cent. Almost any age may be affected, but 75 per cent of the cases occur between the ages of twenty and forty years. The kidney is primarily affected in a majority of the cases, and usually, at first, but one organ is involved. Later the opposite organ may become affected. THE FEMALE URINARY APPARATUS Y73 Fig. 311. " Tuberculous abscesses are produced." — Harkis. Tuberculosis of the kidney secondary to involvement of the lower urinary tract, is not so common in women as in men, in whom we may have a primary affection of the prostate, seminal vesicles, epi- didymis, etc. A tuberculous abscess originating in the ver- tebrae (Pott's disease) or from the bowel, may extend to and involve the kidney secondarily. Pathologic Changes. — The most common form observed is the large tuberculous nodule. Such a nodule is made up of a conglomerate mass of histo- logic tubercles, forming a grayish or yellowish mass vary- ing from 0.5 centimetre to 2 or 3 centimetres in diameter. Often, there is but a single nodule, when it commonly oc- cupies one or the other pole, but they may be multiple and disseminated throughout the kidney. The nodules undergo the usual changes so characteristic of tuberculous tissue, namely casea- tion, and softening or liquefaction. In this manner, tuberculous ab- scesses are produced which may rupture into the pelvis or on the surface of the kid- ney into the perinephric tis- sue (Fig. 311). The walls of such abscesses become lined with the usual tuberculous granulations which show oc- casional giant cells (Fig. 312), and the surrounding kidney tissue shows the ordi- nary inflammatory changes. In tuberculous pyelitis, small tubercles may be found dis- seminated more or less thick- ly in the mucosa. As these soften and break down, small ulcers are formed. A sin- gle small tubei'culous ulcer on one of the pyramids may give rise to pronounced hematuria, which may persist for a long time witlioiit any other symptoms being Fig. 312. — "Tlie wallH of such abscesses . occasional giant cells." — Harris. show 774 A TEXT-BOOK OF GYNECOLOGY present. The ureter may become involved with the production of caseous nodules or masses, which may interfere with the escape of the urine and thus lead to the development of a tuberculous nephropyosis. A mixed infection in these cases is very common, the ordinary pyogenic organisms being the ones most frequently found. In almost all cases of tuberculosis of the kidney that have existed for any length of time, marked changes occur in the perirenal tissues. Some of the fat be- comes absorbed, while the connective tissue is greatly increased in amount. The entire fatty capsule thus becomes converted into a dense, hard mass, surrounding the kidney, and so intimately attached to the adjoining structures, particularly the colon and great vessels, that it is often impossible to detach it from them without great danger of injury. This perinephritis fibrosa may form a tumour of consider- able size easily palpable through the abdominal wall. The tuberculous kidney occupies the interior of this dense capsule, and while it is, at times, difficult or impossible to remove the capsule itself, the kidney is fortunately usually easily enucleable from its centre. Provided all the tuberculous tissue is removed with the kidney, this dense peri- nephric mass may entirely disapj)ear by absorption. When numerous abscesses develop, rupturing into the pelvis or into each other, the en- tire kidney substance may practically be destroyed, and nothing remain but abscess cavities whose walls are lined with tuberculous granula- tions. The lymph glands about the hilum of the kidney may become tuberculous, forming distinct separate nodules. Symptomatology and Diagnosis. — The onset of tuberculosis of the kidney is often obscure. One of the most frequent symptoms in the early stage is hematuria. This may be in quantity scarcely sufficient to give colour to the urine, or quite profuse, and it may persist for some time. It usually apjjears spontaneously, being discovered by the pa- tient by accident, and is not materially influenced by exercise or repose. If the hemorrhage is profuse enough, clots may form, the passage of which along the ureter may give rise to severe pain. Such clots formed in the ureter have a characteristic wormlike appearance when passed. In the later stages, hematuria is less common. Frequent urination, accompanied with more or less pain, is a very common symptom, and may be present when there is no trouble whatever with the bladder. It is then a reflex or irradiation symptom, and is of great diagnostic value in the early stages. More or less jDain or ache in the lumbar region is the rule, and frequently sharp jDains of short duration may be felt, which resemble mild renal colic, but which may occur when no solid substance passes the ureter; they are then, probably, in the nature of neuralgia of the ureter. The kidney is usually somewhat enlarged and tender on pressure. Changes in the urine are always sooner or later present, but during the early stage they may not be very marked. Blood, as already mentioned, may be present. It may be so slight in amount as to require the microscope for its detection, or so profuse that the urine may appear like blood. More or less pus is always pres- THE FEMALE URINARY APPARATUS 775 ent, together with e^Dithelial cells from the pelvis and tubules. Albu- min is found, and in excess of what it is usual to ascribe to the pus present. While casts are not essential to the tuberculous process, a few can usually be found owing to circumscribed patches of ne- phritis. The above-mentioned urinary changes are not characteristic of tuberculosis but are common to j^yelitis or nephropyelitis whatever the nature of the infecting agent may be. The detection of the tubercle bacillus in the sediment, therefore, is necessary to an absolute diag- nosis. In most cases the bacillus can be found, if sufficient urine is sub- mitted to the centrifuge and the sediment properly stained. It may be necessary to examine a number of specimens before finding any, and sometimes one fails even after repeated examinations. In these cases, inoculation experiments may demonstrate the tuberculous nature of the affection. It is quite probable that a jDurulent urine, acid in reaction, in which none of the ordinary bacteria are present, comes from a tuberculous kidney, even when no tubercle bacilli can be found. In later stages mixed infection may occur and the urine may be found to contain the ordinary pyogenic microbes as well as the tubercle bacil- lus. During the early stages, there is usually no fever, but, later, a rise of from one to two degrees is noted toward evening. The prognosis of tuberculosis of the kidney in general is not good, and when both kidneys are involved it is certainly bad, although re- covery is possible. In primary unilateral tuberculosis, where the kid- ney involved is removed, the prognosis is very good. Harris has patients living five and six years after nephrectomy for unilateral tuber- culosis, who are in perfect health. When the bladder becomes affected and mixed infections are present, the prognosis is again bad. Treatment. — While it can not be denied that tuberculosis of the kidney may be recovered from spontaneously or under treatment, still the probabilities of such a favourable termination are too remote to be depended upon. In primary unilateral tuberculosis, the rational treatment is nephrectomy. Even the presence of beginning trouble in the apex of the lungs or of albuminuria from the opposite kidney is not, in itself, a contraindication to nephrectomy in these cases, as, after removal of the principal and primary focus, these secondary conditions may clear up and disappear. Unless the bladder is actually invaded by the tuberculous process, the vesical symptoms, so common when the kidney is involved, may also entirely disappear after removal of the kidney. It is doubtful if resection of the kidney, as has been done, is advisable in tuberculosis, because even in the nodular variety, it is im- possible to tell whether there may not be small impalpable nodules in the apparently healthy portion, or to what extent the pelvis may be involved, thus permitting reinfection. Wbon the kidney infection is secondary to advanced tuberculosis in other portions of the body or when both kidneys are extensively 776 A TEXT-BOOK OF GYNECOLOGY involved, nephrectomy should not be done, but, even here, nephrotomy for the purpose of draining large purulent accumulations, may be advisable. In all cases, proper hygienic, climatic, and medicinal meas- ures, should be instituted. Renal Calculi. — Kidney stones are due to the precipitation and agglutination of salts normally or abnormally present in the urine. These two conditions are absolutely necessary. The substance must not only be precipitated, but the crystals or particles forming it must cohere or become agglutinated to form a mass. Various factors are instrumental in causing precipitates in the urine, such as changes in the reaction and temperature, variations in the relative or absolute pro- portion of the salts present, and the presence of abnormal constituents.. These conditions are brought about by the character and amount of food and drink taken, the nature of the digestive changes, individual peculiarities of internal metabolism, etc. The fact, however, that uric acid, oxalates, urates, phosphates, etc.,. may be passed suspended in the urine for almost indefinite periods of time without calculi appearing, shows conclusively that other condi- tions are essential to stone formation. Among these conditions, may be mentioned a nucleus or centre about which the salts may become deposited. The importance of a nucleus has been mentioned by a num- ber of writers. Ebstein considers that the exfoliated epithelial cells from the tubules or pelvis often form nuclei of stones, but in acute nephritis of scarlatina, where exfoliation is so marked, stones do not occur. Blood clots are likewise often mentioned in this connection, but a blood clot has remained in the kidney a year and a half (Maas) without giving rise to the slightest deposit about it. We must, there- fore, search further for a common cause. This has been suggested b}^ Gallippe to be the presence of microbes. Harris, in a recent article on Renal Calculi {Journal of the American Medical Association, March 17, 1900), has shown by experimental and clinical evidence the causal rela- tion between the presence of microbes in the urine and stone forma- tion. It has long been kno^^Ti that stones frequently develop second- arily to suppurative infections of the kidneys, and, for this reason,, kidney stones have been classed as primary, or those developing in kidneys not the seat of surgical infections, or, in other words, of non- microbic origin; and secondary, or those developing in kidneys the seat of surgical infections, and therefore of microbic origin. Harris has shown, however, that so-called primary stones are likewise of mi- crobic origin. The facts upon which this statement rests, which are elaborated in the article mentioned, may be briefly stated as follows: Precipita- tion alone does not cause stone. Foreign bodies, such as exfoliated epithelial cells, blood clots, or those introduced experimentally from' without, do not cause stone so long as they remain free from microbes. The kidneys frequently eliminate microbes with the urine without themselves becoming the seat of microbic invasion. These microbes; THE FEMALE URINARY APPARATUS 777 may develop in the urine in the pelvis and cause the precipitation of certain salts. The character of the precipitate dejiends, not entirely upon the composition of the urine, but also uj^on the kind of microbe present. The microbes, in developing, form zoogloea masses, in and about which the precipitate takes place. The agglutination of the particles by the zoogloea mass forms the nucleus or starting point of the stone. Such zoogloea masses have been found clinically in the urine. The microbe most frequently found in the urine is the colon bacillus. It grows in acid urine, and under proper conditions causes the pre- cipitation of uric acid or acid urates. The most common primary stone is composed of uric acid and the urates. Microbes have been found in the centre of so-called primary stones. From the clinical side, we find stones frequently preceded by a history of acute or chronic intestinal disorders; of suppurative lesions of the skin; of acute infectious dis- eases, as influenza, pneumonia, typhoid fever, etc.; and women very commonly date the beginning of their trouble from a confinement or imperfect puerperium. These conditions are all such as readily account for the presence of microbes in the urine. These facts briefly men- tioned lead Harris to state that practically all kidney stones are of microbic origin. The only value, therefore, of the classification of stones into primary and secondary is, that the former may occur in a kidney which is not itself the seat of microbic invasion, while the latter are always secondary to an infective process in the kidney. Of the primary stones, from 75 to 80 per cent are composed of uric acid and the urates. Next in frequency, come oxalate of lime and, rarely, dibasic phosphate of lime. A'^ery rarely, stones have been found com- posed of cystin, xanthin, indigo, cholesterin and fibrin. The etiology of these is not fully understood. Those of the uric-acid group are yel- lowish or brown in colour, rather smooth, or even polished if multiple, and often somewhat flattened and oval in shape. Oxalate stones are hard, dark in colour, more or less spherical in shape, and rough or nodular on the surface. Secondary stones are formed of the decomposition products, such as ammonio-magnesium phosphate, phosphate and carbonate of lime, and urate of ammonium. They are usually whitish in colour, irregular in outline, present a rough granular surface, and are fragile. Stones are frequently not of uniform composition, but made up of difi'erent layers. It is very common to find primary stones incrusted with phosphates after the kidney has become septic. Stones may be single or multiple. Harris has removed as many as 52 well-formed bright, polished, uric- acid stones, from a kidney with a history of trouble extending over twenty-five years. In size, they may vary from small granules to a large stone filling the entire pelvis, with irregular bi-anches extending into the calyces and upper end of the ureter, and weighing several ounces. While they usually occupy the pelvis or calyces, stones may be found embedded in the parenchyma of the organ. An important point is the frequency with which stones are found simultaneously in both 778 A TEXT-BOOK OF GYNECOLOGY kidneys. This lias been variously estimated, but about 1 ease in 5 or 6 is 23erhaps near the average. Those of any age may be affected, but from thirty to sixty years is the most favourable time. Pathologic changes always develop sooner or later in kidneys the seat of stone. These take the form of chronic nephritis, the interstitial changes usually being most marked. The changes may be so extensive that the organ becomes greatly atrophied and its excreting function much reduced. The stone may be so located as to obstruct the free escape of urine from the pelvis, thus giving rise to a nephrydrosis. Even in so-called primary stones, the constant trauma which they inflict upon the interior of the kidney renders the organ particularly liable to infection, and, in fact, this almost always, sooner or later, takes place. There are now added all the additional dangers of a septic kidney: Pyelitis, nephropyelitis, nejDhropyosis, parenchymatous and perinephric abscesses, etc. Symptomatology and Diagnosis. — The symptoms may be discussed under three heads: 1. Pain, including tenderness; 3. Changes in the character of the urine; 3. Abnormal urination. The pain is of two kinds: Acute intermittent paroxysms, which are so familiar under the name of renal colic, and the dull more or less con- stant ache in the lumbar or lateral abdominal region. The passage of a small stone along the ureter gives rise to an attack of typical renal colic, but similar attacks, perhaps somewhat less severe, may occur without the passage of a stone. The more or less constant pain is usually increased by exercise (driving or riding) that jolts the body, and may radiate in almost any direction, downward to the bladder, upward to the costal region, across the abdomen, or into the thigh. Persistent pain in the latero-lumbar region or radiating in any direction from this region, which is otherwise unaccountable for, should always excite a suspicion of renal calculus. Tenderness over the region of the kidney or along the ureter is often present, and may be of some importance in determining the side affected. One of the most peculiar features of the pain is the fact that rarely it may be located on the side of the body opposite to the kidney affected (Tuckerman, Battle). Under the head of urinary changes may be mentioned the presence of blood, pus, epithelial cells, crystals, and bacteria, in the urine. The character of the hematuria is of some diagnostic importance. A sudden macroscopic hematuria is probably not due to a stone in the kidney. We more commonly meet with microscopic hematuria. The rather constant presence of a few red blood cells in the urine, discovered only with the microscope, which quantity of blood may be increased by exercise such as dancing, riding, driving, etc., to visible proportions, is quite characteristic of kidney stone. The hemorrhage is due to the local action of the stone on the walls of the cavity which contain it, and is proportionate to the roughness of the surface of the stone and to its degree of mobility. A small movable stone may excite consid- erable bleeding and a very large fixed one almost none. Pus in the THE FEMALE URINARY APPARATUS 779 urine is simply indicative of an infection of some portion of the urinary tract. Its exact point of origin must be known to give it a more specific significance. With the exception of the secreting cells of the kidney, the epithelial cells lining the urinary tract do not present local char- acteristic differences. The rather frequent or persistent presence of particular crystals in the urine in considerable amount, may give a hint as to the character of the stone present. Bacteria in the ui-ine are of diagnostic importance, aside from determining the kind of infection, only when taken in consideration with other symptoms. It will be seen, therefore, that the urinary changes in themselves are not diag- nostic of renal calculus, for the simple reason that it is impossible to tell from their mere presence alone from what part of the urinary tract the pathologic products have had their origin. In order to be certain of their origin, it is often necessary to collect the urines directly from the kidneys, either by catheterizing the ureters, or by the use of the urine segregator. While a stone that gives rise to pain almost always gives rise to pathologic products in the urine, it should not be forgotten that a stone fixed in the parenchyma of the kidney may give rise to pain for years without the appearance of any pathologic elements in the urine (Miiller). Abnormal urination, in the shape of increased frequency or pain, is sometimes present, but is not in itself indicative of stone. At times a stone lodged in the ureter, and rarely one in the pelvis, may be de- tected by the introduction of a ureteral bougie. Keely has recom- mended that the tip of the bougie be covered with wax in order that it may receive impressions if brought in contact with a rough stone. The use of the X-ray is often of great value in the diagnosis of kidney stones. A well-defined positive shadow is, under proper conditions, quite certain evidence, but negative evidence can not at present be considered conclusive. Course and Prognosis. — A stone may exist in the kidney for years without giving rise to serious symptoms, but this is the exception. The chronic nephritis which, to some extent, always follows the presence of a stone, may produce such atrophy as to practically destroy the secret- ing function of the organ. When infection takes place, the patient is subject to all the dangers and sequelse of a septic kidney. One of the most dangerous complications which may occur is sudden suppression of the urine or calculous anuria. This is due to a stone suddenly blocking up the ureter. It is more likely to occur when both kidneys are affected. In unilateral stone, the suppression in the opposite kidney is due to reflex action but, in these cases, it is probable that the stoneless kidney is always the seat of pathologic changes, such as chronic nephritis, atrophy, cystic degenerations, etc. In making the diagnosis, it is often difficult to determine on which side the obsti'iiction has taken place. Previous knowledge of the case may be of assistance, otherwise one must depend upon the history of pain and the presence of tenderness. The danger of this complication 780 ^ TEXT-BOOK OP GYNECOLOGY wall be appreciated when it is stated that the mortality in cases not operated on is about 70 per cent. Treatment. — The acute paroxysms of renal colic should be treated by the hot bath for its relaxing effect, and the administration of hypo- dermatic injections of morphine. It may be necessary at times to resort to the inhalation of chloroform. The possibility of dissolving a stone once formed in the kidney is quite remote. The administration of large quantities of distilled water for a considerable period of time is perhaps the most beneficial. The common mineral waters and alkaline springs recommended for this purpose are usually without benefit, and may even cause an increase in the size of the stone by deposits induced by the excessive alkalinity of the urine maintained (Eovsing). Her- mann recommended the use of glycerine in doses of 50 to 100 grammes a day, but Senator cautions against its use on account of the hematuria which it may induce. When the kidney is septic, urotropin or cystogen in doses of half a gramme (about 7^ grains) three or four times daily, will be of benefit in so far as they inhibit the growth of the microbes, and thus prevent the decomposition of the urine. While these means may aid somewhat in washing out gravel or small stones from the kidnev, when a stone too large to pass the ureter once forms, relief is only to be expected through surgical intervention. Nor should operation be delayed, for the dangers of a septic kidney are great, and the longer a stone remains, the more pronounced are the changes produced in the kidney. The choice of operation will be be- tween nephrolithotomy, nephrostomy and nephrectomy. In an aseptic kidney, with a so-called primary stone, nephrolithotomy is the proper operation. In the presence of sepsis, with pyelitis, nephropyosis, or abscesses in the parenchyma, in addition to the removal of the stones, drainage will have to be established (nephrostomy). The ureter should always be examined and its patency determined. Should obstruction be found, it should be removed, if possible, and a free communication between the pelvis and ureter established. Should this be neglected or impossible of accomplishment, a permanent urinary fistula is almost certain to follow the operation. Primary nephrectomy for stone is seldom advisable. The opposite kidney must be known to be healthy, and the affected one so destroyed as to be beyond repair, to warrant the operation. It is better to do a primary nephrostomy with a secondary nephrectomy should it be necessary. The combined mortality of the two operations is less than that of primary nephrectomy under the conditions usually presented in bad cases of septic nephrolithiasis. In anuria from calculus an attempt may be made, under favourable circumstances, to dislodge the stone by means of the ureteral boiigie. Should this fail, nephrostomy should be performed. In case no stone is found in the first kidney operated on, the other should be opened at once. Tumours of the Kidney. — When speaking of tumours of the kidney, we must confine ourselves to true neoplasms, to the exclusion of such THE FEMALE URINARY APPARATUS 781 conditions as nephrocystosis, nephropyosis, etc. These, wliile giving rise to a " kidney tumour " in a purely clinical sense, are, of course, not true new growths in the strict application of the word. What we find in the older medical literature on renal tumours is almost entirely worthless, since, in these reports, every swelling is spoken of under the head of kidney tumour, and even the true neoplasms, in the absence of a proper microscopic examination, were generally classified very inaccu- rately. Consequently, clinical indications were drawn without proper basis and practical conclusions were utterly unreliable. Only the last few years have brought some system into the unsatisfactory chaos. In certain respects, the permanent kidney is a very peculiar organ. It is preceded in embryonic development by two temporary organs, the pronephros and the " urniere," or Wolffian body. These structures and attached portions of the suprarenal capsule give rise to embryonic rem- nants which may become included in the permanent kidney and fur- nish a fertile matrix for subsequent neoplastic formations. Pathology. — All kinds of tumours may develop in the kidney. Be- side the ordinary types of connective tissue and epithelial neoplasms, benign as well as malignant, we find in the kidney two peculiar kinds of tumours which are of particular pathological interest, the hyper- nephroma and the mixed renal tumours. Neoplasms of the kidney, according to some authors, occur more frequently in the male than in the female. This, however, is denied by Kelynack {Renal Growth, Edinburgh and London, 1898), whose col- lection of 142 cases shows 70 tumours in males and 73 cases in females. Birch-Hirschfeld affirms that in children renal neoplasms are more frequently found in the female than in the male sex. Eenal tumours are found at all ages. The greatest number occur before the tenth year of life. Of White and Martin's 459 tabulated cases, 157 were observed in infants and children up to two years of age. In size, these tumours vary from small nodules to growths of from 30 to 40 pounds in weight. In shape, renal tumours often preserve the outlines of the kidney, even when large. At other times, the kidney shape is entirely lost and the mass becomes irregular and nodular. Of the benign connective-tissue tumours, the fibroma is generally small, hard and round, or elliptical. Occasionally larger fibromata have been observed. The small fibromata frequently found on post-mortem examination are most probably not true neoplasms, but the remnants of focal interstitial inflammatory processes. Lipomata of the kidney are rare, but a small number of cases has been reported. Angeiomata have been sometimes found, but most cases formerly described as such were very vascular sarcomata. Sarcoma is probably the most frequent of all kidney tumours. It is found in foetal life, in infancy and childhood, and in adolescence. The importance and frequency of sarcoma of the kidney in childhood has been pointed out by Jacobi in a number of articles. Herzog be- lieves that renal sarcoma is more frequently found in female than in male children. "Kenal sarcoma occurs as a capsular, a parenchymatous. Y82 A TEXT-BOOK OF GYNECOLOGY and a hilum growth. It may also primarily arise in the suprarenal capsule, to grow secondarily into the kidney. Histologically, we find round and spindle-celled growths, or the cells are of mixed type and char- acter. The sarcoma de- picted in Fig. 313, re- moved by operation from a child nine months old by Harris, and studied as to its histology by Her- zog, was of such a mixed type and showed very heterologous connective- tissue elements. The pro- liferation of tumour cells is well shown in a section (Fig. 31-i) prepared by Herzog. It was for- merly believed that ade- nomata were among the most frequent, if not the most frequent, of renal tumours. But most of the cases formerly re- ported as adenomata did not belong to this class of neoplasms, but to the hypernephromata (see postea.) True nonmalig- nant adenomata occur as nodules varying in size from that of a millet seed to that of a hazelnut. They are sharply defined from the surrounding normal tissue. Histologically, they show either an alveolar or a tubular type. It is sometimes difficult to distinguish be- tween a benign adenoma and an early adenocarcinoma, and the more so since some renal adenomata primarily benign, undergo secondary malignant degeneration. Kelynack describes as such forms the malignant papuliferous cystadenoma of the kidney. Epithelial neo- plasms which, from the very Fig. 313. — "The sarcoma reriioved by operation from a child nine months old by Harris." — Herzog. Fig. 314. — " The proliferation of tumour cells is well shown in a section."— Heezog. THE FEMALE URINARY APPARATUS 7S3 start, are malignant in character, in other words typical carcinomata, are not common in the kidney. They may be either soft or hard, and often lead to considerable enlargement of the kidney affected. An embryonal renal adenosarcoma, mixed tumour, 59 centimetres in circumference, was removed by Dr. Denslow Lewis from a child sixteen months old (Fig. 315). The histogenesis of mixed tumours of the 'kid- ney, or embryo7ial renal adenosarcomata, was cleared up a few years ago by Birch-Hirschfeld, and Herzog was the first to take up this subject in the English language. (Herzog: The Peculiar Mixed Tumours of the Kidney, Chicago Medical Recorder, 1899; Herzog and Lewis: Embryonal Eenal Adenosarcoma, American Journal of the Medical Sciences, June, 1900.) These mixed renal tumours occur very early in life, frequently during the first years, though a very few cases have been reported in adults. They grow very rapidly, speedily lead to general malignant cachexia, and destroy the life of the patient either with or without the formation of metastases. They generally first attract atten- tion by the increasing size of the abdomen. These tumours always de- velop inside the kidney. The kidney tissue proper, however, does not take part in the proliferating neoplastic processes but becomes com- pressed by the new growth and the urinif erous tubules, and their lining epithelia disappear in consecjuence of pressure atrophy. What is left of the kidney sometimes sits on the tumour like a flat cap. These malig- nant renal tumours are so heterologous in their histology that they have been described as carcinomata, sarcomata, endotheliomata, rhabdomyo- mata, and under a variety of compound names. The feature common to them all is the fact that they present a mixture of epithelial, adenoma- tous, and connective-tissue elements, all of which are proliferating in a most extensive embryonal manner (Fig. 31G). These tumours very frequently contain striated muscle fibres which sometimes are so numerous that such new growths were formerly de- scribed as rhabdoinyomata or Hiabfloiiiyosarcoiiiata. Fig. 317 is from a section of mixed tumour, the rhabdomyomatous part showing embryonal Fig. 315. — "An embryonal renal adenosarcoma removed by Dr. Denslow Lewis." — Herzog. T84 A TEXT-BOOK OF GYNECOLOGY Fig. 316. — "Tliuy pnj.-M.-iit a mixture of epitlielial, adenomatous, and connective-tissue elements." — Harris (page 783). striated muscle cells. They do not tend to form early metastases, but, on the contrary, lead to the latter only after the growth has become so very large that it has broken by pressure through the capsule. The neighbouring lymphatics are not affected even when the epithelial type predominates. Several theories have been advanced as to the origin and the histogenesis of these mixed tumours. Herzog {loc. cit.) has advanced the follow- ing theory: " The nephrotome in early embryonic develop- ment is not cut off at the normal site, but in such a manner that a part of the myotome is severed from the main mass and remains in conection with the nephro- tome. The separation may take place so that only a part of the myotome proper is cut off, or a part of the sclerotome may likewise be taken along. If the former is the case, we have the matrix for striated muscle fibres only; if the latter occurs, we have also the matrix for cartilage. If, now, we as- sume that a part of the ne- phrotome (Wolffian body) to which tissues of the myotome have become adherent by an abnormal process of embry- onic separation, becomes in- cluded in the permanent kid- ney, we have a matrix con- taining all those embryonic elements which occur in the mixed renal tumours, name- ly, striated muscle fibres, car- tilage, other connective-tis- sue elements, and epithelial glandular structures. The latter, of course, are derived from the excretory tubules of the nephrotome." Hypernephromata. — Certain renal tumours described formerly as lipomata or adenomata are now known to be derived from supra- FiG. 317. — ". . . A section of mi.xed tumour, the rhabdomyomatous part showing embryonal stri- ated muscle cells." — Herzog (page 783). THE FEMALE URINARY APPARATUS 785 renal tissue misplaced within the kidney during embryonic devel- opment. These tumours were called by Grrawitz^ who first recognised their true nature, Struma suprarenalis lipomatodes aberrans. They are now generally known under the name of hypernephromata (Fig. 318). The included aberrant suprarenal tissue may develop into non- malignant tumours. Even the latter are generally slow in their growth, but they usually give rise to metastases. These new growths generally give rise to a dull pain, and frequently produce periodical intermittent hematuria in consequence of their great vascularity. Histologically, they show a tissue which is an atypical imitation of the structure of the supra- renal capsule. The tu- mour cells are particularly often found in an arrange- ment very much similar to that seen in the zona fas- ciculata of the adrenal gland (Fig. 319). The cells show a universal marked tendency to un- dergo fatty degeneration, and glycogen is likewise often found (Fig. 330). Symptomatology and Diagnosis. - — ■ The symp- toms of renal neoplasms are very meagre, so much so, that it is usually impossible to make a diagnosis as to the par- ticular kind of tumour present. Nearly 50 per cent of the new growths occur in children under five years of age. The appearance of an enlargement in the region of the kidney is, in the majority of cases, the first intimation of trouble. A rapidly growing tumour of the kidney in a child is a sarcoma or a so-called " mixed " tumour. They seldom give rise to urinary symptoms although, in a few cases, some hematuria has been noted. Pain is uncommon but the tumour may be tender. The child may play about with little discomfort until within a few weeks of its death. The tu- mour often becomes of largo size causing great distention of the abdomen. It may be so smootli and soft as to simulate very closely a iluctuating mass. When very large, symptoms due to pressure or distention may be observed. Kapid emaciation and anannia are marked, 51 Fig. 318. — " Hypernephromata." — Herzog. 786 A TEXT-BOOK OF GYNECOLOGY and death takes place by exhaustion in from six to eight months or a year; it is rarely delayed vintil two years. In the adult, hematuria Jll Fig. 319. — " The tumour cells are . . . found in an arrangement very much similar to that seen in the zona fasciculata of the adrenal gland." — Herzog (page 785). is a much more frequent symptom of tumour than in the child, as it is present in malignant tumours in from 70 to 80 per cent of the cases (Guyon). It is spontaneous in character, appears at ir- regular intervals, is painless, and is usually discovered by accident. In the majority of the cases, a tumour is already present when the hematuria is first observed, but hema- turia may exist for some time before any enlargement can be felt. Pain can not be said to be a characteristic symp- tom of renal tumours, but a vague, dull ache in the lum- bar region has been frequent- ly observed. Carcinoma of the pelvis shows a great tendency to extend to the ureter. This causes an obstruction to the free escape of the urine and leads to the development of a nephrydrosis or nephrohematosis. The dura- tion of malignant tumours \llii^ \ i in the adult is much longer, on the average, than in the child, as it is usually from two to three or even five years before death occurs. In tumours of the adrenals, hypernephroma, and carci- noma, hematuria is rare. The kidney may often be dis- tinctly felt displaced down- ward by the tumour enlarg- ing from above. In tumours that destroy the adrenals, such as the carcinomata, marked loss of strength, physical depression, and lan- guor, are quite characteristic symptoms (Eamsay). Some bronzing of the skin has been observed a few times but does not appear to be the rule. There are no char- FiG. 320.—" The cells show a universal tendency to undergo fatty degeneration." — Hebzog (page 785). THE FEMALE URINARY APPARATUS 787 acteristic symptoms by which the rather rare benign tumours can be distinguished. The treatment of tumours of the kidney is removal by nephrectomy. Unfortunately, the onset of the malignant tumours is so insidious that considerable progress has usually already been made when a diag- nosis is established. The remote results in the sarcomata of early childhood are not very encouraging, as very few cases indeed are on record which have survived the operation for three years. Owing to the slower course of these growths in the adult, the remote results are better. Wagner has collected 34 cases surviving the operation for more than two years. The immediate mortality of nephrectomy for carci- noma is 24 per cent (Heresco). Partial nephrectomy has been per- formed a few times for supposed benign growths, usually with recur- rence. As it is so difficult to determine whether a tumour is benign or malignant, the advisability of partial nephrectomy is questionable. Operations on the Kidney. — There are three principal operations performed on the kidney, namely: 1. Nephropexy (nephrorrhaphy) or fixation of a movable kidney. 2. Nephrotomy, the cutting into a kid- ney, including pyelotomy, the cutting into the pelvis of the kidney for exploratory purposes, for the removal of stone (nephrolithotomy) or for the establishment of drainage (nephrostomy). 3. Nephrec- tomy, partial (resection), and complete. There are two routes by which the kidney may be reached — the anterior, or transperitoneal; and the posterior, or lumbar. The advantages claimed for the transperitoneal route are: That it permits palpation of the opposite kidney and affords easier access to the pedicle in nephrectomy for large tumours. These advantages, however, have been overestimated. Palpation of the kid- ney gives little knowledge beyond the mere fact of its existence, which fact can now be learned by other means; and the pedicle can usually be just as easily reached from behind as from the front. On the other hand, the danger of infection, the difficulty of closing the peritoneum pos- teriorly, and the necessity of providing lumbar drainage, have led surgeons to abandon the transperitoneal route except perhaps in rare cases of misplaced or displaced and abnormally fixed kidneys. A num- ber of incisions have been proposed for reaching the kidney through the lumbar region, as the longitudinal, oblique, rectangular, and transverse. The distance from the twelfth rib to the crest of the ilium is so short that the longitudinal incision seldom affords sufficient work- ing space. The rectangular, or Konig's incision, starting from the tip of the twelfth rib and extending obliquely downward toward the an- terior superior spine of the ilium, then suddenly curving forward and upward, and the transverse incision just below the twelfth rib, are chiefly employed for the removal of large tumours; while the oblique incision, extending from just below and posterior to the tip of the twelfth rib, downward and forward, is the one usually employed in nephropexy, nephrotomy, etc. If the oblique incision is started a little in front of the tip of the twelfth rib, and is extended downward in 788 A TEXT-BOOK OF GYNECOLOGY the direction of the fibres of the external oblique, it can be made a muscle-splitting incision, the fibres of the external oblique being sepa- rated longitudinally, and those of the internal oblique transversely, to the cutaneous incision. The kidney can, in this manner, be reached without dividing muscular fibres, thus minimizing the danger of ven- tral hernia. The muscle-splitting incision will be found preferable in the majority of operations on the kidney. Nephropexy or Nephrorrhaphy. — The kidney having been exposed by the muscle-splitting incision, all the perirenal fat should be care- fully removed. In doing this the prerenal fascia should be preserved. Two flaps of the transversalis fascia, about 5 to 6 centimetres in length, are now turned back from 2 to 3 centimetres, one on either side of the incision. The anterior flap should be stitched with cat- gut to the prerenal fascia and to the anterior surface of the kidney, and the posterior flap in a similar manner to the posterior surface of the kidney. We thus have the kidney flrmly fixed to the posterior abdominal wall by two flaps of fascia. The flaps should be made as high up as possible, and fixed to the kidney in such a manner that the pelvis and ureter shall have a proper direction and the upper portion of the latter be free from kink or twist that might offer obstruction to the free escape of the urine. That portion of the kidney between the attached flaps will lie in contact with denuded muscle when the wound is closed. The capsula fibrosa may be scarified to excite a freer pro- liferation of connective tissue. If thought desirable, the kidney may be transfixed by two or more catgut sutures to hold it more firmly in con- tact with the denuded muscle, or it may be denuded of its fibrous cap- sule. The wound is then closed and the patient kept in the recumbent position for three or four weeks, to allow sufficient time for firm adhe- sion to take place. It has been recommended by some simply to expose the kidney freely, draw it up and pack the wound with gauze until granulations are well established, then allow the wound to close. Preference, however, must be given to a closed wound with primary union. The numerous attempts to fix the kidney to the ribs by a variety of sutures have little to commend them. The success of the operation, so far as curing the symptoms is concerned, depends, not so much upon fixing the kidney as high up as possible, as upon fixing it in such a position that its pedicle shall be free and the urine have easy and unobstructed escape. Nephrotomy. — Expose the kidney by the muscle-splitting incision. If the operation is one of exploration or for the removal of stone, free the organ so that it can be palpated throughout, pelvis included. It should be opened along its posterior border. The incision, which may be made with an ordinary scalpel, should extend into the pelvis and may be as long as deemed necessary. As hemorrhage is likely to be profuse, the kidney should never be incised unless under perfect con- trol of the operator. The organ should be grasped in the hand and the incision made between the thumb and fingers. In this manner, pres- THE FEMALE URINARY APPARATUS 789 sure, which readily controls the hemorrhage, is easily applied, and is much to be preferred to clamping the pedicle with forceps. The in- terior of the pelvis may now be explored, and calculi, if present, re- moved. It should then be freely irrigated with hot normal salt solu- tion to check oozing and free it of blood clots or debris which might form nuclei for new stone formations. If not septic, the kidney should be closed by deep and superficial catgut sutures and the external wound closed as usual. When the object of the nephrotomy is drainage of a suppurating organ, the abscess cavity is opened, cleansed by irriga- tion, a good-sized rubber drainage tube inserted, and the wound packed with gauze. Nephrectomy. — The oblique muscle-splitting incision is suitable for kidneys of moderate size. In very large tumours, Konig's, or the trans- verse incision, which is particularly applicable in children, will give more room. In malignant tumours, it is advisable to remove as much as possible of the fatty capsule with the kidney. In nonmalignant cases, the kidney is loosened from its surrounding tissue until the pedicle is reached, when, if accessible, the vessels and ureter should be separately ligated with catgut. Should the presence of the kidney interfere with the ligation of the pedicle, an angular clamp may be placed on the vessels and the kidney removed. Should it still be found impossible to ligate the vessels satisfactorily, the clamp may be left in position for about twenty-four hours, when it may be removed with safety. In septic cases, the upper end of the ureter should be fixed into the lower angle of the wound. When there is considerable peri- nephritis fibrosa, as is common in tuberculosis and other chronic septic conditions, it may be very difficult, or even impossible, to separate the mass from the surrounding organs without great danger of injury, par- ticularly to the colon and vena cava. Harris has seen the colon so in- jured in this manner as to lead to the formation of a faecal fistula. In attempting to separate the inner layer of the mesocolon, there is also danger of clamping or ligating one of the colic arteries, which may produce sloughing of a portion of the colon. In these cases of peri- nephritis fibrosa, it is better to cut directly through to the kidney tissue itself, and to enucleate the kidney from its fibrous capsule. The pedicle may be so involved in the fibrous mass as to render ligation impossible. It will, therefore^ be necessary to apply a clamp and allow it to remain for twenty-four hours. The wound should be packed with gauze and the clamp protected by the dressings. If tuberculous deposits are found in the ureter, this canal should be dissected out as far down as possible or until all the diseased tissue has been removed. In all operations on the kidney, and particularly after nephrectomy, the danger of de- ficient elimination by the opposite kidney should always be borne in mind. It is necessary, therefore, to siipply these patients with an abundance of fluid, either by filling the colon with normal salt solution or by injecting it subcutancously. CHAPTEK XLIX THE FEMALE URINARY APPARATUS (Continued) Cystitis : Etiology, bacteriology, pathologic changes, symptomatology and diag- nosis, treatment — Hypei-^emia, treatment — Foreign bodies in the bladder, treatment — Tumors of the bladder: Symptomatology and diagnosis, treat- ment — Urethral caruncle, treatment — Carcinoma of the urethra, treatment — Sarcoma of the urethra — Diverticula of the urethra, treatment — Strictures of the urethra — Prolapse of the urethra, treatment — Foreign bodies in the urethra — Dilatation of the urethra, treatment — The urachus — Vesieo-umbilical fistula, treatment — Cysts of the urachus. Cystitis is an inflammatory condition due to the invasion of the walls of the bladder by pathogenic microbes. The urine frequently contains microbes but this is not in itself sufficient to produce a cystitis. It is absolutely necessary that the microbes should lodge and develop either upon or within the walls of this organ, before an inflammatory condition can be established. The etiology, therefore, of cystitis may be considered under two heads: 1. Those influences that predispose to the lodgment and development of the microbes; and 2. The manner in which the microbes gain entrance to the bladder. One of the most frequent predisposing causes of infection is congestion. This greatly reduces the resisting power of the bladder and may be induced in a variety of ways. Common among these may be mentioned exposure to cold; overdistention of the bladder from prolonged retention of the urine; obstruction to the free escape of the urine due to stricture of the urethra; intravesical or urethral tumours; displacement of the bladder from extra-vesical tumours, uterine displacements, cystocele, etc.; traumata, such as contusion of the bladder or prolonged pressure from the child's head during labour; contusion from external violence or accidental or unavoidable injury by the surgeon during operations on neighbouring parts; internal trauma produced by foreign bodies, either developed within (vesical calculi), or introduced by the patient from without (hairpins, pieces of pencils, chewing gum, etc.), or by the physician or nurse (catheter, sound, cystoscope, etc.); abnormal states of the urine due to the elimination of irritating substances intro- duced from without (cantharides, turpentine, oil of sabine, etc.), or developed within the body (toxines from intestinal disturbances, acute infectious diseases, etc.). The bladder participates somewhat in the general congestien of the pelvic organs accompanying menstruation, 790 THE FEMALE URINARY APPARATUS 791 and this congestion may be greatly increased by sudden suppression of this function. The second essential factor in the production of the inflammation, namely, the pathogenic microbes, may gain entrance to the bladder: 1. Through the urethra; 2. From the kidneys with the urine; 3. From contiguous parts; 4. From the blood. The most common route is un- doubtedly along the urethra. The shortness of this canal in women makes it much easier for microbes to enter the bladder through it in them than in men. Gonorrhoeal infection, which always affects the urethra, may extend to the bladder. Infections from other microbes involving the vulva, vestibule, or vulvo-vaginal glands, may likewise extend along the urethra. The germs may be carried to the bladder on septic catheters or other instruments. Even a sterilized catheter may carry germs that are within or about the meatus into the bladder. The bruised and congested condition of the bladder following con- finement or operations on the generative organs, makes the introduction of germs by the catheter particularly liable to excite a cystitis. The greatest care should, therefore, always be taken in cleansing the meatus and adjoining parts, and in sterilizing and introducing the catheter under these conditions. The patient herself may introduce the germs on all sorts of foreign bodies used for masturbating purposes or when mentally deranged. Germs frequently reach the bladder by descending with the urine from the kidneys. It is not necessary that the kidneys be diseased, as it is well known that these organs frequently eliminate microbes from the blood without themselves being involved thereby. This may take place in the acute infectious diseases, in diseases of the intestinal tract, and in suppurative conditions in other portions of the body. The kidneys, however, may be the primary point of infection, as in pyelitis, nephropyelitis, etc., and this is particularly common in tuberculous infection. The transmission of microbes to the bladder by contiguity may occur in intrapelvic suppurative conditions such as pyosalpinx, circumscribed suppurative peritonitis, infections of the uterus, etc. Such purulent collections may rupture into the bladder, thus carrying infection directly. Infection may come from the rectum, from a loop of inflamed bowel that has become adherent to the bladder, or even from the appendix, as Harris has seen in one case. The intro- duction of germs by direct trauma, as in bullet wounds, punctured wounds, etc., is possible but not common. Lastly may be mentioned pure hematogenous infections, where germs reach the bladder wall through the blood, as either minute septic emboli or floating germs. The normal bladder possesses considerable immunity to infection. Therefore, in addition to the germs, which are the essential element of inflammation, certain of the above-mentioned predisposing conditions must be present to temporarily reduce the resisting power of the tissues in order that the germs may lodge and develop and cystitis be produced. Barkriohf/y. — To the investigations of Eumm, Clado, Halle and Albarran, Krogiiis, Escherich, Posner, Lewin, Melchoir, Eovsing and 792 A TEXT-BOOK OP GYNECOLOGY others, is due our knowledge of the bacteriology of cystitis. Many varieties of bacteria have been found in the bladder. The one most frequently present is the colon bacillus. It reaches the bladder, usually, from the kidneys with the urine, but may pass directly from the bowel to the bladder when these two organs are connected by inflammatory exudate or adhesions. It may also enter through the urethra. This is most common in very young girls, where, in the presence of acute intestinal disturbances, from lack of cleanliness, a vulvar inflammation develops and the infection extends along the urethra to the bladder. As the colon bacillus does not decompose urea, the urine remains acid in colon cystitis. The gonococcus almost always enters the bladder through the urethra. This may occur during an acute gonorrhoea or during one of the frequent slight exacerbations of a chronic or latent infection. Many of the cases of cystitis following childbirth originate in the latter manner, favoured by the bruised condition of the bladder and urethra incident to the labour. The gonococcus, likewise, does not decompose urea. Of the ordinary pyogenic microbes, the streptococci are more frequently found than the staphylococci. They may reach the bladder on unsterilized instruments or from contiguous suppurat- ing foci, and are frequently found associated with tumours of the bladder, as the epitheliomata, papillomata, etc. The streptococci do not decompose urea but almost all the staphylococci do. Therefore, in the presence of the latter, we find ammoniacal alkaline urine. The proteus of Hauser has been found a number of times in cystitis. It acts very energetically on urea and the urine is therefore strongly ammoni- acal. The prognosis in infection by the proteus of Hauser is unfavour- able, as 3 out of 4 subjects seen by Melchoir died. Krogius saw 2 sub- jects, both of whom died. The tubercle bacillus is a common cause of chronic cystitis and usually infects the bladder from a tuberculous focus in the kidney. The urine in tuberculous cystitis remains acid. Other bacteria have occasionally been found in cystitis, but not with suf- ficient frequency to demand special mention. Mixed infections may likewise occur. The patliologic clianges produced are much the same regardless of the particular kind of microbe present, with the exception of the tubercle bacillus which alone produces somewhat characteristic changes. Marked difi^erences, however, exist in degree. The same variety of microbe may at one time produce the most extensive changes, and at another time almost none, for reasons that can not better be ex- pressed than by the terms, " varying virulence " on the part of the microbes, and " power of resistance " on the part of the bladder. The changes produced are hyperfemia with swelling and infiltration. These may be circumscribed or difi^use. In the former case, they may be limited to a small area about the inner orifice of the urethra, to the trigone, or to a small area about one or the other ureteral orifice. In severe cases, the mucosa is considerably swollen and thrown into folds. It is soft, often oedematous, and small hemorrhages are not infrequent. Erosions THE FEMALE URINARY APPARATUS Y93 may occur, particularly on the folds. Papillomatous elevations which are soft and bleed easily on touch may form. Inflamed areas may become covered by a grayish or yellowish membranelike substance composed of pus cells, mucus, bacteria, detached epithelial cells, etc., in which phosphates may be deposited, and which may adhere quite intimately to the mucosa. The changes may extend to the submucosa and muscularis, where abscesses may form that may rupture into the bladder or into the pericystic tissues. The inflammatory changes may extend through the entire wall of the bladder producing a pericystitis. In chronic cases the muscularis becomes greatly hypertrophied, the walls much thickened, and the capacity of the organ markedly reduced. In a particularly virulent infection following childbirth or some of the acute infectious diseases, the mucosa may slough. A diphtheritic cystitis may likewise occur. In tuberculous cystitis the changes are usually circumscribed and appear first about the ureteral orifices. Small, slightly elevated tubercles, may be seen, which undergo casea- tion and softening, and break down forming small ulcers. There may be but a single ulcer or they may be multiple. When a mixed infec- tion is present, the usual changes may be seen in addition to the ulcers. Symptomatology and Diagnosis. — Cystitis manifests itself by j^ain- ful, frequent urination, and changes in the character of the urine. The severity of the symptoms varies greatly. In acute cystitis, the desire to urinate is very urgent and the pain accompanying the act quite marked. The increased sensitiveness of the mucosa impels the patient to evacuate the bladder so soon as a small amount of urine accumulates within it, and the contraction of the muscle incident thereto is the chief cause of the pain. In severe cases it is necessary to urinate frequently, sometimes as often as every few minutes, day and night; and as the relief obtained is often slight or of short duration, the patient is almost constantly tormented and thus deprived of much needed rest and sleep. In milder cases, urination may be necessary only every hour or two during the day and two or three times at night. The pain is felt deep in the lower part of the abdomen or behind the symphysis pubis. It is often of a burning or smarting character, and may extend along the urethra to the meatus. Changes in the character of the urine are always present. The old idea that cystitis was always associated with ammoniacal urine is an error. The reaction depends upon the kind of infection present, and we may have a severe cystitis with a constantly acid urine, as shown under Bacteriology. When the cystitis is due to a urea-decomposing microbe, the urine is alkaline, ammoniacal, and irritating, and contains the usual triple phosphate crystals. More or less pus is always present. It may vary from microscopical quantities to sufficient to produce a slight turbidity of the urine, or to fi-om 10 to 25 per cent by bulk upon sedimentation. The urine contains an incrcascsd amount of mucus. IsTumerous squa- mous and transitional epithelial cells from the bladder mucosa are always 794 ^ TEXT-BOOK OF GYNECOLOGY found on microscopic examination, and a few blood cells are com- mon. In acute cases, a drop or two of blood is often squeezed out at the end of urination by the spasmodic action of the bladder. In so-called gangrenous or sloughing cystitis, shreds of mucous membrane may be passed. The ordinary case of cystitis is unattended by any material elevation of the temperature, but in case of abscess formation in the wall of the bladder, of pericystitis, or of extension of the infec- tion to the kidneys, fever may become a prominent symptom. The only difference between acute and chronic cystitis is simply one of time, as the symptoms and causation may be the same in each. The acute form frequently passes imperceptibly into the chronic, and chronic cases are subject to repeated acute exacerbations. Acute cystitis may be ex- pected to subside under proper care in from a few days to two or three weeks, while the chronic form may persist with varying intensity for months or years. The great danger in cystitis is the extension of the infection to the kidneys. More remote is the possibility of perforation of the bladder with infection of the peritoneum or the formation of pericystic abscesses. As similar symptoms and changes in the character of the urine may occur in diseases of other portions of the urinary tract, the diagnosis of cystitis must rest upon a demonstration of the lesions of the vesical mucosa or upon establishing the fact that the pathologic elements found in the urine have their origin within the bladder. These facts are determined by palpation of the bladder, by the use of the cystoscope, and by segregation of the urines. Upon bimanual palpation, the bladder will be found to be sensitive if in- flamed; and if the inflammation has been of long duration, the in- creased thickness of the walls can be easily felt. By the use of the cystoscope, either the Kelly tube or the electro-cystoscopes, the various alterations already described under Pathologic Changes may be easily recognised and an absolute diagnosis made. By ureteral catheterization or the use of the urine segregator, the condition of the kidneys, as separate from the bladder, may be determined, but the danger of infecting a healthy kidney with the ureteral catheter in the presence of a septic bladder should always be remembered. The diagnosis is not complete without a bacteriological examination to determine the nature of the infection. The general health in mild cases may be but little affected, but in severe cases the prolonged, almost continuous suffering often greatly reduces the patient. Treatment. — As the bladder possesses considerable reparative power provided the predisposing factors mentioned under Etiology are re- moved, each case of cystitis should be diligently studied in order to discover and abate, if possible, all such factors as favour infection or diminish the resisting power of the bladder. Attention should thus be directed to infections about the vagina, vulva and urethra; to stric- tures of the urethra, or other causes of obstruction to the free escape of urine; to intrapelvic infections or tumours that press upon or dis- tort the bladder; to intestinal diseases that may permit direct or indirect THE FEMALE URINARY APPARATUS 795 infection of the bladder; to septic foci in the kidneys producing de- scending infection; to abnormal, irritating conditions of the urine, and to foreign bodies or tumours in the bladder, etc. Having relieved these conditions, so far as possible, attention may be directed to the bladder itself. In acute cases, the patient should be confined to bed. An abundance of water should be given to dilute the urine, and potas- sium carbonate, citrate, or acetate, to reduce its acidity. The food should be very light and mostly of a liquid character. Hot applica- tions to the hypogastric region and vulva afford some relief to the pain, as do also hot sitz baths, and hot vaginal douches. The pain and burning during urination may be ameliorated by having the patient urinate in the sitz bath or while taking a vaginal douche. In severe cases, morphine or codeine may be necessary to relieve the pain. An excellent combination is salol, 3 grains, with codeine, ^ to :^ of a grain, every two or four hours. In the early stages of very severe acute cases, vesical instrumentation should be avoided; but after the most acute stage has subsided, or in milder cases from the beginning, a vesical douche of warm 3-per-cent boric-acid solution gently and carefully given will be found of great service. In chronic cases, the bladder should be cleansed by irrigation daily with warm boric-acid solution, or formalin 1 to 2,000 or 3,000 in normal salt solution; mercuric bichlo- ride, 1 to 10,000 or 20,000, or silver nitrate 1 to 1,000 or 2,000. In all cases, the interior of the bladder should be inspected, and where the changes are found to be circumscribed, direct application of a 2-per-cent to 3-per-cent solution of silver nitrate should be made to the diseased areas. In tuberculous cystitis with ulceration, the ulcers may be curetted and from 2 to 4 drachms (8 to 15 cubic centi- metres) of iodoform emulsion (10 per cent) allowed to remain in the bladder. Internally, such remedies may be given as have been found to exert an inhibitory action on the growth of the microbes while being eliminated with the urine. Of these, salol and urotropin are the best, the former in doses of 5 grains (0.3) four to six times a day, and the latter of from 7 to 10 grains (0.5 to 0.7) three times daily. The diet should be regulated, and all irritating articles of food and alcoholic drinks interdicted. Should the above means fail to give relief, complete rest to the bladder should be secured by continuous drainage either by the catheter a denicvre or by suprapubic cystotomy. Hypersemia.- — Under the terms hypersemia, irritable bladder, neu- ralgia of the bladder, etc., has been described a condition which is quite common in women, and often very troublesome. While it is possible that a neuralgia of the bladder may occur, the term is entirely unsuited to the condition at present under discussion. Of the other two terms mentioned, hypersemia seems the more appropriate, although it is quite iujpossible to draw a sharp distinguishing line between a siniy)le byperji'niin and a mild cystitis. If the cases of so- called " irritable bladder " are examined with the cystoscopc and the 796 A TEXT-BOOK OF GYNECOLOGY endoscope, changes quite typical of a mild inflammation will be ob- served in a large majority of them. These changes are usually quite circumscribed in outline. They may be limited to the trigone (trigo- nitis) or to a small area about one or the other ureteral opening. Most frequently, the vesico-urethral junction, or that portion which first begins to fold over the end of the endoscope as it is withdrawn from the bladder, will be found involved. These areas are quite red, often swollen or slightly oedematous, very sensitive when touched with the end of a probe or applicator, and, at times,, they bleed easily, par- ticularly the above-mentioned vesico-urethral junction. Many of these cases are undoubtedly due to a mild infection, and the question of infection is the only distinguishing point between a simple hyper- asmia and a beginning true inflammation. "Women with chronic uter- ine displacements are common sufferers in this way, and Harris has seen a number of cases in spinster seamstresses who use the sewing machine to excess, and in women with movable kidneys. A neurotic element is often strongly marked, and many times the vesical symp- toms are but a part of a general neurasthenia. The symptoms are a frequent desire to urinate, with a burning or smarting sensation ac- companying or following the act. The discomfort often becomes quite distressing. Eemissions, or even intermissions, in the symptoms are quite common. The treatment must be governed by the etiologic condi- tions present. Uterine complications must be corrected; and concen- trated and irritating urine must be diluted and modified by giving plenty of pure water and such diuretics as potassium citrate, with triti- cuni repens or stigmata maidis. Codeine may be added if the pain is severe. The neurotic element, when present, must be duly considered and treated with proper diet, tonics^ exercise, etc. The local treatment consists in irrigations with warm boric-acid solution, 2 per cent, or the direct application through the cystoscope of a 2-per-cent to 4-per-cent solution of silver nitrate to the hypersemic patches. In many cases, particularly in those associated with a nervous element, dilatation of the urethra is followed by marked improvement. Foreign Bodies in the Bladder. — By the term foreign bodies is meant, not only such articles as are wilfully or accidentally introduced from without, but also such as originate within the bladder. Under the latter division are to be considered vesical calculi. These, as pri- mary formations, are very rare in the female. Most primary bladder stones have their origin in small calculi that descend from the kidneys and, failing to escape from the bladder, gradually enlarge by the fur- ther deposit about them of the urine salts. The rarity of such stones in the female is due to the short, dilatable urethra which readily per- mits the escape of any concretion that may enter the bladder through the ureters. Whenever, therefore, a primary stone is found in the female bladder, it is usual to find some antecedent condition present which interferes with the prompt and complete evacuation of the urine. Among such conditions may be mentioned strictures of the ure- THE FEMALE URINARY APPARATUS 797 tlira, either from cicatricial contraction or pressure from without; tu- mours within tlie bladder which interrupt the escape of the urine; pouching of the bladder, such as occurs in diverticula and cystocele; distortions or displacements of the bladder from intrapelvic tumours; adhesions of this organ to neighbouring parts, which interfere with its free contraction, etc. In the presence of any of these conditions, a concretion descending from the kidney may remain in the bladder and develop to a stone of considerable dimensions. As such stones are identical in origin and structure with those that develop within the kidneys, the reader is referred to the article on Eenal Calculi for their etiology and composition. By far the large majority of vesical calculi in the female are not of the so-called primary variety, but develop as secondary formations about foreign bodies that have been introduced from without. Most of such bodies enter the bladder through the urethra, but other routes are possible; a pessary, for instance, may ulcerate from the vagina into the bladder; ligatures placed in the bladder wall, or even about pedicles in the pelvis, may find their way into the bladder; particles may enter from the ali- mentary canal in vesico-intestinal fistula; pieces of bone, clothing, etc., may be carried to the bladder by bullet wounds, etc. As already stated, however, the urethra is the most common route, and of 391 cases of foreign bodies in the bladder collected by Denuce, 258 were introduced intentionally, that is, out of morbid curiosity or for mas- turbating purposes. Among the various articles thus introduced, may be mentioned hairpins, glass-headed pins, beads, pieces of lead pencils, slate pencils, chewing gum, straws, small paraffin candles, peas, kernels of corn, etc. Foreign bodies may likewise find their way into the bladder accidentally, as when the end of a catheter breaks oif or a whole glass catheter slips in, as mentioned by Kelly, or a lithotrite or other instrument breaks while being manipulated within the organ. A foreign body may remain in the bladder a long time without inducing any special symptoms. Thus, Letulle mentions a case in which a penholder, 8 centimetres long, remained in the blad- der three months without producing the slightest trouble, and Stein- itz, one where a broken-off rubber catheter remained seventeen years without giving rise to any considerable difficulty. Usually, however, severe symptoms very soon arise. Painful contractions of the bladder may be induced, particularly if the body has sharp points, and per- foration of the organ may occur with the development of a fatal peri- tonitis. Ordinarily, the symptoms are those of a simple cystitis ; pain- ful, frequent urination, with blood, pus, and decomposition of the nn'7)f. The decomposition of the urine leads to the deposition of pliosphates about the foreign body as a nucleus, and thus are devel- oped secondai-y stones. Wbile the pain is usually more severe after emptying the bladder or following exercise or jolting of the body, and wbile the amount of blood present in the urine is usually more pronounced than in ordinary cases of cystitis, still the symptoms are 798 ^ TEXT-BOOK OF GYNECOLOGY not absolutely characteristic of the presence of a foreign body, which fact must be demonstrated by bimanual palpation, the introduction of the sound, or inspection through the cystoscope. The ireatment consists in the removal of the foreign body, whatever it may be. A primary stone, if not too large, may be removed through the dilated urethra, or it may be crushed with the lithotrite and washed out with the evacuator. Much ingenuity must often be dis- played in the removal of irregular bodies or those with sharp points. Much, however, may be done through the dilated urethra with the cystoscope and forceps, while the patient is in the knee-chest position and the bladder distended with air. In dilating the urethra, the ex- ternal meatus should be incised laterally and in the middle line, and the dilatation, which should be made slowly with smooth dilators, should not exceed 18 to 20 millimetres, owing to the danger of pro- ducing permanent incontinence. The incisions of the meatus should subsequently be sutured. When the body can not be removed through the dilated urethra, it will be necessary to incise the bladder either from the vagina or above the pubis. The suprapubic route is usually to be preferred, as it affords easy access to the bladder and there is no danger of injuring the ureters or of leaving a permanent vesico- vaginal fistula. By distending the bladder with air, the peritoneal fold is well raised up and the organ may be opened without difficulty. The incision in the bladder should be closed with catgut stitches which should not enter the vesical cavity, and a catheter a demeure introduced. Tumours of the Bladder. — As both the entoderm and the meso- derm enter into the formation of the bladder, nearly all varieties of tumours have been found taking origin from its walls. The benign, mature connective-tissue tumours, fibromata, myomata, and lipomata, are very rare, and but few well-marked specimens have been recorded. They have their origin in the submucous and muscular layers. The malignant embryonal connective-tissue tumours, myxomata and sarcomata, although more common than the benign growths, are still to be classed with the rarer forms. Of the epithelial growths, the carcinomata are much the more frequent, only a few adenomata having been observed. By far the most common tumour found in the bladder is the so-called papilloma or villous growth. The typical villous growth is made up of a number of delicate, slender prolongations which subdivide or branch similarly to an ordi- nary shrub. Each little prolongation is composed of a central blood- vessel loop, surrounded by a variable amount of loose connective tissue, and the whole covered by several layers of epithelial cells of the vesicle type. While this is the general character of a villous growth, varia- tions may exist in the length and size of the prolongations, number of branches, extent of attachment at the base, amount of connective tissue present, number of layers of epithelial cells on the surface, etc. In size, they may vary from a few millimetres in height and circum- THE FEMALE URINARY APPARATUS 799 ference to several centimetres. Much confusion exists in the litera- ture from an attempt to name and classify the papillomata. A papilloma may exist for years without leading to the destruc- tion of tissue or the patient; it may be removed without displaying the slightest tendency to recur, thus exhibiting every evidence of a benign growth. On the other hand, infiltration and destruction of the bladder walls may result, metastases may form, and rapid recurrence after removal, and death within a short time, may take place, thus exhibiting every evidence of great malignancy. The papillomata may, therefore, be classified as simple, or benign, and carcinomatous, or malignant. The benign growths are usually pedvmculated, with narrow bases and without infiltration. The malignant are more ses- sile, with broad bases and infiltration of the bladder walls. Typical exemplars of these two varieties would perhaps be easily recognised, but unfortunately many atypical eases are found. Cases which show no infiltration macroscopically, may show, upon microscopic examina- tion of serial sections through the base, beginning epithelial inclusions and prolongations from the surface layers. These cases, after re- moval, show a tendency to recur as typical infiltrating carcinomata. The occurrence of such cases makes it impossible always to determine, from gross appearance alone, whether a papilloma is benign or malig- nant. It is, therefore, safer to look upon them all with suspicion and to treat them as if they were malignant. Tumours of the bladder may appear at any time of life from infancy to old age. The large majority of tumours in early life are malignant. Steinmetz {Deutsche Zeitschrift fur Chirurgie, Bd. xxxix, s. 313) collected 33 cases in childhood. There were 14 sarcomata; 13 myxomata; 1 fibromy- oma; 1 cystofibroma; 1 rhabdomyoma; and 2 of a nature not stated. The clinical history of the myxomata differed in no way from that of the sarcomata. Concerning the age, there were 33 between one and five years, and only 6 from five to thirteen years. During adolescence and early adult life, tumours of the bladder are very rare ; after thirty they again increase in frequency, and are most common from forty to sixty. Symptomatology and Diagnosis. — In adults, the first symptom is usually hematuria. This is of the so-called spontaneous variety; appearing and disappearing without apparent cause, and usually unin- fluenced by exercise or exertion. It may last but a short time or per- sist for months or years, and may be slight or quite severe. For a time, there may be no subjective symptoms present; sooner or later, however, increased frequency of urination and pain are noted. These are more marked and appear earlier when the growth occupies the base of the bladder or the region near the internal orifice of the urethra. A peduneulatofl growth in this region may enter the urethra and make its appearance at the meatus urinarius. This has been particularly noted in children, and has frequently been the first symp- tom directing attention to the bladder. When the bladder becomes 800 ^ TEXT-BOOK OP GYNECOLOGY infected, as it is particularly prone to do in malignant cases, the sjanptoms are those of an ordinar}^ cj^stitis. In about 25 per cent of malignant cases, the earlier symptoms are those of a simple cystitis. It is impossible to distinguish between a benign and a malignant growth by the symptoms in the early stage, but later, the cachexia, loss of flesh, failure of general health, etc., stamp the case as ma- lignant. Direct inspection of the interior of the bladder through the cysto- scope is the only means of making a positive early diagnosis of blad- der tumour. By the use of this instrument, the extent and the gen- eral physical characteristics of the growth may be observed. An infil- trating, ulcerating growth is almost certainly malignant, but in the case of a papilloma it will be difficult to decide, and it is better to await the findings of the microscope before expressing a positive opinion. The duration of a benign growth is often one of years, but a malignant tumour is usually fatal in from one to three years. Treatment. — All tumours of the bladder should be removed as soon as possible. Pedunculated growths may often be removed through the dilated urethra Avith the snare or galvano-caustic loop, but in the majority of cases the suprapubic route will be found the most satis- factory, as it permits free access to all parts of the bladder and a more thorough removal of the growth. Even in cases that appear benign, it is safer to remove the base freely, as if it were malignant. In infiltrating malignant growths a resection of the bladder walls should be made. This is not so difficult when the mass occupies the fundus, but when the base is involved, or the region about the ureters, it becomes a very serious and difficult operation. The ureters must be transplanted higher up in the posterior wall or fundus. When the organ is extensively involved, it may be necessary to remove it com- pletely. This has been successfully done, and the case of Pawlik may be taken as a model, although the details of each operation will have to be worked out by the operator and modified to suit the indi- vidual ease. Pawlik turned the ureters into the vagina as a prelim- inary operation. He then removed the bladder working from above and below, but preserved the urethra which he likewise turned into the vagina. The vaginal opening was subsequently closed and this organ made to supply the place of a bladder. The ultimate result was very gratifying. Urethral Caruncle. — With the exception of gonorrhosal urethritis, diseases of the female urethra are rare. The conditions most com- monly met with are tumours, diverticula, strictures, prolapse, the pres- ence of foreign bodies, and dilatation. Of the tumours, the most com- mon is the urethral caruncle. This usually presents itself as a small red mass projecting from the orifice of the urethra and attached by a narrow pedicle to the mucosa within the meatus. It is often some- what flattened laterally owing to pressure between the labia. It is composed of connective tissue abundantly supplied with blood vessels THE FEMALE URINARY APPARATUS 801 and covered with several layers of flattened epithelial cells. These little growths are usually exquisitely sensitive. Urination is so pain- ful that the act is delayed as long as ^^ossible, and, in the married, marital relations are often impossible owing to the acute pain pro- duced by the gentlest touch. They may occur at any age, but are more common later in life. In the presence of such symptoms the diagno- sis is easily made by inspection. Treatment consists in removal. This may be done under local anaesthesia by the application for a few minutes of a 10-per-cent sohition of cocaine. The little mass should be drawn out and the pedicle divided close up to the base. Should the base be quite broad, the wound may be closed by stitches. Carcinoma of the urethra, as either a primary or a secondary affec- tion, is not common. Ehrendorfer (Archiv fur Gynakologie, Bd. Iviii, s. 463) was able to collect 27 cases from the literature including one of his own. These cases presented three forms: 1. Warty, papillo- matous excrescences, developing from the mucosa and projecting from the urethra; 2. Thick, nodular, infiltrating masses in the periurethral tissues, involving more or less of the circumference of the urethra and usually located toward the external end, and 3. Ulcerated surfaces with thickened, irregular and infiltrated edges. These may begin at any point along the canal including the meatus. Enlargement of the inguinal lymph glands was recognised and mentioned in only about one third of the cases. As is usual with carcinoma, the majority of the cases occurred late in life. The symptoms first complained of, are usually a sense of itching and irritation about the meatus or vulva, due to the irritating, acrid discharge commonly present, and pain or smarting on urinating. The presence of these symptoms should always lead to an examination, when, on inspection, with the aid of the endoscope if necessary, and palpation, one of the above-described conditions, should it exist, will be recognised and a diagnosis made. The treatment is early and thorough removal. The anterior por- tion of the urethra may be removed and continence of urine remain. Should it be necessary to remove the entire urethra, the bladder may be closed below and a suprapubic opening made after the method of Witzel. Sarcoma of the urethra has been noted, but the clinical history and treatment do not differ from that of carcinoma (see Neoplasms of the p]xternal Organs, Chapter XIX). Of the benign tumours, a few cases of fihroma have been described occurring for the most part in little girls. They presented as small polypoid masses protruding from the urethra and attached by a narrow pedicle. Their removal is a simple matter. Diverticula usually extend Froin llic posterior wall of the urethra toward tbe vagina. '■J''hey may vary in siz(? from that of a pea to that of a cavity holding several cubic centimetres. According to Eoush, 53 802 A TEXT-BOOK OF GYNECOLOGY they originate from the rupture of retention cysts, blood cysts, or periurethral abscesses into the urethra. The distended pocket pro- duces a protrusion, or bulging, of the anterior wall of the vagina, easily seen on separating the labia. Upon pressure, the enlargement diminishes in size and, at the same time, pus or pus and urine escape from the urethra. An examination with the endoscope will reveal a small opening in the posterior wall of the urethra from which the pus escapes, and through which a probe may be passed into the cavity. Owing to the decomposition of the urine, which takes place in the cavity, a calculus may form therein. Most of these cases give a his- tory of long-continued vesical irritation with frequent, painful urina- tion, etc. The treatment consists in opening the sac freely from the vagina, curetting the walls, or painting with tincture of iodine and packing with gauze. Should this not be successful, an attempt may be made to dissect out the sac. Strictures of the female urethra are quite rare. They are due to cicatricial contraction following injury the result of external violence or lacerations during labour, and they occasionally follow a virulent gonorrhoeal infection or the healing of a urethral chancre. They may be easily recognised with the bougie a houle and should be treated by gradual dilatation or division followed by dilatation. Prolapse of the iirethral mucosa may follow a difficult labour or may occur in poorly nourished young girls following straining, cough- ing, etc. In a severe urethritis the mucosa may become so swollen as to protrude considerably. In some cases it is impossible to assign a direct cause for the prolapse. The prolapsed mucosa presents a dark red or bluish mass, which is sensitive and bleeds easily, and in the centre of which may be found an opening leading into the urethra (Fig. 86, Displacements of the Vagina). If allowed to remain long protruded, the mass may become so constricted as to produce sloughing. Treatment. — An attempt should be made to reduce the mass by gentle pressure. Permanent reduction has followed the application of an ice bag to the parts with the patient in the recumbent position. Should these means fail or should sloughing threaten, the mass may be removed with the knife or scissors, the edges being carefully stitched to prevent hemorrhage and retraction as described under Dis- placements of the Vagina. Foreign bodies in the urethra arc small calculi that have lodged in attempting to pass from the bladder, or that develop in a dilated or pouched urethra; or they are small bodies introduced from without through the meatus. They give rise to painful and difficult urina- tion, and can be felt by the finger pressing along the urethra through the anterior wall of the vagina or by introducing a probe or catheter into the canal. Calculi are usually of the phosphatic variety. Re- moval may be effected through the dilated urethra by means of a THE FEMALE URINARY APPARATUS 803 small forceps or a wire loop. When lodged in a pocket, it may be necessary to incise the pouch from the vagina in order to reach the stone. Dilatation of the urethra may occur from the introduction of large bodies from without or the expulsion of calculi or tumours from within. Coitus per urethram in women with atresia of the vagina, and the introduction of large foreign bodies for masturbating purposes, have given rise to extreme dilatation with eversion and gaping of the urethral orifice. Severe laceration of the urethra has been produced by attempts at coitus. Fritsch is, therefore, of the opinion that at least a congenital disposition to dilate is present in those cases of extreme dilatation that have occurred without the production of symptoms. More or less incontinence of urine is the usual result in these cases. Upon the slightest straining, such as coughing, sneezing, or making a sudden misstep, urine escapes and soils the patient so that the condition becomes very annoying. Treatment. — In slight degrees of dilatation, the application of a lO-per-cent solution of silver nitrate to the interior of the iirethra has been followed by benefit. The use of astringent vaginal douches and tampons may be tried, or a pessary so constructed as to press on the urethra may be worn. When the dilatation is marked, these means will seldom be found sufficient. It will then be necessary to resort to operative measures. Several procedures have been employed, the most reliable of which are: 1. The removal by an elliptical inci- sion of a portion of the anterior vaginal wall, extending down to, or even including, the wall of the urethra, with closure of the space by transverse stitches. 2. Freeing the distal end of the urethra by dis- section and carrying it forward or upward toward the clitoris where it is brought to the surface through a new opening in the vestibule. 3. Gersuny's operation of dissecting the urethra free throughout its entire length and twisting it upon its axis from 180 to 360 degrees. It is then stitched in this position. 4. Fritseh's operation, which consists in removing an elliptical piece from the dorsal surface of the urethra at its junction with the bladder through a transverse incision between the urethra and the arch of the pubis. The urethra is closed with catgut stitches, the wound packed, and the bladder drained by a self-retaining catheter. The selection of the method of operating will depend somewhat upon the severity of the case. Gersuny's and Fritseh's operations are suitable for the more marked cases. The urachus is a cordlike remnant of foetal structure extending from (lie I'undus of the bladder to the umbilicus. It is a portion of the allantoic vesicle, from which were derived the urethra and bladder. This rudimentary canal consists of three layers: (a) an inner epi- thelial layer; (h) a middle basement membrane, and (c) an outer fibrous layer. The epithelial layer consists of a variety of cells, cor- responding in form and size to those found in various parts of the 804 A TEXT-BOOK OF GYNECOLOGY urinary apparatus. They are either ovoid or polygonal, and are gen- erally nucleated. The intermediate layer of basement membrane is described by Luschka as being structureless, delicate and transparent. The outer, or fibrous, layer, while attached to the outer side of the basement membrane, is distinctly separated from the surrounding cellular tissue. It will be seen, therefore, that while this structure exists as a blind, and ordinarily functionless, canal, it possesses all the histological elements, to render it a highway of communication. Luschka declares that, in the majority of male subjects, this canal is found to be partially opened, and goes to the extent of stating that it possesses a mucous membrane. If this is true, as it may be in certain instances, the necessity for its patulousness becomes apparent. Vesico-umbilical fistula is occasionally encountered, and is the result of the failure of the urachus to become closed at both its vesical and umbilical extremities. It is generally observed as a congenital condition, al- though it has been found in patients of forty and even sixty-six years of age. When urine escapes from the navel, this con- dition may be premised. A flexible sound can gen- erally be passed without difficulty from the navel orifice into the bladder. The bladder in such cases can be catheterized by this route. "W^iile in the ma- jority of cases this condi- tion is congenital, there are instances on record in which an opening has been forced through the urachus, by retention of urine. Atresia of the ure- thra, due to gonorrhoea, prostatic enlargement, and phimosis, has been recorded as a direct ex- citing cause of vesico-um- bilical fistula. The treat- ment consists in removing the urachus by abdominal section. A median incision should be made from the umbilicus to near the pubis; the canal should then be dissected out and its lower extremity ligated. As a pre- caution against the extravasation of urine into the peritoneal cavity, it Fig. 3-21. — "The sac extended from near the eusiform cartilage to the pubes." — Eeed (page 805). THE FEMALE URINARY APPARATUS 805 is well to fix the pedicle of the urachus in the lower angle of the ahdomi- nal incision. Before undertaking the operation, it is well to observe the admonition of Douglas, by making sure that the calibre of the urethra is sufficient to enable the urine to escape. Cyst of the urachus may result from an occlusion of both the umbilical and the vesical ends of the canal, secretion from its mucous surface, as described by Luschka, presently converting it into a reten- tion cyst. The fluid in these cases rarely, if ever, possesses any uri- nary elements, and must, consequently, be derived from the wall of the sac. In a case under Eeed's observation, the sac extended from near the ensiform cartilage to the pubes and forced the viscera from their normal positions (Fig. 331). The cyst was enucleated without opening the peritoneal cavity. Similar cases have been reported by Douglas and Alban Doran, and, previously, by Tait, Wolf, 111, Freer and others. The condition may be, and generally is, mistaken for an ovarian cyst. The facts, however, that it is immovable, that it occupies a median position, and that it has generally been a long time develop- ing, should suggest its urachal origin. Cysts of minor size generally elude detection until they are encountered incidentally in the course of an abdominal operation undertaken for another purpose. The treatment of these tumours is by abdominal section. The sac should be carefully enucleated. If ordinary precaution is taken in this manipulation, the peritoneal cavity need not be invaded — at least in the majority of cases. In a number of cases on record, it has been possible to enucleate these sacs without discovering a pedicle, thus showing that the connection between the urachus and the bladder had been broken up — probably in the course of evolution. CHAPTER L THE RECTUM Malformations — Examination — Displacements — General etiology of rectal disease — Relation of mtrapelvic disease to disease of the rectum in women. The rectum is the lower segment of the alimentary canal and extends from the sigmoid flexure to the anus. It passes from opposite the left sacro-iliac s3"nchrondrosis, from left to right, to near the middle of the sacrum, whence it descends in the median line to the anus. It is narrower at its intestinal than at its anal end. Its upper portion is covered by peritoneum, which constitutes the mesorectum; its muscular layers are two in number, one of longitudinal fibres, beneath which are circular fibres comprising the sphincter ani internus. The rectum is lined with a mucous membrane which is united with the muscular layer by connective tissue and is covered with columnar epithelium, being raised into crescentic longitudinal folds called the columns of Morgagni, or the transverse rectal folds. The rectum is held in position by the mesorectum, by its connections with the circumrectal tissues in its lower third, and by the muscular apparatus embraced in the two layers of the pelvic floor. (See The Pelvic Floor.) Malformations of the rectum and anus are of more frequent occur- rence in male than in female children. They may, according to Boden- hamer (Neiv Yorl- Medical Jovrrial, May 35, 1889), consist of (1) a preternatural narrowing or stenosis of the anus at its margin, occasion- ally extending a short distance above this point; (2) complete occlusion, of the anal aperture by a simple membrane or by the common integu- ment or a substance analogous to it, more or less thick and hard; (3) absence of the anus with partial deficiency of the rectum, which ter- minates in a cul-de-sac at a greater or less distance above its natural outlet; (4) a normal anus associated with a rectum which, at variable distances above, is either deficient, obliterated, or completely obstructed by a membranous septum; (5) a rectum terminating externally by an abnormal anus located in some unnatural situation, e. g., the sacral region, the perineum, within the fourchette, etc. (see Malformations of the Vulva), the abnormal anus thus formed being deficient in func- tional power; (6) the rectum opening into the bladder, urethra or vagina, or into a cloaca in the perineum with the urethra and the vagina; (7) a rectum normal in itself, but having the ureters, the vagina or the uterus opening abnormally into it; (8) complete absence of the 806 THE RECTUM 807 rectum; (9) absence of both the rectum and colon and the termination externally of some other portion of the intestinal canal in an abnormal anus in some extraordinary part of the body; e. g., the umbilicus, the left iliac fossa, the lower part of the abdomen just above the symphysis pubis, below the scapula, and at the side of the face, for it has been known to occupy each of these situations. In the last-named class no normal anus ever exists. The prognosis of congenital malformations of the rectum and anus must depend largely upon the character of the malformation. As indi- cated in the preceding paragraph, these malformations vary greatly. It may be stated as a rule, however, that classes (3) and (4) are of rela- tively more frequent occurrence than the others, and to them alone special attention will be given in this chapter. Whenever the malfor- mation is of such character as to obstruct the faecal current, the condi- tion, if not overcome, must necessarily result in death. Without refer- ence to the classification of cases, out of 345 patients upon whom opera- tions had been performed, 160 recovered. This is an encouraging outlook, particularly when the desperate character of the cases is taken into consideration, and when it is remembered that many of the cases embraced in this table, compiled by Bodenhamer, were operated on in the preantiseptic era. Matas {Transactions of the American Surgical Society, 1897), in a valuable contribution on Anorectal Imperf oration, the condition designated in Bodenhamer's third and fourth classes, em- phasizes the fact that, in the development of this condition, the rectum and anus have simply failed to meet in the process of development. There is defective development of either the proctodseum or enteron, leaving the rectal pouch of the colon at a distance varying from a few millimetres to 5 or more centimetres from the perineum; or the enteron may be entirely absent and remain out of the pelvis altogether. The symftoms of imperforate anus consist in an absence of the faecal discharge and in restlessness, which may develop into spasms of the infant. Abdominal distention speedily ensues, but before this occurs, the vigilance of the nurse will have detected the true condition of affairs. The diagnosis of the condition within the pelvis, however, is far more difficult, if, indeed, it is not impossible. Probes, sounds, or guides, passed into the vagina or bladder, and the use of the aspirat- ing needle, are equally fallacious. Treatment consists in establishing the faecal current. This may be done, by establishing an anus either at its normal situation, or in the inguinal region. Matas gives it as an axiom, that it is the duty of the surgeon to presume that there is a rectal pouch in the pelvis and, if possible, to make an anal connection with.it. This presumption is based upon tlie fact made apparent by Bodenhamer's table, namely, that the rectum and colon were totally absent in only 41 out of 465 cases. AVTiatever is done in these cases should be done early. Delay based upon the theory that infants can not resist traumatism, and that in these cases it is better to give tliem time in which to acquire strength. 808 A TEXT-BOOK OF GYNECOLOGY is a fatal and tragic fallacy. Delay under such circumstances means, not only the wasting of the child's strength, but the development of peritonitis followed by stercorfemia and death from exhaustion. The object of an operation should be to establish, if possible, an intestinal outlet in its normal situation in the perineal sacral region with sphincteric control. This should be accomplished by means of procto- plasty — i. e., by dissection down upon the rectal pouch and its fixation to the cutaneous margin. In making this section, it may be necessary to carry the incision well back to the coccyx or even up into the sacrum. If, after making this incision, it is found to be impracticable to attach the terminal portion of the colon (rudimentary rectum) to the external wound, it is justifiable in the emergency to attach the small bowel. Matas states that a median or lateral or exploratory abdominal section is indicated when, after the intraperitoneal exploration through a perineal sacral incision, it is evident that the terminal cul-de-sac of the rectum or any portion of the colon can not be brought down to the pelvic outlet, and that only the small intestine is available for procto- plasty. The aim of the operator, after making an exploratory abdom- inal incision, according to ]\Iatas, should be to guide the colon, the cfficum or the most available loop of the ileum, to the peri- neosacral wound, where it can be drained permanently with greater safety. The perineo- sacral anus, if the operation has been properly performed, is almost certain to be volun- tarily controlled in the course of time. Keen (Medical Mir- ror) suggests inguinal colos- tomy as the operation of choice in imperforate rectum, affirm- ing that it is safer to life and has the additional advantage of being done with facility, there being no groping in the dark in a narrow wound, while the time consumed is much short- er. In this suggestion. Keen follows in the footsteps of Chassaignac, Lannelongue and others, who, however, looked upon the inguinal operation as a tentative measure, to be followed later by a perineal operation for the establishment of an anus at its normal situation. The Examination of the Rectum. — Noninstrumental Proctoscopy.— The essentials of this method are a patient, an assistant, and an operator Fig. 322. — " The surgeon is to close liis hands aiui to point his index fingers." — Martin (page 809). THE RECTUM 809 having at least one finger on each hand. The patient is to be put into the knee-chest posture; the assistant is to place and to hold the patient; and the surgeon's fingers are to be used to open the anus, all in the following manner, to wit: 1. The patient is to be completely anaesthetized as she lies on her back, and then turned toward the assistant and into the Sims posture. 2. The assistant is to station himself at the patient's knees. In his left hand he is to grasp the patient's feet. He is to lean himself against the pa- tient's knees. He is to pass his right arm under the pa- tient's hips. Now steadying the feet and bearing himself firmly against the patient's knees, with his right arm he is to lift the hips and pull his subject into the knee-shoulder posture. Here, securely held in the embrace of the assistant, the patient is to be balanced on her perpendicular right thigh, where, throughout the whole time of the surgeon's manipu- lations, she must be steadily held. (A Simplest Proctos- copy, Martin, Journal of the American Medical Association, August 27, 1898). 3. The surgeon is to close his hands and to point his index fingers (Fig. 322). The wrists are to be crossed, the hands placed back against back, and the nails of the index fingers placed one against the other (Fig. 323). The surgeon is to lubricate these fingers and gently insinu- ate them through the anus and place their ends beyond the borders of the levatores ani. This accomplished, the anus is to be kneaded and divulsed in the direction of the ischial tuberosities, by the surgeon forcibly parting his fingers as is shown in the accompanying illustration (Fig. 322). Under this manipulation the rectum becomes atmospheric- ally inflated. Now, provided the surgeon lowers his head to the level of his fingers and then rises again, or stoops, or moves a little from side to side, he may command under his eye a view of the atmospherically inflated rectum to the depth of 6 or 8 inches (15.24 or 20.32 centimetres), and, in some instances, he may behold even a part of the sigmoid flexure. Tt is possible for the operator to manipulate his patient and to finish Fig. 323. — " The wrists ai-e to be crossed . . . and the nails of the index fingers placed one against the other." — Martin. 810 A TEXT-BOOK OF GYNECOLOGY his inspection within two and a half or three minutes, provided the patient is in a state of complete anesthesia. If this method is practised, as it may be with facility by the gen- eral practitioner, the greater number of rectal diseases may be instan- taneously diagnosticated. But at diagnosis the achievement of the simplest proctoscopy ends, for the reason that the operator's hands are so full of his patient he can do nothing at all for the disease that he may have discovered. In some conditions, and amid some circumstances, the rectum will not become inflated. If there is a close stricture of the rectum; if there is malignant growth or other disease of the rectum, by means of which the gut's coats have become extensively filled and fixed with an organized plastic exudate; if for some reason the intra-abdominal pressure is abnormally increased, as it may be by the bearing down of the patient, by enormous intestinal flatus, or by ascites; or. if there is an impinging uterus, an extrarectal growth or extensive infiltrating Fig. 824. — " A section throush a hardened rectum." — Martin. disease of the contiguous textures, rectal inflation by this method, or by any other which is governed by the same principle, is a physical impossibility. But this need not baffle the man bent on seeing by in- strumental aids. Practised as described, when not embarrassed by the exceptions specified, this method will achieve its purpose and reveal to the surgeon that the transverse diameter of the rectum is variable. Martin has demonstrated this variation by means of a section through a hardened rectum, with the body in ]\Iartin's posture (Fig. 334). A^Hhile in some places it is not more than an inch (2.54 centimetres), in others it is more than four times as much, in diameter. The rectum may present to the eye of the imaginative observer the appearance of a chain of urinary bladders, communicating one with another by means of irregularly elliptic openings set at varying THE RECTUM 811 axes, and bounded by the nonparallel borders of the rectal valves. In the normal rectum, the air pressure smooths the mucous membrane evenly over the entire surface of the gut. The normal mucous mem- brane of the so-called ampulla appears at first wet and of a shining bluish gray. As it dries, under the influence of gravitation the blue venous tint fades out of the gray, and the wall becomes pink-tinged; presently, it assumes the appearance of parchment, and sometimes it appears painted at rare intervals with ramifying little arteries which are crowded and overlapped by the larger comjoanion veins; the latter are less arborescent and more suddenly dive and disappear in the bowel wall. In time, there comes a sheen over all, and the vascular pictures lade. These phenomena appear exactly as described only in the healthy rectum; in the diseased organ the colour varies much. Should the operator deviate from the prescribed directions for the manipxilation of his fingers, and so twist his hands as to divulse the anus in the antero-posterior direction instead of laterally, he invites- defeat upon himself; for, in the male, the fixation of the perineum and the immobility of the coccyx interfere with the requisite dilatation; while in the female, the extreme mobility of the perineum, and particu- larly the backward displaceability of the coccyx, will allow such traction to be made upon the leva- tores ani as to pull their inner borders parallel and almost together; and, in consequence, the wider the female's anus is opened antero - posterior- ly, the closer it shuts laterally to rob one of one's view. Instrumental Proctos- copy. — Special parapher- nalia and much practice in their use are necessary for a rapid, painless and complete inspection of the rectum. The chair which is shown in the illustra- tions * was designed by Dr. T. C. Martin, of Cleveland, to facilitate the placing of the patient in a new posture equivalent to tlie knee-chest posture. This improvement on the Yale Fig. 325. — " Thomas Charles Martin's anoscope." — Martin (page 812). * Much of the mechanism of this excellent invention is necessarily omitted in the siriall dniwinf^s to which alone space can be . 816 A TEXT-BOOK OF GYNECOLOGY Those cases in which there is no apparent lesion at the anus, and which are in a perfunctory way sometimes declared to be catarrh of the rectum, will at once have their real cause, such as a high-up rectal poly- pus or a congenital or organic stricture or ulceration, positively diag- nosticated, and will be made accessible for intelligent treatment. New growths or ulcerations may be seen and, by means of a long- handled curette, scrapings made, in order that the microscopist may determine their exact character. Vesico-rectal, vagino-rectal, and deeper rectal fistulge, are often ap- parent at a glance, but, in any case, may be discovered by the use of the proctoscopic mirror. The existence of stricture of the rectum need no longer be regarded as only doubtful, and this method proves positively, even to the casual observer, how fallacious is the rectal sound as usually employed in the diagnosis of stricture. It has been repeatedly shown how easy it is for an entering or returning bulb-sound to be caught and held by the rectal valves, and to elicit those signs which are generally considered diagnostic of organic stricture of the rectum. The rectal valve constitutes the chief topographical feature of the abdominal rectum. Its histologic character indicates it as the typical anatomic valve (Fig. 335). The attached border of each valve spans a little more than half the circumference of the rectum, and its free border projects half way across the diameter of the inflated rectum. Thus, what has heretofore been regarded as a cavernous ampulla, is seen to be divided in- to several chambers. There are as many chambers in the rec- tum as there are rec- tal valves. The num- ber of rectal valves is variable. Some sub- jects have but two, others have four, but 90 per cent of persons possess three. The uppermost valve is invariably situated at the juncture of the rectum and the sig- moid flexure, and is usually on the left wall; the next is on the right, and the lowermost on the left wall. The positions of the lower two valves are sometimes anterior and posterior respectively. It must be readily seen that the newer methods of rectal inflation for rectal in- spection will determine newer notions of the topography of this part, and will justify consideration of the lowermost chamber as the first rectal chamber; of the cavernous area beyond the first valve and be- Fici. 335. — "The typical anatomic valve.'" . I, mucous mem- brane; B, fibrous tissue ; C, bundles of circular muscular fibres ; D, F, arteries; E, G, veins ; H, areolar and adipose tissue. — Mabtin. THE RECTUM 81Y Fig. 336. — " The ancient arbitrary division of the rectum should be abandoned." (Laparosymphysiotomy, show- ing the rectum packed with scybala.) — Martin. low the second, as the second chamber; and of the upper chamber as the third or perhaps the fourth, according to the number of valves. The ancient arbitrary division of the rectum by the anatomists into upper first, middle second, and lower third parts, should be abandoned (Fig. 336). If this method of ocular examination is practised, there need be no longer any excuse for calling an undiagnosticated disease of the rectum an "obscure disease"; and, whatever the disease present, this method makes it sus- ceptible of demon- stration to the pa- tient's physician or attendant friend. There is no necessity whatsoever that the diag- nosis of rectal disease be taken on faith. (Complete Inspection of the Eectum, Thomas Charles Martin, M. D., American Gynecological and Obstetrical Journal, December, 1898.) Displacements of the rectum in women may be classified as (a) anterior, (b) posterior, and (c) prolapse. Anterior displacement con- sists of the sacculation forward of the anterior wall of the rectum. This constitutes the condition of rectocele (see Eectocele), or more specifically anterior rectocele. It necessarily implies an equal displace- ment of the posterior wall of the vagina. The condition is generally induced by either dilatation of the vaginal outlet or injury of the pelvic floor. It is treated as prescribed in the chapter on Kepair of Surgical Injuries of the Floor of the Pelvis. Posterior displacement of the rectum consists in the sacculation, posteriorly, of the posterior wall of the rectum, and is, in reality, a posterior rectocele (Fig. 337). This condition which is not frequently recognised, is, nevertheless, one of relatively common occurrence. Its symptoms consist of more or less rectal tenesmus and difficulty in defecation, there being a constant sense of the presence of residual faeces after an effort at dejection. If the bowel is loaded with hard- ened fffical matter, much difficulty is experienced in discharging it, the effort being attended with a feeling of retro-anal protrusion. If a patient afflicted witli this condition is placed in either the dorsal or the semiprone position and is asked to strain, a fulness behind the anus will !)<■ ;ip|i;iivii1. Kectal exploration by the finger will reveal a posterior sacculaLi(jn of the rectum, just within the external sphincter. 818 A TEXT-BOOK OF GYNECOLOGY and associated with a diminution or a disappearance of the normal constriction due to the proper action of the levator ani muscle. The pathology of this condition is essentially that of the dilatation of the rectum and is due to either a relaxation or an injury of the deep mus- cular layer of the pelvic floor. When the levator ani has once been damaged, and the rectum has been deprived of its support, there occurs more or less descent of the bowel. This descent is aug- mented by an effort to defecate. The external sphincter fails to act properly because the descending fffical matter is to a certain extent diverted from its course and conse- quently fails to exercise the proper dilating influence iipon the exter- nal muscle. The treatment con- sists (1) in restoring the integrity of the parts upon the damage to which the rectal displacement de- pends, and (2) in restoring the rec- tum itself to its normal position. Reed has operated in these cases by means of the Emmet operation for deep lacerations of the perineum, supplemented by the following steps: An incision is made transversely midway between the anus and the tip of the coccyx, care being taken to avoid the external sphincter. This incision, which is about an inch and a half long, but which may be longer, if required, is carried down to the posterior wall of the rectum, which is then dissected up to a point beyond the levator ani. The sacculated bowel is then lifted above the levator to which it is attached by a few interrupted catgut sutures. The external incision is then closed. Harris's operation for deep injuries of the muscular floor of the pelvis may be substituted with advantage for the Emmet operation in these cases. Prolapsus of the rectum may be either (1) partial, or (2) com- plete. By partial prolapse is implied merely a descent and extrusion from the anus of the mucous membrane of the rectum, and it is the condition generally designated prolapsus ani; complete laceration im- plies the descent and extrusion from the anus of the entire rectal walls, and is the condition ordinarily designated prolapsus recti. Par- tial prolapsus occurs, for the most part, in children, and is caused by efforts at defecation, either in constipation, or in diarrhoea associated with rectal irritation and consequent tenesmus. Complete prolapse occurs more frequently in adults and is the result of straining at stool, either from constipation, vesical tenesmus induced by stone in the Fig. 337. — " Posterior rectocele." — Eeed (page 817). THE RECTUM 819 bladder or other causes, uterine displacements caused by polypi, etc. Injuries of the pelvic floor, relaxation of the muscular apparatus of the rectum, and general enteroptosis, are to be considered as predispos- ing causes. The symptoms of prolapsus of the rectum, whether com- plete or incomplete, consist in the sudden appearance of a mass just outside the anal orifice, which, upon examination, will be found to consist of folds of mucous membrane. If this extrusion is recent and the sphincteric contraction is not extreme, the mass may present a ruddy hue, but, if the case has been one of long standing, it may be dark in appearance, or even gangrenous. The diagnosis is self-evi- dent, but is easily confirmed by introducing the anointed finger into the anus. , The treatment may be either (1) palliative or (2) radical. The palliative treatment consists in the immediate return of the parts. This is accomplished in children by placing the patient upon her side, anointing the fingers of one hand with some sterilized preparation, and then by gentle pressure replacing the extruded mucous mem- brane. An anal compress may be applied following the replacement of the bowel. In some cases, however, the extrusion may have ex- isted for so long a time, and the sphincteric constriction may have been so extreme, that strangulation with death of the structures may have ensued. It is to be remembered that, both in complete and incomplete prolapse of the rectum, spontaneous amputation of the extruded part occasionally occurs, resulting in the cure of the patient. When the condition has gone to the stage that threatens this result, intervention because of its probable danger, is of questionable value. By the slow amputation of the extruded rectum, there occurs a fixa- tion by inflammatory process of the remaining intra-anal segment ; and it is obvious that, if this fixation is disturbed, there may occur a retraction of the upper portion of the rectum, resulting, in the event of cure, in the deposit of a zone of cicatricial tissue and the development, later, of intractable stricture. If, however, in the event of complete prolapsus, there is a reasonable prospect of saving the bowel, the patient should be placed in either the knee-chest or the semiprone posture, and the bowel should be replaced by digital manipulation. If this is not practicable because of intractable sphinc- teric spasm, an ansesthetic should be given to the patient. Divulsion of the sphincter, which would facilitate the reduction of the bowel, is not desirable, for the reason tbat the sphincter, in its full tone and integrity, is required to maintain the replaced bowel in position. For the purpose of restoring the normal contractility of the relaxed bowel, it has been recommended to cauterize it in spots with either the silver nitrate or the cautery. A recta] tube of soft rubber may be used to maintain the reduction. In exceedingly obstinate cases, a V-shaped piece has been removed from the sphincter, the apex of the letter pointing backward toward the coccyx, the sphincter being restored after rfifliiniion of th(; bowel. Jaennel, of Toulouse {Bulletin de 820 A TEXT-BOOK OF GYNECOLOGY VAcacUmie de medecine), believes that rectal prolapse is due, in many- cases, to a weakening of the ligaments that hold these parts in posi- tion, especially the mesocolon and the mesorectum, establishing the condition to which allusion has already been made as that of enterop- tosis. He treats this condition by performing an ordinary colotomy. The sigmoid liexure is sought for, drawn upward, and fixed to the abdominal wall by sutures. The next step is to establish an artificial anus, which will afford the necessary rest until firm adhesion has oc- curred. The opening is not closed until the flexure has become firmly adherent. The operation has been performed with entire success in one case, the patient being cured in two months. It was performed in three sittings and this is one of its disadvantages ; besides, it is not easy to find the sigmoid flexure. It has the advantage over other operations for rectal prolapse, however, in that it removes the cause of the trouble and is less dangerous. It is contraindicated in recent cases of medium severity or in old cases in which the prolapse is due to inflammatory peritoneal adhesions. General Etiology of Rectal Disease. — Because of its peculiar func- tion, the rectum frequently becomes diseased. There are so many factors entering into the etiology of rectal disease that we shall not attempt to mention them all. There is little doubt that the upright position assumed by man is a predisposing cause of hemor- rhoids, because a large amount of blood is thereby thrown upon the valveless veins of the rectum. The most common of all causes, is consfipation induced by irregularities in sleeping, eating, exercising, and attending to the calls of Nature. Fissure is usually the result of constipation in consequence of a tear made in the mucous membrane during the passage of hardened fseces ; ulceration, because of pressure of the faecal mass on the blood vessels causing necrosis; hemorrhoids ensue because of pressure interfering with the return flow of blood and, further, as a result of straining coincident with their expulsion; prolapsus and invagination are of frequent occurrence in the consti- pated on account of straining and the dragging down of the bowel by the fasces. The mucous membrane of the rectum is very fragile and is occasionally injured sufficiently by the faecal concretions to set up a proctitis which may confine itself to the rectum or extend into the circumrectal tissue causing ischiorectal alyscess and fistula. Neuralgia of the rectum is now and then a symptom of costiveness and results from the nerves being caught between bony structures on the one hand, and a faecal mass on the other. Strong drink and other forms of dissipation are responsible for many of the ailments in this locality. Persons suffering from pruritus and hemorrhoids are invariably worse after a spree. The continued use of purgatives is a common cause of rectal disease, owing to the straining and irritation of the mucous membrane induced by them. Clironic diarrlma may incite a prolapsus, ulceration, or hemorrhoids, on account of the frequent stools, tenesmus, and passage over the THE RECTUM 821 sensitive membrane of irritating discharges. Threadworms, pediculi, and anal eczema, not infrequently start an itching about the anus which is difficult to arrest. Constipation, stricture, and fissure, in young children can usually be traced to a congenitally narrow anus. Foreign hodies reaching the rectum by way of the mouth or anus cause considerable suffering and may require an operation to remove them. Traumatism caused by hardened fasces or operation is respon- sible for many of the afflictions in the terminal colon. The Whitehead operation, when primary union is not obtained, results in many un- pleasant sequelae such as ulceration, stricture, fistula, abscess, pruritus, and incontinence; other operations may do the same, but only at rare intervals. Many injuries of the rectum follow the frequent and careless introduction of the syringe nozzle by the person in the habit of taking enemata. Occupation is an important factor in the causation of rectal dis- ease. Persons whose employment requires a sedentary life, their being constantly on their feet, or irregular hours for eating and attend- ing to Nature's demands, are frequent sufferers from hemorrhoids and fissures. The upright position assumed by conductors, brakemen, engineers, and motormen, combined with the irregular jarring motion of trains and street cars, is a predisposing cause of rectal disease. On account of the vascular arrangement, obstructive diseases of the liver and heart are usually accompanied by hemorrhoids. Tumours in, or displacements of, neighbouring organs, as an enlarged prostate or a retroverted uterus, are the cause of many patients going to the proc- tologist. The function of the rectum renders it liable to injury, thus preparing the way for infection, local and general, by the various micro-organisms contained within its walls. Venereal diseases com- mon in the sexual organs are found also in the rectum and about the anus of those who practise pcederasty (rectal intercourse), but with less frequency. Pederasts are recognised by their relaxed sphincters and the funnel shape of the anus. The large rectal veins in passing from without the bowel to the mucous membrane within, go through muscular buttonholes. It is believed by some that frequent muscular contraction around the veins results in their enlargement below, ter- minating in piles. Occasionally the levator ani and external sphincter become hypertrophied and irritable as the result of a faecal mass pounding upon them, and thus interfere with defecation or cause nmch pain by their frequent contractions. Undue force exhibited by the abdominal muscles will produce an engorgement of the rectal veins; this can be demonstrated by having a patient suffering with hemorrhoids strain down, when they will immediately enlarge and turn blue. Houston's folds sometimes become hypertrophied, result- ing in constipation iinrl iillied niliiu'nts. The Relation of Intrapelvic Disease to Disease of the Rectum in Women. — Tntrapclvic disease in women may disorganize the function or compromise Uic iniogrity of tlio rectum. Such results are the 822 A TEXT-BOOK OF GYNECOLOGY product of (1) pressure upon the rectum by means of a displaced uterus or ovary, or of a tumour or adventitious peritoneal band; (3) the extension of an infl.ammation ; (3) adhesion of a viscus to the rectum or sigmoid flexure, or of adhesion of one part of the gut to another. Pressure on the normal rectum of a retroposited but nonadherent uterus will not often obstruct the descent of the faeces provided urina- tion precedes the attempt at defecation. An ovary prolapsed into the cul-de-sac will interfere with defecation, inasmuch as its sensitiveness to pressure arrests the voluntary effort of the patient. An intrapelvic tumour, nonadherent to the rectum, obstructs defecation in propor- tion as it limits the dilatation of the rectum; the same may be said of an adventitious band of peritoneum about the rectum. The pres- ence of any of these con- ditions may interfere with the nutrition of the rectum or obstruct its circulation and provoke l^roctitis, ulceration, and hemorrhoids, and render the rectum prone to other diseases. Inflammation of any pelvic viscus, pelvic peri- tonitis, appendicitis, or pelvic cellulitis, by reason of the usually concomi- tant proctitis and infil- tration of the rectal valves, produces a transi- tory diarrhoea, constipa- tion, or obstipation; if resolution is imperfect, the obstipation will be- come chronic — in such a condition there is always a remote possibility of acute and complete ob- struction from inflamma- tion and oedema of the aifected rectal valve. In- trapelvic abscess finds its quickest avenue of escape into the rectum. This event is character- ized by amelioration of the patient's symptoms and subsequent puru- lent discharge from the rectum. Proctoscopy reveals a more or less general proctitis and, at the vicinity of the fistula, an oedema and corrugation of the mucou.s membrane; if the perforation is not at Fig. 338. — " Adhesions to the rectum, and particularly to the sigmoid flexure, may arrest the descent of fseces." (The dotted portion shows an adhesion which has been broken up.) — Maetin (page 823). THE RECTUM 823 once visible^ pressure on the abdomen will cause pus to be ejected at its site. Adhesions to the rectum, and particularly to the sigmoid flexure, may arrest the descent of solid or semisolid faeces without contracting the bowel's lumen; inasmuch as the immobilization of a portion of an organ which is essentially peristaltic, robs that portion involved, of its intrinsic power of propulsion of its contents (Fig. 338). JSTonperistalsis of the rectum by reason of adhesion to a pelvic viscus is, however, but a minor factor in the resulting obstipation, because the expulsion of solid and semisolid faeces is in the main accomplished by the volun- tary mechanism. In case of such adhesion, the adherent organ inter- feres with the necessary dilatation of the rectum, and, furthermore, the voluntary forces of defecation drive the adherent organ into the sacral hollow ahead of the faecal mass. Grant observes that disease occurring in either the genitalia or the rectum frequently manifests itself in the other organ because of the intimate relation of the veins, nerves, muscles, and lymphatics, sup- plying them. There are certain diseases that interfere with the cir- culation, and result in congestion or anaemia of the rectum, genitals, or both. Pain from disease in the vagina, uterus, ovaries, tubes or bladder, is frequently reflected to the rectum and vice versa. Fissure or ulceration of the rectum, exciting contraction of the external sphincter or levator ani muscles, causes similar contractions in the vagina and vulva. Pain following operations about the perineum and vagina is less when the sphincter is divulsed. Because of these fre- quent muscular contractions, the arrangements of veins in plexuses, and the intimate relation of the lymphatics, the exchange of infections from the genitals to the rectum, and vice versa, is quite frequent. Careful examination should be made both of the genitals and the rec- tum in all obscure diseases affecting either. CHAPTER LI INFECTIONS OF THE RECTUM Inflammation — Periproctitis ; Ischiorectal abscess — Gonorrhoea — Syphilis — Tuber- culosis — Surgical conditions resulting from infections — Anal ulcer or fissure — Ulceration of the rectum — Fistula — Stricture. Infections of the rectum may be classified as (a) mixed, and (h) specific. Mixed infections, i.e., those in whicli the various pus-formers — e. g., Staphylococcvs pyogenes aureus, the various streptococci, and occa- sionally the migrated Bacillus coli communis — are found, are those that are manifested in the superficial inflammations, both catarrhal and fol- licular, and in deeper-seated inflammations, as periproctitis and ischio- rectal abscess. The specific infections which will be considered in this connection are, gonorrhoea, syphilis and tuberculosis. Inflammation of the rectum and sigmoid is a common ailment, and one easily recognised and treated by means of the colon tube. Ordi- narily, the inflammation is confined to the mucous membrane, but occasionally it extends through the muscular coats causing periproc- titis, ischiorectal abscess, and fistula. It is frequently the result of a more serious disease; occasionally, it is due to diphtheria and a mem- brane forms; again, because of proximity of the vagina to the rectum, it is caused by gonorrhoeal infection; while, in tropical countries, it is often the result of a dysentery. Usually the mucous membrane will be inflamed and dry — atrophic catarrh — or spongy and smeared over with an abundance of mucus — hypertrophic catarrh. It may be either acute or chronic. Children are subject to the acute, and old persons to the chronic form; the former because of diarrhoea, and the latter, as a consequence of loss of tonicity resulting in faecal accumulations. It may be caused by exposure to cold, sitting on damp steps, or traumatism due to swallowing a hard indigestible substance or to an o]3eration. Not infrequently, it is brought about as the result of an irritable dis- charge from a stricture, cancer, ulceration, polypus or diarrhoea. Again, it sometimes follows the administration of drugs such as large doses of mercury and arsenic and strong purgatives. Symptoms. — The symptoms of inflammation of the rectum and sigmoid may be briefly summed up as follows — viz., severe tenesmus and sense of weight and fulness in the rectum; sensations of heat, fulness, and soreness on pressure; frequent discharges of mucus and, 824 INFECTIONS OP THE RECTUM 825 occasionally, of pus; spasmodic and unsuccessful attempts to evacuate the bowel. When due to atrophy following catarrh, the skin and mucous membrane about the anus are dry, harsh, and full of cracks; when to hypertrophy associated with catarrh, there will be a constant moisture in this locality. There is often pruritus due to irritating sub- stances getting into the cracks, and to irritation of the skin and mem- brane caused by the discharge. In the acute stage there is a desire to micturate often, and, occasionally, incontinence of urine. Because of straining and frequent stools, a prolapse of the mucous membrane is not uncommon. If the inflammation is complicated by ulceration, bleeding may be a symptom, or fsecal matter may get under the mem- brane and start an abscess resulting in fistula. In general, any symp- tom present in inflammation of any part of the intestine may be pres- ent here, such as radiating and reflected pains and slight elevation of the temperature. Prognosis. — When taken in hand early, inflammation of the rectum and sigmoid is easy to control. An acute attack may last one, two, or three weeks, and the chronic form indefinitely, depending upon the cause and its removal. When it has not existed more than a few weeks, the most apparent change in the former, barring the congested appearance of the mucous membrane, is the oozing of blood from many points when the speculum or colon tube is introdiiced. In cases of long standing, the mucosa becomes thickened, indurated, and loses its sensibility in a measure, so that a considerable amount of fseces may collect in the sigmoid and upper rectum before a warning is given of an approaching stool. Inflammation, when allowed to run an un- interrupted course, usually results in ulceration and stricture. Treatment. — Eemove at the earliest opportunity the source of irri- tation. Discard harsh and indigestible foods for milk, soft-boiled eggs, soups, beef juice, and other nourishing fluid and semisolid foods. Insist upon the discontinuance of eatables fried in grease, and those that are highly seasoned, and at the same time stop all alcoholic drinks. These patients must have regular hours for eating, sleeping, exercising, and attending to the calls of Nature. Keep the stools soft with two ounces of Carabaiia water taken before breakfast, and clear the bowel of offending scybala, by massage, high enemas, Epsom salts, Seidlitz powders or other mild laxatives, and, above all, discon- tinue irritating purgatives. Keep the patients in bed as much as their circumstances will permit. The medical treatment consists in apply- ing soothing, antiseptic, and astringent solutions, emulsions and pow- ders, directly to the affected part by means of the colon tube, applica- tor, atomizer, and insufflator. The remedies which give the most sat- isfactory results are the nitrate of silver, balsam of Peru, sulphate of zinc, lead, alum, argonin, and ichthyol, alone or in combination. Gant is partial to the fluid extract of krameria, half an ounce to two ounces of distilled water, thrown into the sigmoid or rectum and allowed to remain there as long as it can with comfort to the patient. In aggra- 826 A TEXT-BOOK OF GYNECOLOGY vated cases, the krameria may be increased to an ounce and a half, and the water increased in proportion. The treatments should be given two or three times weekly. When the intestine is chafed and irritable and tends to bleed, Gant has the patients use, on the remaining days, enemata of an emulsion composed of olive oil, 2 ounces, and sub- nitrate of bismuth, half a drachm, or nitrate of silver 60 grains, to the pint. When the inflammation is caused by threadworms it can be quickly subdued by a few copious injections of salt or limewater; santonin may be administered if the case justifies it. When due to gonorrhoeal virus, frequent irrigation of the bowel with hot water or bichloride, 1 to 6,000, as hot as it can be borne, will be followed by gratifying results. In a general way, the treatment consists in keeping the bowels open and correcting errors in diet, together with frequent hot and cold irrigations. Periproctitis; Ischiorectal Abscess. — Frequently, an inflammation starting in the mucous membrane extends through the rectal wall into the loose tissues around it, causing a diffused or circumscribed peri- proctitis resulting in ischiorectal abscess. Gant is of the opinion that this condition is made possible through the intestinal bacteria (probably the colon bacillus) having pyogenic properties, escaping into the blood vessels or lymphatics as a result of erosion of the mucous membrane. Another evidence of this is the fact that the pus from nearly all, if not all, ischiorectal abscesses contains the colon bacillus in large num- bers. In addition to the symptoms of a simple inflammation of the rectum, we now have those of a constitutional character, as a chill, high temperature, quick pulse, restlessness, and in fact all the phe- nomena of pus formation. Circumrectal inflammation may be caused by an operation with resulting infection, or by the breaking down of tuberculous deposits. Treatment. — Powell claims to abort ischiorectal abscess by deep in- jections of carbolic acid. Gant has not tried this plan, but has been in the habit of using the ordinary palliative meassures until there is evi- dence of pus formation. He then opens the abscess by a free incision, breaks up all pockets with the finger, curettes out all gangrenous tissues, and then swabs out the cavity with carbolic acid and packs it with sterile gauze. The dressings are removed whenever they are soiled; the Avound is then irrigated and repacked loosely with gauze. Many physicians make the mistake of putting the dressings in too tightly, thereby arresting granulation. Patients should be told that they have a serious trouble which may result in fistula and a second operation, though this is rarely necessary when the abscess has been treated properly, and by that is meant radically. Gonorrhoea of the rectum is of occasional occurrence in America, but more frequent in England, and particularly in France. It is caused by infection of the rectum with the gonococcus of Neisser, although, as ordinarily found, it is here, as elsewhere, a mixed infection. It is generally caused by an associated attack of gonorrhoea infecting pri- INFECTIONS OP THE RECTUM 827 marily the genito-urinary ajoparatus. The discharge, which is generally copious in the acute stages, may bathe the perineum or invade the anal folds, from which it gains ready access to the mucous surfaces above the anal constriction. In other instances, and, perhaps, in the majority of all instances, the infection occurs as the result of using for the pur- pose of a rectal injection a syringe nozzle which has been employed in an infected vagina. The disease may result from perverted sexual indulgences. The pathology is essentially that of an acute inflammation depend- ing for its occurrence, primarily, upon the specific coccus of Neisser. The action of this micro-organism is very virulent and results speedily in the destruction of at least limited areas of rectal epithelium, result- ing in the development of granular patches which are ordinarily desig- nated ulcerations. The mucous follicles are invaded, resulting in their stimulation to catarrhal activity. If the epithelium of the efferent ducts is destroyed, they may become occluded, resulting in the develop- ment of retention cysts. The majority of the follicles, however, un- dergo hypertrophy and become more or less persistently catarrhal. In the presence of an infection atrium, the micro-organisms penetrate the deeper structures and may cause ischiorectal abscesses; or they may invade the lymph spaces causing enlargement of the pelvic lymphatics, or even resulting in some cases in suppuration. The infection may, by traversing the lymph channels, reach the peritoneum, causing septic inflammation of that membrane. When the inflammation has been so intense as to cause extensive epithelial destruction, post-inflammatory contractions resulting in stricture may supervene. The symptoms of gonorrhoea of the rectum consist in pain asso- ciated with burning and tenesmus in the earlier acute stages; there is also a copious muco-purulent secretion which is discharged at frequent intervals. The diagnosis depends upon the demonstration by means of the microscope of the gonococcus of Neisser. Treatment must be based upon the facts that the infection is a virulent one and that the surface of the rectum is very absorbent. Antiseptic agents, such as carbolic acid or the mercuric bichloride, are not eligible, while nitrate of silver is so destructive and so painful that it oiight not to be employed. Strong injections of saturated solutions of boric acid, however, are well borne, and have pronounced antiseptic properties; to secure their best effects, however, they should be pre- ceded by copious injections of a detergent saline solution, such as the bicarbonate of sodium. If the injections are given cool, they will be better borne and have a soothing effect upon the inflamed rectum. It is well, in some cases, to begin the treatment by means of a saline cathartic, as the faecal current induced by that means will wash out much of the infection; and, besides, the Bacilli coli communes, which are brought down in large numbers, have a bactericidal action upon the gonococci. Topical treatment should be continued until the gonococci can no longfu- be demonstrated in the rectal secretions. 828 A TEXT-BOOK OF GYNECOLOGY Syphilis of the Rectum. — Syphilis of the rectum is of frequent oc- currence, and may manifest itself at any stage and in a variety of forms. It is more common in women than men because of the proximity of the anus and vulva. The inoculation of the rectum may be the result of syphilitic discharges coming frqm the vagina dribbling over the anus; again it may be brought about by a chancre on the penis coming in contact with the anal aperture during sexual intercourse, and occa- sionally through unnatural copulation (paederasty). Chancroids will be considered along with syphilis because it is often difficult to distin- guish between the hard and soft sores, and, further, because the local treatment of these two affections is identical. Syphilis may reveal itself at the intestinal extremity in the congenital variety or in the form of a chancre, chancroid, mucous patch, condylomata or gummatous de- posit. In congenital syphilis of the rectum, the anus and vulva will be disfigured by multiple mucous patches and irritating fissures, which cause the child much pain when a hard stool is passed. Such children have notched teeth and the usual characteristic markings of inherited syphilis. True chancre of the rectum is uncommon, but, when present, its appearance does not differ greatly from that of chancre elsewhere. There is but one ulcer, surrounded by a hard, raised, inflammatory band, which is not very sensitive to the touch, and does not give much pain unless irritated. It is sometimes quite difficult to distinguish between it and a chronic fissure or ulcer, and for that reason we should not be hasty in making our diagnosis, but should wait for the eruption which will certainly settle the question. Chancroids at the anal margin are quite common, especially in pros- titutes, but cause more suffering than when located on the penis or vulva, which fact is attributable to the irritation caused by the passing over them of the fgeces. They are usually multiple, superficial, and have sharply defined edges, are sensitive to the touch, and give off a discharge which irritates the skin, causing a pruritus that is difficult to relieve. Now and then they extend up the rectum and, when healed, a sufficient amount of contraction follows to produce a stricture. They are occasionally seen to become phagedenic and rapidly eat their way into adjoining structures, entirely destroying the external sphincter in less than a week's time. Mucous patches are disposed to form at the anal margin during the second stage of syphilis. They are moist, slightly elevated, and give off a foul odour, are grayish in colour, and are found more frequently in this locality than, perhaps, any other manifestation of this disease. When the parts are not kept clean, they multiply swiftly and coalesce, forming thick warty masses, called condylomata (Fig. 339), and are covered with an offensive discharge that soon inoculates the neigh- bouring skin and membrane; in fact, if allowed to run an uninterrupted course, they may attain enormous proportions. At times, these masses INFECTIONS OP THE RECTUM 829 will be separated by deep fissures, in other cases they degenerate into a low form of ulceration. Gummata are not seen especially frequently, even by those physi- cians who do a large practice in rectal surgery; at the same time they are to be found in the rectum more often than is generally believed by the profession, and with greater frequency in this lo- cality than elsewhere in the intestine. When detected early in their formation, they give to the finger a sensation simi- lar to that of an abscess before fluctuation is present; in other words, they feel like thick, flat, indurated masses in the rectal wall. After they break down, the rectum feels ragged to the touch because of the nodules and intervening ul- ceration. As a rule, healing occurs as the mass gives way, and the ulceration extends un- til sufficient contractile tissue is formed to make a tight stricture. Gummata are rare- ly numerous and large enough to obstruct the calibre of the bowel to any serious extent. Neither do they cause a great deal of pain by pressure upon the nerves. On the other hand, when a stricture has followed their breaking down, the suffering of such patients is pitiable to behold, they spend most of their time in the closet without relief, have local and reflected pains, itching about the anus, pass large quantities of pus, blood, and mucus, and frequently suffer from abscess, fistula, and, occasionally, incon- tinence. Treatment. — Infants suffering from congenital syphilis must be put through a course of treatment early in their career, if we would rid them of this terrible inheritance. The treatment should not be ccmfined to the child alone, the mother should be given the usual anti- syphilitic remerlies diiring the nursing period. She should take ten grains of the iodide of potassium three times daily, a short time before the baby is permitted to be nursed. In addition, if she is run down, tonics should be given to build her up. The child should be given small doses of tiK'i-cin-y, pforcrably in ilu; forin of an ointment rubbed j MM Hw^4 ml ' 3 4^ l^'l "':, 1 ^ ''■'?•■ J ]?iHmii'j, Fig. 339. — " They multiply swiftly and coalesce, forming thick warty masses." — Gant (page 828). 830 A TEXT-BOOK OF GYNECOLOGY in over the abdomen or soles of the feet. For the local manifestations about the anus, cleanliness is the principal thing. To encourage heal- ing, solutions of alum, zinc, lead, or the bichloride of mercury, or pow- ders such as calomel, iodoform, orthoform, subiodide of bismuth, or tannic acid, judiciously applied, will render ef&cient service. In chancres and chancroids, persons suffering from the former should be j)ut through the ordinary antisyphilitic treatment. The local treatment for the soft and hard sores is practically the same. They should be cleansed several times a day with antiseptic and stimulating solutions, and covered with a reliable ointment or powder known to have healing powers. Sometimes it becomes necessary to make strong applications to them of the nitrate of silver, carbolic or nitric acid, or perhaps the actual cautery; the latter is especially valuable where they take on a phagedenic character. When they are seen in the early stage, mucous patches require the same treatment as the chancre; but later on, when they have pro- liferated and formed numerous condylomatous masses upon both the skin and mucous membrane, they require radical measures. Gant excises them with the scissors and thoroughly cauterizes their base with the Pacquelin cautery, and then treats them in the same manner as traumatic ulceration. They are so persistent that even this operation may have to be repeated. Gummata require both constitutional and local treatment. The iodide of potassium in large doses seems to prevent the formation of new deposits and to hasten the absorption of those present, when accompanied by massage of the rectum by means of the Wales rectal bougie. Stricture following their breaking down should be treated as a stricture from other causes similarly located (see Stricture of the Eectum). Tuberculosis of the Rectum. — The rectum, like other organs of the body, is occasionally the seat of tuberculosis; here, however, suffering is greater and healing more difficult to obtain because of the function of this organ. It is interesting to note the proportion of persons suffer- ing from phthisis who are subjects of anal fistula and the number of the latter who are phthisical. Probably " from 4 to 6 per cent of all phthisical patients have fistula, while a much larger percentage of those afflicted with fistula have phthisis — 12 to 15 per cent." Koch holds that tuberculosis of the intestine may be primary, or secondary to pulmonary involvement. The bacilli may be introduced in food, especially milk, or through the swallowing of sputum coming from a tuberculous lung. In perfect health, tubercle bacilli are destroyed by the gastric juice, but in cases of i^hthisis where there is a lowered vitality and a weakened gastric fluid, it is believed that they pass through the stomach into the intestine without losing their activity. Earle maintains " that the tuberculous process in mucous membranes, as well as in the lungs, can advance independently of the formation of miliary tubercles." He also reports 3 cases of primary tuberculosis, all INFECTIONS OP THE RECTUM 831 in negroes. He says, " What was particularly striking, was the apparent acuteness of the process; the mucous membrane between the points of ulceration was swollen and injected; in some cases covered with a slight fibrinous exudation. The ulcers appeared to result from the simple breaking down of this swollen and injected mucous membrane." Gant has never observed the condition just described. On the con- trary he has often seen tuberculous ulceration of the rectum where the mucous membrane was thin, pale, and covered with a thin rice- coloured discharge. Tuberculosis manifests itself in and near the rectum in three dif- ferent forms, viz., ulceration, stricture, and fistula. Ulceration. — From a clinical standpoint there are two kinds of tuberculous ulceration about the rectum, neither of which is of com- mon occurrence, but both are difficult to cure. One is a real tuber- culosis and can be demonstrated by the presence of the little tubercles and the bacilli. The second is a simple ulceration, from whatever cause, which is persistent owing to the debilitated condition of the patient caused by tuberculosis in the lung. In many cases of tuberculosis of the rectum, the disease is not con- fined to this organ, but distributes itself along the entire intestinal tract, and the breaking down of the deposit in one locality is followed shortly by a similar process in other parts, until the field of ulceration covers a considerable portion of the gut. In such cases, the prog- nosis is bad; on the other hand, when the disease is located in the anal region, we stand a fair chance of efi'ecting a radical cure, if we resort to heroic measures. Tuberculous stricture is a rare disease in the rectum because the tendency of ulceration is to extend rather than to heal and form con- tractile tissue. Gant has observed in young women 2 cases of tight stric- ture undoubtedly of tuberculous origin. There are also two kinds of tuberculous fistulce, the one the result of tuberculous infection, and the other due to ordinary causes, but made more difficult to combat because of the run-down condition of the patient, occasioned by tuberculosis in other organs. Symptoms. — The general appearance of patients suffering from the different forms of tuberculosis of the rectum is about the same. They are usually much debilitated, have a sallow complexion, pinched face, sunken cheeks, prominent ears, clubbed nails, absence of fat in the ischiorectal fossa, and patulous . anus surrounded by abundant long silky hairs. Many have an ugly cough and occasional hemorrhages, and are bothered with annoying night sweats. An ulceration, fistula, or stricture of tuberculous origin, bleeds less and is freer from pain than a similar condition from other causes. The mucous membrane is pale and thin, and the discharge from the diseased area is profuse, watery, and rice-coloured. Fistulous openings, instead of being small as in the ordinary fistula, are large, irregular in shape, bluish around the edges, and droop into the opening because of the undermined skin. 832 A TEXT-BOOK OP GYNECOLOGY A probe can be inserted along the sinus without pain or difficulty. Those accustomed to treating rectal diseases have little trouble in distinguishing between the ordinary and the tuberculous types of fistula. Treatment. — In spite of our best efforts, a good percentage of per- sons afflicted with tuberculosis of the rectum will die in from six months to three years. The results of treatment are not so good in this ]ocality, because the disease is being constantly aggravated by the passage over it of fa?ces. The most essential thing in the treatment is to see that these sufferers get a reasonable amount of exercise in the sunshine, and are not confined in bed in a dark room. In fact, we should make everything about them as cheerful as possible. Every means should be resorted to, to build them up; generally, for this pur- ]3ose, there is nothing better than plenty of nourishing food, stimulants, and tonics, such as creosote, guaiacol, cod-liver oil, malt extracts, iron occasionally, and, in fact, any tissue builder. If they can afford it, nothing will do them more good than a trip to the seaside or a change of altitude. Intestinal antiseptics should be given, as they sometimes benefit these patients very much; at other times, however, they are worthless. Ulceration rarely yields to palliative treatment, though we have to rely on it now and then when operation is refused. The ulcers should be cleansed frequently, after which some stimulating or anti- septic solution or powder should be applied. If they have a tendency to spread, a thorough burning with nitric or carbolic acid becomes necessary. A^^ien the treatment of tuberculosis is left entirely in Gant's hands, he treats it as though it was malignant. He curettes and trims the edges of the ulcers; after this, the affected area is thoroughly cau- terized with a Pacquelin cautery. The post-operative treatment is the same as for a granulating wound of the rectum from other causes. Tu- berculous fistula? should be laid open and all diseased tissue removed, and should then be cauterized as though it were an ulceration. Care should be used not to sever the sphincter more than once, for incon- tinence occasionally follows the operation. If it is thought best not to give a general ana?sthetic, to lose much blood, or to put the patient to bed, a ligature may be passed through the sinus and brought out at the anus, where it is tied and allowed to cut its way out. A cure will sometimes follow this method. Tuberculous stricture requires prac- tically the same treatment as a constriction in the rectum from other causes. In the majority of cases, however, nothing short of colostomy and the prevention of faecal irritation will do any good. After this operation a radical improvement will follow. Surgical conditions resulting from infections of the rectum are various. Those which will be considered in this connection are (a) anal ulcer or fissure; (6) ulceration of the rectum; (c) fistula; {d) stricture. Anal Ulcer or Fissure. — Salient Symptoms. — Often, there is itching at the anus. Pain on defecation or immediately thereafter is charac- INFECTIONS OF THE RECTUM 833 teristic. Intolerably painful anal spasm is often present. This dis- ease sometimes afEords a multiplicity of reflected symptoms. Diagnosis. — Anoscopy reveals a narrow gray or red erosion or ulceration lying between the pilasters. Careful and systematic digi- tal eversion of the anal folds, at the time when the patient bears down, may disclose the lesion. When the point of the probe comes in contact with the fissure, the patient usually signifies that the lesion is discovered. Fissures are most commonly situated posteriorly but may be situated at any point in the anal circumference. A hypertrophied bit of tissue of a pale gray colour, and of about the size of a pin head, is often noticeable at the lower end of the fis- sure; this is the thickened wall of the anal pocket, to which Ball has given the name of sentinel pile. Treatment. — The ulcer, if superficial, is to be touched with caustic or the electric cautery. This treatment is to be repeated after inter- vals of several days. It may be alternated with, or replaced by, the application of ointment, stimulating or sedative according to the re- quirements of the ulcer. A convenient method of applying the oint- ment is shown in the obturator-applicator (Fig. 337). This may be done by placing the ointment in the cup, as shown in the illustration, lubricating the distal end of the instrument with the ointment, and introducing the anoscope to the necessary depth. This manoeuvre places the ointment at a point opposite the diseased area where the obturator is to be steadied while the anoscope is drawn ofi^ it. The anus clasps the applicator around the anointed neck. Gentle rotation and withdrawal of the instrument expands the anus and exposes the otherwise infolded and concealed diseased area, and rubs into its surface the medicament which the grasping anus completely strips from the obturator. Application of nitrate of silver solution is efficacious. The simplest and most efficacious treatment in that form of fissure that undermines the integument at its inferior end, consists in splitting the pocket by means of a small scalpel under infiltration anesthesia by means of eucaine or nirvanine solution. The hypertrophied tissue should be trimmed away. The ulcer should then be touched with a solution of nitrate of silver, 40 grains to the ounce, and an opium sup- pository introduced. The anus should be subsequently dilated twice daily and the wound kept open till perfectly healed. Semidaily im- mersion of the hips in hot water should be practised. The conven- tional operation for fissure which requires general anaesthesia, divul- sion of the sphincters, and their division by incision, is haphazard surgery and not uniformly curative, mutilates an important organ, is hazardous to its functions, and, in a measure, dangerous to the life of the pationi:. Ulceration of the Rectum. — Salient 8ym.ptoms. — There is usually steady ficliing or scnsaiion of heat and weight in the sacral region anrl liiMihMr spine; tlio disease is initiated with a short period of obsti- 54 834 A TEXT-BOOK OF GYNECOLOGY pation or constipation, sometimes followed by a somewhat longer period of diarrhoea; finally, there are discharges of mucus. The feces are sometimes streaked with mucus, with patches of membrane, and with specks of blood, and there is always more or less purulent material discernible. Pain and soreness are not uniformly present when the disease is situated high up in the rectum, but are invariably present when it is situated near or at the anus. Diagnosis. — Proctoscopy reveals the fact that the mucous mem- brane lining the rectal chambers is deeply injected. The arborescent arterioles may appear in clusters of bright red twigs. The club-shaped venous radicles, which are of a purple colour, may be observed some- what elevated above the surface of the mucous membrane at various points throughout the chambers, and there is a generally diffused red- ness throughout the entire area involved. Extensive proctitis some- times prevents inflation of the rectum. This may be overcome by spraying the rectum with a 4-per-cent solution of cocaine, which causes an ischemia, thins the wall of the organ, and renders it inflat- able or dilatable by the use of the coactor. The ulceration is charac- terized by the destruction of a circumscribed area of epithelium occu- pied by reddish granulation tissue; the surface is often seen coated with inspissated muco-pus. Ulceration may be accompanied by a more or less diffused chronic proctitis with general superficial erosion of the mucous membrane. Venereal ulcers present their typical fea- tures when situated in this organ. Tuberculous ulceration presents a clearly defined border and is usually surrounded by a pale blue mucous membrane. Microscopic examination of scrapings positively determines its character. Treatment. — Inflammation and ulcerations of the rectal mucous membrane may be rapidly cured by spraying the part with silver- nitrate solutions of 3 or 4 grains to the ounce. With the patient under proctoscopic examination, the operator should take the proctoscope in his left hand, and in his right, the anal atomizer which should be attached to a compressed-air reservoir. By co-ordinate movement of the hands, each of the chambers involved in the disease may be rap- idly and systematically sprayed with the solution (Fig. 340). If the hand-bulb spray is used, an assistant will be required to hold and direct the proctoscope from chamber to chamber. Fig. 3-iO. — "Each of the chambers involved in the dis- ease may be rapidly and systematically sprayed." — Maktin. INFECTIONS OF THE RECTUM 835 Because of the humidity of the rectum, the actual cautery should not be introduced into it as the consequent rapid evaporation occa- sions intense pain. Chancroid ulcers should be coated once with the charcoal-and-sulphuric-acid paste. Enemas of bovinine prove decid- edly reparative. Rectal lavage should be employed daily. Fistula. — Salient Symptoms. — Muco-purulent discharges from the rectum, or sero-purulent discharges from an opening in the adjacent anal surface, are the common manifestations of this disease. Diagnosis. — With the patient in the Sims posture, manual eversion of the buttocks should be practised while the patient is required to bear down. At this moment, ocular inspection of the field should be made. Crypts, lacuna, or other depressions of the surface, should be critically examined with the point of the probe. .Should the probe enter, the patient should be required to relax the parts, and a tentative search should be made for the internal orifice of the fis- tula. The probe should be steadied and the patient put into Martin's posture, which usually smooths out the intra-anal folds of membrane, and the anoscope introduced, and, by means of another probe, in- spection should then be made of the mucous surface of the anus to determine if there is an internal orifice. The internal orifice of a fistula discharging internally is usually marked by small granulations or vegetations. The search may be made more thorough if a small applicator is employed to smooth out intra-anal folds of mucous mem- brane. The sphincters should be cocainized and a fenestrated conoid speculum, such as Aloe's, inserted on its obturator, and the obturator or slide withdrawn. This instrument should be introduced with its fenestrum straddling the tissues penetrated by the first probe. Care- ful search for an internal orifice should be repeated. If none is dis- covered, the probe should be withdrawn and the cavity of the fistula injected, at its external orifice, with a sterile solution of milk or per- oxide of hydrogen and the anoscopy repeated. If even this manip- ulation fails to discover an internal orifice, further search should be abandoned till the time of operation. Treatment. — The probe should be introduced into the external orifice of the fistula, the conoid speculum reintroduced, and its fenes- trum made to straddle the probe as already described. The tissue from the external orifice of the fistula to a point within the anus as bigh as the distal end of the probe, should be subjected to infiltration anaBsthesia. The probe should be thrust onward through the mucoiis membrane and into the channel of the gut. An incision should be made through both mucous and cutaneous surfaces down to the probe. If, on the other hanrl, the fistula has an internal, but no external open- ing, the probe should be bent to form a long hook-end and should be carried through the anoscope or Aloe's speculum, and into the in- terna] orifice. When it has been made to pass as deeply toward the cutaneous surface as possible, the anoscope should be withdrawn and an effort made to draw tlio prob(!-hook deeper tbrough the relaxed g3<3 A TEXT-BOOK OF GYNECOLOGY tissues and toward the skin. The probe should be steadily maintained in this position while the fenestrated conoid speculum is made to straddle it. Infiltration anaesthesia should be established, and an incision made in the manner already described. The wound should be antiseptically dressed and cared for. The more radical operation, con- sisting in dissecting out the sac and suturing together the freshened surfaces of the walls of the fistula, may be performed under local anaesthesia. This operation begins where the simpler procedure just described leaves off, inasmuch as that technique is necessary to expose the fibrous structure of the fistula wall. Bleeding vessels should be clamped and hot gauze pads applied to the wound till all hemorrhage is checked, for a bloodless field is necessary for infiltration anaes- thesia. The hemorrhage stopped, the anesthetic solution should be injected all about the fibrous tissue to be removed, the most accessible portions should be seized with a hemostat for convenience of manipu- lation, and a rapid dissection made. An assistant must follow each sweep of the knife with the hot gauze, for anaesthesia and a non- bleeding field go hand in hand. The fibrous tissue should not be re- moved piecemeal; the portion dissected loose may be used as a re- tractor to facilitate the dissection of that still attached. The parts, fascia, sphincter and other muscle, and integuments, should be re-an- nesthetized and the wound closed by suture. Fistul^e located laterally and anteriorly to the anus, and having an external orifice, if the recto- vaginal^ septum is not divided, take a course forward into the labium majus, or backward toward the anterolateral anal quadrants, which they tend to enter between the sjDhincters. Fistulfe situated in the ischiorectal fossae usually penetrate the rectum on the side of their origin and between the sphincters. If they enter the body farther, they generally take an outward direction beneath the levator ani or cocc5'geus muscle. External fistulae are not often situated posteriorly. But, not infrequently, a complete internal fistula may be discovered by means of the diagnostic technique described, situated posteriorly, and having an inferior orifice at the border of the internal sphincter and a superior orifice posteriorly and above the coccygeo-levator ani. When the probe has entered an inch (2.54 centimetres) or more, a fenestrated curette should be introduced into the rectum to a point Fig. 341. — The valvotome. — Martin (page 837). higher than the estimated site of the end of the probe, and an endeav- our made to hang the curette thereon. If this succeeds, and the curette can not be directly withdrawn, the diagnosis of the complete IXFECTIOXS OF THE RECTUM 837 fistula just described is made. A grooved director should be substi- tuted for the probe, a 3-inch needle fixed to the hypodermic syringe, and the tissue between the director and the rectal lumen infiltrated with the anaesthetic; then the special knife shown in Fig. 341 may be put into the director and made to cut through the ano- rectal wall. When this is ac- complished, the director and curette may be withcbawn without removing the former from the f enestnim of the lat- ter. The fibrous base of the fistula should now be curetted and subsequently packed. Daily anal dilatation should be enjoined till the wound heals. Simple external fis- tulas of recent origin may be cured by curettage, by injec- tion of stimulating fluids, and by vigilant general care. Abscesses and fistulte in the pelvic floor about the anus, often present the most complex problems. Their per- fect comprehension involves a study of the faseise of the pelvic floor. Stricture of the rectum is a diminution of tlie calibre of the bowel from any cause. Usually it is the result of an ulceration leaving thickened walls of contractile tissue (Fig. 342). Tumours within or without the bowel are often responsible for this affection; again, it may be the result of an enlarged prostate, or of the pressing of the rectum back upon the bony structures by a retroverted uterus. In exceptional ca.ses, it is due to fibrous bands extending from one side of the bowel to the other. From the standpoint of physical exploration, strictures may be divided into three classes: viz., (a) annu- lar or narrow; (h) tubular or broad, and (c) nodular. In the first, only a small portion of the bowel is involved; in the second, the strictured area may occupy several inches; while in the third, the obstruction is the result of one or more nodular tumours projecting into the Fig. ?A-2 -•• Ulceration leaving thickened walls of contractile tissue."' — Gaxt. 838 A TEXT-BOOK OF GYNECOLOGY calibre of the bowel at one or more points. Again, strictures are further divided, and are called complete when there is total obstruction, and incomplete when all or a part of the faeces escape through them. Congenital strictures will not be dealt with here. From a pathological standjaoint, Gant classifies strictures of the rectum as follows: (1) Traumatic; (2) syphilitic; (3) tuberculous; (4) catarrhal; (5) dysenteric; (6) malignant. (1) Traumatic. — All agree that traumatism is a frequent cause of stricture of the rectum. It may be the result of any one of a number of operations performed about the rectum and anus for the relief of hemorrhoids, fissure, ulceration, fistula, prolapse, or cancer. It is sometimes caused by direct injury to the rectum as the result of an accident, or the swallowing of some hard substance, as a piece of bone or a pin, which lodges near the anus and keeps up a constant irrita- tion. The most frequent cause of traumatic stricture is constipation and impaction. Chronic constipation, where the faeces are allowed to remain in the bowel for several days at a time, is a frequent cause of stricture. (2) Syphilis may be the cause of stricture of the rectum as a resiilt of chancres or chancroidal ulceration in the initial stage, of gummatous deposits, or of extensive ulceration following the break- ing down of such deposits, the latter being by far the more frequent cause. Syphilis probably causes as many strictures as all the other etiological factors put together. (3) T uhfrculosis of the rectum sel- dom causes stricture, because, when the tubercles begin to give way, they can only exceptionally be successfully healed, in consequence of the absence of contractile tissue. Gant has seen cases of marked constriction, however, that could not be attributed to other causes, (■i) Chronic catarrhal inflammation of the rectum may result in stric- ture as the result of occlusion brought about by the inflammatory thickening of the bowel, or from an ulceration started and maintained by the presence of large quantities of irritating mucus. (5) Dysen- teric stricture is rarely seen in this section of the country, because here we have dysentery only in a mild form, but in tropical countries, where it is common in the severe form, it frequently results in a light stricture. (6) Stricture due to cancer is found as often in the rec- tum, as in all other parts of the intestines. It may be the result of one or more large hard masses obstructing the calibre of the bowel, or be due to cicatrization following ulcerations when they break down, or to both these causes. The symptoms of stricture may be local or constitutional, depend- ent upon the condition at the time of observation; if extensive ulcera- tion is present and the obstruction is complete, the usual symptoms of the accumulation of pus and obstruction will be present. The symptoms usually met with in a bad case of stricture are, constipation at the beginning; diarrhoea, intermitting with constipation; intense straining; a sensation as though the bowel never completely emptied itself; slight rise in temperature; occasional chill; indigestion; mild INFECTIONS OF THE RECTUM 839 peritonitis; tympanites; usually loss in weight; incontinence; dis- charges of pus, blood and mucus; pain in the rectum and distant parts ; change in size and character of the faeces ; numerous long slen- der skin tags, and partial or complete obstruction. Diagnosis. — A large majority of rectal strictures are located in the lower 3 inches of the bowel and are easily recognised. When in the upper part, if they can not be located by the aid of bougies and the colon tube, an ansesthetic should be given, the abdomen opened, and the gut pulled up and examined. Treatment. — The treatment is (a) palliative, and (b) operative. (a) Palliative measures for the relief of stricture consist in keeping the stricture open and hastening absorption; softening the fgeces that they may pass through it ; alleviating pain, and protecting the system against the absorption of poisons contained in the rectum because of the pus and retained faeces. Iodide of potassium in increasing doses and the massage of the stricture with the fingers or soft bougies, do a great deal of good in the earlier stages; but when the constriction is composed of contractile tissue the results are not so good. The diet should be restricted, so far as possible, to fluid and semi- solid foods, and to those which leave little residue. Pain is best alleviated by keeping the rectum clean with astringent, stimulating, or antiseptic solutions; when faecal masses accumulate above the stricture, mild laxatives should be used, and high enemata of water, soap- suds, or oil and glycerine, but strong purgatives should never be given. In order patient may get at night, opium, chloral, or the intelligently ad- that the some rest morphine, bj'omides. Fig. 343. — ^"The calibre of a stricture may be ma- terially increased by means of gradual . . divulsion." — Gant (page 840). ministered, will do as well as any other drugs; but they must be given with caution, for this affec- tion is chronic, and many of these sufferers readily fall into the habit of taking them to ease their pain. (b) Operaiive. — In spite of the best palliative treatment, most stric- tures gradually progress until partial or complete obstruction is pres- ent, anrl it is rie(;essnry to resort to ;iti operation to give them tempo- g40 A TEXT-BOOK OF GYNECOLOGY rary or permanent relief. Enthusiasts in the use of electricity main- tain, that, by this means, they can destroy the stricture or cause it to be absorbed. Gant, however, from what he has seen, is inclined to doubt the accuracy of this claim. The following are the most favoured surgical procedures for the relief of stricture of the rectum, viz. : 1, dilatation ; 3, internal proc- totomy; 3, external proctotomy; 4, excision; 5, colostomy. The calibre of a stricture may be materially increased by means of gradual (Fig. 343) or forcible divulsion. The first is accomplished gradually by the passage of graduated soft-rubber bougies ; steel in- struments should not be used because of the danger of rupturing the bowel. Bougies should be used two or three times each week until relief is obtained. If the patient will give her consent, forcible divul- sion is preferable, because, under general anaesthesia, we can accom- plish with the fingers in five minutes what would otherwise take weeks. Strictures of more than 3^ inches should not be divulsed un- less every precaution has been taken, for if the bowel is ruptured, the rectal contents are dumped into the peritoneal cavity and death will shortl^v result. Inter tied proctotomy is done by guiding a blunt-pointed bistoury with the index finger until it is above the point of constriction, when the latter is severed at one or more points as the case demands. A piece of gauze is then placed in the incisions, to be changed from time to time, and the rectum cleansed as after any other wound in it. External (or complete) proctotomy is performed by carrying the knife above the stricture, as in the internal method; it is then pointed backward until the bony structures are reached, when it is brought down and out, dividing the stricture and other tissues including both sphincters, thus leaving a long, deep, triangular cut. The advantages of this operation over the one Just described, are several; it permits of free drainage, bleeding can easily be detected and arrested, it allows the free exit of accumulated faeces, and admits of medication, at all times, both below and above the strictured area. When a stric- ture involves only the superficial structures of the rectum, is freely movable, and is situated near the anus, excision is justifiable. When ulceration is extensive and obstruction is threatened, colostomy should be insisted upon, for it is the only thing that offers any permanent relief from the never-ending desire to stool. Frequently, after this operation, patients gain flesh and return to their work feeling like new beings. This operation is described in the chapter on Malignant Growths of the Eectum. CHAPTER LII NEOPLASMS OF THE RECTUM AND ANUS Adenoma — Lipoma — Fibroma — Papilloma — Angeioma — Teratoma (dermoid cysts) — Retention cysts — Myoma and enchondroma — Malignant growths, symptoms, treatment — Operations : Divulsion ; internal proctotomy ; posterior proctot- omy ; curettage ; colostomy ; excision — Hemorrhoids, causes : External, symp- toms, treatment : Internal, symptoms, treatment — Operations : Injection ; Whitehead's; ligature; clamp and cautery. The rectum and anus are the seat of new growths as frequently as other parts. Some writers labour under the mistaken idea that ma- lignant tumours and simple polypi are about the only neoplasms to be found in this locality. Gant does not deny that they are of fre- quent occurrence, but there are a variety of other growths which mani- fest themselves in the rectum with varying frequency. Any of the fol- lowing-named tumours are likely to be met with by physicians having a large rectal following: (1) adenoma (polypus); (2) lipoma; (3) fibroma; (-i) papilloma; (5) angeioma; (6) teratoma (dermoid cysts); (7) retention cysts ; (8) myoma; (9) enchondroma; (10) malignant growths; (11) varicose tumours (hemorrhoids). Adenoma (Polypus). — Adenomata are found more frequently in the rectum than in any other part of the intestinal canal. In fact they occur there with greater regularity than almost any other tumour. Benign or simple adenomata are common in childhood, and com- paratively rare in adults, unless preceded by some other disease with a coincident discharge. On the other hand, malignant adenomata usu- ally attack those past middle life, and are rarely seen in children. All rectal tumours have a tendency to become pedunculated, because 'they are dragged down daily by the faeces. The word polypus is com- monly applied to any growth in this locality having a narrow or pedunculated laminar attachment, with a large movable pendulous ex- tremity. Van Buren once said that "in proportion as a tumour becomes pedunculated its danger of being malignant lessens." Gant's experi- ence has been in accord with Van Buren's. ISTevertheless, it is at times diflicult to flistinguish between the benign and malignant forms of adenoma. There are two kinds of polypi, the adenoid, or soft (Fig. 344), and the fibrous, or hard (Fig. 345). In rare instances, either of these growths may be found in great numbers scattered over the en- tire rectal mucosa; they are then distinguished as disseminated polypi. 841 842 A TEXT-BOOK OF GYNECOLOGY Symptoms. — Polypi vary in size from that of a pea to that of an English walnut. The symptoms depend largely upon the size, loca- tion, number, and condition, of the tumours when seen. When situ- ated high up in the rectum or sigmoid, they manifest their presence by irritating the mucous membrane, causing a sensation of uneasiness and the discharge of considerable mucus. Occasionally, they cause Fig. 344. — " The adenoid or soft polypus."- Gant (page 841). Fig. 345.- ■ The fibrous or hard polypus."- Gant (page 841). invagination, tenesmus, and straining. If ulcerated, they bleed, and, when located near the anus, they protrude during stool. As a rule, they cause little pain unless strangulated. Treatment. — Ordinary polypi are easily cured when within reach. They may be clamped with Gant's clamp, cut off, and the stump thor- oughly cauterized with the Pacquelin cautery. When a cautery is not available, ligature and excision will prove quite as effective, but will cause more pain. When small, they may be seized with forceps and ^ twisted off; when high up in the rectum, the snare is sometimes serv- iceable; Gant prefers in such cases to seize the growth with a long- handled clamp forceps and allow it to remain in situ until it comes off of its own accord. Medication in these cases will prove unsatis- factory. Once in a while polypi come away spontaneously or are detached by faecal accumulations. Lipoma. — Fatty tumours are occasionally met with in the anal region and do not differ in their construction from that of similar tumours in other localities. Gant has seen them both in the circumrectal tissues and under the skin at the anal margin. One tumour on the buttock at the verge of the anus was quite as large as a goose's egg. NEOPLASMS OP THE RECTUM AND ANUS 843 Treatment. — The treatment consists in their enucleation and the closure of the wound with catgut. Fibroma. — In rare instances fibromata develop about the anus and vulva, and in the rectal wall, without becoming pedunculated. They then present themselves in the form of hard, smooth tumours (Pig. 346). They resemble fibromata of the cutaneous surface in every way, except that they are cov- ered by mucous membrane. Papilloma. — Papillomata are not uncommon in this re- gion because of the irritation of the parts by the faeces and infectious discharges coming from the vagina. Senn has frequently seen the rectum studded with papillary tu- mours varying in size from that of a hemjD-seed to that of a cherry. They are to be seen on the skin about the anus just about as frequently as upon the mucous mem- brane. As before intimated, they may be the result of a syphilitic, chancroidal, or gonorrhoeal infection, or they may reveal themselves with- out any previous discoverable irritation. When located in- side the rectum they are ac- companied by occasional hemorrhages, the discharge of mucus, and tenesmus; when upon the skin, by smarting, soreness, and a foul odour when multiple and in clusters. Treatment. — Palliative measures are now and then effective. These consist in cleanliness, cauterization with acids, carbolic and nitric, or the application of astringent powders, as tannic and gallic acid, aluiii, zinc, or calomel. The radical method of cutting them off with scissors and cauterizing the stumps with the actual cautery is the most satisfactory way of dealing with them. Angeioma. — A few cases of angeioma (nsevus) of the rectum have bo(!n recorded. Gant has never seen what he considers a typical case, though he has met with vascular growths which bled freely from vari- ous points. They were flat tumours, located about 3 inches above the anus. Fig. 346. — " In rare instances fibromata develop about the anus and vulva and in the rectal wall." — Gant. 84^ A TEXT-BOOK OF GYNECOLOGY Treatment. — They should be extirpated by ligation or cut away with scissors, the bleeding being arrested with the Pacquelin cautery. Teratoma (Dermoid Cysts). — Dermoid cysts containing hair and sometimes teeth are not at all uncommon in the sacral region, and are frequently the exciting cause of fistula. Now and then they are found in the rectal wall and the hairs may be seen projecting into the rectum or out at the anus. They vary in size from that of a cherry to that of an apple. Their symptoms and management in this locality are the same as in other parts; the safest treatment is complete removal. Retention Cysts. — Eetention cysts filled with secretions and excre- tions, which may or may not have undergone degeneration, are at times found in and outside the rectum. They occasionally reach enormous proportions, Gant having removed one 8 inches in circumference. In one case, they may be filled with firm sebaceous material, in another, with a fairly thick whitish fluid. They cause no discomfort further than a fulness of the part affected. Treatment. — The entire cyst wall should be carefully dissected out and the wound united with catgut, otherwise the cyst will refill. Myoma and Enchondroma. — New growths composed of muscular and cartilaginous structures have been found in the rectum. The former is of more frequent occurrence than the latter, and is found in that situation with greater frequency than in other parts of the intestine. Nothing short of removal should be considered for their relief. Malignant Growths. — There is still doubt as regards the true cause of malignant tumours. Statistics, however, show that they are on the increase in the rectum as well as in other organs. This does not apply to the negro race, as negroes are practically immune to this disease. Because of its function and make-up, the rectum is the seat of about 80 per cent of all morbid growths occurring in the intes- tines. Malignancy is common in middle life, less so in old age, and rarer still in childhood. The prognosis is, as a rule, bad, few living more than a year after the disease is recognised. In exceptional cases^ however, patients may live two, three, and even four years. The younger the person, the sooner death will ensue. Malignant growths of the rectum develop principally from glandular tissue, and are grouped by Cripps {Rectal Cancer, third edition, p. 56) under the one head of adenocarcinoma. Sarcoma is extremely rare in this region, but Gant operated on a case of fibrosarcoma with multiple fistula involv- ing the rectum and anus (Fig. 347). Carcinomata may manifest themselves as flat tumours in the rectal wall, may project into the lumen of the bowel, or circumscribe the lumen by a nodular band. Because of this difference in their clinical appearance. Cooper and Edwards (Diseases of the Eectvm and Anns, p. 190) have de- scribed them as laminar, tuberous, and annular. Squamous-celled carcinoma (epithelioma) is occasionally met with at the mucocuta- neous margin. NEOPLASMS OF THE RECTUM AND ANUS 845 Symptoms. — In the earlier stages of rectal cancer, patients do not complain of acute pain, but of sensations of uneasiness, weight, and fulness in the bowel. When the tumour grows to considerable pro- portions and breaks down leaving a large ulcerated area, the following symptoms will be present : (1) Irregular or constant pains in the rectujn, neighbouring or- gans, and back of and down the limbs; (2) typical cachectic waxy complexion; (3) tape or ribbonlike stools; (4) prolonged straining and a never-ending desire to empty the bowel; (5) abundant dis- charges of blood, pus, and mucus; (6) loss of flesh; (7) because of increased peristalsis, food is rushed through the alimentary canal un- digested; (8) constipation intermitting with diarrhoea; (9) low Fig. 347.— "A case of fibrosarcoma with multii^le tistulfe involving the rectum and anus." — Gant (page 844). form of peritonitis; (10) obstruction partial or complete ; (11) when the growth is located at the verge of the anus, pain is much more severe owing to sphincteric contraction; (12) in the majority of cases there is partial or complete incontinence. Treatment. — The treatment of malignant tumours of the rectum is unsatisfactory because most patients die in spite of anything that can be clone. While Gant does not feel justified in stating that this disease is incurable, he does believe that total extirpation results more often in failure than its advocates would have the profession believe. Medication is useless beyond the relief it offers from pain, in the liquefaction of the faeces, and as a disinfectant in the various solu- tions used Tor iiiigating purposes. The diet should be regulated and these sufferers slnndd have plenty of sunshine and strengthening food. 846 A TEXT-BOOK OF GYNECOLOGY Operations. — The following operations have been suggested for the relief of cancer of the rectum : ( 1 ) Divulsion, rapid, with the fingers, or gradual with bougies; (3) internal proctotomy; (3) posterior proc- totomy; (4) curettage and cauterization; (5) colostomy (Ailing- ham); (6) excision. The operations to be described should, with the exception of excision, be regarded as palliative measures only, and those who hope to make a radical cure with them will be disappointed. Divulsion. — Sometimes there are patients suffering from new growths at the anus and low down in the rectum, who are threatened with obstruction, and are constantly annoyed by straining in their endeavour to relieve the bowel, who yet refuse to let the knife be used. In such cases, it is justifiable to resort to stretching the rectum, either wdth the fingers or bougies as may be deemed best (Fig. 3-il), and temporary relief will follow, because the fseces escape and the rectum can be irrigated. Internal proctotomy consists in passing a probe-pointed bistoury beyond the point of constriction and incising the stricture or growth one, two, three, or as many times as becomes necessary, to relieve the obstruction. As a rule, the wound soon heals, contraction follows, and the operation requires to be repeated. Posterior proctotomy is, next to colostomy, the best of all the palliative operative procedures. It is performed as follows : Protect the knife with the finger and pass it well above the obstruction, then directly backward to the bony structures, and thence downward, carry- ing it through the rectum and sphincters, until the cut is on a level with the tip of the coccyx, thus making a long deep triangular wound that gives plenty of room for the escape of accumulated faeces and at the same time permits free drainage, a great advantage over the inter- nal method. Post-operative treatment consists in topical applications to the ulceration, and the occasional passage of a bougie to prevent rapid contraction. Curettage. — Persons suffering from that form of malignant growth in which numerous cauliflowerlike masses project into the rectum, inducing pain and the frequent discharge of pus and blood, can fre- quently be relieved by scraping them down to a level with the rectal wall, and then burning the raw surface thoroughly with the actual cautery. The operation should be repeated as soon as the growth returns. Colostomy is the most satisfactory measure we have for the relief of rectal cancer, and we do not except excision, taking one case with another. It diminishes the patient's suffering because it permits a free exit to the fascal matter above the diseased part, thereby doing away with the diarrha3a and straining. It permits free irrigation of the rectum. Many patients soon regain the flesh they had lost and, in fact, feel like new beings; and they are not constantly annoyed by the escape of faeces through the artificial anus as some writers have stated. The lumbar opening has been discarded for the inguinal (Fig. 348), NEOPLASMS OF THE RECTUM AND ANUS 847 principally because the patient can take care of herself after the latter. The most important point in the operation is to make a good spur, so that, when the gut external to the skin is removed, the ends of the Fig. 348. — "The lumbar opening has been discarded for the inguinal." — Gant (page 846j. intestines will remain parallel, thus insuring that the faeces shall be deposited on the outside and not escape into the rectum as is the case when this precaution is not taken. A procidentia may ensue (Fig. 349) when the mesentery is too long, in which case several inches of the in- testine should be cut off to prevent this accident. Excision. — Some writers af- firm that by ex- tirpation of the growth they can effect a perma- nent cure in a Fig. 349. — " A procidentia may ensue." — Gabtt. large percentage of their cases; such claims are just the opposite of the experience of those surgeons that confine their practice to diseases of the rectum. Gant does not say that life is not materially prolonged by this operation, 848 A TEXT-BOOK OF GYNECOLOGY but he does believe^ however, that the patients radically cured in this way are few indeed; it has been his experience that the growth soon re- turns. Excision is all right in properly selected cases, but, in most in- stances, the surgeon does not see the patients until the disease is far advanced. A gro\\i;h situated near the anus can usually be removed by making a posterior incision as far back as the coccyx. After the coccyx is removed, sufficient room will be obtained to enable the operator to free the rectum from its attachments, this being best done with the fin- ger or a jjair of blunt scissors. The growth is then cut away, leaving the sphincter if possible, and the distal and proximal ends united; when there is too much tension, bleeding should be arrested and the bowel allowed to retract. If the peritoneum has been opened, it should be closed with catgut sutures or protected with sterile gauze and let alone. Bougies should be passed biweekly to prevent too much contraction. The high excision, or Kraska method, consists in removing a portion of the sacrum for additional room, and the suturing of the gut into the upper end of the wound when it can not be brought down and united to the severed gut below. The chief advantage claimed for this operation is that it gives sufficient room for the surgeon to remove the Fig. 850.^" Eecurring adenocarcinoma about the sacral anus following Kraska's operation." — Gant. entire growth. However, Gant had a case of recurring adenocarcinoma about the sacral anus following Kraska's operation (Fig. 350). Hemorrhoids differ so widely in location, appearance, and make-up, that it is impossible to give a satisfactory definition of them. In a general way we might define them as being vascular tumours of the mucous membrane of the rectum, the anus, or both. They may be external or internal; the former are covered by integument, and the latter by NEOPLASMS OP TFIE RECTUM AND ANUS 849 mucous membrane. Tumours covered in part by skin and in part by membrane are known as combination piles. Causes. — The larger rectal veins pass through the rectal wall by means of little slits (Fig. 351). Verneuil believes the return flow of venous blood is impeded by the contraction of the muscular fibres around them, and, for this reason, he thinks that these little button- holes are an important factor in the causation of hemor- rhoids. We believe this to be in a measure true, but there are other factors that play a much more important part; because of gravitation, and the fact that the rectal veins have no valves, the erect pos- ture assumed by man has a great deal to do in the pro- duction of enlarged veins. Again the fasces, by the time they reach the rectum, are solid, and frequently cause venous obstruction. Certain obstructive diseases of the heart and liver, a retroverted uterus, stricture of the rectum or urethra, chronic diarrhoea, overpurgation, stone in the bladder, or anything that presses upon the veins, are causes ; frequent and pro- longed straining will, sooner or later, produce hemorrhoids. Many cases can be traced di- rectly to irregularities in liv- ing. In fact, anything that forces an abnormal amount of blood into the rectum, or interferes with its return therefrom, may be regarded as a cause. External Hemorrhoids. — There are two kinds of external piles; when composed of hypertrophied folds of skin, they are called cutaneous, when filled with a firm dark clot, thrombotic. The former are usually cbronic and are the colour of the skin, the latter come on suddenly, have a bluish tint, and look like a bullet beneath the skin. Symptoms. — Under favourable circumstances they produce a sen- sation of fulness about tlie anus. When inflamed, a smarting is felt, and when relief is not to be had, the sphincter becomes irri- table and the suffering is materially increased by its frequent con- traction. Fig. 351. — " The larger rectal veins pass through the rectal walls by means of little slits." — Gant. 850 A TEXT-BOOK OF aYNECOLOGY Treatment. — In so far as the palliative treatment is concerned, both varieties of external piles should be treated alike. The diet should be restricted to fluids and semisolids, and if this does not suflice, a laxative should be given. For this Gant prefers Carabana water, 2 ounces in a tumbler of warm water before breakfast. The inflammation should be reduced by constant application of hot poultices, cold appli- cations, or lotions composed of lead, zinc, alum, opium, krameria, or other astringent remedies. When the suffering is sufficient to keep the patient awake, relief may be had by an injection of one fourth of a grain of morphine sulphate. To allay pain and soothe the sphincter muscle, the following ointment, which the patient may use freely both inside and outside the anus, may be given: 1$ Morphinse sulphatis grana vj to viij ; Calomel grana xij; Vaseline 5J- Sig. Use freely. An ointment composed of opium and belladonna is a good com- bination and will diminish pain. Surgical Treatment. — When the physician has the election of the method of treatment in a given case, he should not waste time with palliative measures, but should relieve the patient quickly and per- manently by operation, in one of two ways. The cutaneous pile should be cut off with the scissors and the edges of the wound brought to- gether with catgut or allowed to granulate. The tliromhotic variety should be laid open with a bistoury, the clot turned out, the rent in the vessel cauterized, and the cavity packed with gauze, which prevents hemorrhage and allows the blood to escape in case bleeding occurs. A combination pile should be treated as the internal variety, except that the incision should be extended to include some of the adjoining skin. Internal Hemorrhoids. — There are two varieties of internal hemor- rhoids: capillary and renous. The former are supplied principally by the superficial vessels of the mucous membrane, and the latter by the veins of the mucous and submucous tissues. Capillary piles are broad flat tumours that bleed readily and look very much like strawberries. Venous piles are of frequent occurrence and are composed of dilated veins. They may be small, may remain within the bowel and bleed freely, or they may be large and protruding, and may bleed occasionally (Fig. 353). The symptoms of hemorrhoids vary according to the duration, kind, and violence of the attack. The following are some of the more com- mon symptoms subject to the above conditions: (1) Protrusion all or a part of the time. (3) Bleeding varying from a few drops to a pro- fuse hemorrhage. (3) A sensation in the rectum as if there was some- thing in the bowel that ought to come away. (4) Pain, intermittent and slight, or excruciating and constant, according to the amount of inflammation, ulceration and strangulation. (5) Spasmodic contrac- NEOPLASMS OF THE RECTUM AND ANUS 851 tion of the anal sphincters. (6) Extreme nervousness and loss of flesh. (7) When piles are ulcerated, there is more or less pruritus caused by the discharge. (8) When strangulation continues for several days, it causes constipation and a slight rise of the temperature. Treatment: Palliative. — Correct errors in diet, keep the faeces soft, and return all protruding tumours when seen before strangulation has begun, for once they are caught outside the anus no at- tempt at reduction should be made, because the irritable sphincter would immediately throw them out again. The re«iedies suggested in the treat- ment of external hemorrhoids for the relief of pain and in- flammation can be successfully employed in the treatment of internal hemorrhoids. When there is bleeding, it becomes necessary to inject astringent solutions into the rectum and, by means of a speculum, to apply styptics directly to the ulcers. This procedure will re- quire several days, and the pa- tient will suffer considerable pain before piles that are stran- gulated • can be relieved, and patients should be made to un- derstand this from the start. Surgical. — Many authorities discountenance operation on piles that are strangulated, ul- cerated, or inflamed, until after the reduction of the tumours and inflammation and the healing of the ulceration. Gant advises an operation irrespective of their condition, so soon as the patient's consent can be obtained, for the reason that she will be about after a radical operation in a shorter time than it takes to reduce the inflammation. Many operations have been devised for the cure of hemorrhoids, but the injection, Whitehead's, the ligature, and the clamp-and-cautery methods, are the only procedures worthy of spec'al consiflecation. Injection. — This method was the rage ten. years ago; to-day, it is resorted to only in carefully selected cases. Any one who is foolish enough to attempt to cure all piles, irrespective of location or condi- tion, by injecting tbem, will be sadly disappointed. He will not only fail to cure his patients, but will cause them much unnecessary Fig. 352. — "They may be large and protrud- ing, and may bleed occasionally." — Gant (page 850). 852 A TEXT-BOOK OF GYNECOLOGY suffering and a greater loss of time than if they had had the clamp- and-cautery or ligature operation performed. This method of treating piles apjjeals to the patients because they do not have to take an an- aesthetic, submit to the knife, and suffer pain, and they are not pre- vented from following their occupations. This is true in successful cases; but in others, their suffering is excruciating, because of slough- ing, ulceration, abscess, or fistula, and they fail to be cured after all they have gone through. If only small pendulous piles, situated well above the grasp of the external sphincter, are injected, the results will be gratifying. Many solutions have been brought forward, but only those containing carbolic acid deserve commendation. This drug has been used successfully in combination with distilled water, glyc- erine, and olive oil, varying in strength from 4 to 75 per cent. Yount prefers the weaker, and Agnew the stronger, solution. Gant uses the following mixture: I^ Carbolic acid 3j ; Glycerine, ) ^^ '^-: ^.'',.„ ' , y aa oi. Distilled water, j M. Sig. Inject from 5 to 10 drops in small, and from 10 to 15 in large piles, and see that they are pushed out of reach of the sphincter. Whitehead's Operation. — This operation consists in detaching the mucous membrane from the skin and dissecting it from the submucosa until the upper part of the pile-bearing area is reached; it is then amputated and the distal end brought down and sutured to the skin with silk sutures, which are allowed to cut their way out. Whitehead says that it is the most natural method, requires few instruments and little dexterity, and that there is less pain, and danger of secondary hemorrhage from it than after either the ligature or the clamp-and- cautery operations. The operation is radical, but Gant's experience bears him out in saying that it is difficult and bloody, and requires more instruments, a longer time to perform, and causes more pain owing to tension, than either the clamp-and-cautery or the ligature. Because of tension and the danger of infection, nonunion is common. As a result, the portion of the bowel between the anus and the retracted gut is uncovered by mucous membrane, leaving a broad circular ulcer- ated band that eventually terminates in stricture, incontinence, and pruritus. There is also an absence of the normal secretions to lubricate the fgeces, and a loss of sensibility to warn the patient of an approach- ing stool. When primary union is obtained, these patients are up and about in two weeks. Ligature. — Only a few years ago nearly all the prominent surgeons of this country were doing the ligature operation. To-day, the clamp- and-cautery ranks equally with it in popularity, and in a few years more it will probably be the operation of election for the radical cure of piles. Hippocrates and Celsus used the ligature by simply placing NEOPLASMS OF THE RECTUM AND ANUS 853 Fill. J.) > - i; M Eicketts uses the hgatuie submu- cously, beginning at the muco-eutaneous margin." — Gant. it around the pile and allowing it to slough off. Modern surgeons first make an incision at the mucocutaneous border before applying the ligature, in order that the nerves may not be includ- ed, and severe afterpain may be thus avoided. The final result of either op- eration is equally good, for both effect a radical cure in a much shorter time, and with fewer com- plications and less incon- venience than any other operation. B. M. Eick- etts uses the ligature sub- mucously, beginning at the muco-cutaneous mar- gin (Fig. 353). The liga- ture may encircle in its sweep the bases of sev- eral tumours. Then, be- ing brought out at the point of original insertion, it is tied, causing subsequent atro- phy and disappearance of the hemorrhoids (Fig. 354). Clamp-and-Cautery. — This operation, as com- pared with the ligature, is comparatively new, yet it has been given sufficient trial by the profession to gain for itself an enviable reputation. Gant j^refers this to the ligature opera- tion because after it there is less pain, spasm of the sphincter, and bladder dis- turbance, and patients are able to resume their oc- cupations m.ore quickly. Hemorrhoids can be re- moved just as quickly with the clamp-and-cautery as with the ligature, and there is just as much dan- ger of secondary h(!morrhage occurring after one as the other (Fig. 355). Before he flevis(!(] liis own clamp (Fig. 350) Gant had a serious hemor- rhage after tin's operation, due to an imperfect instrument allowing Fui. 354.- -" Being brought out at the point of original innertion, it is tied." — Gant. 854 A TEXT-BOOK OF GYNECOLOGY a part of the stump to slip through the clamp after the tumour had been cut away, and before there was an opportunity to cauterize it. He has also had the same accident because of a ligature slipping dur- ing a violent attack of coughing. Bleeding does not occur when Fig. 356. — "Hemorrhoids can be removed just as quickly with tlie clamp-and-cautery as with, the ligature." — Gant (page 853). cauterization is properly done; the tissues should be thoroughly burned with the cautery at a red heat, and the clamp loosened and read- justed if there is any bleeding. G-ant has been doing this operation constantly for the past ten years and has not had a fatal hemorrhage or a stricture or other accident following it. Mathews says: "I use this plan (clamp-and- cautery) in selected cases, viz., where there is a large amount of skin around the anus, which is embraced in, or goes to make up, a part of the internal hemorrhoid. If this amount of skin is cut off, excessive bleeding may occur. If an incision is made around it and it is ligated, we are chary about cutting too close to the liga- ture, and therefore we have much skin left and many ligatures." Gant's Fig. 356. — Gant's clamp (page 853). NEOPLASMS OF THE RECTUM AND ANUS 855 experience has been the opposite of tliis; he has found that the bleed- ing following the removal of piles covered by skin is of no importance, and is easily arrested by a gauze compress. It is not surprising that patients thus operated on suffer great pain, for excruciating pain fol- lows the cauterization of the skin in any part of the body, and Gant never removes a skin pile by the clamp-and-cautery for this reason; he does operate on all internal hemorrhoids in this way, because there is so little post-operative pain when the cauterization is confined to mucous and submucous tissues. Allingham says: " My most careful researches have led me to a conclusion that it (clamp-and-cautery) is quite six times as fatal as the ligature, properly and dexterously ap- plied." He does not, however, point out what causes these fatalities, nor does he give statistics to substantiate his statement. Gant has never known of a i^erson dying from this operation, nor has he seen such a case recorded in medical journals. No doubt there are cases of death from this cause on record, but the same can be said of the ligature operation. CHAPTEE LIII PELVIC DISEASES AND NERVOUS AFFECTIONS Coincidence of pelvic and nervous diseases — Neurasthenia: Symptoms, conclusions — Hysteria : Symptoms, pathology, conclusions — Operations for the neuroses — Nervous symptoms of pelvic disorders. Coincidence of Pelvic and Nervous Diseases. — It has been thought wise that some one should present briefly in this treatise, from the standpoint of the neurologist, the essential facts in regard to the nervous affections to which women are especially liable. As is well known, pelvic and nervous diseases frequently exist concurrently in the same patient. This fact alone makes a consideration of the nerv- ous features of special importance. Besides, the advance made in the study of functional nervous diseases has been equally great with that made in gynecology. Views, new and comprehensive, now throw light upon fields where formerly there was only darkness and confusion. Neurasthenia is one of the two great neuroses to which women are especially liable, the other being hysteria. Too often the physician turns aside from the subject of neurasthenia as uninteresting, as being a term applied to a condition rather than a disease, and as pre- senting symptoms that are vague and ill defined, from a study of which nothing definite can be gained. In reality, neurasthenia is an exceedingly interesting affection; one which, far from displaying a vague and ill-defined symptomatology, presents a symptom group as fixed and as definite as that of any disease with which we are acquainted. It is true that, now and then, the symptoms differ widely in detail, but they always present the same essential features. They are always expressive of fatigue, and Dercum has, therefore, proposed for neu- rasthenia the far more expressive name of the fatigue neurosis. The stamp of fatigue is ineffaceably fixed upon every case. Every symp- tom is expressive of weakness, of irritability, and of ready exhaustion. A brief glance at the clinical picture will bear this statement out. The symptoms of neurasthenia resolve themselves into sensory, motor, general somatic, and psychic disturbances. Most of them are the direct result of chronic overfatigue; a smaller number are an indirect result, and these serve, at times, to complicate the picture. Dercum has separated the symptoms into two great groups: first, the primary or essential symptoms of neurasthenia; and, secondly, the secondary or adventitious symptoms. 856 PELVIC DISEASES AND NERVOUS AFFECTIONS 857 Beginning with the sensory symptoms we have, first, a general sense of fatigue or tiredness. This may be diffused throughout the entire body, but is generally accentuated in special regions, e. g., the head, the back, or the limbs. It is characteristic of this sense of fatigue that, in the simple and typical cases, it is brought on if absent, or made worse if present, by effort. It is expressive of diminished power for the sustained expenditure of energy, and it is to be looked upon as one of the primary symptoms of neurasthenia. The sensation that characterizes it is one of generalized distress or discomfort diif used throughout the entire body, and is not referred to any particular re- gion. In this respect, it closely resembles the sensation of fatigue that follows prolonged exertion in perfectly healthy persons. However, if the conditions causing this general sense of tiredness persist, the sensa- cion ceases to be merely one of fatigue and becomes one of pain. In other words, when fatigue sensations become exaggerated, they become painful, and they are then described by the patient as aches of various kinds and are referred to special regions. Very commonly, for in- stance, the patient complains of headache. When present in a mild degree, this headache is diffused, and is described as -a dull feeling or a dull aching, and is then relieved by the mere cessation of work, that is, by rest. When it is more pronounced, it becomes accentuated in certain regions. Thus, it is referred especially to the occiput and the upper portion of the neck, and is often associated with sensations of drawing and tension. At other times, though less frequently, it is referred to the brow or to the vertex. Often other sensations are present, such as pressure, constriction, giddiness or ringing in the ears. These sensations are not themselves the direct ovitcome of fatigue, but belong to the group of the secondary or adventitious symptoms, men- tioned above. They may or may not be present. JSText in frequency to headache, patients complain of backache. This, at first, may consist of a simple feeling of fatigue referred to the lumbar region, which is relieved by lying down, but which, later, may become so exaggerated as to make backache the most prominent feature of the case. This backache is, as a rule, widely diffused over the lumbar region; it sometimes extends over the sacrum and gluteal regions, and at other times, and more frequently, upward over the dorsal region, especially between the shoulder blades. Often, cutaneous hyperes- thesia makes its appearance, so that the back, especially over the vertebra?, becomes sensitive to pressure. Frequently, this painful hypersesthesia is present in spots that can be covered by the tip of the finger. It is found especially over the seventh cervical spine, over the upper thoracic spine, sometimes over the lumbar spine and sacrum, and very frequently indeed over the coccyx. Without going into de- tails, it may be said that these symptoms, which were formerly and in- correctly grouped under the head of spinal irritation, clearly belong to the secondary, or adventitious, symptoms of neurasthenia. Not infre- quently, an (;spf:ci;illy i);iinrul sfjot is foiiiHl sliglilly below and within 858 ^ TEXT-BOOK OF GYNECOLOGY the left shoulder blade. Less frequently, a painful area is found in a similar situation below the right shoulder blade. Fatigue aches may also be referred to the limbs, namely, to the arms and shoulders, the hips, the thighs, or the legs. They consist, as a rule, of a dull aching, which is diffused through the tissues, generally diminished or relieved by rest and made worse by exertion. Limb ache is not infrequently associated with the special occupation of the patient. Thus Dercum has observed arm ache in a neurasthenic pocket- book-maker, leg ache in neurasthenic letter carriers and collectors, and not infrequently, as a matter of course, in neurasthenic sales- women. When we turn our attention to the phenomena presented hy the special senses, we find that the symptoms are also expressive of chronic fatigue; but without stopping to analyze them here, as this would be too great a departure from the legitimate object of this chapter, it may be merely stated that the symptoms are those of ready exhaustion. As regards the eye, they are referable to fatigue of the accommodative apparatus, of the retina, or, it may be, of the cerebral centres. One of the common statements which we hear from neurasthenics is that they can not read for more than a few minutes at a time, that the letters become blurred, and that the effort gives rise to pain, generally headache or other cephalic distress, such as vertigo. Similar truths obtain with re- gard to the other special senses. When we turn to the motor symptoms of neurasthenia, we find that these, also, are expressive of fatigue. They consist more especially of muscular weakness, which develops rapidly under exertion, of tremor, and of various modifications of the tendon reactions. The -object of this chapter forbids their discussion in detail, as well as a consideration of the visceral and general somatic disturbances. These have been fully considered elsewhere. Suffice it to say, that the disturbances of circula- tion, of digestion, of secretion, and of the sexual functions are, all of them, manifestations of chronic fatigue. For instance, the primary symptom referable to the digestive tract is that of digestion delayed and enfeebled, an atonic indigestion, both gastric and intestinal. The disturbances of circulation are manifested by feebleness of the pulse, coldness of the extremities, disturbances in the rhythm. of the heart's action, and even by heart murmurs. The disturbances of secretion are evidenced by change in the character and quantity of the perspira- tion, of the urine, and of the saliva; these again are also purely and solely related to fatigue. Allien we turn our attention to the psychic disturbances, we find that they, too, are expressive of fatigue. A marked and characteristic sjmiptom, namely, the diminution of the capacity for sustained intellectual effort, is invariably present. As the patient is incapable of long-continued physical labour, so is she in- capable of long-continued mental labour. The attempt to perform mental labour, sooner or later brings on symptoms of exhaustion, and if the task is persisted in, marked fatigue sensations make their appear- PELYIC DISEASES AND NERVOUS AFFECTIONS 859 ance, especially headache. Associated with the impairment of the power of sustained effort, there is a lack of power of concentrating the attention, and this the patient frequently mistakes for loss of memory. In addition to these symptoms, there is a lack of spontaneity of thought and a diminution in the strength of the will, a condition of general indecision and of mental and emotional irritability. Frequently, fear also is present, and may assume a general or a special form; in the latter case, it gives rise to the various specialized fears, such as claustrophobia, agoraphobia, etc. If we pause to analyze the primary symptoms of neurasthenia, we find that they are always expressive of chronic fatigue, but there is present, as the essential condition, not only a marked and persistent diminution of nervous energy, but also an increased reaction, mental and physical, to external impressions. In other woTds, to nervous weak- ness there is of necessity joined nervous irritability. Diminished re- sistance to fatigue implies diminished resistance to impressions from without; weakness and irritability are thus necessarily associated. This is seen, for instance, in the motor symptoms, where muscular weakness is associated with increased reflex excitability, and in the sensory symp- toms, where, to the fatigue sensations, there are sooner or later added the symptoms of local hypereesthesia; this is the explanation of the hypersesthesia so often found over the spinous processes, over the coccyx, and over various other areas. Another illustration of the same general truth is found in the fatigue of the eye; here, the patient is not only unable to use the eyes persistently, but there is also present, sooner or later, painful hypersesthesia, i. e., an irritability of the eye to light, so that neurasthenics often begin to wear smoked glasses of their own accord. It is this increased reaction to impressions from without that is of striking importance, as we shall presently see, when we deal with organic affections occurring in neurasthenic subjects. Briefly restating the facts, we find that the two cardinal conditions of the fatigue neurosis, neurasthenia, are (1) persistent nervou.s weak- ness, and (2) increased nervous irritability, that is, increased reaction of the organism to impressions from without. When we apply this interpretation of neurasthenia to the study of the diseases of the vari- ous special organs, we find at once that a ready explanation is pre- sented for many of the strange facts we meet with. How remarkable it is that an eye defect often remains undiscovered for years; but a man who has become neurasthenic now finds that exertion of the eyes brings on headache, or makes headache worse, if present, because his resistance to fatigue has been diminished; in other words, an exertion so slight as to he utterly inadequate to evoke any symptoms whatever in a healthy man, may in a neurasthenic rapidly bring on a fatigue head- ache, now termed an eye headache. In the same way, a local defect or disease in other portions of the body may remain undiscovered so long as the general ]ic;ill li icmains good, and may only make itself felt when neurasthenia hccouics established — i. e., when the nervous system pre- 860 A TEXT-BOOK OF GYNECOLOGY sents the phenomenon of increased or abnormal reaction to local im- pressions. This fact has especial application to gynecology. It is well known that a woman with a laceration of the cervix or perineum, a displacement, or possibly a prolapsus, of the ovary, may make no com- plaint so long as her general health remains good; not infrequently, she fails to seek medical advice for the pelvic condition until neuras- thenia has become established. The foregoing considerations of neurasthenia warrant the following almost self-evident condusions: First, that neurasthenia may exist independently of any local dis- ease, pelvic or otherwise. Secondly, that neurasthenia and pelvic disease may exist independ- ently in the same individual. Thirdly, that when pelvic disease is present with neurasthenia, the pelvic symptoms may be more readily recognised by the patient and therefore become more prominent, because in neurasthenia the reaction of the nervous system to abnormal or pathologic impressions is greatly increased. Without pausing to apply these conclusions to the question of surgical intervention let us turn our attention to hysteria. Hysteria, as has already been stated, is one of the two leading neuroses occurring in women. Dercum knows of no affection concern- ing which there is still so great a lack of knowledge in this country and in England, notwithstanding the fact that the French, and later the Germans, have unmistakably defined and described the symptom- atology of this disease. We frequently hear it stated, and almost as frequently see it printed, that hysteria is a disease without a syndrome; that it is a disease which presents an " infinitude of shifting polymor- phic nervous disturbances.^' This last phrase is borrowed from a text- book on the practice of medicine, published in this country no earlier than 1897; and nothing could be more untrue. In reality, hysteria presents a syndrome that is as fixed and as definite as that of any other disease with which we are acquainted. The symptoms of hysteria, particularly its cardinal symptom, like those of neurasthenia, are always present and always characteristic; while it is equally true that other symptoms, secondary in importance, are from time to time added, though the number of the secondary symp- toms is far less than those met with in neurasthenia. Dercum terms hys- teria a psychoneurosis because the physical symptoms present in it are dominated by mental phenomena, themselves the result of a genuine and profound affection of the cerebral centres. Prominent, for instance, are emotional disturbances and modifications of the will, but to these are added phj^sical signs so striking that they can never be misunderstood. The symptoms of hysteria, like those of neurasthenia, consist of sensory, motor, general somatic and psychic phenomena. Let us begin with the sensory symptoms. In neurasthenia, the sensory symptoms consist for the most part of fatigue sensations combined with symptoms of sen- sory irritability. In hysteria, on the other hand, fatigue sensations are PELVIC DISEASES AND NERVOUS AFFECTIONS 861 absent, but instead there may be present true anaesthesia, complete or partial; in other words, we are at once impressed with the fact o± true sensory loss, which never occurs in neurasthenia. Further, this sensory loss or anesthesia is so characteristic as to enable us frequently to make a diagnosis of hysteria from it alone. Allusion need only be made to the symptom of hemiansesthesia, in which anesthesia is confined to one half of the trunk and head, and to the limbs of one side. Strange to say, this sensory loss involves most frequently the left side. Again, the loss of sensation may be less widely distributed, in which case it is frequently characterized by peculiarities of location; for instance, it may be confined to a segment of a limb, that is, it may extend from the elbow to the wrist, or from the knee to the ankle, and is then termed segmental anaesthesia; again, it may cover the fingers, hand, wrist, and the arm up to a certain level, like a glove, and is then spoken of as glovelike angesthesia; or it may cover the foot, ankle, and the leg up to a certain level, and then is spoken of as stockinglike angesthesia. At other times, it assumes curious geometrical or irregular shapes. A fact which strikes the observer at once is the absence of correspondence between the various areas of anesthesia and any nerve supply or any sensory representation in the spinal cord. This fact naturally refers us, while seeking for the seat of the disturbance, to the cerebrum. As regards hysterical hemianesthesia, this cerebral involvement is fur- ther rendered probable by what we know of the pathology of organic hemianesthesia, and it becomes still more probable when we reflect that the facts at our disposal lead us to infer that the representation of the limbs in the cortex is by segments. To sum up, therefore; in hysteria it is the distribution of the sensory loss which is characteristic, and which at once stamps it as hysterical. An important fact, however, should in this connection be borne in mind, and that is that the sen- sory losses in hysteria are most frequently far from being complete. Indeed, the most frequent condition that we find is that of diminution of respojise to tactile, to painful, and to thermal impressions, there being present under these conditions merely a general lessening of sensation, a hypo-esthesia, or hypesthesia — as it is termed technically. Partial sensory losses, therefore, having the peculiar distribution that has been stated, are as unmistakable in their significance as total sen- sory losses, which are less frequently met with. Far more important, however, than anesthesia or hypesthesia, is the hypercestJiesia which is found in hysteria. This, also, may have a most varied distribution, but as a matter of clinical fact it seeks by preference certain localities. Thus, most frequently, there are found areas of hyperesthesia under the breasts, so-called " inframammary tenderness,'' and areas of hyperesthesia above the groins, grossly mis- named " ovarian tenderness." These areas of hyperesthesia are some- times found on both sides of the body; more frequently, however, they are limited to one side of the body, and, curiously enough, like hemi- anesthesia, they are found most frequently upon the left side. Areas 862 A TEXT-BOOK OF aYNECOLOGy of hypersesthesia are also frequently found upon the scalp, and here the patch is often so small that it can be covered with a finger-tip. Not infrequently, these areas of hyperesthesia become areas of excessive pain, hyjDeralgesia. The areas are not only tender, but they become painful — not only painful to touch, but spontaneously painful. A familiar instance is found in the hypergesthetic area upon the scalp, which, when spontaneously painful, gives rise to severe headache, that form of headache known as clavus hystericus. What is true of the hyperffisthetic area of the scalp, is also true of the hyperaBsthetic area below the breast; sometimes it centres in the nipple and then gives rise to mastodynia. That both clavus and mastodynia are affections attended with much suffering, no one will deny. AYhen the area of hyperesthesia in the inguinal region becomes painful, the suffering may be equally great. Owing to the anatomical relation which the inguinal region bears to the ovary, inguinal pain has been greatly misunderstood. As already stated, it has been misnamed ovarian tenderness, and has been directly attributed to the ovary; and yet there can be no doubt with regard to the nature of this pain, for we must remember that it is quite frequently found in men, as well as in women in whom the ovaries have been removed — removed sometimes in a vain attempt to relieve this pain. The pain is not ovarian; it should never have been called ovarian. Inguinal tenderness, groin pain, or, as Dercum prefers, inguinodynia, are terms much simpler and in strict accordance with facts. The pain is, as a rule, confined to a limited area, and is found most frequently upon the left side; and it is very often associated with a similar, though somewhat larger, area of tenderness beneath, or over, the left mammary gland, and, it need hardly be added, with other definite, well- marked hysterical stigmata. As a rule, it is revealed, by careful exami- nation, to be superficial and not deep. It is situated in the skin and the tissues of the abdominal wall, and not within the pelvis. Dercum has frequently demonstrated this to be a fact by means of the following procedure : The painful area having been carefully localized on the abdominal surface, the tip of the forefinger of the right hand is allowed to rest lightly upon it; the left forefinger is then introduced into the vagina and directed upward and to the right, until its tip is immediately be- neath the tip of the forefinger of the right hand which is upon the abdominal wall. Just as soon as pressure is made between the two fingers, the patient flinches; while the patient does not flinch when pressure is made in other directions or when other portions of the abdominal wall are included. By this means Dercum has succeeded not infrequently in isolating and demonstrating beyond a doubt the site, and therefore the character, of this pain. In some cases, just as in spinal tenderness, the pain radiates and becomes somewhat diffused; but it always radiates from a superficial centre in the abdominal wall; and just as there are cases of spinal tenderness in which the tenderness PELVIC DISEASES AND NERVOUS AFFECTIONS 863 is at one time superficial, and at another deep, so there are cases of inguinal tenderness in which the tenderness seems at times to be deep- seated; but even here, by the procedure just described, the maximum point of pain can always be isolated and shown to exist in the abdom- inal tissues. This hysterical inguinal pain has frequently forcibly sug- gested to Dercum the clavus hystericus — the boring penetrating pain that hysterical patients feel in limited areas about the head; and, indeed, not infrequently this inguinal jaain is just as severe, but it is no more intrapelvic in its origin than is the clavus of the head. It is not necessary to speak of the contracture of the visual fields in hysteria, nor of the reversal of the colour fields, as they do not in this cha|)ter directly concern us. They must, however, be borne in mind as affording valuable corroborative evidence of the existence of hysteria. The motor symptoms of hysteria are less frequently met with than the sensory disturbances which we have just considered. The motor symj^toms consist, in brief, of paralysis, contracture, tremor and inco-ordination. The jaresence of motor sym]3toms generally causes the case to be referred to the neurologist in the beginning, rather than to the gynecologist, and they, therefore, will not be considered in this con- nection. Similarly, with the visceral symptoms, which consist of dis- turbances of digestion, of the circulation, of the heart, of respiration, of fever, of cough, of loss of voice, of yawning, of phantom tumours, etc. They also are less likely to come before gynecologists for inter- pretation, and, moreover, are so characteristic as to stamp the case at once as hysterical. The psychic symptoms of hysteria, however, are important for the gynecologist. There is always some abnormity of the mental faculties in hysteria, more particularly a hypersesthesia and irritability of the affectional or emotional faculties. The patient is, as a rule, exceedingly impressionable, and reacts inordinately to impressions involving these faculties. She is abnormally sensitive to suggestions, especially with regard to her physical condition, and willingly accepts explanations attributing her symptoms to local disease. JSTot infrequently, hysterical symptoms are brought to the surface, or, if present, are made promi- nent, by the ill-considered statements or injudicious interest manifested by the patient's friends. It can be readilv seen how doubly injurious under such circumstances incautious statements by a physician, or a pelvic examination, even when the latter yields a negative result, may be. One can hardly judge of the enormous mental impression a first examination must make upon a young girl, especially if that girl is already hysterical, already neuropathic by heredity and predisposition. Not only is the great evil of the moral shock to be taken into account, but also the fact that tbere is lodged in the patient's mind a more or less vague but fixed belief tliat she has some mysterious local disease to which she only too willingly agrees to attribute her nervous mani- festations. In consequence, she sooner or later insists upon a repeti- tion of the exaininfil ion or a continuance of the local treatment once 864 A TEXT-BOOK OF GYNECOLOGY begun, and the morbid idea thus implanted may become hopelessly rooted, never, i^erhaps, to be displaced. The enormous role which the mental condition in hysteria plays, must constantly be borne in mind. Hysteria appears to be a functional disturbance of the entire nervous system, but with a special involvement of the cerebral cortex. The conclusions that the above considerations justify, are the fol- lowing: First, that hysteria may exist independently of any local disease, pelvic or otherwise. Secondly, that there is no essential relation between pelvic dis- ease and hysteria, even when the two affections coexist in the same case. Thirdly, that while in hysteria there is an increased reaction to external impressions, this reaction is purely psychic. The patient is exceedingly impressionable, and reacts inordinately to impressions in- volving the affectional or emotional faculties. This reaction to external impressions differs altogether from that seen in neurasthenia, for, in the latter, the reaction involves the nervous system as a whole. In hysteria, the jjatient readily accepts the suggestion — often a spontane- ous self-suggestion — of pelvic disease, especially as groin pain is so common a symptom of hysteria. Fourthly, that the pain areas of hysteria bear no relation to dis- ease of the deeper structures. Operations for the Neuroses. — -Evidently the surgeon can not hope by operation to remove the symptoms characteristic of the neuroses, but only those symptoms properly belonging to the pelvic disease itself; and his operation should never be undertaken for any other purpose. To state the truth in other words, the surgeon should operate for the pelvic condition itself. For instance, if he operates on a tear of the perineum, he should do so because the tear has resulted in mechanical difficulties — because it has given rise to a displacement of the uterus or perhaps to a rectocele, not because the tear occurs in a neurasthenic or hysterical woman. If he removes an ovary, it should be because the ovary is unmistakably diseased. If he removes an appendix, he should do so because the characteristic symptoms of appendicitis are present, and not because the patient suffers from neurasthenia or hysteria. If he sews fast a movable kidney, it should be because the mobility of the organ is such as to threaten mechanical obstruction of the ureter with its consequent hydrops of the kidney, or because the patient suffers from irregularly recurring attacks of gastro-intestinal cramp directly dependent upon the abnormal mobility of the organ, and not because she is neurasthenic or hysterical. Operations should be performed, not for the relief of an incidental nervous symptom, but because of the local condition itself; just as we set a broken leg in an insane man, not because he is insane, but because the leg is broken. The surgeon should approach cases of neurasthenia and cases of hysteria somewhat differently. Contrary to what might, perhaps, be PELVIC DISEASES AND NERVOUS AFFECTIONS 865 inferred, Dercum believes that, in neurasthenia, operations for the cure of actual pelvic lesions are indicated, and should, other things being equal, be performed. We remember that in neurasthenia there is added to nervous weakness, nervous irritability; that there is an in- creased reaction to local disease, and it is just as clearly indicated to correct local pelvic disease in neurasthenic patients as it is to give such patients glasses to relieve their ocular symjjtoms. It is important, however, in considering operations upon neurasthenics, to bear in mind that these patients are excessively sensitive to nervous shock. All gynecologists are familiar with the persistent nervous symptoms — the persistent surgical neurasthenia — that ensues in some patients after jDclvic operations. If such operations are undertaken u23on persons already neurasthenic, great harm may be done. Therefore, if, in a <3ase requiring pelvic operation, neurasthenia is present in any degree (provided, of course, that the operation is not urgently indicated for •surgical reasons), Dercum believes that the patient does better if the •operation is preceded by a j^eriod of rest. If the patient, instead of being neurasthenic, is hysterical, a period of i^reliminary rest is even more strongly indicated. This he believes to be specially true when the hysteria is very profound. In the latter case, operation should be deferred, unless, of course, the surgical indications are urgent. Nervous Symptom^ of Pelvic Disorders. — A view is entertained by many physicians that certain nervous disorders are the direct result of pelvic lesions. Unfortunately, the increase of our knowledge regarding functional nervous diseases does not bear out these assertions. The nervous symptoms caused by pelvic disease are, as a matter of fact, exceedingly limited. It is true that there is present pelvic pain, pain referred to the back and to the hips and thighs, together with more or less marked indications of general ill-health, but certainly these symp- toms can not be dignified by the term of a nervous disorder. They are a part of the pelvic disease itself, and are directly symptomatic of it. They do not constitute neurasthenia or hysteria. ]\Iany years ago a doctrine, known as the doctrine of reflex nervous disorders, had an exceedingly strong hold u^^on the profession. An increasing knowledge of the various functional nervous diseases has demonstrated this doctrine to be utterly fallacious. Long since, the practice of circumcision for ei^ilepsy has been abandoned, as has also the removal of ovaries for the cure of the same disease and of hysterical convulsions. Both procedures had equally little foundation and both were equally unscientific and barbarous. The reader can readily understand why it is unnecessary to discuss the relation between the pelvic disease and epilepsy, chorea, and other nervous diseases. The truth can all be summed up in a word, there is 710 relation. The same truth obtains with regard to the insanities. For instance, the various abnormities of menstruation that are observed in the course of an insanity, are the indirect sequela? of the general ill- lie;! lib from wliifli IIk; paiifnt suffers, and not due to any apocryphal 866 A TEXT-BOOK OF GYNECOLOGY relation between the condition of the pelvic organs and the insanity.. Insanity, like epilepsy, depends upon morbid changes within the ner- vous system itself; these changes in turn being dependent, in all proba- bility, upon profound, and as yet undetermined, changes in the general nutrition of the organism. The statement is sometimes made that insane patients who have been subjected to operation sometimes get well, but we should remember that a lucid interval or even an apparent cure sometimes follows a mere physical shock, such as a fall or other trauma. Indeed, a recovery is not an infrequent result of some inter- current infectious malady, such as erysipelas or typhoid fever. A full and dispassionate consideration of the entire subject leaves to the surgeon no other option than to operate for surgical indications- only; and, in certain cases, where the nervous disorder is grave, as in profound hj^steria, profound neurasthenia, and in insanities attended with great exhaustion, operation should be undertaken only when the- surgical indications are urgent. (See Indications for Oophorectomy.), INDEX Abbe, 692. Abdomen, auscnltation of, 40. bandage for. 111; illus., p. 112. massage, 24. nonpeudulous, 466. pendulous, 466; illus., p. 467. percussion of, 40. palpation of, 40. regions of, 41; illus., 41. Abdominal section, 99. drainage in, 114. instruments foi', 103. location of incision, 103. making the incision, 107. preliminary treatment for, 100. preparation of field, 66. terminology, 99. Abel, 362, 389, .556. Abortion, as a cause of menorrhagia, 716. as a cause of metrorrhagia, 719. criminal, 10. tubal, 655. Abscess, ischiorectal, 826. kidney, 768. metastatic, 57, 58. pelvic, 689. vulvo-vaginal gland, 245. Absence of, Fallopian tubes, 473. hymen, 133. kidney, 849. ovary, 560. rectum, 806. uterus, 276. vagina, 126. Adamkiewicz, 442, 443. Adams, 294. Adenoma malignum evertens, 430. invertens, 4.30; illus., p. 431. Adenoma, of kidney, 782. histology, 782. ovary, contents, 620. histology, 620. rectum, 841. symptoms, 842. treatment, 842. uterus, 429. cautery in, 431. curettage in, 431. hemorrhage from, 431. recurrence of, 432. treatment, 431. Adenomyoma of uterus, 397, 399. Adenosarcoma of kidney, 783. histogenesis, 784. Adhesion, as a complication of ovarian tu- mours, 631. inguinal, 297. labial, 120, 212. of movable kidney, 717. preputial, 120, 211. treatment, 212. rectal, 832; illus., 822. separation of, 547; illus., p. 548. treatment of, 294. treatment of, in ovariotomy, 642. vulvar, 211. Accidents, in anaesthesia, 95. hj'sterectomy, 415. Acconci, 576. Aetius, 1. Afanassiew, 166. Ahlfeld, 436. Air embolism, 74. in use of chloroform, 94. Albarran, 747, 760, 763, 764, 767, 772, 791. Albicans oidium, 167. Albuminuria, 681. Alcohol, as an anaesthetic, 97. Alexander, 294, 295, 297, 303, 305, 309, 324, 361, 564. Alexander's operation on round ligament, 294. Allingham, 855. Allis inhaler, 92; illus., p. 92. Aloe, 835. Alquie, 294. Altormyan, 394. Alyard, 448. Amann, 434, 440. Ameiss, 278, 279. Amenorrhcea, acquired, 721. frequency of, 720. treatment, 721. Amputation of the cervix, 340; illus.. p. 342. Ansemia, as a cause of amenorrhcea, 722. as a cause of menorrhagia, 714. causes, 722. treatment, 722. Anaeslhesia, 87. accidents in, 95. alcohol in, 97. 867 868 A TEXT-BOOK OF GYNECOLOGY Anaesthesia, cause of bronchitis, 91. central, 97. cyanosis in, 90. for children, 91. hypnosis for, 98. in examination, 40. kidneys in, 102. local, 98. manipulation of head, 96. sexual, 9. struggling in, 90. vomiting in, 91. Anaesthetic agents, 87. selection of, 88. Anatomy, of corpus luteum, 13. Fallopian tubes, 489. hair follicle, 199. movable kidney, 755. parovarium, 670. pelvic floor, 250. rectum, 806. urachus, 803. vulvo-vaginal glands, 243. Anderson, 41. Andrews, Edmund, 441. Angeiodystrophia ovarii, 17. Angeioma of kidney, 781. rectum, 843, 844. Angeiosarcoma, 624. Angeiotribe, 81. for hemostasis. 81. in panhysterectomy, illus., p. 419. Animal extracts, 21. Animals, menstruation of, 699. Anomalies, see Malformations. Anoscope, 812. use of, 814. Ante-deviations of the uterus. 310. cuneohysterectomy for, 315. curettage for, 312. diagnosis of, 310. dilatation for, 312. pathology of, 311. surgical treatment of, 312. symptoms of, 310. treatment of, 311. Antisepsis, 56, 60. post-operative, 68. precautions for, 295. Anuria, 780. Anus, Assure of, 820, 832. imperforate, 120. malformations of, 806. ulcer of, 832. vulvar, 121; illus.. p. 122. Aphthae of external genitalia, 179. treatment, 179. Apostoli, 24, 680. Appendicitis, diagnosis of, 504. Appetite, sexual, 588. Approximation of abdominal incision, 104, 105. Aretseus, 328. Arloing, 180. Armanientarium, 27. Armamentarium, gynecological, 27. ofHce examination, 31. Aron, 388. Asche, 235. Aschoff, 231, 769. Ascites, 630. as a complication of ovarian tumour, 635. Asepsis, 56. Ashton, W., 348, 349, 735. Askanazy, 174. Aspiration, 546. as a means of examination, 47. instrument for, 546; illus., p. 546. Assault, indecent, 160. Astringents, 22. Astruc, 1. Atlees, 638. Atmocausis, 367. Atresia ani vestibularis, 221; illus., p. 122. Atresia, of cervix, 279. Fallopian tubes, 495. hymen, 132. ureters, 150. vagina, 126; illus., p. 127. vulva, 119; illus., p. 119. Atrophy of, ovaries, 592. causes, 592. symptoms and treatment, 593. uterus, 18. vulva, 207; illus., p. 208. diagnosis, 210. etiology, 208. treatment, 210. Auscultation of abdomen, 40. Auto-infection, 165. Avicenna, 328. Aveling, 329. Ayner, 764. Bacilli, 53; illus., p. 54. Bacillus aerogenes capsulatus, 54: illus., p. 58. infection by, 180. Bacillus coli communis, illus., p. 54. Bacillus coli infection of Fallopian tubes, 487, 528. causes, 528. pathology, 529. symptoms, .528. Bacillus coli, infection of ovary, 575. Bacillus diphtheria, 167. Bacillus phlegniouis emphyseniatosus, ISO. Bacillus tuberculosis, 55; illus., p. 54. infection by, see tuberculosis of. Bacini, 677. Bacon, 18. 212, 427. Backer, 358. Bacteria of, cervix, 353. chancroid, 183. cystitis, 791. Fallopian tubes in disease, 484. in health, 484. methods of access, 486. external genitalia, 163. INDEX 869 Bacteria of lochia, 166. ovaries, 570. puerperal fever, 376. pyosalpinx, 485. renal infection, 769. salpingitis, 484. sepsis, 18. uterus, 352. vagina, 163. Baer, 720, 740. Bagot, 683. Baldy, 136, 257, 678, 680. Ball, John, 312, 313, 8.33. Ballantyne, 120, 121, 122, 123, 124, 127, 131, 133, 134, 279, 318, 473, 474, 475, 562. Ballottement, 634. Ballowitz, 749, 750. Balneotherapy, 22. Band, vestibular, 131: illus., p. 132. Bandage, abdominal. 111; illus., p. 112. Bandelocque, 463. Bandl, 331, 683. ring of, 332. Bandouin, 294. Bangs, 774. Bantock, 588, 6 Barbier, 131. Barnes, Robert, 329, 461, 649, 700, 711. Barth, 478. Bartholin, glands of, 243. Bartlet, H. L., 459. Baruch, 367. Basedow, 712. Bath, sitz, 204. Battey, 2, 584, 723. Battey's operation, 584. Battle, 778. Beaucoudray, 617. Becker, 753. Bell, 638. Benbrook, 346. Bennet, 2. Berggriin, 694. Bergh, 200. Bergmann, von, 24. Bernard, 192, 763. Bernitz, 649. Bernliardes, 279. Bettman, 209. Bicornate uterus, 281: illus., p. 279. menstruation from, 280. symptoms, 278. Bigcard, 458. Bilharz, ISO. Bilharzia, of vagina, 180. Billroth, 24, 038. 626. Bimanual examination, 37: illus.. p. 37. Birch, 781, 78.3. I'.itncr, 12.3. I'.lafkr-r, .562. Bladder, calculus in, 140, 141. congest iou of, 780. inrcfllori of. 701. infl:ijiini;il i'.ii uf. T;iO. Bladder, neuralgia of, 795. tumours of, 798. Blondel, 277. Blood cyst, of corpus luteum, 600. structure, 601; illus., p. 601. Blood, examination of, 49. extravasation of, 492. transfusion of, 76. Bloom. 737. Blot, 473. Blumer, 514. Blundell, 471. Bockart, 53, 198. Bode, 294. Bodenhamer, 806, 807. Bodenstein, 867. Boeck, Cajsar, 216. Boisleux, 503. Bossi, 370. Bovee, 477, 647, 648. Bouilly, 458. Bowditch, 5. Bozeman. 148. Bozeman's dressing forceps, illus., p. 369. table, 143. Braetz, 434. Brain wei.ght, 7. Brandt. Thure, 25, 353, 3.59. Braun. Carl. 180, .324, 329, 681. Braxton-Hicks, 725. Brehmer. 692. Breisky, 207, 208, 429. Brenner, 747. Broese, 372, 373. Bromide of ethyl, as an ansesthetic, 91. administration of, 95. Bronchitis as a result of ansesthesia, 91. Brosson, 204. Brown, Baker, 638. Browne, Sir J. Crichton, 7. Brues, 389. Bruhn, 229. Brunn, 692. Bubo, 515. chancroidal. 181. internal. 392. Buchner. 098. Buckmaster. 122. Buds, syncytial, 427; illus., p. 428. Bulbo-cavernosus muscle, 250. Bulius, 17. 599, 610, 695. Bulkley, 206. Bullard, J. W., 257. Bumm, 16. 52, 53, 244, 246, .353. 334, 376, 377. 378, 379, 517, 617, 698. 791. Burns, 462. Burow, 19.3, 196. Byford, 257, 294. 301, 302, 546. Byrne, .Tohn, 83, 456, 4.58. 4.59. Byrne's electro-hysterectomy, 4.56: illus.. p. 546. Csesarean scriion, 460. after-troatmont, 470. closure of uterus, 469. 870 A TEXT-BOOK OF GYNECOLOGY Csesarean section, dangers of, 465. definition, 460. diet, after operation, 470. drainage after, 469. hemorrhage in, 467. history, 460. indicatioris, 463. instruments, 465. ligation of tubes, 469. location of incision, 466; illus., 466. 4G7. manipulation of foetus, 467. measurement of pelvis, 464. position of fcetus, 465. Porro"s modification, 471. preparation of patient, 465. removal of placenta, 468. removal of sutures, 470. results, 462. rupture of membranes, 470. Sanger's method of closure, 470. technique, 466. treatment of tubes, 468. Calcareous tumours of, corpus luteum. 617. ovary, 615. etiology, 617. histology, 616. treatment, 618. Calculi, renal, 776. etiology, 776. pathological changes, 778. primary, 776. removal of. 761. secondary, 777. stricture from, 761 symptoms, 778. treatment, 780. Calculi, vesical, 140, 141. 7>.Mi. removal, 798. Calyces, dilatation of, 763. Cameron, 462, 463, 465, 471. Camescasse, 514. Canquoin, 366, 370. Capsularis, in ectopic pregnancy, 6-58. Carcinoma, bacillus of, 441. Carcinoma of, broad ligament, 386. cervix, 362, 438. ovary, 619. adenocarcinoma, 620; illus., p. 620. medullary, 619. primary, 619. secondary, 022. portio vaginalis, 438. rectum, 844. stricture from, 838. symptoms of, 845. treatment, 845. urethra, 801. iiterus, 447; illus., p. 440. age influence, 440. amputation of cervix for, 447. cauterization for, 447. complications, 443. course, 439. cnrettement for, 447. Carcinoma of uterus, diagnosis of, 442. diagnosis, by inoculation, 443. discharge in, 442. electro-hysterectomy for, 456. etiology, 440. extended operation for, 453. hemorrhage in, 442. histology of, 439. hysterectomy for, 447. involvement of lymphatics, 439. metastasis from. 481. mortality in, 437. mortality from operations, 458. origin, 438, 441. panhysterectomy for, 417. pathology. 438. pregnancy in, 443. prognosis, 444. radical treatment, 447. recurrence of, 458. results of hysterectomy, 458. removal of vagina for, 455. serum treatment, 446. symptoms, 442. tampon for, 446. topical medication, 444. vaginal hysterectomy for, 447. vagina, 233. primary, 233. secondary, 234. vulva, 227. classification, 227. prognosis, 228. vulvo-vaginal gland, 228, 249. Carniso, 470. Carstens, 444. 445, 446, 453. Cartledge, 377, 383, 603. Caruncle, urethral, 800. treatment, 801. Casper, 772, 747. Castex, 328. Castration. 407. Catgut, suture, 67, 3.37. Catheter, glass; illus., p. 368. use of, 148. Catheterization of ureters, 746. by cystoscope, 747. Pawlik-Kelly method, 746. Caustic, in treatment of syphilis, 190. Cauterization, for carcinoma, 445. condylomata, 210. hemorrhoids, 853. hemostasis, 80. syphilis of uterus, 393. tubercular endometritis, 391. Cautery, Paquelin's, 80. thermo-, in vaginal hysterectomy, 449. Cazeaux, 463. Cazin, 427, 428. Celsus, 852. Central ansesthesia, 97. Cervix, amputation of, 340; illus., p. 342. for carcinoma, 447. Cervix, atresia of, 279. bacteria of, 352. INDEX 871 'Cervix, carcinoma of, 362, 438. chancre of, 392. dilatation of, 356, 364, 421, 726. eversion of, 392. fixation of, 304. function of, 350. hypertropliy of, 319, 335; illus., 320. immunity of, 355. in endometritis, 364. laceration of, 334. menstruation from, 435. secretion of, 353.. tuberculosis of, 385. ■Cliadwick, 394. •Chain tampon, 292; illus., p. 292. Chamberlain, 61, 461. ■Chancre, cervical, 392. ecthymatous, 185. exulcerated, 186. hard, 184, 201. pudendal, 181. rectal, 828. uterine, 391. 'Chancroid, 181. course of, 182. diagnosis of, 175, 183. pathology, 183. prevalence, 182. phagedenic, 181. rectal, 828. treatment, 184. vulvar, 228. "Chancrous erosion, 185. Chantemesse, 379. Charcot, 98. Chase, W. D., 721. Chassaignac, 808. Chenieux, 686. Cheyne, 750. Chiari, 180, 521. Chiarleoni, 120. •Childbirth, as a cause of disease in women, 10. as a cause of uterine disphicement, 206. ■Children, anaesthesia for, 91. ■Chloroform, administration of, 94. inhaler, 94. relative safety of, 88. ■Chlorosis, as a cause of menorrhagia,714. Chorio-epitlielioma, see Syncytioma malig- num. Chrobak, 580. Cilia, of endometrial epithelium, .351. Circumcision, 120, 220. Cirrhosis, of ovaries, .593. causes, 593. syitir)tonis, treatment, 594. C'i vilizaliriii, as a cause of disease, 6. Clado, 791. Claisse, 682. Clark, 13, 115, 478, 479, 488, 490, .5.34. Clavus hysfcricux, 862. Clay, 4r?f;, 638. rianiii, cl'clric. In panliysterectomy, 419. igitation, exploratory, .364. Dilatation of cervix, ?>'>C,, 364, 421. as a cause of infection, .302. clfctriflty in, 7.30. for aiitc-d''viMtions, 312. tochnlf|ue, 31.''.. Dilatation of nrctlira, 803. causes, 803. operations for, 803. Dilator, as a means of examination, 45. Goodell's, 40; lllns., p. 40. Hegar's, .309; lllns., p, .309. Dilator, Reed's, 541; illus., p. 541. urethral; illus., p. 746. Diplococcus pneumoniae, 486. in Fallopian tuljes, 486. Dlphallus, 120, 121. Diphtheria, bacillus of, 167. Diphtheria of external genitalia, 179. diagnosis, 179. symptoms, 179. treatment, 179. Disease, Raynaud's, 196. hypertrophic and hyperplastic, of puden- dum, 21.3, Diseases of women, civilization as a fac- tor, 6. general etiology of, 5. Indian women, 6. prevalence, 5. systemic causes, 9. Disorders, pelvic, 865. nervous symptoms of, 865. Displacements of, Fallopian tubes, 47.3, 477. kidneys, 750. ovaries, 560. causes, 564. rectum, 817. uterus, 284. ante-deviations. 310. bimanual examination of, 38. classification, 285. etiology, 285. inversion, 324. pathology of, 286. prolapse, 317. treatment, 288. vagina, 237. pathology, 238. symptoms, 238. treatment, 2.39. Distoma haematobium, infection, 180. . Dittrich, 481. Diverticula of urethra, 801. treatment, 802. Divulsiou of rectum, 846. Doderlein, 16, 164, 166, 170, 372, 490, 513, 531. Doleris, 478, .546, 600. Doran, Alban, 422, 478, 628, 635, 670, 805. Dorsal position, 33; illus., 3.3. Dorsett, 2.55. Double uterus, 278. Douche, intrauterine, for hemostasis, 425. vaginal, 33. apparatus for, .32. in gonorrhoea, 169. infections of ovary, 581. malignant diseases, 236. pruritus, 204. salpingitis, .37, .5.35. Douglas, 204, 285, 314, 0.30, 805. Doyen, 81, 418, .528, 5.30, .554, 555, 556, 557, 558, 559. Doyen's operation of hysterectomy, .5.56. modifications. 567. 874 A TEXT-BOOK OF GYNECOLOGY Doyen's operation of hysterectomy, Pry- or's modification, 558. Drainage, 112, 115, 116. abdominal incision, 112. abdomino-vaginal incision, 544. after, abdominal section, 114. liysterectomy, 414. myomectomy, 410. ovariotomy, 644. salpingectomy, 553; illus., 553, 554. exploratory incision for, 543. inguinal incision, 542. inguinal vaginal incision, 542. of pelvic abscess, 689. salpingitis, 540. tlirough-and-through, 544, 545. tubercular peritonitis, 697. tube. Reed's, 114; illus., p. 115. Reed's through-and-through, 544; il- lus., p. 544. vaginal puncture, 542; illus., .542. Dranitzin, 123. Dressing, for abdominal incision, 470. sterilization of, 62. Dronius, 460. Drysdale, 606. Dsirne, 648. Dubois, 461. Ducrey, 183. Duct of Gartner, 671. of Muller, 117, 118, 126. Wolflaan, 671. Dudley, A. Palmer, 97, 265, 294, 682, 683. 685. Dudley, E. C, 32, 219, 282, 314, 730. Diihrssen, 235, 437, 441. Dujon, 245. Duke, Alexander, 44. Dumesnil, 210. Dumont-Leloir. .365, .370. Dumont forceps, 370. Duncan, IMatthews, 189, 429, 682, 726. Dunlap, 633, 638. Dunn, 588. Dunning, 425. Duplay, 606. Dupuytren, 725. Dwight, 682. Dysentery, 838. as a cause of stricture, 838. Dysmenorrhcea, 130, 360. as a symptom of salpingitis, 502. effect of corsets, 729. etiology, 725. exercise as a preventive, 729. medical treatment, 731. membranous, 752; illus., p. 732. causes, 732. symptoms, 733. treatment, 734. treatment of, 728. Dyspepsia as a cause of amenorrhoea, 722. Earle, 830. Ear, menstruation from, 736. Ebstein, 776. Ecchymosis in endometritis, 362. Echinococcous infection of, broad liga- ment, 690. uterus, 393. diagnosis, 394. liysterectomy for, 395. pregnancy in, 394. symptoms, 394. treatment, 395. Eckhard, 626. Ecraseur, application of, 424. Eckstein, 683. Ectopic pregnancy, see Pregnancy, ec- topic. Eczema intertrigo, 191. Eczema marginatum, 205. Eczema rubrum, 197. Eczema of vulva, 196. acute, 196. chronic, 197. treatment, 197. Edebohls, 313, 527, 695, 752. Education as a cause of disease in wom- en. 6. Edwards, W. A., 123, 844. Ehrendorfer. 229, 801. Eiselberg, 52. Elder, George, 122. Electric forceps, 84; illus., p. 84. Electricity, apparatus, 539. as a therapeutic, 23. for fibroid tumours, 124. for fibromyomata, 404. for hemostasis, 83. for menorrhagia, 719. for pruritus vulvae, 204. for salpingitis, 539. in dilatation of cervix, 730. in uterine dsplacements, 291. indications for use, 23. Electro-hemostasis, 83. Elephantiasis of vulva, 216. classification, 217. etiology, 219. histology, 218. Ellinger, 312. Eisner, 167, 179. Emanuel, 387. Emboli, 73. Embryology, of hymen, 131. of parovarium, 670. of vagina, 117. Emerich. 52. Emmet, 2, 4, 22, 144, 173, 262, 263, 267, 271, 285, 306, 323, 324, 334, 339, 341, 342, 349, 366, 391, 421, 422, 42.3, 725, 730, 818. Emmet's operation for, incomplete lacera- tion of perineum, 260. modifications, 265. prolapsus, 323. Emotion, as cause of menorrhagia, 714. Enchondromata of, rectum, 844. vulva, 223. INDEX 875 Endoeervix, eversion of, 335. Endometritis, 357; lllus., p. 359. as cause of dj'smenorrhoea, 360. cauterization in, 366. cervix in, 364. curettage for, 313, 368. diagnosis of, 364. discliarge in, 363. ecctiymosis in, 362. escliarotics in, 365. etiology, 361, 362. exfoliative, 352. glands in, 363. tiemorrhage in, 363. hot-water irrigation for, 367. hypertrophic, 361. packing for, 366. Reed's treatment, 365. section, illus., p. 352. steam treatment, 366. symptoms, 363. tampon for diagnosis, 363. topical remedies, 365. treatment, 365. tuberculous, 388. Endometrium, function of, 350. inflammation of, 357. in menstruation, 351. microscopic anatomy of, 350. secretion of, 350. Endothelioma of ovary, 624. histology, 625. recurrence of 626. section, illus., 625. types of, 625. uterus, 434. origin, 435. vagina, 233. Engelmann, 22, 23, 680. Engorgements of liver, as a cause of gen- ital disorders, 9. Enteroclysis, 77. Enucleation of myoma, 409. of uterine tumours, 420. technique, 421. Epispadias, 123; illus., p. 124. treatment, 123. Epistaxis, 127. Epithelioma, of cervix, 386. resemblance to tuberculosis, 387. clitoris, 228; illus., p. 229. kidney, 78.3. Epithelium of endometrium, .351. reproduction of, 370. of tnl)al mucosa, 489. hyiicrplasia of, 522. Eppinger, 429. Ernst, 718. Erosion, chanfrous, 185. sniierlicial, 185. iOrysipclas, 52. as a cause of genital disorders, 9. of external genitalia, 177. syniptorns of, 177. treatment of, 178. Erythema, etiology of, 194. treatment, 195. Escharotics, in endometritis, 365. Escherich, 791. Eskimo, menstruation of, 700. Esmarch, 24. Esmarcli's chloroform inhaler, 94 ; illus., p. 95. Ether, administration of, 90, 92. contraindications for use, 90. indications for use of, 88. inhaler, 94. relation to bodily temperature, 89. relative safety of, 88. Etheridge, J. H., 446. Etiology of, diseases of women, 5. sterility, 141. Eversion of the endoeervix, 335. Examination, of various parts of the body, 47. auEcstliesia in, 40, 92. bimanual, 37; illus., p. .37. digital, 35. gynecological, 30. instrumental, 42. of blood, 49. of external genitals, 34. of fseces, 48. of Fallopian tubes, 516. of kidneys, 744. of inverted uterus, 326. of menstrual discharge, 48. of nervous system, 49. of ovary, 632. of prolapsus uteri, 321. of rectum, 808. of urinary apparatus, 744. of urine, 47. of uterine displacement, 290. physical, 31, 744. rectal, 39. vaginal, 30. Excision of clitoris, 234; illus.. p. 234, 235. of rectum, 847. Excrescence, masturbatory, 215. Exosmosis, 22. Exposure, as cause of shock, 72. External genitalia, 34. development, 117. diseases of skin, 191. examination, 34. hypertrophic and hyperplastic disease, 213. infections of, 163. injuries of, 135. Extirpation of vagina, 2.3.5. Extract, of ovary, 21. supr.'ironal, 75. thyroid, 21. Extra-utorine pregnancy, see Ectopic pregnancy. Eackler, 186. Firces, examination of, 48. Fainting, 7.3. 876 A TEXT-BOOK OF GYNECOLOGY Falconiis, Xicolai, 460. Fa Ik, 22. Fallopiau tubes, absence of, 473. accessory tubes, 474. actinomycosis, 231. anatomy, 489. anomalies of, as cause of ectopic preg- nancy, 651. atresia, cause, 495. bacillus coli, infection of. 528. bacillus tuberculosis in, 486. bacteria in disease, 484. bacteria in health, 484. carcinomata of, 48. chronic salpingitis, 489. morbid histology. 491. conservative operations in, 546. cystomata of, 480. development, 473. defective development, 473; illus., p. 474. displacements, 473, 477. diplococcus pneumoniae in, 486. fibromyomata of, 481. gonococcous infection of, 512. hernia of, 477. hydrosalpinx. 484. infections of. 483. 512. infection, relative to inflammation of, 487. irrigation. .584. ligation of, in Caesarean section. 469. lipomata of, 480. malformations, 473. manual examination of. 38. menstrual function of. 709. •' mixed infection " of, 486. neoplasms, 478, 481. origin, 117. ostia, 474; illus., p. 475. papillomata of, 478. pneumococcous infection of, 529. pyosalpinx, 486. radical operations on, 549. salpingitis, acute, 489. salpingitis, catarrhal, 489. salpingitis, chronic, 486. saprophytic infection of, 530. sarcomata of. 482. section, salpingitis, illus., pp. 491. 492. septic vibrion infection. 531. staphylococcous infection of, 5.30. streptococcous infection of, 516. structure of mucosa, 489. supernumerary. 474. Tait's operation for removal of, 551. tuberculosis of, 519. Farmer, 463. Farnsworth, 436. Fat embolism, 73. Fat, subcutaneous, retraction of, 110, 113 : illus., p. 111. Fehleisen, 376. Fehling, 213, 376, 391, 606. Fehrenbatch, Colonel John, 61. Feinberg, 204. Fenger, 761, 764, 767. Ferguson, 307, 308. Ferguson's operation of ventral fixation, 308; illus., p. 309. Fernet, 520. Fever, puerperal, 52, 376. bacteria of, 376. curettage in, 381. diagnosis, 381. endometrium in, 377. hysterectomy in, 383. irrigation in, 382. lochia in, 380. myometrium in, 377. pathology of, 376. perspiration in, 380. respiration in, 381. syphilis in, 376. symptoms, 380. tampon for, 382. temperature curve, 380. treatment, 381. Fibrocystoma, of uterus as a complication of ovarian tumours, 636. Filiroid, recurrent, 435. Fibroid tumours of, broad ligament, 677. cervix, 420. Fallopian tubes, 480. kidney, 781. ovary, 614: illus., 61.5. rectum, 843; illus., 843. uterus, 396. vagina, 226. vulva, 222. I'^ibroma molluscum of vulva, 223. Fibromyomata, classification, 397. degeneration of. 299. .399; illus., 401. Fibromyomata of broad ligament, 677, 682.^ uterus, 396. diagnosis, 401. etiology, 397. hemorrhage, 401. histology of, 398. hysterectomy for, 404; illus., 405. interstitial, 398; illus., 402. intraligamentous, 398. pain, 401. pregnancy, 403; illus., 404. subserous, 398. treatment. 404. Fallopian tubes, 480. origin. 480. vulva, 18. 222. Filters, 61. Fimbria in streptococcous infection of tubes, 517. Fischel, W., 670, 671, 672, 673. Fisclier, 245. Fischer, J., 21. Fissure, anal, 820. diagnosis, 833. symptoms, 832. treatment, 833. Fistula, faecal, 1.52, 831; illus., 151. INDEX 877 Fistula, fsecal, diagnosis, 835. symptoms, S3o. treatment, 835. Fistulse, urinary, illus., 344, 345. diagnosis of, 141. etiology of, 140. operations, 142, 155. prognosis, 142. symptoms, 141. treatment, 142. vesico-umbilical, 804. Fixation, ventral, of uterus, 305. vagina, 303. Flaischlen, 610, 626. Flap-splitting operation, 267; illns., p. 207. Flexner, .514. Floor, pelvic, 250. Florence solution, 158, 159. Foetal uterus, 277. menstruation from, 277. symptoms of, 277. treatment of, 277. Fcetus, location of, 465. manipulation of, 467. Follicle, hair, 198. Follicular cysts of ovary, illus., p. 598. development of, 598. contents, 599. histology, 599. Folliculitis, 198. symptoms, 199. treatment, 199. Forceps, Bozeman's dressing, illus., 369. cervix, 370. dissecting, illus., p. 448, 639. electric (hemostasis), 84; illus., p. 84. hemostatic, 80. hemostatic, application of, 107. mouse-toothed, illus., p. 747. Pean's, 423; illus., p. 422. pressure, illus., p. 640. Pryor's traction. 5.58. Reed's, for round ligament, 300. serrated cervix, 370. tongue, 95. Ford, 136. Fordyce, 129, 131. Foreign bodies in bladder, 796. in uterus, 348. Formula, condylomata treatment, 216. erythema, treatment of, 195. interti'igo, treatment of. 193. leucorrhoea, treatment of, 374. resorcin salve, 194. Wilkinson's ointment, 194. Fornia, 185. Foster, Frank P., 3, 50, 56, 100. Fourchette, see Vulva. Fournior, 161, 392. Francke. 441. Frank, 294, 7.57. Friinkel, 180, 386, .",87, .599, 611. Franque, 386, 389, 4.'52, 4;;7, 575, 57(;. Freer, 805. Frcri'lis, 577. Freund, 21, 271, .304, 394, 458. Freund, W. A., 691. Freymuth, 166. Friedlander, 385, 175. Fritsch, 2.35, 241, 366, 556, 813. Froebel, 7. Frommel, .529, 530, 574, 575. Frorieps, 389. Fuller, 692. Function of cervix, 350. of endometrium, 351. of pelvic floor, 250, 254. of vulvo-vaginal gland, 243. Fused kidney, 751. Fiitterer, 758. Gaither, 382. Galen, 1. Ganghoffer, 440. Gant, 823, 825, 826, 830, 831, 832, 838, 840, 841, 842, 843, 844, 845, 847, 848, 851, 852, 853. Gant's clamp, 854. Gardien, 460. Gardiner, 647. Gartner, 248. Gartner's duct, 671. cysts of, 224. Gau, 382. Gau's curette, 345; illus., p. .346. speculum, 44; illus., p. 43. Gauze for drainage, 614. Gaylord,. 184, 647. Gebhard, 13, 4.30, 434, 611. Gehle. .526. Gehrung, 726. Geil, .389. Geist, 249. Gemmell, 702. Generative organs in ovulation, 14. pathology, 12. Genital glands, 117. groove, 117. tubercle, 117. Genitalia, external, aerogenous infection of, 180. aphthae of, 179. bacteriology of, 16.3. cutaneous diseases of, 191. development of, 117. diphtheria of, 179. erysipelas of, 178. gonorrhoea of, 53, 166. infection of, 16.3, 165. injuries of, 156. neoplastic changes, 18. parasites of skin, 205. syphilis of, 17, 189. trophic changes, 17. tulierculosis of, 17. Geraldes, 670. fiei-iiiicidiil iigeiits, (!.'!, 170. Ciersuny, 12.3, 80.3. Gersuny's opei'alioii for dilatntion of the urcllira, 80.3. 878 A TEXT-BOOK OF GYNECOLOGY Gessner, 364. Grcstation, relation to pathological states, 14. Giglio, 531. Gilliam, 604. Girode, 528, 530. Glands, inguinal, suppuration of, 515. genital, 117. lymphatic, removal of, 452. sexual, 126. uterine, dihitation of, 361, 363. vulvo-vaginal, 170, 243; illus., p. 243. carcinoma of, 228. extirpation of, 170. gonorrhcea of, 167. Glans of clitoris, 118. G leaves. 124, 783. Glenard's disease, 757. Gloves, rubber, 70, 295. Glycosuria, as a cause of erythema, 194. at menopause, 740. Goelet, 719. Geonner, 353. Gofife, 294, 301, 328, 681. Goglio, 387. Goldspohn, 68, 271, 298. Gonococcus, 53. as a cause of disease in women, 11. destructive action, 374. means of diagnosis, 373. of Neisser, 53, 163: illus., p. 53. superinfection with, 375. Gonococcous infection of, external geni- talia, .53, 166. course of, 166. diagnosis, 167. pathology, 167. treatment, 168. Fallopian tubes, 512. action of leucocytes, 513. bimanual examination in, 515. course of, 512. desquamation in, 513. discharge in, 515. fimbriae in, 513. location of gonococci, 513. pain in, 515. symptoms, 515. inguinal glands, 515. ovary, 569, 574. origin, 574. sclerosis in, 574. symptoms, 580. results, 580. rectum, 826. etiology, 826. pathology, 827. treatment, 827. Skene's glands, 245. uterus, 372. diagnosis, 373. etiology, 372. in puerperium, 373. pathology, 373. secretion in, 732. Gonococcous infection of uterus, symp- toms, 373. tampon for, 375. treatment, 374. vulvo-vaginal glands, 170. histology, 244. symptoms, 245. Gonorrhoea, see Gonococcous infection. Gonzalez, 588. Goodell, 9, 46, 429, 313, 730, 681. Gordon, S. C, 4. Gortier, 686. Gottscbalk, 354, 627. Goulard, 196. Goulliund, 750. Goutil, 649. Graafian follicle, 13, 14. Gram, 183, 487, 513. Griinicher, 232. Grape, 434. Grawitz, 115, 571, 785. Green, 473. Groove, genital, 117. Guerin, 224. Guilbert. 2. Guillemeau, 461. Guillemain, 576. Gummata, 688. of rectum, 829. Gunning, 7.34. Gusenthal, Yon Roguer, 565. Gusserow, 436, 460, 696, 671. Guyon, 528, 765, 786. Gynandria, 126. Gynecological armamentarium, 27. Gynecology, conservative, 4. definition, 1. etymology, 1. examination in, 3. historical resume, 1. nomenclature, 3. radical, 4. specialism in, 2. therapeutics of, 20. Habits, personal, as a cause of pelvic dis- ease, 8. Haeckel, 230. Hages, 686. Hair follicle, 198. anatomy of, 198. infection of, 199. Halbertsma, 391. Hall, 676, 677. Halle, 791. Halstead, 70. Hammarsten, 603, 606. Handfleld-Jones, 726, 727. Hands, sterilization of, 69. Hanks, 313, 403. Hannan, 442. Hare, 74, 88, 89, 93. Harris, M. L., 251, 253, 273, 474, 754, 758, 761, 763, 764, 776, 777, 782, 789, 791,^ 796, 818. INDEX 870 Harris, R. P., 100. Harris's operations for deep injuries of pelvic floor, 272. urine segregator, 747; illus., p. 748. Hart, 131. Hart, Berry, 126, 131. Hartman, 528. Hassmer, 725. Hauser, 792. Haussman, 163. Hawkins, 676, 677. Head, manipulation of, in anaesthesia, 96. in birth, 2.56. Heape, Walter, 699, 708, 710. Heat, hemostasis by, 80. sterilization by, 61. treatment of shock by, 75. Hebra, 205. Hecker, 137. Hegar, 385, 388, 427, 520, 521, 524, 525, 526, 527, 578, 584, 597, 632, 680, 681. Hegar's dilator, 369. Heiberg, 627. Heidenhain, 205. Heil, 318. Heimbs, 389. Heineke, 761. Heinrichs, 623. Heitzmann, 210. Heller, 764. Hemangeiomata of pudendum, 221. Hematocele, pudendal, 135, 136, 137, 138. rupture of, 137. suppurating, 664. Hematocolpus, 119, 127, 130, 133; illus., p. 127. Hematoma of ovary, 618. diagnosis, 618. pathology, 618. pudendum, 137. Hematonietra, 127, 133. Hematosalpinx, 127. etiology, 499. histology, 499. Hematuria, as a symptom of renal tu- mour, 786. renal tuberculosis, 774. vesical tumours, 799. Hemoptysis, 7.36. Hemorrhage, 73, 78. diagnosis of, 73. follicular, 618. in lacerated cervix, 3.36. in rape, 157. I in rupture of uterus, 535. intervillous, 654. interplacental, 654. symptoms, 78. tampon for, 215. treatment of, 79, 630. vulvar, 1.'{5. HcmoiThoJds, capniai-y, 850. causes, 849. clamp-and-cautery operation for, 85.'i. clamp for, Illus., p. 854. Hemorrhoids, cutaneous, 849. external, 849. injection of, 851. internal, 850. ligation of, 852. symptoms, 849. thrombotic, 849. treatment, 849, 851. venous, 851. Whitehead's operation for, 852. Hemostasis, by, cautery, 80. electric forceps, 83. heat, 80. ligature, 86. pressure, 80. styptics, 79. Heunig, 124, 489. Henoch, 696. Henrotin, 4.30, 476, 655. Herbert, C, 244. Hereford, 436. Heresco, 682, 787. Herman, 180, 392, 780. Hermaphroditism, 121, 124. bilateral, 562. pseudo, 125. unilateral, 562. Hernia, inguinal, 298. of Fallopian tube, 477. of ovary, 126, 564. post-operative, 104, 106. Herpes progenitalis, 200. diagnosis, 201. etiology, 201. treatment, 202. Herzog, 13, 14, 15, 17, 18, 399, 400, 427, 429, 433, 440, 476, 650, 651, 654, 656, 658, 659, 660, 781, 782, 783. Heppner, 271, 562. Heterogeneity, 2. Hewitt, Graily, 311, 726. Hewitt's pessary, 311. Heyse, 590. Hildebrandt, 271, 697. Hippocrates, 1, 24, 437, 852. Hirschfeld, 781, 783. Hirst, 2.57. His, 427. Hislop, 394. Histology, of actite salpingitis, 489. adenocarcinoma, 620. atrophy of vulva, 209. calcareous tumours of ovary, 616. carcinoma uteri, 439. chronic salpingitis, 491. cysts of corpus luteum, 600. cysts of vulvo-vaginal glands, 247. dermoid cysts, 611. ectopic pregnancy, 616. endothelioma, 625. fibroma of ovary, 615. fil)roma of uterus, 398. follicular cysts, 599. gonoi'rha'n, 166. hematosalpinx, 499. 880 A TEXT-BOOK OF GYXECOLOGY Histology, of hypernephromata, 783. medullary carcinoma. 619. melano-carcinoma, 231; illiis., p. 231. ovarian abscess. 14. papilary cysts, 609. papilloma, 609. pseudo-cysts, 606. renal adenomata, 782. renal adenosarcomata, 783. renal sarcoma, 782. sarcoma of Fallopian tubes, 482. sarcoma of ovary, 682. sarcoma of kidney, 782. sarcoma of uterus, 433. sarcoma of vagina, 233. serous cysts, 608. syncytioma malignum, 427. sypliilis of broad ligament. 690. tuberculous peritoneum. 692. tuberculous tubes, 521. tuberculous ovary, 570. tuberculous vagina, 172. tubo-ovarian cyst, 576. Hofbauer, 390. Hoffmann, 549. Hofmann, E. V., 157. Hofnieier, 351, 458. Hofmeister, 67, 08. Holder, 6. Holmes, Oliver Wendell. 87. 113. 178, 376. Horseshoe kidney. 751. Hottentot apron, 213. Howie. 703. Huguier, 189, 224. Hunter, 397. Hutchinson. Jonathan. 4. Hydatid of Morgagni. 071. Hyde, 189. Hydrocele of round ligament, pathology, 077. treatment. 677. Hydronephrosis, see Xephrydrosis. Hydrosalpinx, calculus in. 497. deHnition. 495. diagnosis, 505, 510. discharge from. 505. distention in. 496. etiology. 484. menstrual disturbance from, 505. pain from. 505. pseudo-follicularis, 497. relation to pyosalpinx, 495. secretion in. 497. symptoms, .505. types. 497. Hydrops tubse profiuens. 497. Hymen, absence of, 35, 133. anomalies of. 131. 133. atresia of. 132. biforis. 130. bilamellatus, 133. cysts of. 224. development of, 118. double. 133. embryology of, 131. Hymen, laceration of, 136, 157. malformations of, 131. operation on, for atresia, 133. puncture of, 725. Hyperemia of bladder, 595. treatment, 796. ovary, 567. treatment, 568. Hypersesthesia, 801. Hypercatharsis. 101. Hypernephromata, 784; illus., p. 785. histology of, 785. Hyperplasia, of lymphatics, 688. pudendum, 213. Hypertrophy of cervix, 319. etiology, 335. clitoris, 126, 213. glands of uterus, 361. labia minora. 124, 213. ovaries, pathology, 594. treatmenr, 595. prepuce, 220. operation. 218, 219. pudendum, 213. uterus, treatment, 393. vulva, 213. Hypnosis, in annesthesia, 98. Hypodermoclysis, 74, 70. Hypospadias. 118. operation for, 122; illus., p. 123. perineo-scrotal, 125; illus., p. 125. Hysterectomy, accidents in, 415. classification of, 405. complete, see Panhysterectomy, definition, 405. Doyen's, 5.56. electro, 456. advantages of, 457. definition, 4.56. results, 4.59. technique. 456. hemorrhage after, 415. supra-vaginal. 410. drainage after, 414. hemostasis in, 411, 413. instruments for, 103, 412. technique, 412. vaginal, 419. 447. after-treatment, 452. angeiotribe in, 81. cautery in, 449. indications for, 559. instruments for, 103, 448. position of patient, 556. removal of ligatures, 452. technique, 448. technique. Doyen's operation, 556. treatment of adhesions, 557. treatment of glands, 453. Hysteria. 800. symptoms, 860. Hystero-myomectomy, see Myomectomy. Hysteroscope, 44; illus., p. 45. INDEX 881 Ichthyosis vulvae, 207. Ilio-coccygeus muscle, 2ol. Ill, 3S2, 805. Immervvahr, 3.54. Incision, exploratorj', G37. Incision for, abdominal section, closure of, 109. direction of, 105. general observations on, 107. inguinal, 106. location of, 103. lumliocostal, 107. lumbo-iliac, 107. oblique subcostal, 106. oblique ventral, 107. transverse suprapubic, 106. transverse umbilical, 106. vertical median, 105. drainage, abdominal, 544, 689. abdominal vaginal, 544. dilator for, 541. inguinal, 542. inguino-vaginal, 542. rectal, 546. vaginal, 541. nephrectomy, 787. ovariotomy, 641. perineorrhaphy, 2.58. Incontinence of urine, 134, 141. Indian women, menstrual habits of, 6. Infantile uterus, 277. treatment, 280. Infantilism, 120. Infections, of, bladder, as a symptom of rape, 158. puerperal, 10, 18, 165. etiology, 178. Infections, of bladder, 790. bacteriology of, 791. diagnosis, 793. etiology, 790. pathology, 792. symptoms, 793. treatment, 794. broad ligament, 688. course of, 163. etiology, 688. pathology, 088. external genitalia, 163. mixed, 165. course of, 163. Fallopian tubes, 483. course of, .5.'{2. douche in, 5.V>. hygienic treatment, 5.35. libi'ration of pus, 534. local treatment, 537. massage for, .5.38. medicinal treatment, 5.36. prognosis, ,533. ra(1ical ti'calnjent, 540. relation lo Inflammation, 487. ruj)ture In, 5.34. symptoms, 501. 57 Infections of Fallopian tubes, treatment, 5.32. tampon for, 537. hair follicle, 199. kidneys, 768. bacteria of, 769. diagnosis, 770. etiology, 768. pathology, 770. treatment, 772. urination in, 771. lacerated cervix, 3.37. lymphatics, 392, 395. ovary, 567. conservative treatment, .582. mortality, 579. natural termination, 579. opium in, 581. radical treatment, 584. results of conservative treatment, 583. palliative treatment, 581. vaginal douche in, 581. peritoneum, 115, 688. pudendal hematocele, 136. rectum, 824. diagnosis, 824. prognosis, 825. results, 822. symptoms, 824. treatment, 825. uterus, 16, 350, .3.57, 372. endometrium in, 3.57. etiology, 362. mixed, .358. myometrium, 3-58. specific, 357. treatment, 365. vagina, 16, 163, 180. vulva, 16.3. vulvo-vaginal gland, 243, 248. Inflammation of, bladder, 790. Fallopian tubes, 487. ovary, 567. rectum, 424. uterus. 358. vagina, 163. vulva, 15, 153. vulvo-vaginal gland, 244. Infusion, intravenous, 77. subcutaneous, 76. rectal, 77. Inguinal hernia, 298. incision, 107. Inguihodynia, 862. Inhaler, chloroform, 94. ether, 92. mixed vapours, 94. Injection, cocaine, 97. treat nieiit of hemorrhoids, 851. ' Injuries of, hymen, 157. pelvic floor, 2.53, 271. perineum, 162. rectum, 153. 882 A TEXT-BOOK OF GYNECOLOGY Injuries, of pudendum, 136, uterus, 162, 331. vagina, 135, 139. vulva, 135, 136, 157, 162. Instrumental examination, 42. Instruments for, abdominal section, 103. Csesarean section, 465. fistula operations, 145. ovariotomy, 639. perineorrliaptiy, 259. supra-vaginal tiysterectomy, 412. trachelorrhaphy, 338. vaginal hysterectomy, 448. Instruments, sterilization of, 66. Intercourse, sexual, injuries from, 136. Intercutaneous suture, 110; illus., p. 110. Intertrigo, vulvar, 191. diagnosis, 192. etiology, 191. pathology, 192. treatment, 193. Intravenous infusion, 77. Inversion of uterus, 324. acute, 327. chronic, 328. diagnosis, 326. etiology, 324. examination, 326. pathology, 327. surgical treatment, 329. symptoms, 326. tampon for, 329. Irion, 702. Irrigation, in gonorrhoea, 170. in puerperal fever, 382. of Fallopian tubes, 384. Israel, 764. Ischio-coccygeus muscle, 251. Ivanhoff, 25. Jilcksch, 576. Jacobi, 781. Jacobs, 366, 458, 556, 576. Jacobson, 373. Jadassohn, 375. Jaennel, 819. Jaksch, 48. James, Alexander, 127. Jameson, 195. Jan, 119. Jani, 388, 520, 576. Janni, 683. Jans, .521, 692. Jenks, 21. Jevonsky, 209. Johnson, Joseph Taber, 641, 642, 644. Johnstone, A. W., 585. Jones, A. P., 327. Jones, George E., 313, 338, 382, 421, 425, 433, 448. Jones, H. C, 721. Jones, Macnaughton, 308, 428, 736. Jones, Mary Dixon, 8. Jones's speculum, 370; illus., p. 370. Jonesco, 310. Jouin, 21. Jung, 233. Kahlden, 435- Kaltenbach, 680, 681. Kalustow, 233. Kangaroo tendon, 68. Karagan, 171, 172. Karevi'ski, 163. Katz, 694. Kaufmann, 387. Keely, 779. Keen, 808. Kehrer, 163, 278, 329, 377. Keith, SO, 638, 680. Kelly, 171, 175, 241, 279, 306, 389, 391, 548,. Oil, 635, 671, 672, 678, 680, 694, 746,. 772, 779, 797. Kelynack, 781. Kerley, 737. Kholmogoroff, 204. Kidney, absence of, 749. adenomata of, 782. adenosarcoma of, 783. angeiomata of, 781. anomalies of form, 751. location, 750. numbers, 749. cystadenoma of, 782. epithelioma of, 783. examination of, 744. fibromata of, 781. fused, 751. horseshoe, 751. infections of, 768. liporaata, 781. movable, 752. operations on, 787. palpation of, 40. sarcoma of, 781. tuberculosis of, 772. tumours of, 780. Kiefer, 294. King, 538. Kirck, 330. Kisch, 7.39. Kitasato, ISO. Kivisch, 480, 481, 525, 670. Klebs, 179, 495, 576, 609, 692. Klein, 2.3.3, 702. Kleinschmidt, 435. Kleiuwachter, 68.3, 733. Klob, 495, 678, 683. Klotz, 294. Knauer, 525. Knee-chest posture, 34, 291; illus., p. 34. Knife, Newman's, 339. canaliculus, 248. Knot, Stafford.shire, 552. Kobelt, 670. Kobelt's tubes, 671. cyst of, illus., p. 475. Koch, 55. 172, 180, 697, 830. Kocher, 70, 105, 234. Koeberie, 2, 81, 306, 407, 638. INDEX 883 Kolisko, 232. Konig, G18, 787, 789. Kneftning, 183. Krajewski, 123. Kraska's operation, 848. Kraurosis vulvae, 207; illus., p. 208. diagnosis, 210. etiology, 208. histology, 209. macroscopic appearance, 207. treatment, 210. Kretschmer, 17. Krogius, 791, 792. Kronauer, 137. Kronig, 16, 70, 165, 373, 486. Kube, 475. Kuehne, 587, 658. Kumpf, 759. Kuster, 281, 282, 752, 754, 767. Kiistner, 318, 320. Kuttner, 753. Labadie-Lagrave, 518. Labia, adhesions of, 119, 120, 212. circulation of, 221. hypertrophy of, 213. malformations of, 124. neoplasms of, see Vulva. Lacassagne's schedule, 159. Laceration, of, cervix, 334. classification, 337. complication, 337. hemorrhage, 336. infection in, 337. operations for, 338. pathology of, 334. symptoms of, 385. treatment, 337. perineum, 253. classification, 255. complete, illus., p. 266. operations for, 267. Harris's operation for deep injuries, 272. immediate operation for, 258. incomplete, 260. Emmet's operation, 260. Reed's suture, 263. prevention of, 256. La grippe, as cause of genital disorders, 9. Lair, 2. Laminated suture, 109. Landau, 497, 525, 558, 755, 763. Landon, 302. Langhans, 656. Lannelongue, 808. Laparotomy, see Abdominal section. Laser, 166. Lassar, 195. Lassar's paste, 200. Law of Metschnikoff, 60. Law of Wyssakovil.Kch, 60. Lawrence, 562, 708. Lawrle, 94, 95. Le Bee, 558. Ivebedeff, 435. Le Cat, 120. Lebert, 385. Le Fort, 271. Legueu, 756. Leick, 179. Leiomyoma of broad ligament, 677. Lembert, 333. Lemhoff, 753. Leopold, 463. 624, 626, 638, 710. Lermoyez, 7.36. Lesion, tubercular, 172. anatomy of, 176. L'esthiomene, 171. Letulle, 797. Leucocytosis, 49. Leucoplakia, 228. Leucorrhoea, 176. Levator-ani muscle, 252, 253. restoration of, 271. Levret, 460. Levy, 180. Lewin, 201, 791. Lewis, 783. Libido sesualis after oophorectomy, 588. Liborius, 531. Ligament, broad, aneurismal varix of, 682. cysts of, 67. infection of, 688. neoplasms of, 669. parasitic infection of, 690. phleboliths in, 682. pyogenic infection of, 682. suppuration in, 689. tuberculosis of, 691. varicocele of, 682. Ligament, round, dermoid tumours of, 681. flbromyomata of, 682. hydrocele of, 677. in uterine displacements, 287. shortening of, 294. Alexander's operation, 294. Byford's operation, 302. Goffe's operation, 301. Mann's operation, 299. Ligature, catgut, 67. hemostasis with, 86. kangaroo tendon, 68. operation for hemorrhoids, 852. silk, 86. sterilization of, 66. Lipomata, of broad ligament, 677. Fallopian tubes, 480. kidney, 781. rectum, 842. vulva, 223. Lister, 2, 50, 67. Liszt, 255. liitliokelyphopsedion, 655. Lil liokclyfilios, 655. LilliopfTMlion, 655. Litten, 617. Lizars, 638. 884 A TEXT-BOOK OF GYNECOLOGY Lochia, bacteriology of, 166. LocliC, 76. Locliett, 70. Loeffler, 179. Loewentlial, 706, 711. Lohlein, 289, 352. Lomer, .353. Loops, Pfliiger's, 671. Lopez, 703. Lotion, Goulard's, 196. Louse, body, 206. Lubricant, for vaginal examination, 32. Ludwig, 332. Lumbocostal incision, 107. Lumbo-iliac incision, 107. Lupus vulvae, 171. Luschka, 814. Lusk, 331, 463, 470. Luther, 574. Lymphadenitis, 392, 690. Lyuiphangeiitis, 690. Lymphangeioma cystomatosum of ovary, 624. Lymphangeiomata, 217. Lymphangeiosarcoma of ovary, 624. Lymphatics, hyperplasia of, 688. infection of, 377, 392, 395. uterine, 351. Lymphorrha?a, 219. Maas, 776. Macacus rhesus, menstruation of, 699. ovulation of, 710. Mackenzie, 392. Mackenrodt, 249, 304. MacNeven, 393, 394. Maculse, gonorrhcese, 245. Madlener, 389, 378. Madleur, 373. Magill, 513, 517, 518, 528, 529, 530. Maier, 521. Malaria as a cause of menorrhagia, 714. Male, hypospadiac, 125. Malformations of anus, 806. clitoris, 124. Fallopian tubes, 473. hymen, 131. kidney, 749. labia, 124. ovary, 560. rectum, 124. prognosis, 807. symptoms, 807. varieties, 806. round ligament, 298. ureters, 760. uterus, classification, 274. etiology, 275. treatment, 280. vagina, 126. vestibular band, 134. vulva, 118. Malins, E., 683, 685. Malpighian layer, 215. Malthus, 10. Mandl, 13. Mann, 288, 289, 297, 299, 300, 301, 303, 304, 306, 314, 324, 429, 564, 678. Mansfield, 460. Manton, 721. Marchand, 187, 428, 610. Marshall, Balfour, 230. Martin, A., 114, 148, 211, 249, 257, 271, 304, 366, 368, 441, 480, 482, 493, 495, 499, 524, 525, 526, 570, 575, 578, 583, 589, 638, 680, C81, 781, 810, 811, 812, 835. Martin, Christopher, 126, 706, 738. Martin's curette, 368. Massage, abdominal, 24. pelvic, 25, 538. position of patient, 538. technique, 538. treatment of uterine displacement, 291. treatment of movable kidney, 759. Massen, 476. Massey, 726. Massin, 362. Masturbation, as cause of disease, 9. etiology, 212. evidences of, 160. excrescences from, 215. labia minora in, 35. Matas, 807, 808. Matthews, 97, 386, 854. Mauriceau, 460, 461. Mayer, W., 432, 521. McDowell, Ephraim, 2, 638, 639. McParland. 434. McLaury, 703. McMurrick, 751. McMurtry, L. S., 263, 351, 403, 458, 663, 666. Meadows, 749. Meatus urinarius, 230. melanosarcoma of, 230. Mechanism of prolapsus uteri, 318. Medication, general, 20. local, 22. Melano-carciuoma of vulva, 231. Melanosarcoma of vulva, 229. histology of, 231. of meatus urinarius, 230. Melchoir, 791, 792. Melier, 2. Membrane, uterine, reproduction of, 370. Menciere, 565, 566. Menge, 16, 353, 354, 487, 490, 495, 496, 521, 530, 684, 685, 686, 687. Menopause, 203. age of occurrence, 738. carcinoma at, 740. effect on heart, 740. on ovaries, 738. on uterus, 738. glycosuria at, 740. inducement of, 584. mental condition at, 741. metrorrhagia at, 739. oophorectomy at, 587. tachycardia at, 740. INDEX 885 Menopause, treatment of associated con ditions, 742. Menorrhagia, causes, 714. complications, 717. definition, 714. local causes, 714. pelvic causes, 715. rectal complications, 717. systemic causes, 714. tampon for, 716. treatment, 537, 716. uterus in, 715. Menses, cessation of, 738. examination of, 48. retention of, 282, 723. suppression of, 706. symptoms of retention, 723. Menstruation, absence of, 720. arrest of, 585. ciiaracter of discharge, 705. cycle of, 704. disorders of, 714. disturbances of, 764. effect of general systemic diseases, 714. endometrium in, 351. Fallopian tubes in, 709. from, bicornate uterus, 278. cervix, 735. ear, 736. infantile uterus, 280. nsevus, 737. nose, 736. septate uterus, 277. stomach, 736. hygiene of, 712. in atrophy of ovaries, 593. in cirrhosis of ovaries, 593. inducing cause, 706. ectopic pregnancy, 661. ovarian disease, 632. tubal tuberculosis, 526. normal, 699. of, domestic animals, 699. Eskimo, 700. Indian women, 6. Macacus rhesus, 699. savages, 699. Semnopithecus, 699. students, 8. ovaries in, 709. pain in, 725. persistence of, 588. precocious, 701. profuse, 719. fiuuntity of discharge, 704. relation to, conception, 711. ovulation, 710. piitliological state, 12. time of appearance, 701. uterus in, ].'5, 708. vicarious, 735. white, 705. Mesenteric cysts, 635. Metaljolism, effect on oophorectomy, 589. Metastasis, 2:51, 621. Metastasis, causes, 610. from carcinoma uteri, 481. from syncytioma malignum, 429. Metritis, 358. as a cause of dysmenorrhcea, 727. as a cause of menorrhagia, 715. classification, 358. diagnosis, 364. pathology, 359. Reed's method of treatment, 365. symptoms, 363. treatment, 365. Metrorrhagia, as a symptom of carcinoma, 720. at menopause, 729. etiology, 719. treatment, 720. Metrostaxis, post-operative, 587. Metschnikoff, 60. Meyer, 253, 391. Micrococcus gonorrhoese, 52. Mikulicz, 70, 83, 761. Miller, 44. Millikin, Dan, 699, 702, 704, 705, 706. Miner, 680. Minor, 643. Mirror, proctoscopic, 815. Mitchell, H. W., 720. Mittelschmerz, 277. Mittermaier, 349. Mixed vapours for anaesthesia, 93. Molluscum pendulum of vulva, 223. Monclaire, 458. Montgomery, 257, G47. Monti, 178, 376. Moostakoff, 120. Morax, 513, 528, 530. Morcellement, forceps for, 423. hemorrhage in, 423. Pean's method, 423. technique, 422. treatment of pedicle, 422. uterine tumours, 420. Morgagni, 594. hydatid of, 671. Morris, 211, 212, 695. Morse, 783. Mosetig, von, 24. Mosler, 521, 575, 692. Mouth gag, 95. Movable kidney, 752. adhesions of, 757. as a cause of nephrydrosis, 763. etiology, 752. examination of, 752. gastric symptoms, 758. indications for operation, 760. massage for, 7.59. mechanical influences, 754. operations for, 760. pain In, 758. pathologic anatomy of, 755. supporlor for, 759. ireatmont, palliative, 759. Movement of uterus, 285. A TEXT-BOOK OF GYNECOLOGY Mucosa, tubal, in streptococcic infection, 517. in tuberculosis, 524. structure of, 489. Mucosa, uterine, in endometritis, 362. tuberculosis, 389. Miiller, 9, 131, 230, 235, 303, 362, 476, 556, 779. Miillerian vagina, 126, 127. Muller's duct, 117, 118. Munclimeier, 458. Munde, 257, 366, 647, 678, 679, 734. Miioster, 525. Muret, 130. Muscatello, 115. Muscles of pelvic floor, 250. Museus, 421. Myomata of bladder, 799. broad ligament, 677. rectum, 844. uterus, 396, 503. vulva, 222. Myomectomy, 404, 407. definitiou, 404. drainage after, 410. indications, 407. pregnancy after, 408. technique, 407. treatment of pedicle, 407. Myometrium, inflammation of, 358. in puerperal fever, 377. microscopic anatomy of, 352. Myomotomy, vaginal, 420. Myxomata of vulva, 223. Myxosarcoma of vulva, 229. Naegele, 710. Nagel, 126, 561, 599. Naplieys, 6. Napier, 707, 738. Necrosis, 110. Needle, aneurismal, 452. holder, 450 Holmes's, 113. Reed's curved, 339. Neisser, 53, 165, 167, 373, 374, 827, 166. Neisser, gonococcus of, 53. Neoplasms of, bladder, 798. diagnosis of, 799. symptoms of, 799. treatment, 800. broad ligament, carcinoma, 686. cysts, 670. dermoids, 6. fibromata, 677. lipomata. 677. myomata, 677. sarcoma, 686. Tallopian tubes, 478. adenosarcomata, 783. carcinoma, 481. cystomata, 480. flbromyomata, 481. lipomata, 480. Neoplasms, of Fallopian tubes, papillo- mata, 478. sarcoma, 482. kidneys, 780. diagnosis, 785. fibromata, 781. hypernephromata, 784. involvement of ureter, 786. pain from, 786. sarcoma, 781. symptoms, 785. treatment, 787. ovary, benign cysts, 597. bimanual examination of, 632. carcinoma, 619. complications of, 627. adhesions, 031. albuminuria, 631. ascites, 630, 635. echinococcous cyst, 635. flbrocystoma of uterus, 636. mesenteric cysts, 635. nephrydrosis, 635. phantom tumour, 636. pregnancy, 627, 634. rupture of tumour, 631. torsion of pedicle, 628. cysto-adenoma, 18. diagnosis, 633. effect on menstruation, 632. endothelioma, 624. hematoma, 618. palpation of, 633. sarcoma, 622. solid tumours, 614. symptoms, 503, 632. treatment, 637. pudendum, benign, 221. carcinomata, 227. enchondromata, 223. fibromata, 222. fibromyomata, 18. lipomata, 223. malignant, 221, 227. melano-carciuomata, 321. myomata, 222. myxomata, 223. sarcoma, 230. sarcomata, 229. treatment, 233. varices, 221. uterus, adenoma, 429. benign, 397. carcinoma, 437. etiology, 396. flbromyomata, 326. malignant, 426. sarcomata, 432. syncytioma malignum, 426. urethra, carcinoma, 801. caruncle, 80. melanosarcoma, 230. sarcoma, 801. vagina, benign, 224. carcinomata, 233. INDEX 887 Neoplasms, of vagina, cysts, 224. fibromata, 22G. malignant, 231. polypi, 226. sarcomata, 231. treatment, 226. vulva, see Neoplasms of pudendum. vulvo-vaginal gland, 247. carcinoma, 249. cysts, 247. treatment, 248. Neoplastic changes in genitalia, 18. Nephrectomy, 767. clamp for, 789. technique, 789. treatment of pedicle, 789. treatment of ureter, 789. , Nephritis, as a cause of menorrhagia, 714. Nephrocystosis, definition, 762. classification, 762. Nephropexj', technique, 788. Nephropyelitis, 768. Nephropyosis, 766, 768. Nephrorrhaphy, 788. Nephrotomy, 767. hemorrhage in, 788. technique, 788. Nephrydrosis, acquired, 763. as a complication of ovarian tumour, 635. aspiration in, 767. causes of, 762. congenital, 762. diagnosis of, 765. intermittent, 765. nephrectomy for, 767. nephrotomy for, 767. partial, 764. pathological changes, 763. symptoms, 765. treatment, 766. Nerve derangements, 120. Nervous complications in gynecology, 856. Nervous symptoms of pelvic disorders, 865. Nervous system, examination of, 49. Netter, 51. Neugebauer, 120, 133, 224, 329, 348. Neuralgia of rectum, 820. Neurasthenia, 856. as a cause of genital disorders, 9. symjjtoms, 856. Neuromata of vulva, 223. Neuroses, from oophoritis, 580. operations for, 864. Neurosis, fatigue, 856. Newman, 339, 849. Newman's nngeiotribe, 81. volsella, 338. Nicolle, 513, 529. Nidus perlniei, 251. Nlefer, Jacob, 460. NIetort, :',46. Nll5!<-, 717. NoIjIi', Ocorgo II., 443, 444. Nodule, indurated, 186. Noeggerath, 2, 11, 166. Nolen, 608. Noma of vulva, 167. Nomenclature, of gynecology, 3. Normal salt solution, 74, 75. Nose, menstruation from, 736. Nott, 365. Nott's speculum, 44. Nourse, 282. Nuck, 298, 564, 677. Numa, 175, 183. Nurse, requirements of, 63. Nussbaum, 67. Nuttall, 54, 180. Nympha-, see Vulva. Obolonsky, 562. Obturator coccj^geus muscle, 250. Occlusion of cervical canal, 279. Occupation, as a cause of disease, 8. rectal disease, 821. uterine displacement, 286. Oildema of vulva, 195. treatment, 196. Ohmann, 210. Oidium albicans, 167. Ointment, Wilkinson's, 194. Wilson's, 193, 200. Oligochromsemia, 49. Oliver, 429. Olshausen, 209, 235, 458, 482, 598, 611, 624, 647, 648, 671, 672, 673, 674, 676, 679, 680, 681, 763. Omentum, adhesions of, 642. laceration of, 643. tuberculosis of, 693. Oneida community, 9. Oophorectomy, 584. effect on, constitutional condition, 587. general metabolism, 589. intrapelvic conditions, 590. libido sexualis, 588. menopause, 587. menstruation, 587. sexual function, 587. history, 584. indications, 584. manipulation of tubes, 585. metrostaxis after, 587. mortality, 586. secondary effects, 587. technique, 585. treatment of pedicle, 585. unilateral, 585. Oophoritis, acute, .568. as cause of dysmenorrhcea, 728. chronic, 569. etiology, 569. histology, .569, .580. tu))erculous, 575. Operating room, 64. Operating tabic, improvised, 64. Opium, in infection of ovary, 581, Oppenheim, 176. A TEXT-BOOK OF GYNECOLOGY Orgasm, sexual, in bimanual examination, 39. Ortlimann, 209, 210, 303, 304, 478, 481, 525, 600. Os, pin-liole, 283. Osiander, 447. Osier, 327, 692, 696. Osteomalacia, 590. Ostia, accessory, 474. relation to ectopic pregnancy, 476. Otroschkevitch, 739. Ott, 435, 707. Ovarian abscess, histology, 514. bacteriology, 514. Ovarian extract, 21. Ovariotomy, 638. abdominal incision, 641. accidents in, 646. after-treatment, 645. closure of incision, 644. drainage after, 644. dressing, 644. during pregnancy, 647. emptying of cyst, 641. history, 638. incomplete, 646. indications, 639. instruments, 639. ligature material, 642. mortality from, 646. peritoneal incision, 641. protection of intestines, illus., p. 108. technique, 639. toilet of peritoneum, 643. treatment of adhesions, 642. treatment of pedicle, 642. Ovary, absence of, 560. accessory, 501. at menopause, 738. atrophy of, 592. bacillus coli infection of, 575. bacteria of, 570. bimanual examination of, 38. calcification in, 017. cirrhosis of, 593. coexistence with testicles, 562. conservative operation on, 582. constricted, 561. cysts of, 597. development of, 117. displacement of, 560, 563. effects of removal, 586. gonococcous infection of, 574. hematoma of, 618. hernia of, 126, 564. hyperaemia of, 567. hypertrophy of, 594. individual infections of, 571. infections of, 567. inflammation of, 567. in myomectomy, 407. malformations of, 560. menstrual function of, 709. neoplasms, malignant, 619. neoplasms of, 597. Ovary, papilloma of, 608. pneumococcous infection, 574> prolapse of, 553. psammoma of, 621. radical operations on, 584. rudimentary, etiology, 561. diagnosis, 561. frequency, 560. treatment of infections, 581. trophic diseases of, 592. tuberculosis of, 575. unilateral removal of, 585. Ovulation, 710. dangers of, 14. in INIacacus rhesus, 710. pathological states, 13. relation to menstruation, 710. Semnopithccus, 710. Ovum, impregnation of, 650. Oxygen in anaesthesia, 93. Pacinian corpuscle, 203. Pack, dry, 8.3. Packer, vaginal, 450. Paederasty, 821. Pain, as a symptom of, adhesions, 631.. cirrhosis, 591. ectopic pregnancy, 661. hematoma of ovary, 618. hemorrhage, 78. hydrosalpinx, 505. flbromyomata, 401. movable kidney, 758. ovarian neoplasms, 632. pyosalpinx, .506, 509. renal calculi, 778. renal neoplasms, 786. salpingitis, 501, 535. torsion of tumour pedicle, 628. tubal tuberculosis, 526. tubercular peritonitis, 694. Pain, intermenstrual, etiology, 734. pathology, 735. treatment, 735. Pain, menstrual, 725. Pajot, 470. Palmer, C. D., 313, 364, 680, 734. Palmer's dilator, 364. Palpation, abdominal, 40. of Fallopian tubes, 516. of kidney, 40. Panhysterectomj', abdominal, 415; illus.,. p. 416. advantages, 419. angeiotribe in, 418. electric clamp in, 419. hemostasis in, 417. Reed's operation, 417. results, 555. specimen, illus., pp. 418, 420. technique, 415. Panhystercciomy, abdomino-vaginal, 453,. indications, 453. Paoli, 171, 175. INDEX 889 Papillae in condylomata, 214. Papillary cyst, 607. development, 607. Papilloma, of, bladder, 798. Fallopian tubes, 478. histology, 479. origin, 478. rupture of, 480. symptoms of, 480. treatment, 480. ovary, 608. histogensiS, 609. histology, 608. rectum, causes, 843. treatment, 843. Paquelin, 349. Paquelin's cautery, 80. Paralysis of uterine wall, 325. Parasites of external genitalia, 205. Phtheirius inguinalis, 206. Trichophyton tonsurans, 205. Par§, 461. Park, Roswell, 437, 442. Parker, Rushton, 392, 593, 707. Parks, 736. Paroophoron, 671. cysts of, 671. Parovarium, anatomy, 670. embryology, 670. neoplasms of, 669. Parry, 649. Parsons, A., 706. Parturition, injuries from, 136. Parvin, 649. Passet, 55. Paste, Lassar's 200. Pasteur, 50, 61, 531. Patches, mucous, 187. treatment, 188. Pathologic laws, deviations from, 12. Pathologic states, due to gestation, 14. menstruation, 12. ovulation, 13. Pathology of, atrophy of ovaries, 593. vulva, 209. displacements of, Fallopian tubes, 47.3. ovaries, 560. rectum, 818. uterus, 286. vagina, 2.38. female generative organs, 12. Infections of, bladder, 792. broad ligament, 688. external genitalia, 163. Fallopian tubes, 489. ovary, 571. uterus, 359. inversion of uteru.s, 327. laceration of cervix, 334. prolapsus uteri, 319. pruritus vu\y>f% 203. puerperal fi-vcr, .'!76. Bliock, 72. Patient, preparation for operation, 412. for Caesarean section, 403. Patient, sterilization of, 66. Paul, of iEgina, 1. Paul, 70 Pawlick, 635, 746, 767, 800. Pean, 81, 380, 385, 386, 544, 557, 638. Pean's forceps, 422. Peaslee, 144, 269, 312, 638. Pedicle, extra-peritoneal treatment of, 414. ligation of, in ovariotomy, 642. torsion of, 629. treatment in mj'omectomy, 407. Pediculi pubis, 206. treatment, 206. Pelvic diaphragm, 284. Pelvic diseases and nervous affections^ 856. Pelvic floor, anatomy of, 250. deep injuries, 271. function of, 250. injuries, 253. muscles of, 250. restoration of, 258. Pelvic massage, 25. varicocele, 684. Pelvis, measurement of, 464. suppuration in, 165, 689. Penis, imperforate, 125. Peraire, 391. Percussion of abdomen, 40. Perimetritis, 575. Perineorrhaphy, 258. Emmet's operation, 260. immediate operation, 258. instruments for, 259. posture for, 260. Reed's operation, 263. Tait's operation, 267. Perineo-scrotal hypospadias, 125. Perineum, definition, 231. function of, 2.54. injuries of, 162. laceration of, 253. malformations of, 124. preservation of, 256. syphilitic ulcers of, 189. Perioophoritis, 367. Periproctitis, causes, 826. treatment, 826. Peritoneum, incision of, 108. infection of, 115, 688. toilet of, in salpingectomy, 553. in ovariotomy, 643. tuberculosis of, 692. Peritonitis, 116. puerperal, 380. Pessary, 240. danger of, 362. gauze, 305. in Caesaroan section, 467. in treatment of uterine displacement^ 311, .322, 393. medicinal, 144. I'estalozzi, 7. I'eters, 427, 657, 658. 890 A TEXT-BOOK OF GYNECOLOGY Petit. Paul, 600, 685, 721. Pfahler, 70. Pfannenstiel, 603, 606, 607, 609, 610, 611, 620, 622. Pfeiffer, 201. Pflster, 587, 588, 589. Pfliiger, 609, 710. Pfliiger's loops, 671. Phj'sical examination, 31. Physique of women, 5. of Indian women, 6. Pichevin, 366. Pick, 373, 434, 436, 625. Pieque, 458. Pilliet, 600. Pincus, 367. Pirmer, 521. Placenta, location of, 466. location of, in ectopic pregnancy, 666. removal of, in Csesarean section, 408. Placontoma malignum, see Syncytioma maiignum. Phleboliths of broad ligament, 682. Plethora, as a cause of menorrhagia, 714. Pliny, 460. Plumb, 702. Pneumococcous infection of Fallopian tubes, etiology, 529. course of infection, 529. symptoms, 529. Pneumococcous infection of ovaries, 574. pus in, 575. treatment, 582. Poise of uterus, 15. Poisoning, septic, 73. Polk, 21, 294, 369. Polypus, rectal, 841. uterine, 424. extirpation of, 424. hemorrhage from, 425. vaginal, 226. vulvar, 219. Pomorski, 626. Pompilius, 460. Porro, 335. Porro's operation, 465. indications, 471. technique, 472. Portio vaginalis, carcinoma of, 438. Position, normal, of uterus, 285. Posner, 791. Post-operative antisepsis, 68. Posture, dorsal, 33; illus., p. 33. for examination of uterine displace- ments, 290; illus., p. 290. for perineorrhaphy, 260; illus., p. 262. knee-chest, 34; illus., p. 34. Sims's, 42; illus., p. 43. standing, 35; illus., p. 35. Trendelenburg, 454; illus., p. 454. Potter, 7, 32, 647. Poupinel, 225. Powder, dusting, 196. Powell, 826. Pozzi, 131, 171, 218, 240, 282, 358, 368, 390, 391, 440, 521, 635, 647, 679. Precocity in development of vulva, men- strual, 701. Pregnancy, after, conservative operation on ovary, 583. myomectomy, 408. rupture of uterus, 334. complicating carcinoma, 443. ovarian tumours, 627, 634. echinococcous infection in, 394. gonorrhoea in, 375. ovariotomy in, 647. rape in, 158. tuberculosis in, 389. Pregnancj', ectopic, 15. abortion in, 655. action of syncytium, 655. ampullar, 652. capsularis in, 658. changes in muscularis, 659. classification, 652. course, 054. decidua in^ 656. definition, 650. diagnosis, 662. etiolog}', 650. histology, 656. history, 649. interstitial, 652. intervillous space in, 659. instruments for, 103. isthmic tubal, 652. menstrual changes, 661. mortality, 665. operation, 665. pain in, 661. placental site, 666. rupture of, 654, 661. symptoms, 660. termination, 654. treatment, 664. treatment of sac, 666. tubo-abdominal, 653. tubo-ovarian, 653. tubo-uterine, 652. vaginal examination of, 662. Pregnancy, ovarian, illus., pp. 653, 654. Prepuce, adhesions of, 120, 211. hypertrophy of, 220. operations on, 218. Pressure, as a hemostatic, 80. Preuschen, 224. Prevention of conception as cause of genital disorders. 10. Price, Joseph, 403, 552, 653, 703. Priestley, 734. Prochownick, 671. Procidentia after colostomy, 847. Proctitis, 820. Proctoscope, 812. use of, 815. Proctoscopy, instrumental, chair for, 811. instruments, 812. postures for, 813. INDEX 891 Proctoscopy, instrumental, technique, 813. noninstrumental, technique, 808. Proctotomy, internal, 840. external, 840. posterior, 846. Prolapse of, ovary, 563. diagnosis, 564. symptoms, 564. treatment, 564. rectum, 820. causes, 818. colotomy for, 820. symptoms, 819. treatment, 819. urethra, causes, 802. treatment, 802. uterus, 161, 275, 317; illus., p. 317. -Congenital, 279. diagnosis, 321. hygienic treatment, 322. infection in, 362. mechanical treatment, 318. mechanism of, 318. medicinal treatment, 321. pathologic changes, 319. pessary for, 322. symptoms, 321. tampon for, 322. vagina, 237. etiology, 238. Prolegomena, 1. Proliferating cysts, classilication, 602. contents, 603. histology, 603. Prophylaxis, 258. Prostitutes, 9. chancroid in, 182. gonorrrhoea in, 166. herpes in, 281. Protonuelein, 21. Pruritus ani, 825. Pruritus vulvae, 203. etiology, 204. in kraurosis, 209. pathology, 203. treatment, 204. Pryor, 295, 304, 305, 555, 558, 559. Pryor's operation for retro-displacements of uterus, 305. Psammoma of ovary, 621. Pseudo-hermaphroditism, 213. feminine, 126. masculine, 125. Pseudo-mucin, 606. test for, 606. Pseudo-mucinous cyst of ovary, contents, 605. frequency, 603. histology, 606. section, Illus., p. 605. symptoms, 604. Psychoses, as a result of oophoritis, 580. Pubertas praicox, 124. Pubescent uterus, symptoms, 277. treatment, 277. Pubo-coccygeus muscle, 250. I'ubo-rectalis muscle, 252. Pudendal hematocele, 135. infection of, 138. symptoms, 137. treatment, 138. Pudendum, definition, 117. hypertrophic and hyperplastic diseases of, 213. infections of, 163. neoplasms, benign, 221. malignant, 227. Puerperal fever, 52. infection, 10, 18, 178. tuberculosis, 389 Puncture, as means of diagnosis, 635. Pus, evacuation of, 548. chancroidal, 183. gas-bearing, 180. gonorrhoeal, 515. post-operative, 68. Pustules, papulo-, 199. Pyaemia, 57. symptoms, 58. Pyelitis, 768. tuberculous, 773. Pyosalpinx, bacteria of, 485. contents of, 500. cultures from, 500. diagnosis, 508, 510. etiology, 499. pain from, 506. pulse in, 506. relation to hydrosalpinx, 495. section from, 501. symptoms, 506. temperature, 506. Quadrants of abdomen, 41. Quain, 670. Quervain, 681. Quincke, 195. Rabenan, 383. Raciborsky, 710, 738. Radicalism in gynecology, 4. Ramsay, 786. Ranieri, 130. Rape, general indications, 159. hemorrhage from, 158. infection from, 158. injuries from, 158. objective evidences, 156. pregnancy, 158. Ravogli, 18, 184, 187, 188, 189, 191, 192, 193, 195, 196, 197, 198, 199, 200, 202, 204, 206, 215, 216. Raynaud, 712. Raynaud's disease, 196. Recamier, 1, 2, 368, 447. Recklinghausen, von, 397, 401. Rectal infusion, 77. Rectocelc, 238, 240, 257. 892 A TEXT-BOOK OF GYNECOLOGY Rectocele, anterior, 817. operations for, 269, 241. pathology, 818. posterior, 817. treatment, 818. Recto-vaginal fistula, illus., p. 151. etiology, 152. operation, 153. suture for, 153. Rectum, adenoma of, 841. adhesions of, 823. anatomy of, 806. angeioma of, 843. carcinoma of, 844. chancre of, 828. chancroid, .828. condylomata of, 828. curettage of, 846. dermoid cysts of, 844. displacements of, 817. divulsion of, 840, 846. enchondroma of, 844. etiology of diseases, 820. examination by, 39. examination of, 808. excision of, 847. fibroma of, 843. fistula of, 831, 835. foreign bodies in, 821. gonorrhoea of, 826. gummata, 829. infections of, 824. in pelvic inflammations, 822. lipoma of, 842. malformations, 806. malignant growths of, 844. myoma of, 844. neuralgia of, 820. papilloma of, 843. prolapse of, 120, 818. relation of diseases to intrapelvic dis- ease, 821. results of pressure on, 822. retention cysts of, 844. sarcoma of, 844. spraying of, 834. stricture of, 831, 8.37. syphilis of, 828. teratoma of, 844. tuberculosis of, 830. ulceration of, 820, 831, 833. valves of, 810. Reduction of inverted uterus, 328. Reed, 49, 57, 68, 70, 74, 98, 146, 209, 210, 211, 231, 270, 282, 300, 310, 315, 316, 325, 332, 339, 365, 400, 403, 410, 433, 435, 443, 458, 542, 544, 552, 555, 578, 582, 583, 588, 628, 805, 818. Reed's treatment of endometritis, 365. operation for vesico-uterine fistula, 344. vesico-vaginal fistula, 146. operation of panhysterectomy, 417. suture for incomplete laceration of perineum. 263. Regions of abdomen, 41; illus., p. 41. Rein, 703, 735. Reinecke, 716. Reis, Bmil, 454, 458. Remy, 318. Repositor, uterine, 291, 328. Respiration in puerperal fever, 381. use of chloroform, 95. Rest, as a general remedy, 20. Restoration of pelvic floor, 258. levator-ani muscle, 71. posture for, 260. Retention of cervical fluid, 282. menstrual fluid, 282, 783. Retro-deviations of uterus, diagnosis, 289. symptoms, 289. treatment, 290. Reuss, 681. Reymond, 483, 492, 513, 515, 517, 518, 528, 529, 530, 574, 580. Reynaud, 176. Rhabdomyomata, 783. Rhabdomyosarcomata, 783. Rhagades, 187. Rhazas, 328. Rheinstein, 525. Ricard, 392, 458. Richardson, 629. Richelot, 556, 559. Ricketts, Edwin, 678. Ricketts, B. M., 853. Ricketts's operation for hemorrhoids, 853. Rieck, 171, 173. Ring of Bandl, 332. Rishmiller, 636. Robb, 229, 575. Robin, 600. Robinson, 346, 711, 719. Robson, ^layo, 154, 155. Robson's operation for fsecal fistula, 153. Rockel, 389. Rogivue, 437. Rohrer, 201. Rokitansky, 325, 385, 435, 480, 495, 525, 575, 599. Rollin, COO. Room, operating, 64. Rosenbach, 57, 180. Rosenmiiller, 670. Rosenwasser, 372, 678. Ross, J. P. W., 45, 135, 142, 150, 403, 414, 415. Rosthorn, 514, 601. Rothrock, 245, 246, 624. Round ligament, hydrocele of, 677. malformations of, 298. opei-ations for shortening of, 294. Reed's forceps for, 300. Rousan, 683. Roush, 801. Rousset, 461, 464. Roux, Thomas, 368. Rovsing, 778, 791. Rubber gloves, 70, 295. Rubber, Turck's protective, 102. Rudimentary uterus, symptoms, 276. INDEX 893 Rudimentary uterus, treatment, 276. Rueff, 137. Ruggi, 294. Ruppolt, 474. Rupture of cysts of broad ligament, 675. ectopic pregnancy, 654, 661, 662, 663. hematocele, 137. ovarian cyst, 631. perineum, 255. pyosalpinx, 507. tubal papillomata, 480. uterus, 231. diagnosis, 332. etiology, 331. hsemorrhage from, 335. mechanism, 331. pregnancy, 334. symptoms, 332. treatment, 333. vagina, 139. Rut, menstrual, 700. Sactosalpinx hemorrhagica, 499. purulenta, 499. Sahli, 25. Saline waters, 321. Salochin, 374. Salpingectomy, 549. drainage after, 553. enucleation of tumour mass, 555. history, 549. indications, 551. objections to, 550. Tait's operation, 551. technique, 552. toilet of peritoneum, 553. treatment of pedicle, 552. Salpingitis, acute, histology, 489. secretion in, 489. section (infiltration), illus., p. 491. section (replacement of mucosa), illus. 492. catarrhal, 489. chronic, adhesions, 493. as cause of peritonitis, 493. bacteria of, 484. histology of, 491. Salpingitis, illus., p. 494. complications of diagnosis, 503. compression of bladder, 507. conservative operations for, 546. constipation in, 507. diagnosis, 501. distention of tube, 502. Doyen's operation, 556. drainage in, 540. dysmenorrhoea in, 502. electricity In, 539. evacuation of pus, 548. extension of, 501. extravasation of lilood in, 492. folllciil:irIs, 49:',. Koiiorrhf/'al, 507. diagnosis, 510. 8ymr)torns, 507. Salpingitis, hemorrhagic, 493. mechanical symptoms, menstruation in, 502. morbid histology, 489. pain from, .501, 502. palpation as a means of diagnosis, 503. panhysterectomy for, 555. peritoneal complications, 501. pseudo-foUicularls, 492. purulent, 494. radical treatment, 549. secretion in, 493. separation of adhesions, 547. sterility from, 502. streptococcous, 507. symptoms, 507. diagnosis, 510. symptoms, 501. tuberculous, 511, .521. Salpingo-oophorectomy, 551. Salt solution, 74. infusion of, 76. Salve, resorcin, 194. Sanger, 70, 167, 245, 246, 247, 289, 294, 427, 463, 470, 476, 478, 479, 638, 670, 676, 677, 678, 679, 689. Sanger's closure in Csesarean section, 470. Saprsemia, 57. Saprophytic infection of Fallopian tubes, 530. uterus, 377. pathology, 378. Sarcoma deciduo-chorio-cellulare, see Syn- cytioma malignum. Sarcoma of broad ligament, course, 686. treatment, 686. Fallopian tubes, 482. histology, 482. treatment, 482. kidnej^ 781. histology, 782. origin, 781. meatus urinarius, 200. ovaiy, frequency, 622. histology, 623. sections, illus., 624. symptoms, 623. urethra, 801. uterus, 432. etiology, 4.36. consistency, 4,32, 435. frequency, 432. hemorrhage in, 434. histology, 433. injection of, 436. inversion in, 433. origin, 435. papilliferous type, 433. recurrence of, 437. secondary degeneration, 434. treatment, 436. vagina, 232. adults, 2.32. children, 231. etiology, 232. 894 A TEXT-BOOK OF GYNECOLOGY Sarcoma of vagina, histology, 233. vulva, 229. Sasonoff, 137. Satti, 697. Sauter, 447. Savages, menstruation in, 699. Savor, 769. Saw, spoon, 421; illus., p. 422. Sawlzky, 55. Scanzoni, 674, 678, 739. Scar, abdominal, 105. Schaeffer, 131. Schatz, 69, 272, 674. Schauta, 348, 349, 391, 513, 528, 530, 579, 580, 665. Schedule for determination of rape, 160. Schenck, 171, 681. Schetelig, 678. Scheurlen, 441. Schick, 367. Schiller, 373. Sehleich, 97. Schleich's anaesthetic mixture, 97. Schlenker, 615. Schlesinger, 549. Schmidt, 678, 769. Schmorl, 389, 562. Schniir, 763. Schonheimer, 733. Schottlander, 575, 576. Schramm, 521. Schroeder, 171, 175, 366, 435, 440, 525, 638, 671, 678, 692, 730. Schuckbardt, 520. Schiicking, 76. Schiill, 389. Schultze, 362, 363, 372. Schiitt, 385. Schwartz, 227, 392. Searcher, ureteral, 747. Section, abdominal, 99. Csesarean, 460. Secretion of cervix, 353. retention of, 282. operation for retention, 279. endometrium, 350. vagina, 1G4, 351. vulvo-vaginal gland, 243. Segond, 529, 554, 682. Segregator, urine, 747. Seleneff, 374. Semen, stains from, 158. Semnopithecus, menstruation of, 699. ovulation of, 710. Senator, 780. Senn, 67, 68, 678, 679, 681, 843. Sepsis, bacteria of, 50. definition of, 50. general, 57. symptoms, 58. treatment, 58. local, 56. symptoms, 56, 73. preventive treatment, 66. Septate uterus, 277. Septate uterus, menstruation from, 277. pregnancy in, 277. symptoms, 277. Septicaemia, see Sepsis. Serous cysts, 607. contents, 608. frequency, 607. histology, 608. Serpentine suture. 111. Serum therapy, 21, 44, 45. in general sepsis, 59. Sex, differentiation of, 117. Sexual anaesthesia, 9. perversions, 9. Seydel, 549. Shock, causes, 72. definition, 72. diagnosis, 73. pathology, 72. symptoms, 72. treatment, 74, 630. Silk ligature, 86. Simon, G., 144, 230, 447, 541, 635. Simon-Hegar operation for complete lac- eration, 270. Simon's speculum, 371. Simpson, 2. Simpson, Sir James, 91, 312, 950. Sims, J. Marion, 2, 42, 143, 145, 146, 154,. 305, 312, 313, 314, 323, 326, 337, 368, 420, 425, 445, 448, 4.52, 538, 726, 730. Sims's operation for urinary fistula, 144. posture, 33. speculum, 142. Sinclair, 352, 355, 356, 357, 361, 364, 484, 487, 5.30. Sinus, urogenital, 122. Sippel, 385, .391, 453, 588, 692, 697. Sitz bath, 204. Skene, 84, 85, 148, 244, 419, 448, 642, 681. Skene's gland, 244. gonorrhoea of, 244. Skin, disinfection of, 295. of genitalia, 191. Skirving, 121. Slansky, 478. Smith, Albert, 293. Smith, Greig, 681. Smith, Nathan, 638. Smith, Tyler, 329. Sneguireff, 364. Social evil, as cause of diseases of women,. 10. Solowieff, 3.5.3. Solution, Burow's, 196. Florence, 158, 159. Soranus, 1. Sound, 32. as means of diagnosis, 4.5. dangers of, 291. Ross's intrauterine, 45. uterine, 345. Spaeth, 324, 385, F87. Specialism in gynecology, 2. Speculum, as means of examination, 42.. INDEX 895 Speculum, Gau's, 44; lllus., p. 4.'5. infection from, 362. Jones's, 370. Miller's, 44. Nott's, 44. Simon's, 371. Sims's, 32; illus., p. 42. Sims-Emmet, 43. vesical, 746. Spermatozoa, determination of, 159. Speth, 481. Spliincter-ani-externus muscle, 250. restoration of, 269. Sphincter vagina muscle, 237. Spiegelberg, 137, 671, 674. Sponge hoklei-, 450. Spores, annihilation of, 61. Spronius, 549. StafEordshire knot, 552. Stains, seminal, 158. Standing posture, 35. Stanley, 24. Staphylococcous epidermidis albus, 51. infection, 196, 5.30. pyogenes albus, 51, 196. aureus, 50, 53. citreus, 52. St. Braunwas, 334. Steffeck, 610. Steihitz, 797. Steinmetz, 799. Steinschneider, 514. Stemann, 524. Stenosis, as cause of dysmenorrhoea, 726. electricity in, 730. operation for, 281. uterine, 280. vaginal, 129. Stephenson, 707. Stephenson's wave, 707. Sterility, 502, 509. etiology, 141. Sterilization, germicidal agents for, 63. heat for, 61. mechanical means, 61. Sterilization of, dressings, 66. hands, 69. instruments, 66. operating room, 64. patients, 66. surgeon, 69. sutures and ligatures, 67. vagina, 313. Sterilizer, steam, of Colonel John Fehren- batch, 61; illus., p, 61. Sternberg, 51, 53, 61. Stethoscope, as means of examination, 47. Stf^venson, 24. Still.', 376. Stirton, James, 699. Stockard, .'!97. Stocfkllii, .571. Ktollz, 463. Sloiiiach, inenstruaf Ion from, 7.'i6. StomatoplaBcy, IIIuh., p. 280. Stomatoplasty, indications for, 282. technique, 283. Storer, 471. Stratz, 401. Streptococcous infection of external geni- talia, 177. treatment, 178. Fallopian tubes, 516. diagnosis, 516. fimbria, 517. mucosa in, 517. palpation of, 516. pathology, 517. pus from, 517. symptoms, 516. ovaries, 569. course, 569. pathology, 571. treatment, 581. uterus, 376. diagnosis, 381. pathology, 376. symptoms, 380. treatment, 381. pudendum, 177. vagina, 177. Streptococcus pyogenes, 52; illus., p. 52. erysipelatos, 52. Streptothrix actinomyces, infection of Fallopian tubes, 531. Stricture, of rectum, carcinoma as a cause, 838. etiology, 837. diagnosis, 839. dysenteric, 838. symptoms, 838. syphilitic, 838. traumatic, 838. treatment, 839. tuberculous, 838. ureter, 760. dilatation of, 761. operation for, 761. urethra, 802. etiology, 802. treatment, 802. Stroganoff, 163, 165, 353, 530. Struma suprarenalis lipomatodes aber- rans, 785. Styptics, 79. Subcostal incision, 106. Sultcutaneous infusion, 76. Suggestion as a therapeutic agency, 23. Superinfection, gonococcous, 375. Suppinger, 120. Suppuration, 55. pelvic. Suprapubic incision, 106. Suprarenal extract, 75. Sufjra vaginal hysterectomy, 410. indications, 411. ills! I'uriienis, 103. techni(|ue, 412. Surgeon, pr('i)aralion for examination, 33. sterilization of, 69. 896 A TEXT-BOOK OF GYNECOLOGY Sutton, Bland, 475, 478, 480, 489, 493, 495, 497, 552, 558, 588, 589, 617. Suture, buried serpentine, 111. catgut, 67. crown, Emmet's, 262. Reed's, 263. en masse, 112. figure-of-eigiit, 113. intercutaneous, 110. laminated, 109. removal of, 340. after urinary fistula, 150. sterilization of, 67. wire, 144. Syms, Parker, 698. Syncope, 73. Syncytioma malignum, 15, 231, 426. diagnosis, 428. etiology, 428. hemorrhage in, 428. histology, 427. metastasis in, 429. pain in, 428. pathology of, 427. results of operation, 429. source of, 427. symptoms, 428. treatment, 429. Syncytium, action of, 655. in ectopic pregnancy, 660. Syphilis, as cause of pelvic diseases, 11. bacteriology of, 186. from rape, 1.58. Syphilis of broad ligament, 690. histology. G90. diagnosis, 690. external genitalia, 17, 189. uterus, 391. cauterization in, 393. diagnosis, 393. primary, 392. secondary, 392. symptoms, 392. treatment, 393. rectum, congenital, 828. stricture from, 838. treatment, 829. Syringe, Davidson's, 76. Szancer, 394. Table, Bozeman's, 143. Tachycardia at menopause, 740. Tait, Lawson, 2, 99, 126, 137, 144, 1.54, 166, 210, 216, 266, 267, 269, 271, 272, 306, .328, 329, 345, 347, 350. 3.52, 353, 357, 584, 586, 637, 638, 640, 641, 649, 689, 709, 805. Tait's operation for complete laceration of perineum, 267. removal of Fallopian tubes, 551. Tampon, chain, 292; illus., p. 292. improper, 292; illus., p. 292. lamb's wool, 293; illus., p. 29.3. method of inserting, 537. Tampon, proper, 292. Tampon for, bleeding, 215. carcinoma uteri, 445. diagnosis of endometritis, 363. eczema, 197. gonorrhoea of uterus, 875. inversion of uterus, 329. menorrhagia, 716. prolapsus uteri, 322. pruritus vulvae, 204. puerperal fever, 382. salpingitis, 537. uterine displacement, 291. Tarulli, .589. Taylor, George H., 24, 182. Temesvary, 624. Temperature, in puerperal fever, 380. Tenacula, 371. Cullen's, 450. Tent, laminaria, 356. Teratoma, of ovary, 614. of rectum, 844. Testicle, coexistence of, with ovary, 562. Thayer, 514. Themison, 328. Therapeutics of gynecology, 20. Therapy, serum, 21. Thlem, C, 161. Thiriar, 310, 315. Thomas, Gaillard, 293, 322, 329, 429, 447. Thomas's serrated spoon saw, 421. Thomson, 279, 318, 754. Thorn, 389, 458. Thornton, 628, 638. Thrush, 179. Thumin, 81. Thyroid gland, extract of, 21. as a styptic, 79. relation to uterus, 21. Til laud, 388. Tilt, 738. Tongue forceps, 95. Toxaemia, 57. Toxine, treatment with, 436. Trachelorrhaphy, illus., p. 339. instruments for, 338. sutures for, 339. technique, 338. Transfusion of blood, 76. Transversus-perinsei muscle, 250. Trekaki, 7.54. Trendelenburg, 304, 315. posture, illus., p. 454. Treub, .325, 327. Trichophyton tonsurans, 205. Trifld uterus, 275. Trocar, illus., p. 640. Trommer, 606. Trophoblast, 657. Tsokana, 149. Tubercle, genital, 117. double, 121. Tuberculosis, bacillus of, 55. Tuberculosis, of bladder, 792. broad ligament, 691. INDEX 897 Tuberculosis, of cervix, 385. classilication, 385. diagnosis, 386. diffuse form, 386. etiology, 385. miliary form, 385. morbid anatomy, 385. papillary form, 386. resemblance to epithelioma, 387. symptoms, 386. treatment, 387. Fallopian tubes, 519. acute, 524. adenomatous tumour formations 525. ascending form, 520. chronic, 324. complications of, 526. descending form, 521. diagnosis, 526. distention from, 522. frequency of, 520. gonococcus in, 525. hematogenous infection, 521. menstruation in, 526. method of infection, 520, 521. morbid anatomy of, 521. mucosa in, 524. pain in, 526. primary, 520. prognosis of, 527. secondary, 520. spontaneous cure, 525. symptoms, 525. treatment, 527. kidney, 772. abscesses in, 773. changes in urine, 774. diagnosis, 774. frequency of, 772. giant cell, illus., p. 77.3. hematuria in, 774. involvement of ureter, 774. method of infection, 772. pain in, 774. pathology, 77.3. symptoms, 774. treatment, 775. ovary, 575. diagnosis, .577. frequency of, 575. mode of infection, 576. morbid anatomy, 576. symptoms, 577. treatment, .578. peritoneum, 692. anatomy, morbid, 692. caseous variety, 693. diagnosis of, 695. drainage in, 697. <•! iology, (J92. fever In, 694. fibroid variety, 694. miliary variety, 692. omental tumour In, 695. pain from, 694. 58 ruberculosis, of peritoneum, prognosis, 696. results of operation, 697. symptoms, 694. treatment, 696. rectum, 830. etiology, 830. fistula from, 830. forms of, 831. stricture from, 831, 838. symptoms, 831. treatment, 832. urethra, 173. uterus, 357, 384. caseous form, 390. cauterization of, 391. course of infection, 388. curettage for, 391. diagnosis of, 390. discharge in, 390. etiology, 388. fibroid type, 390. glands in, 391. hysterectomy for, 391. miliary form, 389. morbid anatomy, 389. pathology, 389. pregnancy in, 389. symptoms, 390. treatment, 391. vagina, 175. diagnosis, 177. etiology, 175. symptoms, 176. treatment, 177. vulva, 17, 165. diagnosis of, 174. etiology of, 171. morbid anatomy, 172. symptoms, 174. treatment, 175. Tubes, accessory, 749. drainage, 112, 114. through-and-through, 542. Fallopian, see Fallopian tubes. Kobelt's, 671. supernumerary, 474. Tubo-ovarian cyst, 69, 601. classification, 601. contents, 602. etiology, 601. histology, 602. origin, 418. Tuclierman, 778. TufHer, 81, 97, 528, 772. Tumours, see Neoplasms. Turck, 75, 102. Turck's intragastric resuscitator, 75. protective rubber, 102. Ulcer, anal, 8,32. destructive, 171. follicular, ]8]. syphilitic, 189. ITlceration, of rectum, 820, 8.31. diagnosis of, 834. 898 A TEXT-BOOK OF GYNECOLOGY Ulcei'ation, of rectum, symptoms, 833. treatment, 834. Ulcus elevatum, 186. rodens vulvEe, 171. Umbilical incision, 106. Unicoinate uterus, 276. Urachus, anatomy of, 803. cyst of, 804. Ureters, anomalies of, 760. catheterization of, 744. duplication of, 760. injuries of, 762. in hysterectomy, 413. in nephrectomy, 789. involvement of, in carcinoma, 786. operations on, 761. stricture of, 760. Uretero-cystotomy, 761. Uretero-vaginal fistula, 140. operations for, 151. Urethra, atresia of, 150. carcinoma of, 801. caruncle of, 800. dilatation of, 803. diseases of, 800. diverticula of, 801. foreign bodies in, 802. prolapse of, 802. sarcoma of, 801. stricture of, 802. tuberculosis of, 173. Urinary apparatus, examination of, 744. flstulse, 139. Urines, bacteria of, 779. examination of, 102. incontinence of, 123, 134, 141. in cystitis, 793. in renal infection, 771. residual, 239. segregation of, 747. suppression of, 779. Urogenital sinus, 123. persistent, 122. Uronephrosis, see Nephrydrosis. Urticaria of Wilson, 195. Uterus, absence of, 276. accessorius, 275. adenoma of, 429. adenomyoma of, 397, 399. ante-deviations of, 310. atrophy of, 18. bacteria of, 352. bicornate, 281. carcinoma of, 437. chancre, 391. contraction of, 468. curettage of, 368. development of, 274. displacements of, 38, 284. double, 281. echinococcous, cyst of, 394. infection of, 393. endothelioma of, 434. examination of, 47. fibromyomata of, 396. Uterus, fcetal, 277. foreign bodies in, 348. gonorrhoea of, 354, 372. in menorrhagia, 715. infantile, 277. infection of, 16, 350, 372. injuries of, 162, 331. inversion of, 324. lymphatics of, 350. malformations of, 274, 279. malignant neoplasms of, 426. menstrual function of, 13, 708. movements of, 284. myoma of, 396. neoplasms of, 396. normal position of, 284. poise of, 15. polypoid growths of, 424. prolapse of, 161, 275. pubescent, 277. repositor for, 291, 328. rudimentary, 276. rupture of, 331. saphrophytic infection of, 377. sarcoma of, 432. septus, 277. stenosis of, 280. streptococcous infection of, 376. suspensory apparatus of, 285. suture for, in Csesarean section, 468. syncytioma malignum of, 231, 428. syphilis of, 391. trifld, 275. tuberculosis of, 357, 384. unicornate, 276. vaginal fixation of, 303. wounds of, 345. Vagina, absence of, 126. atresia of, 163. Bilharzia of, 180. carcinoma of, 2.33. coitional, 128. cysts of, 224. dermoid cyst of, 225. displacements of, 237. douche for, 32. endothelioma of, 233. examination by, 30, 165. extirpation of, 455. fibroid tumours of, 225. infections of, 16, 163. injuries of, 139, 162. malformations of, 126. neoplasms of, 224. malignant, 231. Miillerian, 126. polyps of, 226. prolapse of, 237. sarcoma of, 231. secretions of, 164, 351. septate, 129. stenosis of, 129. sterilization of, 313. tuberculosis of, 175. INDEX 899 Vagina, virgin, 252. Vaginal liysterectomy, 419. instruments, 103. myomotomy, 420. Vaginitis, 163. exfoliative, 167. Valve, rectal, 810. Valvotome, 836. Van Buren, 841. Vander Veer, 403, 647. Van de Warker, 9. Van Gieson, 480. Van Heukelom, 427, 657. Van Hook, 701, 762. Van Scliaick, 372, 373. Varicocele, pelvic, 682. diagnosis, 684. etiology, 683. history, 684. Reed's operation for, 68.5. symptoms, 684. Varicocele, pudendal, 222. Varix, aneurismal, of broad ligament, 682. Vassmer, 385, 388, 389, 390. Veins of labia, 221. Veit, 171, 224, 226, 232, 318, 391, 397, 429, 434, 470, 499, 521, 522, 525. Velits, von, 626. Ventral fixation, 306. incision, 100. Verneuil, 711, 849. Vertical median incision, 105. Vesicles, herpes progenitalis, 201. Vesico-umbilical fistula, 804. Vesico-uterine fistula, 140, 343. diagnosis, 343. Reed's operation, 344. Vesico-vaginal fistula, 1.39. Vestibular band, 1.34. Vibriou septique, 531. Vidal, 377, 379. Vineberg, 129, 276, 294, 304, .383. Vinegar as a styptic, 79. Violence, injuries from, 1.36. Virchow, 4.32, 435, 575, 609, 678. Virgin, examination of, 30. vagina, 252. Virus, chancroidal. 183. Vitrac, 387. Volbrecht, 677. VoLsella, Newman's. .3.38. Vomiting in anaesthesia, 91. Von PMselberg, 5], 57. Von Guerard, .■'.67. Von Kohlden, 351, 352, 370. \'on Laiig{'iib('ck, 447. ^'oIl Ilosthoni, 496, 574. ViilvM. 117. adhesions of, 211. atresia of, 119. atrophy of, 207. blood supply of. 221. Ciircliioina of, 227. chancre of, 228. cloaca, 121. Vulva, cysts of, 223. eczema ot, 196. elephantiasis of, 216. enchondromata of, 223. fibromata of, 222. fibroma molluscum of, 223. fibrosarcoma of, 229. folliculitis of, 198. hematoma of, 222. hemorrhage from, 135. hypertrophy of, 213. infantile, 120. injuries of, 135, 157, 162. intertrigo of, 191. lipomata of, 223. malformations of, 118. malignant neoplasms of, 227. melano-carcinoma of, 231. melanosarcoma of, 229. metastases in, 231. molluscum pendulum of, 223. myomata of, 222. myxoflbromata of, 223. myxosarcoma of, 229. neuromata of, 223. noma of, 169. cedema of, 195. polypi of, 219. precocious development of, 124. pruritus of, 202. pseudo-hermaphroditism, 126. sarcoma of, 229. tuberculosis of, 171. varicose tumours of, 221. Vulvitis, 163. Vulvo-vaginal anus, 122. Vulvo-vaginal gland, abscess of, 245. anatomy, 243. carcinoma of. 228, 249. cysts of, 224, 247. function of, 243. gonorrhoea of, 170. infection of, 243. inflammation of, 144. Wagner, 787. Waldeyer, 602. 670. 689. Waldstein, 2.33. Wallace, J. R., 737. Walther, 389, 391. Walton, P., 128, 129. Warburg, 536. Warnecke, 697. Warren, 70, 73. 74. Wart, venereal, see Condylomata. Wave, Stephenson's, 707. Weber, 248, 681. Webster, 126, 203, 205. Weigert, 694. Weight of brain, 7. Weir, R. P., 70, 207. Welch, 52, 54, 180, .358. Wells, Spencer, 2, 627, 636, 638, 640, 642, 676. Werder, 455. 900 A TEXT-BOOK OF GYNECOLOGY Wernltz, 229. Werth, 56, 610, 670. Wertheim, 199, 294, 354, 356, 374, 375, 485, 486, 513, 515, 529. Westermai'k, 485, 513. Westermeyer, 576. Westphalen, 13. Wetherill, 474. Whitacre, 228, 384, 385, 387, 491, 493, 576, 577. White, J. W., 216. 329, 781. Wliitehead, 392, 821. Whitehead's operation for hemorrhoids, 852. Wiart, Pierre, 477. Wiclilein, 180. Widal, 52, 376. Wilhelm, 671. Wilson's ointment, 193, 200. Williams, 386, 389, 473, 474, 475. 480, 520, 521, 524, 525, 562, 610, 617, 692, 627. Williams, J. Whitridge, 164, 105, 293. 427, 615. Williams, Roger, 427, 429, 433, 436. Wilms, 14, 613. Wiucke, F. von, 274. Winckel, 137, 229, 289, 474, 525, 561, 676, 678, 679, 681, 682. Wing, 329. Winter, 164, 353, 360, 437, 484, 598. Withrow, 653, 720, 736. Witte, 484, 513, 528, 530, 531, 574, 575. Witzel, 801. Wladimiroff, 702. Wolf, 249, 805. Wolff, 525, 575, 577. Wolffian body, 117. ducts. 126, 671. Wounds of uterus, 345. Wumsehein, 769. Wyder, 351. Wylie, 294, 299, 679. Wyssakovitscli, 60. Zahn, 389. Zeman, 531, 575. Zetter, 627. Ziegler, 597, 621. Zinke, 675, 678, 679, 680, 682, 683, 684, 685, 686, 687. Zuckerkandl, 689. Zweifel, 180, 387, 470, 495, 513, 529, 530, 550, 574. THE END A TEXT-BOOK ON SUROERY: GENERAL, OPERATIVE, AND MECHANICAL. By JOHN A. WYETII, M. D., Professor of Surgery in the New York Polyclinic ; Surgeon to Mount Sinai Hospital, etc. TRIRB EDITION, REVISED AND ENLABGED. 997 pages, with 938 Illustrations. Buckram, uncut edges, $7.00 ; sheep, $8.00 ; half morocco, $8.50. SOLD ONLY BY SUBSCRIPTION. From Autliofs Preface. The original edition of this work was published in 1886. It was revised and enlarged in a second edition in 1890. "Within the period of seven years to this date (November, 1897) so many important advances have been made in surgical sci- ence and the operative technique that the author has found it necessary again to revise and practically rewrite this volume. To add all that was new and acceptable to that which experience had already demonstrated to be useful has of necessity increased the number of pages and size of the book. By careful elimination of matter which could with least disadvantage be left out, this volume, however, only exceeds the former by one hundred and twelve pages. 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The work covers the entire field of general surgery and of surgical diseases, deahng not so much with special operations as with the conditions which should govern them— general directions for their performance, after-treatment, and the etiology, pathology, ancV treatment of the various surgical diseases. Volume II, Regional Surgery, is devoted to the surgery of the head, neck, thorax, and spine and spinal cord ; including in Xhe, first division injunes and diseases of the scalp, of the cranial bones, of the brain and its adnexa, of the face, of the nose and nasal fossas, of the jaws, of the mouth, fauces, and phai-ynx, of the ear, and of the salivary glands. The second divisio7i includes injuries and surgical diseases of the neck, of the larynx and trachea, and of the oesophagus. The third division covers injuries and diseases of the thorax and of tlie heart; and the fovrtli division treats of the surgery of the spine and spinal cord, including deformities, fractures, gunshot injuries, tumors, etc. The list of subjects is so full that it includes even tlie great surgical rarities, and the descriptions are sufficiently complete to save the reader from the necessity of consulting other works to obtain the knowledge necessary to understand and to treat. D. APPLETON AND COMPANY, NEW YORK. THE DISEASES OF mnmj and childhood. I^or the Use of Students and Practitioners of Medicine. By L. EMMETT HOLT, A. M., M. D., Professor of Dkeases of Children in the New Yorlc Polyclinic ; Attending Physician to the Babies' Hospital and to the Nursery and Child's Hospital, New Yorlc; Consulting Physician to the New Yorlc Infant Asylum, and to the Hospital for Ruptured and Crippled. With 7 full-page Colored Plates and 203 Illustrations. Cloth, $6.00 , sheep, $7.00 ; half morocco, $7.50. SOLID OlSTLY BY SXJBSCRIFTIOJnT. American Medico-Surgical Bulletin: " This work is in every sense of the word a new book ; for, while the best work of other authors in this and other countries has been drawn upon, especially that in the form of monoj^raphs and in the flies of psediatric literature, the majority is derived from the author's own clinical observations. Obsolete dicta handed down from text-book to text-book are here conspicuously absent, and nothing has been accepted which has not been carefully tested. ... It is not venturing too much, after a careful perusal of these pages, to predict for this volume a pre-eminent and lasting position among the treatises upon this subject. We heartily recommend that it find a place not only in the library of every physician, but wide open at the elbow of every man who desires to deal iutelligently with the problems which confront him in the treatment of infants and children intrusted to his care." Nashville Journal of Medicine : " This magnificent work is one of the most valuable recent contributions to medical liter- ature. It will rapidly win its way to a front rank with other standard works upon kindred subjects. It is as neai'ly complete as a treatise upon tliis subject can be." Virginia Medical S e mi- Monthly : " When one recalls the teachinars of a decade or two ago and compares the inculcationa of to-day, he can scarcely help recognizing that ' old things have passed away, and all things have become new.' The volume before us is practically the record of information obtained by the author from eleven years of special study and practice, so that nearly every subject is presented from the standpoint of personal observation and experience. The information given is therefore reliable, for Dr. Holt Ls a close observer and a careful student of his ripe experience. ... In short, this book appears to us to be the best all-round, up-to- date book for practitioners and students of children's diseases that we know of." Medical Progress : " The work before us is one which reflects great credit upon the distinguished author. Dr. Holt has long been known as a most industrious and painstaking investigator, and in this volume he sustains tfiat reputation. The work, we may say in a sentence, is fully up to the ref|iiir(;mentH of tlie times, and there is no advance known to paediatrics which has not been fully dealt with according to its merits." D. APPLETON AND COMPANY, NEW YORK. THE DISEASES OF THE STOMACH. . By Dr. C. A. EWALD, EXTRAORDINARY PROFESSOR OF MEDICINE AT THE UNIVERSITY OF BERLIN. Second American Edition, translated and edited, with numerous Additions, from the Tldrd German Edition, By MORRIS MANGES, A. M., M. D., ASSISTANT VISITING PHYSICIAN TO MOUNT SINAI HOSPITAL ; LECTURER ON GENERAL MEDICINE, NEW YORK POLYCLINIC, ETC. This work has been thoroughly revised, rearranged, largely rewritten, and brought up to date from the most recent literature on the subject. 8vo, 602 pages. Sold by subscription. Cloth, $5.00; sheep, $6.00. "In giving the medical profession this second revised translation of Prof. Ewald's treatise on the Diseases of the Stomach, Dr. Manges has placed the profes- sion under even greater obligations than we owed for the first. The first transla- tion was then an almost exhaustive treatise, and now, with so much new and valuable data added, the work is a sine qua nan." — Atlanta Medical and Surgical Journal. " This work as it now stands is the best on the subject of stomach diseases in the English language. No physician's library is complete without it. It is in every way well adapted to the requirements of the general practitioner, although complete enough to meet also the requirements of the specialist." — American Medico- Surgical Bulletin. " The present American edition is a peculiarly valuable one, as the editor.. Dr. Manges, has done his work in a thoroughly creditable manner. His numer- ous notes, additions, and new illustrations have made the book a classic one. Under these circumstances it should find a place in the library oE every Amer- ican physician, as their clientele is composed of such a large proportion of patients suffering from gastric complaints and more or less improper medication which most often ends in failure. There is no doubt that more properly directed efforts in the proper direction, as outlined in Ewald's book, would soon remove from Americans the reputation of being a nation of dyspeptics." — St. Louis Medical and Surgical Journal. " Dr. Ewald's book has met with a very cordial reception by the medical pro- fession. Within a short period three editions have appeared, and translations published in England, Spain, Prance, Italy, and the United States. To the present edition the author has not only added considerable new matter, but he has also entirely rewritten the work. The arrangement of the chapters has been somewhat changed, and many new personal observations and therapeutic experi- ences added. The desirability of surgical interference is carefully considered, and the pros and cons given so far as would be necessary to enable a physician to determine whether the aid of the surgeon might be required. The translator has done his work well, and has incorporated much new matter into the text and footnotes." — North American Journal of Homoeopathy. D. APPLETON AND COMPANY, NEW YOPvK. DATE DUE OtMCO 38-296 COLUMBIA UNIVERSITY LIBRARIES Ihslstxi RG 101 R252 1901 C.I A Tex' '■'■■'■ '■' - 2002292343